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Lewandrowski KU, Vira S, Elfar JC, Lorio MP. Advancements in Custom 3D-Printed Titanium Interbody Spinal Fusion Cages and Their Relevance in Personalized Spine Care. J Pers Med 2024; 14:809. [PMID: 39202002 PMCID: PMC11355268 DOI: 10.3390/jpm14080809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/17/2024] [Accepted: 07/24/2024] [Indexed: 09/03/2024] Open
Abstract
3D-printing technology has revolutionized spinal implant manufacturing, particularly in developing personalized and custom-fit titanium interbody fusion cages. These cages are pivotal in supporting inter-vertebral stability, promoting bone growth, and restoring spinal alignment. This article reviews the latest advancements in 3D-printed titanium interbody fusion cages, emphasizing their relevance in modern personalized surgical spine care protocols applied to common clinical scenarios. Furthermore, the authors review the various printing and post-printing processing technologies and discuss how engineering and design are deployed to tailor each type of implant to its patient-specific clinical application, highlighting how anatomical and biomechanical considerations impact their development and manufacturing processes to achieve optimum osteoinductive and osteoconductive properties. The article further examines the benefits of 3D printing, such as customizable geometry and porosity, that enhance osteointegration and mechanical compatibility, offering a leap forward in patient-specific solutions. The comparative analysis provided by the authors underscores the unique challenges and solutions in designing cervical, and lumbar spine implants, including load-bearing requirements and bioactivity with surrounding bony tissue to promote cell attachment. Additionally, the authors discuss the clinical outcomes associated with these implants, including the implications of improvements in surgical precision on patient outcomes. Lastly, they address strategies to overcome implementation challenges in healthcare facilities, which often resist new technology acquisitions due to perceived cost overruns and preconceived notions that hinder potential savings by providing customized surgical implants with the potential for lower complication and revision rates. This comprehensive review aims to provide insights into how modern 3D-printed titanium interbody fusion cages are made, explain quality standards, and how they may impact personalized surgical spine care.
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, Division Personalized Pain Research and Education, Tucson, AZ 85712, USA
- Department of Orthopaedics, Fundación Universitaria Sanitas Bogotá, Bogotá 111321, Colombia
| | - Shaleen Vira
- Orthopedic and Sports Medicine Institute, Banner-University Tucson Campus, 755 East McDowell Road, Floor 2, Phoenix, AZ 85006, USA;
| | - John C. Elfar
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Tucson, AZ 85721, USA
| | - Morgan P. Lorio
- Advanced Orthopedics, 499 East Central Parkway, Altamonte Springs, FL 32701, USA;
- Orlando College of Osteopathic Medicine, Orlando, FL 34787, USA
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2
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Wu LC, Hsieh YY, Hsu TS, Liu PY, Tsuang FY, Kuo YJ, Chen CH, Van Huynh T, Chiang CJ. 3D-printed porous titanium suture anchor: a rabbit lateral femoral condyle model. BMC Musculoskelet Disord 2024; 25:559. [PMID: 39026178 PMCID: PMC11256369 DOI: 10.1186/s12891-024-07666-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 07/05/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND The inclusion of a connecting path in a porous implant can promote nutrient diffusion to cells and enhance bone ingrowth. Consequently, this study aimed to evaluate the biomechanical, radiographic, and histopathological performance of a novel 3D-printed porous suture anchor in a rabbit femur model. METHODS Three test groups were formed based on the type of suture anchor (SA): Commercial SA (CSA, Group A, n = 20), custom solid SA (CSSA, Group B, n = 20), and custom porous SA (CPSA, Group C, n = 20). The SAs were implanted in the lateral femoral condyle of the right leg in each rabbit. The rabbits (New Zealand white rabbits, male, mean body weight of 2.8 ± 0.5 kg, age 8 months) underwent identical treatment and were randomized into experimental and control groups via computer-generated randomization. Five rabbits (10 femoral condyles) were euthanized at 0, 4, 8, and 12 weeks post-implantation for micro-CT, histological analysis, and biomechanical testing. RESULTS At 12 weeks, the CPSA showed a higher BV/TV (median 0.7301, IQR 0.7276-0.7315) than the CSSA and CSA. The histological analysis showed mineralized osteocytes near the SA. At 4 weeks, new bone was observed around the CPSA and had penetrated its porous structure. By 12 weeks, there was no significant difference in ultimate failure load between the CSA and CPSA. CONCLUSIONS We demonstrated that the innovative 3D-printed porous suture anchor exhibited comparable pullout strength to conventional threaded suture anchors at the 12-week postoperative time-point period. Furthermore, our porous anchor design enhanced new bone formation and facilitated bone growth into the implant structure, resulting in improved biomechanical stability.
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Affiliation(s)
- Lien-Chen Wu
- Department of Orthopaedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, 110, Taiwan
| | - Yueh-Ying Hsieh
- Department of Orthopaedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
| | - Ting-Shuo Hsu
- Department of Orthopaedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
| | - Po-Yi Liu
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
| | - Fon-Yih Tsuang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei City, 10022, Taiwan
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, 10022, Taiwan
| | - Yi-Jie Kuo
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
- Department of Orthopedic Surgery, Wan Fang Hospital, Taipei Medical University, Taipei City, 116, Taiwan
| | - Chia-Hsien Chen
- Department of Orthopaedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, 110, Taiwan
| | - Tin Van Huynh
- Department of Interventional Cardiology, Thong Nhat Hospital, Ho Chi Minh City, Vietnam
- International Ph.D program in medicine, college of medicine, Taipei medical university, Taipei, Taiwan
| | - Chang-Jung Chiang
- Department of Orthopaedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan.
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan.
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Lee JJ, Jacome FP, Hiltzik DM, Pagadala MS, Hsu WK. Evolution of Titanium Interbody Cages and Current Uses of 3D Printed Titanium in Spine Fusion Surgery. Curr Rev Musculoskelet Med 2024:10.1007/s12178-024-09912-z. [PMID: 39003679 DOI: 10.1007/s12178-024-09912-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE OF REVIEW To summarize the history of titanium implants in spine fusion surgery and its evolution over time. RECENT FINDINGS Titanium interbody cages used in spine fusion surgery have evolved from solid metal blocks to porous structures with varying shapes and sizes in order to provide stability while minimizing adverse side effects. Advancements in technology, especially 3D printing, have allowed for the creation of highly customizable spinal implants to fit patient specific needs. Recent evidence suggests that customizing shape and density of the implants may improve patient outcomes compared to current industry standards. Future work is warranted to determine the practical feasibility and long-term clinical outcomes of patients using 3D printed spine fusion implants. Outcomes in spine fusion surgery have improved greatly due to technological advancements. 3D printed spinal implants, in particular, may improve outcomes in patients undergoing spine fusion surgery when compared to current industry standards. Long term follow up and direct comparison between implant characteristics is required for the adoption of 3D printed implants as the standard of care.
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Affiliation(s)
- Justin J Lee
- Northwestern University, Simpson Querrey Institute (SQI), 808 N Cleveland Ave. 901, Chicago, IL, 60610, USA.
| | - Freddy P Jacome
- Northwestern University, Simpson Querrey Institute (SQI), 808 N Cleveland Ave. 901, Chicago, IL, 60610, USA
| | - David M Hiltzik
- Northwestern University, Simpson Querrey Institute (SQI), 808 N Cleveland Ave. 901, Chicago, IL, 60610, USA
| | - Manasa S Pagadala
- Northwestern University, Simpson Querrey Institute (SQI), 808 N Cleveland Ave. 901, Chicago, IL, 60610, USA
| | - Wellington K Hsu
- Northwestern University, Simpson Querrey Institute (SQI), 808 N Cleveland Ave. 901, Chicago, IL, 60610, USA
- Department of Orthopedic Surgery, Northwestern University, Chicago, IL, USA
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Chang SY, Kang DH, Cho SK. Innovative Developments in Lumbar Interbody Cage Materials and Design: A Comprehensive Narrative Review. Asian Spine J 2024; 18:444-457. [PMID: 38146053 PMCID: PMC11222887 DOI: 10.31616/asj.2023.0407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 12/27/2023] Open
Abstract
This review comprehensively examines the evolution and current state of interbody cage technology for lumbar interbody fusion (LIF). This review highlights the biomechanical and clinical implications of the transition from traditional static cage designs to advanced expandable variants for spinal surgery. The review begins by exploring the early developments in cage materials, highlighting the roles of titanium and polyetheretherketone in the advancement of LIF techniques. This review also discusses the strengths and limitations of these materials, leading to innovations in surface modifications and the introduction of novel materials, such as tantalum, as alternative materials. Advancements in three-dimensional printing and surface modification technologies form a significant part of this review, emphasizing the role of these technologies in enhancing the biomechanical compatibility and osseointegration of interbody cages. In addition, this review explores the increase in biodegradable and composite materials such as polylactic acid and polycaprolactone, addressing their potential to mitigate long-term implant-related complications. A critical evaluation of static and expandable cages is presented, including their respective clinical and radiological outcomes. While static cages have been a mainstay of LIF, expandable cages are noted for their adaptability to the patient's anatomy, reducing complications such as cage subsidence. However, this review highlights the ongoing debate and the lack of conclusive evidence regarding the superiority of either cage type in terms of clinical outcomes. Finally, this review proposes future directions for cage technology, focusing on the integration of bioactive substances and multifunctional coatings and the development of patient-specific implants. These advancements aim to further enhance the efficacy, safety, and personalized approach of spinal fusion surgeries. Moreover, this review offers a nuanced understanding of the evolving landscape of cage technology in LIF and provides insights into current practices and future possibilities in spinal surgery.
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Affiliation(s)
- Sam Yeol Chang
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul,
Korea
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul,
Korea
| | - Dong-Ho Kang
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul,
Korea
- Department of Orthopaedic Surgery, Spine Center, Samsung Medical Center, Seoul,
Korea
| | - Samuel K. Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
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5
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Levy AS, Maddy K, Murray A, John DL, Kumar V, Urakov T. Transforaminal lumbar interbody fusion with placement of steerable banana cage: A single-center retrospective analysis of radiographic parameters of success. Radiography (Lond) 2024; 30:163-167. [PMID: 38035428 DOI: 10.1016/j.radi.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION The transforaminal lumbar interbody fusion (TLIF) is among the most utilized methods for the surgical treatment of lumbar degenerative disc disease. The TLIF has advanced significantly with several iterative changes since its inception in the early 1980s, with the advent of several generations of interbody types, shapes, and materials. Steerable curvilinear interbodies are among the most recent innovations in this space and may offer biomechanical advantages, namely in preservation of lumbar and segmental lordosis. While radiographic parameters have been investigated for other cage shapes and lumbar interbody fusion techniques, no study has investigated postoperative radiographic outcomes specific to TLIFs done with curvilinear interbodies. METHODS This study is a retrospective review of TLIFs performed with curvilinear interbodies between 2019 and 2022 at a single institution. Upright radiographs were obtained preoperatively and at several timepoints postoperatively. Radiographic variables including interspace height and segmental lordosis were collected. RESULTS 26 surgeries with 32 curvilinear interbodies were performed across 3 years. There was significant increase in segmental lordosis at the L4-L5 (p = 0.0183) and L5-S1 levels (p = 0.004) as well as interspace height postoperatively at levels L3-L4 (p = 0.011) and L4-L5 (p = 0.002). Pain as measured with the numeric rating scale significantly improved in the overall cohort postoperatively (p<0.001). CONCLUSIONS TLIF with curvilinear interbody placement increases segmental lordosis and interspace height at the L4-L5 and L5-S1 levels, and increased interspace height at the L3-L4 and L4-L5 levels. Further investigation into additional radiographic parameters is warranted and expanded cohort size would benefit deeper analysis of other spinal levels. IMPLICATIONS FOR PRACTICE As an increasing number of cage designs and materials are brought to market, studies such as this allow for better understanding of cage specific outcomes allowing for better informed device selection.
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Affiliation(s)
- A S Levy
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - K Maddy
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - A Murray
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - D L John
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - V Kumar
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - T Urakov
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, Miami, FL, 33136, USA.
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Habib A, Jovanovich N, Muthiah N, Alattar A, Alan N, Agarwal N, Ozpinar A, Hamilton DK. 3D printing applications in spine surgery: an evidence-based assessment toward personalized patient care. 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 2022; 31:1682-1690. [PMID: 35590016 DOI: 10.1007/s00586-022-07250-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Spine surgery entails a wide spectrum of complicated pathologies. Over the years, numerous assistive tools have been introduced to the modern neurosurgeon's armamentarium including neuronavigation and visualization technologies. In this review, we aimed to summarize the available data on 3D printing applications in spine surgery as well as an assessment of the future implications of 3D printing. METHODS We performed a comprehensive review of the literature on 3D printing applications in spine surgery. RESULTS Over the past decade, 3D printing and additive manufacturing applications, which allow for increased precision and customizability, have gained significant traction, particularly spine surgery. 3D printing applications in spine surgery were initially limited to preoperative visualization, as 3D printing had been primarily used to produce preoperative models of patient-specific deformities or spinal tumors. More recently, 3D printing has been used intraoperatively in the form of 3D customizable implants and personalized screw guides. CONCLUSIONS Despite promising preliminary results, the applications of 3D printing are so recent that the available data regarding these new technologies in spine surgery remains scarce, especially data related to long-term outcomes.
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Affiliation(s)
- Ahmed Habib
- Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, USA.,Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nicolina Jovanovich
- Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nallammai Muthiah
- Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, USA
| | - Ali Alattar
- Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, USA
| | - Nima Alan
- Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, USA
| | - Nitin Agarwal
- Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, USA
| | - Alp Ozpinar
- Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, USA.
| | - David Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, USA
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7
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Zhang H, Wang Z, Wang Y, Li Z, Chao B, Liu S, Luo W, Jiao J, Wu M. Biomaterials for Interbody Fusion in Bone Tissue Engineering. Front Bioeng Biotechnol 2022; 10:900992. [PMID: 35656196 PMCID: PMC9152360 DOI: 10.3389/fbioe.2022.900992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/21/2022] [Indexed: 12/04/2022] Open
Abstract
In recent years, interbody fusion cages have played an important role in interbody fusion surgery for treating diseases like disc protrusion and spondylolisthesis. However, traditional cages cannot achieve satisfactory results due to their unreasonable design, poor material biocompatibility, and induced osteogenesis ability, limiting their application. There are currently 3 ways to improve the fusion effect, as follows. First, the interbody fusion cage is designed to facilitate bone ingrowth through the preliminary design. Second, choose interbody fusion cages made of different materials to meet the variable needs of interbody fusion. Finally, complete post-processing steps, such as coating the designed cage, to achieve a suitable osseointegration microstructure, and add other bioactive materials to achieve the most suitable biological microenvironment of bone tissue and improve the fusion effect. The focus of this review is on the design methods of interbody fusion cages, a comparison of the advantages and disadvantages of various materials, the influence of post-processing techniques and additional materials on interbody fusion, and the prospects for the future development of interbody fusion cages.
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Affiliation(s)
- Han Zhang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zhonghan Wang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- Orthopaedic Research Institute of Jilin Province, Changchun, China
| | - Yang Wang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zuhao Li
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- Orthopaedic Research Institute of Jilin Province, Changchun, China
| | - Bo Chao
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Shixian Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Wangwang Luo
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Jianhang Jiao
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Minfei Wu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
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Spinal Implant Osseointegration and the Role of 3D Printing: An Analysis and Review of the Literature. Bioengineering (Basel) 2022; 9:bioengineering9030108. [PMID: 35324797 PMCID: PMC8944949 DOI: 10.3390/bioengineering9030108] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/12/2022] [Accepted: 03/04/2022] [Indexed: 11/17/2022] Open
Abstract
The use of interbody implants for spinal fusion has been steadily increasing to avoid the risks of complications and donor site morbidity when using autologous bone. Understanding the pros and cons of various implant designs can assist the surgeon in choosing the ideal interbody for each individual patient. The goal of these interbody cages is to promote a surface area for bony ingrowth while having the biomechanical properties to support the axial skeleton. Currently, the majority of interbody implants consists of metal or polyether ether ketone (PEEK) cages with bone graft incorporated inside. Titanium alloy implants have been commonly used, however, the large difference in modulus of elasticity from bone has inherent issues. PEEK implants have a desirable surface area with the benefit of a modulus of elasticity closer to that of bone. Unfortunately, clinically, these devices have had increased risk of subsidence. More recently, 3D printed implants have come into the market, providing mechanical stability with increased surface design for bony ingrowth. While clinical outcomes studies are limited, early results have demonstrated more reliable and quicker fusion rates using 3D custom interbody devices. In this review, we discuss the biology of osseointegration, the use of surface coated implants, as well as the potential benefits of using 3D printed interbodies.
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Wickramasinghe ML, Dias GJ, Premadasa KMGP. A novel classification of bone graft materials. J Biomed Mater Res B Appl Biomater 2022; 110:1724-1749. [DOI: 10.1002/jbm.b.35029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 12/19/2022]
Affiliation(s)
- Maduni L. Wickramasinghe
- Department of Biomedical Engineering General Sir John Kotelawala Defense University Ratmalana Sri Lanka
| | - George J. Dias
- Department of Anatomy, School of Medical Sciences University of Otago Dunedin New Zealand
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Sousa JM, Ribeiro H, Silva JL, Nogueira P, Consciência JG. Clinical outcomes, complications and fusion rates in endoscopic assisted intraforaminal lumbar interbody fusion (iLIF) versus minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): systematic review and meta-analysis. Sci Rep 2022; 12:2101. [PMID: 35136081 PMCID: PMC8825843 DOI: 10.1038/s41598-022-05988-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 01/20/2022] [Indexed: 12/23/2022] Open
Abstract
This meta-analysis aims to determine the clinical outcomes, complications, and fusion rates in endoscopic assisted intra-foraminal lumbar interbody fusion (iLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for lumbar degenerative diseases. The MEDLINE, Embase, and Cochrane Library databases were searched. The inclusion criteria were: five or more consecutive patients who underwent iLIF or MI-TLIF for lumbar degenerative diseases; description of the surgical technique; clinical outcome measures, complications and imaging assessment; minimum follow-up of 12 months. Surgical time, blood loss, and length of hospital stay were extracted. Mean outcome improvements were pooled and compared with minimal clinically important differences (MCID). Pooled and direct meta-analysis were evaluated. We identified 42 eligible studies. The iLIF group had significantly lower mean intra-operative blood loss, unstandardized mean difference (UMD) 110.61 mL (95%CI 70.43; 150.80; p value < 0.0001), and significantly decreased length of hospital stay (UMD 2.36; 95%CI 1.77; 2.94; p value < 0.0001). Visual analogue scale (VAS) back, VAS leg and Oswestry disability index (ODI) baseline to last follow-up mean improvements were statistically significant (p value < 0.0001), and clinically important for both groups (MCID VAS back > 1.16; MCID VAS leg > 1.36; MCID > 12.40). There was no significant difference in complication nor fusion rates between both cohorts. Interbody fusion using either iLIF or MI-TLIF leads to significant and clinically important improvements in clinical outcomes for lumbar degenerative diseases. Both procedures provide high rates of fusion at 12 months or later, without significant difference in complication rates. iLIF is associated with significantly less intraoperative blood loss and length of hospital stay.
Study registration: PROSPERO international prospective register of systematic reviews: Registration No. CRD42020180980, accessible at https://www.crd.york.ac.uk/prospero/ April 2020.
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Affiliation(s)
- José Miguel Sousa
- Orthopaedics Department, Centro Hospitalar Lisboa Ocidental, Estrada do Forte do Alto Duque, 1449-005, Lisbon, Portugal. .,Comprehensive Health Research Center, NOVA Medical School - Universidade NOVA de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisbon, Portugal.
| | - Hugo Ribeiro
- Orthopaedics Department, Centro Hospitalar Lisboa Ocidental, Estrada do Forte do Alto Duque, 1449-005, Lisbon, Portugal
| | - João Luís Silva
- Orthopaedics Department, Centro Hospitalar Lisboa Ocidental, Estrada do Forte do Alto Duque, 1449-005, Lisbon, Portugal
| | - Paulo Nogueira
- Área Disciplinar Autónoma de Bioestatística (Laboratório de Biomatemática), Faculdade de Medicina, Instituto de Medicina Preventiva e Saúde Pública, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - José Guimarães Consciência
- Orthopaedics Department, Centro Hospitalar Lisboa Ocidental, Estrada do Forte do Alto Duque, 1449-005, Lisbon, Portugal.,Comprehensive Health Research Center, NOVA Medical School - Universidade NOVA de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisbon, Portugal
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Corso KA, Kothari P, Corrado K, Michielli A, Ruppenkamp J, Bowden D. Early revision events among patients with a three dimensional (3D) printed cellular titanium or PEEK (polyetheretherketone) spinal cage for single-level lumbar spinal fusion. Expert Rev Med Devices 2021; 19:195-201. [PMID: 34937486 DOI: 10.1080/17434440.2022.2020637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Three-dimensional (3D) printed spinal cages are a new design of intervertebral body fusion devices. Clinical data on these devices are limited. The objective of this study was to describe six-month events for a new and older cage design. METHODS A retrospective, descriptive cohort study of patients that received a 3D-printed-titanium or PEEK (polyetheretherketone) cage with single-level lumbar fusion was performed using a United States hospital-based database. Outcomes evaluated were device-related revision and non-device related reoperation events 6 months after lumbar fusion. The 3D-printed-titanium and PEEK groups were propensity-score matched. Both unmatched and matched groups were descriptively analyzed. There were 93 and 2,082 patients with a 3D-printed-titanium and PEEK cage that met study criteria. The sample size was 93 patients per group after matching. RESULTS There were no occurrences of revisions in the 3D-printed-titanium and eleven occurrences in the PEEK group before matching; PEEK had no occurrences of revision after matching. Ten total reoperation events were identified. DISCUSSION Our findings suggest occurrence of 6-month revision or reoperation is similar or lower for both cages than reported in published literature. The low occurrence of early events for 3D-printed-titianium cages is promising. Further, real-world studies on 3D-printed cages are warranted.
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Affiliation(s)
- Katherine A Corso
- Johnson & Johnson, Medical Devices, Medical Device Epidemiology and Real World Data Sciences, New Brunswick, NJ, USA
| | | | | | | | - Jill Ruppenkamp
- Johnson & Johnson, Medical Devices, Medical Device Epidemiology and Real World Data Sciences, New Brunswick, NJ, USA
| | - Dawn Bowden
- Johnson & Johnson, Medical Devices, Health Economics and Market Access, Raynham, MA, USA
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Phani Kiran S, Sudhir G. Minimally invasive transforaminal lumbar interbody fusion - A narrative review on the present status. J Clin Orthop Trauma 2021; 22:101592. [PMID: 34603954 PMCID: PMC8463772 DOI: 10.1016/j.jcot.2021.101592] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 08/12/2021] [Accepted: 09/06/2021] [Indexed: 01/01/2023] Open
Abstract
Minimally invasive lumbar transforaminal interbody fusion (MIS TLIF) has become the most commonly performed lumbar fusion procedure. There are multiple variables such as bone graft properties, use of rhBMP (recombinant human bone morphogenic protein), interbody cage properties, image guidance techniques, etc., that may impact the outcomes and fusion rates. Radiation exposure to the patient as well as to the operating team is an important concern. The minimally invasive anterior approaches for lumbar fusion with ability to insert larger cages and achieve better sagittal correction have added another option in management of lumbar degenerative deformities. A literature review of recent studies and systematic reviews on different aspects impacting the outcomes of MIS TLIF has been done to define the present status of the procedure in this narrative review. Iliac crest bone graft can help achieve very good fusion rate without significantly increasing the morbidity. RhBMP is most potent enhancer of fusion and the adverse effects can be avoided by surgical technique and using lower dose. The use of navigation techniques has reduced the radiation exposure to patient and the surgeons but the benefit seems to be significant only in long segment fusions.
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Key Words
- ALIF, Anterior lumbar interbody fusion
- Bone graft substitutes
- DBM, Demineralised Bone Matrix
- JOABPEQ, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire
- LLIF, Lateral lumbar interbody fusion
- MIISA, Minimally Invasive Interbody Selection Algorithm
- MIS TLIF
- MIS TLIF, Minimally invasive transforaminal interbody fusion
- Minimally invasive lumbar interbody fusion
- Navigation assisted lumbar fusion
- OLIF, Oblique lumbar interbody fusion
- SiCaP, Silicate-substituted Calcium Phosphate
- Transforaminal interbody fusion
- XLIF, Extreme lateral lumbar interbody fusion
- rhBMP, recombinant human bone morphogenic protein
- β-TCP, β-Tricalcium Phosphate
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Affiliation(s)
- S. Phani Kiran
- Gleneagles Global Health City, Chennai, India,Corresponding author. Gleneagles Global Health City, 439 Cheran Nagar, Perumbakkam, Chennai, 600100, Tamilnadu, India.
| | - G. Sudhir
- Department of Spine Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
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Meena VK, Kumar P, Kalra P, Sinha RK. Additive manufacturing for metallic spinal implants: A systematic review. ANNALS OF 3D PRINTED MEDICINE 2021. [DOI: 10.1016/j.stlm.2021.100021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Fiani B, Newhouse A, Cathel A, Sarhadi K, Soula M. Implications of 3-Dimensional Printed Spinal Implants on the Outcomes in Spine Surgery. J Korean Neurosurg Soc 2021; 64:495-504. [PMID: 34139795 PMCID: PMC8273772 DOI: 10.3340/jkns.2020.0272] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/07/2020] [Indexed: 12/31/2022] Open
Abstract
Three-dimensional printing (3DP) applications possess substantial versatility within surgical applications, such as complex reconstructive surgeries and for the use of surgical resection guides. The capability of constructing an implant from a series of radiographic images to provide personalized anatomical fit is what makes 3D printed implants most appealing to surgeons. Our objective is to describe the process of integration of 3DP implants into the operating room for spinal surgery, summarize the outcomes of using 3DP implants in spinal surgery, and discuss the limitations and safety concerns during pre-operative consideration. 3DP allows for customized, light weight, and geometrically complex functional implants in spinal surgery in cases of decompression, tumor, and fusion. However, there are limitations such as the cost of the technology which is prohibitive to many hospitals. The novelty of this approach implies that the quantity of longitudinal studies is limited and our understanding of how the human body responds long term to these implants is still unclear. Although it has given surgeons the ability to improve outcomes, surgical strategies, and patient recovery, there is a need for prospective studies to follow the safety and efficacy of the usage of 3D printed implants in spine surgery.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Alexander Newhouse
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Alessandra Cathel
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Kasra Sarhadi
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Marisol Soula
- New York University School of Medicine, New York, NY, USA
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Plantz MA, Gerlach EB, Hsu WK. Synthetic Bone Graft Materials in Spine Fusion: Current Evidence and Future Trends. Int J Spine Surg 2021; 15:104-112. [PMID: 34376499 DOI: 10.14444/8058] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Historically, iliac crest bone autograft has been considered the gold standard bone graft substitute for spinal fusion. However, the significant morbidity associated with harvesting procedures has influenced decision-making and practice patterns. To minimize these side effects, many clinicians have pursued the use of bone graft extenders to minimize the amount of autograft required for fusion in certain applications. Synthetic materials, including a variety of ceramic compounds, are a class that has been studied extensively as bone graft extenders. These have been used in combination with a wide array of other biomaterials and investigated in a variety of different spine fusion procedures. This review will summarize the current evidence of different synthetic materials in various spinal fusion procedures and discuss the future of novel synthetics.
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Affiliation(s)
- Mark A Plantz
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Erik B Gerlach
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Wellington K Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Three-dimensional Printing in Orthopaedic Surgery: Current Applications and Future Developments. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:e20.00230-11. [PMID: 33877073 PMCID: PMC8059996 DOI: 10.5435/jaaosglobal-d-20-00230] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 03/09/2021] [Indexed: 12/27/2022]
Abstract
Three-dimensional (3D) printing is an exciting form of manufacturing technology that has transformed the way we can treat various medical pathologies. Also known as additive manufacturing, 3D printing fuses materials together in a layer-by-layer fashion to construct a final 3D product. This technology allows flexibility in the design process and enables efficient production of both off-the-shelf and personalized medical products that accommodate patient needs better than traditional manufacturing processes. In the field of orthopaedic surgery, 3D printing implants and instrumentation can be used to address a variety of pathologies that would otherwise be challenging to manage with products made from traditional subtractive manufacturing. Furthermore, 3D bioprinting has significantly impacted bone and cartilage restoration procedures and has the potential to completely transform how we treat patients with debilitating musculoskeletal injuries. Although costs can be high, as technology advances, the economics of 3D printing will improve, especially as the benefits of this technology have clearly been demonstrated in both orthopaedic surgery and medicine as a whole. This review outlines the basics of 3D printing technology and its current applications in orthopaedic surgery and ends with a brief summary of 3D bioprinting and its potential future impact.
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Lo WC, Tsai LW, Yang YS, Chan RWY. Understanding the Future Prospects of Synergizing Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery with Ceramics and Regenerative Cellular Therapies. Int J Mol Sci 2021; 22:3638. [PMID: 33807361 PMCID: PMC8037583 DOI: 10.3390/ijms22073638] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 12/14/2022] Open
Abstract
Transforaminal lumber interbody fusion (TLIF) is the last resort to address the lumber degenerative disorders such as spondylolisthesis, causing lower back pain. The current surgical intervention for these abnormalities includes open TLIF. However, in recent years, minimally invasive TLIF (MIS-TLIF) has gained a high momentum, as it could minimize the risk of infection, blood loss, and post-operative complications pertaining to fusion surgery. Further advancement in visualizing and guiding techniques along with grafting cage and materials are continuously improving the safety and efficacy of MIS-TLIF. These assistive techniques are also playing a crucial role to increase and improve the learning curve of surgeons. However, achieving an appropriate output through TLIF still remains a challenge, which might be synergized through 3D-printing and tissue engineering-based regenerative therapy. Owing to their differentiation potential, biomaterials such as stem/progenitor cells may contribute to restructuring lost or damaged tissues during MIS-TLIF, and this therapeutic efficacy could be further supplemented by platelet-derived biomaterials, leading to improved clinical outcomes. Thus, based on the above-mentioned strategies, we have comprehensively summarized recent developments in MIS-TLIF and its possible combinatorial regenerative therapies for rapid and long-term relief.
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Affiliation(s)
- Wen-Cheng Lo
- Department of Surgery, Division of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (Y.-S.Y.); (R.W.Y.C.)
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
| | - Lung-Wen Tsai
- Department of Medical Education and Research, Taipei Medical University Hospital, Taipei 11031, Taiwan;
| | - Yi-Shan Yang
- Department of Surgery, Division of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (Y.-S.Y.); (R.W.Y.C.)
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
| | - Ryan Wing Yuk Chan
- Department of Surgery, Division of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (Y.-S.Y.); (R.W.Y.C.)
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
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Three-dimensional Printing in Orthopedic Surgery. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Cottrill E, Premananthan C, Pennington Z, Ehresman J, Theodore N, Sciubba DM, Witham T. Radiographic and clinical outcomes of silicate-substituted calcium phosphate (SiCaP) bone grafts in spinal fusion: Systematic review and meta-analysis. J Clin Neurosci 2020; 81:353-366. [PMID: 33222944 DOI: 10.1016/j.jocn.2020.09.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/10/2020] [Accepted: 09/28/2020] [Indexed: 12/13/2022]
Abstract
Pseudarthrosis continues to affect a nontrivial proportion of spine fusion patients. Given its ties to poorer patient outcomes and high reoperation rates, there remains great interest in interventions aimed at reducing the rates of nonunion. Recently, silicate-substituted calcium phosphate (SiCaP) bone grafts have been suggested to improve fusion rates, yet there exists no systematic review of the body of evidence for SiCaP grafts. Here, we present the first such review along with a meta-analysis of the effect of SiCaP bone grafts on fusion rates. Using the PubMed, Embase, and Web of Science databases, we queried the English-language literature for all studies examining the effect of SiCaPs on spinal fusion. Primary endpoints were: 1) radiographic fusion rate at last follow-up and 2) postoperative improvements in Visual Analog Scale (VAS) pain scores and Oswestry Disability Index (ODI) at last follow-up. Meta-analyses were performed for each endpoint using random effects. Ten articles (694 patients treated with SiCaP bone grafts) were included. Among SiCaP-treated patients, 93% achieved radiographic fusion (range: 79-100%), with comparable rates across subgroups. Meta-analysis of the three randomized controlled trials demonstrated no difference in fusion rates between SiCaP-treated patients and patients receiving grafts with recombinant human bone morphogenetic protein-2 (rhBMP-2) (OR: 1.11; p = 0.83). Patients treated with SiCaP bone grafts experienced significant improvements in VAS back pain (-3.3 points), VAS leg pain (-4.8 points), and ODI (-31.6 points) by last follow-up (p < 0.001 for each). Additional high-quality research is needed to evaluate the relative cost-effectiveness of SiCaP bone grafts in spinal fusion.
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Affiliation(s)
- Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine Premananthan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abstract
PURPOSE OF REVIEW To provide information on characteristics and use of various ceramics in spine fusion and future directions. RECENT FINDINGS In most recent years, focus has been shifted to the use of ceramics in minimally invasive surgeries or implementation of nanostructured surface modification features to promote osteoinductive properties. In addition, effort has been placed on the development of bioactive synthetics. Core characteristic of bioactive synthetics is that they undergo change to simulate a beneficial response within the bone. This change is based on chemical reaction and various chemical elements present in the bioactive ceramics. Recently, a synthetic 15-amino acid polypeptide bound to an anorganic bone material which mimics the cell-binding domain of type-I collagen opened a possibility for osteogenic and osteoinductive roles of this hybrid graft material. Ceramics have been present in the spine fusion arena for several decades; however, their use has been limited. The major obstacle in published literature is small sample size resulting in low evidence and a potential for bias. In addition, different physical and chemical properties of various ceramics further contribute to the limited evidence. Although ceramics have several disadvantages, they still hold a great promise as a value-based graft material with being easily available, relatively inexpensive, and non-immunogenic.
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3D-printed spine surgery implants: a systematic review of the efficacy and clinical safety profile of patient-specific and off-the-shelf devices. 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; 29:1248-1260. [DOI: 10.1007/s00586-019-06236-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 10/05/2019] [Accepted: 11/25/2019] [Indexed: 02/07/2023]
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