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Jain N, Hernandez E, Medina Y, Gottlich C, MacKay BJ. Intramedullary Plate Fixation and Viable Bone Allografting in a Complex Intra-articular Distal Radius Fracture Nonunion: A Case Report. Cureus 2024; 16:e57308. [PMID: 38690450 PMCID: PMC11059219 DOI: 10.7759/cureus.57308] [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] [Accepted: 03/30/2024] [Indexed: 05/02/2024] Open
Abstract
In this report, we detail a 69-year-old female who sustained a comminuted intra-articular left distal radius fracture that failed to heal with bridge plate fixation. Given the patient's poor subchondral bone stock and refusal of bone autograft, we designed a construct using a dorsal spanning plate and an intramedullary fragment-specific plate as a volarly placed strut in combination with viable bone allograft and cancellous bone chips to treat this nonunion. This case demonstrates an option for distal radius non-union treatment and highlights the importance of ingenuity that orthopedic surgeons should demonstrate when trying to accommodate patients' wishes.
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Affiliation(s)
- Neil Jain
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Evan Hernandez
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Yasier Medina
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Caleb Gottlich
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Brendan J MacKay
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, USA
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2
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Zakko P, Blankenship A, Jawad A, Kasir R, Lee M, Park D. Anterior Cervical Discectomy and Fusions Supplemented With Cellular or Noncellular Allografts Have Similar Radiographic Fusion and Clinical Outcomes. Clin Spine Surg 2023; 36:426-430. [PMID: 37381143 DOI: 10.1097/bsd.0000000000001475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 05/17/2023] [Indexed: 06/30/2023]
Abstract
STUDY DESIGN A retrospective, single-center study. OBJECTIVE The aim of this study was to assess radiographic fusion after anterior cervical discectomy and fusion (ACDF) supplemented with either demineralized bone matrix or ViviGen in a polyetheretherketone biomechanical interbody cage. SUMMARY OF BACKGROUND DATA Cellular and noncellular allografts are utilized as adjuncts in attempts to improve fusion after ACDF. The purpose of this study was to assess radiographic fusion and clinical outcomes after ACDF supplemented with cellular or noncellular allografts. MATERIALS AND METHODS A single surgeon's clinical practice database was interrogated for consecutive patients who underwent a primary ACDF using cellular or noncellular allograft from 2017 to 2019. These subjects were matched by age, sex, body mass index, smoking status, and levels operated. Patient demographic and preoperative and postoperative patient-reported outcome measures (PROMs) including Visual Analog Scale Pain, Neck Disability Index, EuroQol-5 Dimension (EQ-5D), Patient-Reported Outcomes Measurement Information System (PROMIS), and Eating Assessment Tool 10 were collected preoperatively and at 3, 6, and 12 months postoperatively. Radiographic evidence of fusion was determined by <2 mm motion between spinous processes on flexion and extension radiographs and assessing bony bridging at 3, 6, and 12 months postoperatively. RESULTS There were 68 total patients, with 34 patients in each group, and 69 and 67 operative levels in the cellular and noncellular allograft groups, respectively. There was no difference in age, sex, body mass index, or smoking status between groups ( P >0.05). There was no difference in number of 1-level, 2-level, 3-level, or 4-level ACDFs between cellular and noncellular groups ( P >0.05). At 3, 6, and 12 months postoperatively, there was no difference in the percent of operated levels with <2 mm motion between spinous processes, complete bony bridging, or both <2 mm motion and complete bony bridging in the cellular and noncellular groups ( P >0.05). There was no difference in the number of patients fused at all operated levels at 3, 6, or 12 months postoperatively ( P >0.05). No patient required revision ACDF for symptomatic pseudarthrosis. There was no significant difference in PROMs between the cellular and noncellular groups at 12 months postoperatively except for improved EQ-5D and PROMIS-physical in the cellular compared with noncellular group ( P =0.03). CONCLUSIONS Similar radiographic fusion rates were achieved with cellular and noncellular allografts at all operated levels with similar PROMs in the cellular and noncellular groups at 3, 6, and 12 months postoperatively. Thus, ACDFs supplemented with cellular allograft demonstrate adequate radiographic fusion rates when compared with noncellular allografts with similar patient outcomes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Philip Zakko
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, MI
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3
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Issa TZ, Lambrechts MJ, Toci GR, D'Antonio ND, Kanhere AP, Lingenfelter K, Schroeder GD, Vaccaro AR. Cellular Bone Matrix Leading to Disseminated Tuberculosis After Spinal Fusion: A Report of 2 Cases. JBJS Case Connect 2023; 13:01709767-202306000-00016. [PMID: 37094038 DOI: 10.2106/jbjs.cc.23.00047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
CASE Although implanted tuberculosis (TB) is rare, a single lot of cellular bone matrix was found to be infected with TB, leading to devastating outcomes. We present 2 cases referred to our institution because of instrumentation failure caused by TB inoculation of cellular bone matrix. CONCLUSION Irrespective of spinal region of implanted TB infection, excision of infected bone, extensive irrigation and debridement, and instrumented stabilization are of primary importance to ensure TB eradication and adequate stabilization.
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Affiliation(s)
- Tariq Z Issa
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mark J Lambrechts
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Gregory R Toci
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nicholas D D'Antonio
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Arun P Kanhere
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Gregory D Schroeder
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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4
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Kim PD, Raiszadeh R, Bomback DA, Kramer DL, Moghimi M. 12-Month clinical and radiographic outcomes of ViBone viable bone matrix in patients undergoing cervical and lumbar spinal fusion surgery. J Orthop Surg Res 2023; 18:239. [PMID: 36964582 PMCID: PMC10039495 DOI: 10.1186/s13018-023-03686-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/07/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND To investigate the clinical safety and efficacy of ViBone® Viable Bone Matrix (VBM), a next generation cellular bone matrix allograft that comprises all three essential bone-forming components: osteogenic, osteoinductive, and osteoconductive factors, and is optimized to enhance cell viability and bone formation. METHODS This was a multi-center, prospective, post-market study evaluating the safety and efficacy of ViBone VBM in patients undergoing 1-3 level anterior cervical discectomy and fusion or lumbar interbody fusion surgery. Patients were evaluated at baseline, 6-month, and 12-month follow-up clinically and radiographically. Clinical assessment included Visual Analog Scale for pain (VAS-pain), the Neck Disability Index (NDI) for patients with cervical pathologies, and the Oswestry Disability Index (ODI) for patients with lumbar pathologies. Fusion success defined by an independent radiologist was determined radiographically by plain films. RESULTS Clinical outcomes evaluated with VAS-pain, NDI, and ODI scales were improved significantly at 6 and 12 months compared to baseline. All patients reached clinically significant improvements at 12 months. There were no adverse events or infections attributed to ViBone VBM. At 12 months, the fusion rate per patient was 88.1% in cervical and 97.6% in lumbar patients, while per-level fusion was 98.5% for cervical and 100% for lumbar segments. CONCLUSIONS Patients undergoing cervical and lumbar spinal fusion implanted with ViBone VBM demonstrated favorable outcomes at 6 months and 12 months as measured by subjective clinical measures and radiographic fusion rates. Trial registration This study was registered as NCT03425682 on 1/29/2018.
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Affiliation(s)
- Paul D Kim
- Spine Institute of San Diego, 6719 Alvarado Road Suite 308, San Diego, CA, 92120, USA.
| | - Ramin Raiszadeh
- Spine Institute of San Diego, 6719 Alvarado Road Suite 308, San Diego, CA, 92120, USA
| | - David A Bomback
- Connecticut Neck and Back Specialists, 39 Hospital Ave, Danbury, CT, 06810, USA
| | - David L Kramer
- Connecticut Neck and Back Specialists, 39 Hospital Ave, Danbury, CT, 06810, USA
| | - Michael Moghimi
- Orthopaedic Specialists of Austin, 4611 Guadalupe Street Suite 200, Austin, TX, 78751, USA
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Kim YH, Ha KY, Kim YS, Kim KW, Rhyu KW, Park JB, Shin JH, Kim YY, Lee JS, Park HY, Ko J, Kim SI. Lumbar Interbody Fusion and Osteobiologics for Lumbar Fusion. Asian Spine J 2022; 16:1022-1033. [PMID: 36573302 PMCID: PMC9827209 DOI: 10.31616/asj.2022.0435] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 12/28/2022] Open
Abstract
Lumbar interbody fusion (LIF) is an excellent treatment option for a number of lumbar diseases. LIF can be performed through posterior, transforaminal, anterior, and lateral or oblique approaches. Each technique has its own pearls and pitfalls. Through LIF, segmental stabilization, neural decompression, and deformity correction can be achieved. Minimally invasive surgery has recently gained popularity and each LIF procedure can be performed using minimally invasive techniques to reduce surgery-related complications and improve early postoperative recovery. Despite advances in surgical technology, surgery-related complications after LIF, such as pseudoarthrosis, have not yet been overcome. Although autogenous iliac crest bone graft is the gold standard for spinal fusion, other bone substitutes are available to enhance fusion rate and reduce complications associated with bone harvest. This article reviews the surgical procedures and characteristics of each LIF and the osteobiologics utilized in LIF based on the available evidence.
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Affiliation(s)
- Young-Hoon Kim
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee-Yong Ha
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Youn-Soo Kim
- Department of Orthopaedic Surgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Ki-Won Kim
- Department of Orthopaedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee-Won Rhyu
- Department of Orthopaedic Surgery, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Jae-Hyuk Shin
- Department of Orthopaedic Surgery, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Young-Yul Kim
- Department of Orthopaedic Surgery, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Jun-Seok Lee
- Department of Orthopaedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Youl Park
- Department of Orthopaedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jaeryong Ko
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea,Corresponding author: Sang-Il Kim Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6775, Fax: +82-2-535-9837, E-mail:
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Moran TE, Sequeira S, Cooper MT, Park J. A Retrospective Analysis of Outcomes From Foot and Ankle Arthrodesis and Open Reduction and Internal Fixation Using Cellular Bone Allograft Augmentation. Foot Ankle Spec 2022; 15:312-320. [PMID: 32865044 DOI: 10.1177/1938640020952301] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND ViviGen is an allogeneic cellular bone matrix product containing lineage-committed bone cells, and can be used as an alternative to autograft bone or other augments to aid in arthrodesis or to enhance bony healing in open reduction and internal fixation (ORIF) procedures. METHODS This study included 153 consecutive patients undergoing ankle, midfoot, or hindfoot arthrodesis or ORIF procedures from January 2017 to October 2018, in which an allogeneic cellular bone matrix product was used to aid in bony healing. Retrospective chart review identified patient demographic factors and medical comorbidities and evaluated clinical and radiographic data to determine fusion/union rate and complications. RESULTS The overall fusion rate for the arthrodesis cohort was 97/113 (85.8%). The overall complication rate in this cohort was 22/113 (19.5%). Smokers had significantly lower rates of fusion compared with nonsmokers (P = .01). The observed bony healing rate for the ORIF cohort was 19/22 (86.4%), with a complication rate of 3/22 (13.6%). CONCLUSION With satisfactory fusion rates and relatively few complications, our findings suggest that ViviGen is a safe and efficacious alternative to other forms of bone graft augmentation for fusion and ORIF procedures about the foot and ankle. Further study is needed to compare the efficacy of ViviGen with autograft bone and other augments. LEVELS OF EVIDENCE Level IV: Case series.
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Affiliation(s)
- Thomas E Moran
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia (TEM, MTC, JP).,School of Medicine, University of Virginia, Charlottesville, Virginia (SS)
| | - Sean Sequeira
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia (TEM, MTC, JP).,School of Medicine, University of Virginia, Charlottesville, Virginia (SS)
| | - Minton Truitt Cooper
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia (TEM, MTC, JP).,School of Medicine, University of Virginia, Charlottesville, Virginia (SS)
| | - Joseph Park
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia (TEM, MTC, JP).,School of Medicine, University of Virginia, Charlottesville, Virginia (SS)
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Steijvers E, Ghei A, Xia Z. Manufacturing artificial bone allografts: a perspective. BIOMATERIALS TRANSLATIONAL 2022; 3:65-80. [PMID: 35837344 PMCID: PMC9255790 DOI: 10.12336/biomatertransl.2022.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 11/16/2022]
Abstract
Bone grafts have traditionally come from four sources: the patients' own tissue (autograft), tissue from a living or cadaveric human donor (allograft), animal donors (xenograft) and synthetic artificial biomaterials (ceramics, cement, polymers, and metal). However, all of these have advantages and drawbacks. The most commercially successful bone grafts so far are allografts, which hold 57% of the current bone graft market; however, disease transmission and scarcity are still significant drawbacks limiting their use. Tissue-engineered grafts have great potential, in which human stem cells and synthetical biomaterials are combined to produce bone-like tissue in vitro, but this is yet to be approved for widespread clinical practice. It is hypothesised that artificial bone allografts can be mass-manufactured to replace conventional bone allografts through refined bone tissue engineering prior to decellularisation. This review article aims to review current literature on (1) conventional bone allograft preparation; (2) bone tissue engineering including the use of synthetic biomaterials as bone graft substitute scaffolds, combined with osteogenic stem cells in vitro; (3) potential artificial allograft manufacturing processes, including mass production of engineered bone tissue, osteogenic enhancement, decellularisation, sterilisation and safety assurance for regulatory approval. From these assessments, a practical route map for mass production of artificial allografts for clinical use is proposed.
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8
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Pinter ZW, Elder BD, Kaye ID, Kepler CK, Wagner S, Freedman BA, Sebastian AS. A Review of Commercially Available Cellular-based Allografts. Clin Spine Surg 2022; 35:E77-E86. [PMID: 34654775 DOI: 10.1097/bsd.0000000000001262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN This was a narrative review. OBJECTIVE This review discusses our current knowledge regarding cellular-based allografts while highlighting the key gaps in the literature that must be addressed before their widespread adoption. SUMMARY OF BACKGROUND DATA Iliac crest bone graft is the gold-standard bone graft material but is associated with donor site morbidity. Commonly utilized bone graft extenders such as demineralized bone matrix and bone morphogenetic protein have conflicting data supporting their efficacy and lack the osteogenic potential of new cellular-based allograft options. METHODS An extensive literature review was performed. The literature was then summarized in accordance with the authors' clinical experience. RESULTS There is not widespread evidence thus far that the addition of the osteogenic cellular component to allograft enhances spinal fusion, as a recent study by Bhamb and colleagues demonstrated superior bone formation during spine fusion in an aythmic rat model when demineralized bone matrix was used in comparison to Osteocel Plus. Furthermore, the postimplantation cellular viability and osteogenic and osteoinductive capacity of cellular-based allografts need to be definitively established, especially given that a recent study by Lina and colleagues demonstrated a paucity of bone marrow cell survival in an immunocompetent mouse posterolateral spinal fusion model. CONCLUSIONS This data indicates that the substantially increased cost of these cellular allografts may not be justified. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
| | | | - I David Kaye
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | | | - Scott Wagner
- Walter Reed National Military Medical Center, Bethesda, MD
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9
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Viola A, Appiah J, Donnally CJ, Kim YH, Shenoy K. Bone Graft Options in Spinal Fusion: A Review of Current Options and the Use of Mesenchymal Cellular Bone Matrices. World Neurosurg 2021; 158:182-188. [PMID: 34875392 DOI: 10.1016/j.wneu.2021.11.130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Spinal fusion is the mainstay treatment for various spinal conditions ranging from lumbar and cervical stenosis to degenerative spondylolisthesis as well as extensive deformity corrections. A new emerging category of allograft is cellular bone matrices (CBMs), which take allogeneic mesenchymal stem cells and incorporate them into an osteoconductive and osteoinductive matrix. This study reviewed the current spinal fusion options and new emerging treatment options. METHODS Articles were searched using PubMed. The search included English publications since January 1, 2014, using the search terms "cellular bone matrix," "mesenchymal stem cells spinal fusion," "spinal arthrodesis AND mesenchymal stem cells," and "spine fusion AND cellular bone matrix." RESULTS Spinal fusion is accomplished through the use of allografts, autografts, and bone graft substitutes in combination or alone. An emerging category of allograft is CBMs, in which an osteoconductive and osteoinductive matrix is filled with mesenchymal stem cells. Studies demonstrate that CBMs have achieved equivalent or better fusion rates compared with traditional options for anterior cervical discectomy and fusions and posterolateral lumbar fusions; however, the studies have been retrospective and lacking control groups and therefore not ideal. CONCLUSIONS Many treatment options have been successfully used in spinal fusion. Newer allografts such as CBMs have shown promising results in both animal and clinical studies. Further research is needed to determine the therapeutic dose of mesenchymal stem cells delivered within CBMs.
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Affiliation(s)
- Anthony Viola
- Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA.
| | - Jude Appiah
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York, USA
| | | | - Yong H Kim
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York, USA
| | - Kartik Shenoy
- Mike O'Callaghan Military Medical Center, Nellis Air Force Base, Nevada, USA
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10
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De la Vega RE, Atasoy-Zeybek A, Panos JA, VAN Griensven M, Evans CH, Balmayor ER. Gene therapy for bone healing: lessons learned and new approaches. Transl Res 2021; 236:1-16. [PMID: 33964474 PMCID: PMC8976879 DOI: 10.1016/j.trsl.2021.04.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
Although gene therapy has its conceptual origins in the treatment of Mendelian disorders, it has potential applications in regenerative medicine, including bone healing. Research into the use of gene therapy for bone healing began in the 1990s. Prior to this period, the highly osteogenic proteins bone morphogenetic protein (BMP)-2 and -7 were cloned, produced in their recombinant forms and approved for clinical use. Despite their promising osteogenic properties, the clinical usefulness of recombinant BMPs is hindered by delivery problems that necessitate their application in vastly supraphysiological amounts. This generates adverse side effects, some of them severe, and raises costs; moreover, the clinical efficacy of the recombinant proteins is modest. Gene delivery offers a potential strategy for overcoming these limitations. Our research has focused on delivering a cDNA encoding human BMP-2, because the recombinant protein is Food and Drug Administration approved and there is a large body of data on its effects in people with broken bones. However, there is also a sizeable literature describing experimental results obtained with other transgenes that may directly or indirectly promote bone formation. Data from experiments in small animal models confirm that intralesional delivery of BMP-2 cDNA is able to heal defects efficiently and safely while generating transient, local BMP-2 concentrations 2-3 log orders less than those needed by recombinant BMP-2. The next challenge is to translate this information into a clinically expedient technology for bone healing. Our present research focuses on the use of genetically modified, allografted cells and chemically modified messenger RNA.
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Affiliation(s)
- Rodolfo E De la Vega
- Rehabilitation Medicine Research Center, Mayo Clinic, Rochester, Minnesota; Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic, Rochester, Minnesota; cBITE, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, Netherlands
| | - Aysegul Atasoy-Zeybek
- Rehabilitation Medicine Research Center, Mayo Clinic, Rochester, Minnesota; Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Panos
- Rehabilitation Medicine Research Center, Mayo Clinic, Rochester, Minnesota; Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Martijn VAN Griensven
- Rehabilitation Medicine Research Center, Mayo Clinic, Rochester, Minnesota; Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic, Rochester, Minnesota; cBITE, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, Netherlands
| | - Christopher H Evans
- Rehabilitation Medicine Research Center, Mayo Clinic, Rochester, Minnesota; Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic, Rochester, Minnesota.
| | - Elizabeth R Balmayor
- Rehabilitation Medicine Research Center, Mayo Clinic, Rochester, Minnesota; Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic, Rochester, Minnesota; IBE, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, Netherlands
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11
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Le Q, Madhu V, Hart JM, Farber CR, Zunder ER, Dighe AS, Cui Q. Current evidence on potential of adipose derived stem cells to enhance bone regeneration and future projection. World J Stem Cells 2021; 13:1248-1277. [PMID: 34630861 PMCID: PMC8474721 DOI: 10.4252/wjsc.v13.i9.1248] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/22/2021] [Accepted: 08/18/2021] [Indexed: 02/06/2023] Open
Abstract
Injuries to the postnatal skeleton are naturally repaired through successive steps involving specific cell types in a process collectively termed “bone regeneration”. Although complex, bone regeneration occurs through a series of well-orchestrated stages wherein endogenous bone stem cells play a central role. In most situations, bone regeneration is successful; however, there are instances when it fails and creates non-healing injuries or fracture nonunion requiring surgical or therapeutic interventions. Transplantation of adult or mesenchymal stem cells (MSCs) defined by the International Society for Cell and Gene Therapy (ISCT) as CD105+CD90+CD73+CD45-CD34-CD14orCD11b-CD79αorCD19-HLA-DR- is being investigated as an attractive therapy for bone regeneration throughout the world. MSCs isolated from adipose tissue, adipose-derived stem cells (ADSCs), are gaining increasing attention since this is the most abundant source of adult stem cells and the isolation process for ADSCs is straightforward. Currently, there is not a single Food and Drug Administration (FDA) approved ADSCs product for bone regeneration. Although the safety of ADSCs is established from their usage in numerous clinical trials, the bone-forming potential of ADSCs and MSCs, in general, is highly controversial. Growing evidence suggests that the ISCT defined phenotype may not represent bona fide osteoprogenitors. Transplantation of both ADSCs and the CD105- sub-population of ADSCs has been reported to induce bone regeneration. Most notably, cells expressing other markers such as CD146, AlphaV, CD200, PDPN, CD164, CXCR4, and PDGFRα have been shown to represent osteogenic sub-population within ADSCs. Amongst other strategies to improve the bone-forming ability of ADSCs, modulation of VEGF, TGF-β1 and BMP signaling pathways of ADSCs has shown promising results. The U.S. FDA reveals that 73% of Investigational New Drug applications for stem cell-based products rely on CD105 expression as the “positive” marker for adult stem cells. A concerted effort involving the scientific community, clinicians, industries, and regulatory bodies to redefine ADSCs using powerful selection markers and strategies to modulate signaling pathways of ADSCs will speed up the therapeutic use of ADSCs for bone regeneration.
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Affiliation(s)
- Quang Le
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA 22908, United States
| | - Vedavathi Madhu
- Orthopaedic Surgery Research, Thomas Jefferson University, Philadelphia, PA 19107, United States
| | - Joseph M Hart
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA 22908, United States
| | - Charles R Farber
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA 22908, United States
- Departments of Public Health Sciences and Biochemistry and Molecular Genetics, University of Virginia, Charlottesville, VA 22908, United States
| | - Eli R Zunder
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, United States
| | - Abhijit S Dighe
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA 22908, United States
| | - Quanjun Cui
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA 22908, United States
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12
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Golubovsky JL, Ejikeme T, Winkelman R, Steinmetz MP. Osteobiologics. Oper Neurosurg (Hagerstown) 2021; 21:S2-S9. [PMID: 34128067 DOI: 10.1093/ons/opaa383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/06/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Osteobiologics are engineered materials that facilitate bone healing and have been increasingly used in spine surgery. Autologous iliac crest bone grafts have been used historically, but morbidity associated with graft harvesting has led surgeons to seek alternative solutions. Allograft bone, biomaterial scaffolds, growth factors, and stem cells have been explored as bone graft substitutes and supplements. OBJECTIVE To review current and emerging osteobiologic technologies. METHODS A literature review of English-language studies was performed in PubMed. Search terms included combinations of "spine," "fusion," "osteobiologics," "autologous," "allogen(e)ic," "graft," "scaffold," "bone morphogenic protein," and "stem cells." RESULTS Evidence supports allograft bone as an autologous bone supplement or replacement in scenarios where minimal autologous bone is available. There are promising data on ceramics and P-15; however, comparative human trials remain scarce. Growth factors, including recombinant human bone morphogenic proteins (rhBMPs) 2 and 7, have been explored in humans after successful animal trials. Evidence continues to support the use of rhBMP-2 in lumbar fusion in patient populations with poor bone quality or revision surgery, while there is limited evidence for rhBMP-7. Stem cells have been incredibly promising in promoting fusion in animal models, but human trials to this point have only involved products with questionable stem cell content, thereby limiting possible conclusions. CONCLUSION Engineered stem cells that overexpress osteoinductive factors are likely the future of spine fusion, but issues with applying viral vector-transduced stem cells in humans have limited progress.
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Affiliation(s)
- Joshua L Golubovsky
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tiffany Ejikeme
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Robert Winkelman
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael P Steinmetz
- Center for Spine Health, Department of Neurosurgery, Neurologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Commercial Bone Grafts Claimed as an Alternative to Autografts: Current Trends for Clinical Applications in Orthopaedics. MATERIALS 2021; 14:ma14123290. [PMID: 34198691 PMCID: PMC8232314 DOI: 10.3390/ma14123290] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 02/08/2023]
Abstract
In the last twenty years, due to an increasing medical and market demand for orthopaedic implants, several grafting options have been developed. However, when alternative bone augmentation materials mimicking autografts are searched on the market, commercially available products may be grouped into three main categories: cellular bone matrices, growth factor enhanced bone grafts, and peptide enhanced xeno-hybrid bone grafts. Firstly, to obtain data for this review, the search engines Google and Bing were employed to acquire information from reports or website portfolios of important competitors in the global bone graft market. Secondly, bibliographic databases such as Medline/PubMed, Web of Science, and Scopus were also employed to analyse data from preclinical/clinical studies performed to evaluate the safety and efficacy of each product released on the market. Here, we discuss several products in terms of osteogenic/osteoinductive/osteoconductive properties, safety, efficacy, and side effects, as well as regulatory issues and costs. Although both positive and negative results were reported in clinical applications for each class of products, to date, peptide enhanced xeno-hybrid bone grafts may represent the best choice in terms of risk/benefit ratio. Nevertheless, more prospective and controlled studies are needed before approval for routine clinical use.
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14
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Diaz RR, Savardekar AR, Brougham JR, Terrell D, Sin A. Investigating the efficacy of allograft cellular bone matrix for spinal fusion: a systematic review of the literature. Neurosurg Focus 2021; 50:E11. [PMID: 34062505 DOI: 10.3171/2021.3.focus2179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of allograft cellular bone matrices (ACBMs) in spinal fusion has expanded rapidly over the last decade. Despite little objective data on its effectiveness, ACBM use has replaced the use of traditional autograft techniques, namely iliac crest bone graft (ICBG), in many centers. METHODS In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review was conducted of the PubMed, Cochrane Library, Scopus, and Web of Science databases of English-language articles over the time period from January 2001 to December 2020 to objectively assess the effectiveness of ACBMs, with an emphasis on the level of industry involvement in the current body of literature. RESULTS Limited animal studies (n = 5) demonstrate the efficacy of ACBMs in spinal fusion, with either equivalent or increased rates of fusion compared to autograft. Clinical human studies utilizing ACBMs as bone graft expanders or bone graft substitutes (n = 5 for the cervical spine and n = 8 for the lumbar spine) demonstrate the safety of ACBMs in spinal fusion, but fail to provide conclusive level I, II, or III evidence for its efficacy. Additionally, human studies are plagued with several limiting factors, such as small sample size, lack of prospective design, lack of randomization, absence of standardized assessment of fusion, and presence of industry support/relevant conflict of interest. CONCLUSIONS There exist very few objective, unbiased human clinical studies demonstrating ACBM effectiveness or superiority in spinal fusion. Impartial, well-designed prospective studies are needed to offer evidence-based best practices to patients in this domain.
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Bergin SM, Wang TY, Park C, Rajkumar S, Goodwin CR, Karikari IO, Abd-El-Barr MM, Shaffrey CI, Yarbrough CK, Than KD. Pseudarthrosis rate following anterior cervical discectomy with fusion using an allograft cellular bone matrix: a multi-institutional analysis. Neurosurg Focus 2021; 50:E6. [PMID: 34062497 DOI: 10.3171/2021.3.focus2166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of osteobiologics, engineered materials designed to promote bone healing by enhancing bone growth, is becoming increasingly common for spinal fusion procedures, but the efficacy of some of these products is unclear. The authors performed a retrospective, multi-institutional study to investigate the clinical and radiographic characteristics of patients undergoing single-level anterior cervical discectomy with fusion performed using the osteobiologic agent Osteocel, an allograft mesenchymal stem cell matrix. METHODS The medical records across 3 medical centers and 12 spine surgeons were retrospectively queried for patients undergoing single-level anterior cervical discectomy and fusion (ACDF) with the use of Osteocel. Pseudarthrosis was determined based on CT or radiographic imaging of the cervical spine. Patients were determined to have radiographic pseudarthrosis if they met any of the following criteria: 1) lack of bridging bone on CT obtained > 300 days postoperatively, 2) evidence of instrumentation failure, or 3) motion across the index level as seen on flexion-extension cervical spine radiographs. Univariate and multivariate analyses were then performed to identify independent preoperative or perioperative predictors of pseudarthrosis in this population. RESULTS A total of 326 patients met the inclusion criteria; 43 (13.2%) patients met criteria for pseudarthrosis, of whom 15 (34.9%) underwent revision surgery. There were no significant differences between patients with and those without pseudarthrosis, respectively, for patient age (54.1 vs 53.8 years), sex (34.9% vs 47.4% male), race, prior cervical spine surgery (37.2% vs 33.6%), tobacco abuse (16.3% vs 14.5%), chronic kidney disease (2.3% vs 2.8%), and diabetes (18.6% vs 14.5%) (p > 0.05). Presence of osteopenia or osteoporosis (16.3% vs 3.5%) was associated with pseudarthrosis (p < 0.001). Implant type was also significantly associated with pseudarthrosis, with a 16.4% rate of pseudarthrosis for patients with polyetherethereketone (PEEK) implants versus 8.4% for patients with allograft implants (p = 0.04). Average lengths of follow-up were 27.6 and 23.8 months for patients with and those without pseudarthrosis, respectively. Multivariate analysis demonstrated osteopenia or osteoporosis (OR 4.97, 95% CI 1.51-16.4, p < 0.01) and usage of PEEK implant (OR 2.24, 95% CI 1.04-4.83, p = 0.04) as independent predictors of pseudarthrosis. CONCLUSIONS In patients who underwent single-level ACDF, rates of pseudarthrosis associated with the use of the osteobiologic agent Osteocel are higher than the literature-reported rates associated with the use of alternative osteobiologics. This is especially true when Osteocel is combined with a PEEK implant.
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16
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Trends in Spinal Surgery Performed by American Board of Orthopaedic Surgery Part II Candidates (2008 to 2017). J Am Acad Orthop Surg 2021; 29:e563-e575. [PMID: 32947350 DOI: 10.5435/jaaos-d-20-00437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/30/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination is typically taken two calendar years after fellowship completion. Despite previous studies using ABOS Part II Oral Examination data in other subspecialties, types of cases performed by spine surgeons in initial independent practice have not been well-studied. Such data may help trainees anticipate case composition observed in early practice and allow spine fellowship programs to understand emerging trends. METHODS We retrospectively reviewed surgical cases submitted to the ABOS by candidates taking the Part II Oral Examination between 2008 and 2017 whose designated subspecialty was spine. A hierarchical, restrictive algorithm was used to determine procedures based on candidate-reported International Classification of Diseases 9th/10th Revision and Current Procedural Terminology codes. Adjusted multivariable Poisson regression analyses were used to assess changes in procedure incidence rates over time. RESULTS We identified 37,539 cases, averaging 3,754 cases/yr, and an average of 49 cases per candidate per 6-month collection period. The most common procedures were lumbar diskectomy (22% of all procedures), posterolateral spinal fusion (PSF) (19%), and anterior cervical diskectomy and fusion (ACDF) (17%). Rates of ACDF and cervical disk arthroplasty significantly increased over time (incidence rate ratios of 1.41 and 23.3 times higher, respectively, at the end of the study period), whereas rates of cervical foraminotomy, lumbar diskectomy, PSF, and structural autograft use decreased (incidence rate ratios of 0.35, 0.84, 0.55, and 0.30). Rates of anterior lumbar interbody fusion/lateral lumbar interbody fusion and transforaminal lumbar interbody fusion did not significantly change over the study period. DISCUSSION Recent spine fellowship graduates are performing more cervical disk arthroplasties and ACDFs while decreasingly using structural autograft as well as performing fewer PSFs and lumbar diskectomies. Techniques such as anterior lumbar interbody fusion/lateral lumbar interbody fusions and transforaminal lumbar interbody fusions have not changed significantly over the last decade. LEVEL OF EVIDENCE Level IV (retrospective case series study).
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Darveau SC, Leary OP, Persad-Paisley EM, Shaaya EA, Oyelese AA, Fridley JS, Sampath P, Camara-Quintana JQ, Gokaslan ZL, Niu T. Existing clinical evidence on the use of cellular bone matrix grafts in spinal fusion: updated systematic review of the literature. Neurosurg Focus 2021; 50:E12. [PMID: 34062506 DOI: 10.3171/2021.3.focus2173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/24/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal fusion surgery is increasingly common; however, pseudarthrosis remains a common complication affecting as much as 15% of some patient populations. Currently, no clear consensus on the best bone graft materials to use exists. Recent advances have led to the development of cell-infused cellular bone matrices (CBMs), which contain living components such as mesenchymal stem cells (MSCs). Relatively few clinical outcome studies on the use of these grafts exist, although the number of such studies has increased in the last 5 years. In this study, the authors aimed to summarize and critically evaluate the existing clinical evidence on commercially available CBMs in spinal fusion and reported clinical outcomes. METHODS The authors performed a systematic search of the MEDLINE and PubMed electronic databases for peer-reviewed, English-language original articles (1970-2020) in which the articles' authors studied the clinical outcomes of CBMs in spinal fusion. The US National Library of Medicine electronic clinical trials database (www.ClinicalTrials.gov) was also searched for relevant ongoing clinical trials. RESULTS Twelve published studies of 6 different CBM products met inclusion criteria: 5 studies of Osteocel Plus/Osteocel (n = 354 unique patients), 3 of Trinity Evolution (n = 114), 2 of ViviGen (n = 171), 1 of map3 (n = 41), and 1 of VIA Graft (n = 75). All studies reported high radiographic fusion success rates (range 87%-100%) using these CBMs. However, this literature was overwhelmingly limited to single-center, noncomparative studies. Seven studies disclosed industry funding or conflicts of interest (COIs). There are 4 known trials of ViviGen (3 trials) and Bio4 (1 trial) that are ongoing. CONCLUSIONS CBMs are a promising technology with the potential of improving outcome after spinal fusion. However, while the number of studies conducted in humans has tripled since 2014, there is still insufficient evidence in the literature to recommend for or against CBMs relative to cheaper alternative materials. Comparative, multicenter trials and outcome registries free from industry COIs are indicated.
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18
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Woo SH, Goh TS, Ahn TY, You JS, Bae SY, Chung HJ. Subtalar distraction arthrodesis for calcaneal malunion - comparison of structural freeze-dried versus autologous iliac bone graft. Injury 2021; 52:1048-1053. [PMID: 33423772 DOI: 10.1016/j.injury.2020.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/04/2020] [Accepted: 12/13/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study aims to analyze the outcomes of subtalar distraction arthrodesis (SDA) for calcaneal malunion using structural freeze-dried iliac allograft (FDIA) compared to using autologous iliac bone (AIB). METHODS We retrospectively evaluated 57 consecutive cases (51 patients) of calcaneal malunion between March 2006 and December 2017. All patients were followed for an average of 22.8 months. All cases were treated by SDA using structural FDIA (17 cases, group 1), or AIB (40 cases, group 2). The outcome measures included the American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores, visual analog scale (VAS) pain scores, and radiographic measurements. RESULTS The mean postoperative 3, 6, and 12 months of AOFAS scores and VAS pain score were significantly better in group 2 than those in group 1 (p < 0.05, for all). There were 3 cases (17.6%) of nonunion in the group 1, whereas the group 2 had 2 cases (5.0%), which did not shown significant difference between two groups (p = 0.492). Although the mean pre-, postoperative, and final follow-up radiologic parameters in both groups were similar, (p > 0.05, for all) the difference of talocalcaneal height, talocalcaneal angle, and talar declination angle from postoperative to final follow-up were significantly bigger in the group 1. (p < 0.05, for all). CONCLUSION Although union rate was not significantly different between the two groups, we obtained more favorable clinical and radiologic outcomes in the autologous iliac bone group. Using FDIA without any orthobiological agent for SDA, there were significant more loss of radiological parameters due to inferior incorporation and biomechanical properties. When considering the SDA for calcaneal malunion, routine use of FDIA without any orthobiological agents as an interpositional graft for SDA is not recommended.
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Affiliation(s)
- Seung Hun Woo
- Department of Orthopedic Surgery, Pusan National University Yangsan Hospital, 20 Geumo-ro, Mulgeum-eup, Yangsan 50612, Republic of Korea
| | - Tae-Sik Goh
- Department of Orthopedic Surgery, Pusan National University Hospital, 179 Guduk-ro, Seo-gu, Busan 49242, Republic of Korea
| | - Tae-Young Ahn
- Department of Orthopedic Surgery, Pusan National University Hospital, 179 Guduk-ro, Seo-gu, Busan 49242, Republic of Korea
| | - Jun Sang You
- Department of Orthopedic Surgery, Inje University, Sanggye Paik Hospital, 1342 Dongil-ro, Nowon-gu, Seoul, 01757, Republic of Korea
| | - Su-Young Bae
- Department of Orthopedic Surgery, Inje University, Sanggye Paik Hospital, 1342 Dongil-ro, Nowon-gu, Seoul, 01757, Republic of Korea
| | - Hyung-Jin Chung
- Department of Orthopedic Surgery, Inje University, Sanggye Paik Hospital, 1342 Dongil-ro, Nowon-gu, Seoul, 01757, Republic of Korea.
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Abstract
BACKGROUND Back pain is a common chief complaint within the United States and is caused by a multitude of etiologies. There are many different treatment modalities for back pain, with a frequent option being spinal fusion procedures. The success of spinal fusion greatly depends on instrumentation, construct design, and bone grafts used in surgery. Bone allografts are important for both structural integrity and providing a scaffold for bone fusion to occur. METHOD Searches were performed using terms "allografts" and "bone" as well as product names in peer reviewed literature Pubmed, Google Scholar, FDA-510k approvals, and clinicaltrials.gov. RESULTS This study is a review of allografts and focuses on currently available products and their success in both animal and clinical studies. CONCLUSION Bone grafts used in surgery are generally categorized into 3 main types: autogenous (from patient's own body), allograft (from cadaveric or living donor), and synthetic. This paper focuses on allografts and provides an overview on the different subtypes with an emphasis on recent product development and uses in spinal fusion surgery.
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Affiliation(s)
- Justin D. Cohen
- Department of
Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Linda E. Kanim
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrew J. Tronits
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Hyun W. Bae
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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20
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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: 6] [Impact Index Per Article: 2.0] [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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21
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Abedi A, Formanek B, Russell N, Vizesi F, Boden SD, Wang JC, Buser Z. Examination of the Role of Cells in Commercially Available Cellular Allografts in Spine Fusion: An in Vivo Animal Study. J Bone Joint Surg Am 2020; 102:e135. [PMID: 33079897 DOI: 10.2106/jbjs.20.00330] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite the extensive use of cellular bone matrices (CBMs) in spine surgery, there is little evidence to support the contribution of cells within CBMs to bone formation. The objective of this study was to determine the contribution of cells to spinal fusion by direct comparisons among viable CBMs, devitalized CBMs, and cell-free demineralized bone matrix (DBM). METHODS Three commercially available grafts were tested: a CBM containing particulate DBM (CBM-particulate), a CBM containing DBM fibers (CBM-fiber), and a cell-free product with DBM fibers only (DBM-fiber). CBMs were used in viable states (CBM-particulatev and CBM-fiberv) and devitalized (lyophilized) states (CBM-particulated and CBM-fiberd), resulting in 5 groups. Viable cell counts and bone morphogenetic protein-2 (BMP-2) content on enzyme-linked immunosorbent assay (ELISA) within each graft material were measured. A single-level posterolateral lumbar fusion was performed on 45 athymic rats with 3 lots of each product implanted into 9 animals per group. After 6 weeks, fusion was assessed using manual palpation, micro-computed tomography (μ-CT), and histological analysis. RESULTS The 2 groups with viable cells were comparable with respect to cell counts, and pairwise comparisons showed no significant differences in BMP-2 content across the 5 groups. Manual palpation demonstrated fusion rates of 9 of 9 in the DBM-fiber specimens, 9 of 9 in the CBM-fiberd specimens, 8 of 9 in the CBM-fiberv specimens, and 0 of 9 in both CBM-particulate groups. The μ-CT maturity grade was significantly higher in the DBM-fiber group (2.78 ± 0.55) compared with the other groups (p < 0.0001), while none of the CBM-particulate samples demonstrated intertransverse fusion in qualitative assessments. The viable and devitalized samples in each CBM group were comparable with regard to fusion rates, bone volume fraction, μ-CT maturity grade, and histological features. CONCLUSIONS The cellular component of 2 commercially available CBMs yielded no additional benefits in terms of spinal fusion. Meanwhile, the groups with a fiber-based DBM demonstrated significantly higher fusion outcomes compared with the CBM groups with particulate DBM, indicating that the DBM component is probably the key determinant of fusion. CLINICAL RELEVANCE Data from the current study demonstrate that cells yielded no additional benefit in spinal fusion and emphasize the need for well-designed clinical studies on cellular graft materials.
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Affiliation(s)
- Aidin Abedi
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Blake Formanek
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | - Scott D Boden
- Department of Orthopedic Surgery, Emory University, Atlanta, Georgia
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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22
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Childs PG, Reid S, Salmeron-Sanchez M, Dalby MJ. Hurdles to uptake of mesenchymal stem cells and their progenitors in therapeutic products. Biochem J 2020; 477:3349-3366. [PMID: 32941644 PMCID: PMC7505558 DOI: 10.1042/bcj20190382] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/15/2020] [Accepted: 08/24/2020] [Indexed: 12/11/2022]
Abstract
Twenty-five years have passed since the first clinical trial utilising mesenchymal stomal/stem cells (MSCs) in 1995. In this time academic research has grown our understanding of MSC biochemistry and our ability to manipulate these cells in vitro using chemical, biomaterial, and mechanical methods. Research has been emboldened by the promise that MSCs can treat illness and repair damaged tissues through their capacity for immunomodulation and differentiation. Since 1995, 31 therapeutic products containing MSCs and/or progenitors have reached the market with the level of in vitro manipulation varying significantly. In this review, we summarise existing therapeutic products containing MSCs or mesenchymal progenitor cells and examine the challenges faced when developing new therapeutic products. Successful progression to clinical trial, and ultimately market, requires a thorough understanding of these hurdles at the earliest stages of in vitro pre-clinical development. It is beneficial to understand the health economic benefit for a new product and the reimbursement potential within various healthcare systems. Pre-clinical studies should be selected to demonstrate efficacy and safety for the specific clinical indication in humans, to avoid duplication of effort and minimise animal usage. Early consideration should also be given to manufacturing: how cell manipulation methods will integrate into highly controlled workflows and how they will be scaled up to produce clinically relevant quantities of cells. Finally, we summarise the main regulatory pathways for these clinical products, which can help shape early therapeutic design and testing.
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Affiliation(s)
- Peter G. Childs
- Centre for the Cellular Microenvironment, Division of Biomedical Engineering, School of Engineering, College of Science and Engineering, University of Glasgow, Glasgow G12 8QQ, U.K
- Centre for the Cellular Microenvironment, SUPA Department of Biomedical Engineering, University of Strathclyde, Glasgow G1 1QE, U.K
| | - Stuart Reid
- Centre for the Cellular Microenvironment, SUPA Department of Biomedical Engineering, University of Strathclyde, Glasgow G1 1QE, U.K
| | - Manuel Salmeron-Sanchez
- Centre for the Cellular Microenvironment, Division of Biomedical Engineering, School of Engineering, College of Science and Engineering, University of Glasgow, Glasgow G12 8QQ, U.K
| | - Matthew J. Dalby
- Centre for the Cellular Microenvironment, Institute for Molecular, Cell and Systems Biology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, U.K
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23
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Yang JZ, Qiu LH, Xiong SH, Dang JL, Rong XK, Hou MM, Wang K, Yu Z, Yi CG. Decellularized adipose matrix provides an inductive microenvironment for stem cells in tissue regeneration. World J Stem Cells 2020; 12:585-603. [PMID: 32843915 PMCID: PMC7415251 DOI: 10.4252/wjsc.v12.i7.585] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/27/2020] [Accepted: 05/30/2020] [Indexed: 02/06/2023] Open
Abstract
Stem cells play a key role in tissue regeneration due to their self-renewal and multidirectional differentiation, which are continuously regulated by signals from the extracellular matrix (ECM) microenvironment. Therefore, the unique biological and physical characteristics of the ECM are important determinants of stem cell behavior. Although the acellular ECM of specific tissues and organs (such as the skin, heart, cartilage, and lung) can mimic the natural microenvironment required for stem cell differentiation, the lack of donor sources restricts their development. With the rapid development of adipose tissue engineering, decellularized adipose matrix (DAM) has attracted much attention due to its wide range of sources and good regeneration capacity. Protocols for DAM preparation involve various physical, chemical, and biological methods. Different combinations of these methods may have different impacts on the structure and composition of DAM, which in turn interfere with the growth and differentiation of stem cells. This is a narrative review about DAM. We summarize the methods for decellularizing and sterilizing adipose tissue, and the impact of these methods on the biological and physical properties of DAM. In addition, we also analyze the application of different forms of DAM with or without stem cells in tissue regeneration (such as adipose tissue), repair (such as wounds, cartilage, bone, and nerves), in vitro bionic systems, clinical trials, and other disease research.
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Affiliation(s)
- Ji-Zhong Yang
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
| | - Li-Hong Qiu
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
| | - Shao-Heng Xiong
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
| | - Juan-Li Dang
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
| | - Xiang-Ke Rong
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
| | - Meng-Meng Hou
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
| | - Kai Wang
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
| | - Zhou Yu
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
| | - Cheng-Gang Yi
- Department of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
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Abstract
The biologic steps involved in creating a bony fusion between adjacent segments of the spine are a complex and highly coordinated series of events. There have been significant advancements in bone grafts and bone graft substitutes in order to augment spinal fusion. While autologous bone grafting remains the gold standard, allograft bone grafting, synthetic bone graft substitutes, and bone graft enhancers are appropriate in certain clinical situations. This article provides an overview of the basic biology of spinal fusion and strategies for enhancing fusion through innovations in bone graft material.
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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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Lin C, Zhang N, Waldorff EI, Punsalan P, Wang D, Semler E, Ryaby JT, Yoo J, Johnstone B. Comparing cellular bone matrices for posterolateral spinal fusion in a rat model. JOR Spine 2020; 3:e1084. [PMID: 32613160 PMCID: PMC7323463 DOI: 10.1002/jsp2.1084] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/28/2020] [Accepted: 02/29/2020] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Cellular bone matrices (CBM) are allograft products that provide three components essential to new bone formation: an osteoconductive scaffold, extracellular growth factors for cell proliferation and differentiation, and viable cells with osteogenic potential. This is an emerging technology being applied to augment spinal fusion procedures as an alternative to autografts. METHODS We aim to compare the ability of six commercially-available human CBMs (Trinity ELITE®, ViviGen®, Cellentra®, Osteocel® Pro, Bio4® and Map3®) to form a stable spinal fusion using an athymic rat model of posterolateral fusion. Iliac crest bone from syngeneic rats was used as a control to approximate the human gold standard. The allografts were implanted at L4-5 according to vendor specifications in male athymic rats, with 15 rats in each group. MicroCT scans were performed at 48 hours and 6 weeks post-implantation. The rats were euthanized 6 weeks after surgery and the lumbar spines were harvested for X-ray, manual palpation and histology analysis by blinded reviewers. RESULTS By manual palpation, five of 15 rats of the syngeneic bone group were fused at 6 weeks. While Trinity ELITE had eight of 15 and Cellentra 11 of 15 rats with stable fusion, only 2 of 15 of ViviGen-implanted spines were fused and zero of 15 of the Osteocel Pro, Bio4 and Map3 produced stable fusion. MicroCT analysis indicated that total bone volume increased from day 0 to week 6 for all groups except syngeneic bone group. Trinity ELITE (65%) and Cellentra (73%) had significantly greater bone volume increases over all other implants, which was consistent with the histological analysis. CONCLUSION Trinity ELITE and Cellentra were significantly better than other implants at forming new bone and achieving spinal fusion in this rat model at week 6. These results suggest that there may be large differences in the ability of different CBMs to elicit a successful fusion in the posterolateral spine.
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Affiliation(s)
- Cliff Lin
- Department of Orthopaedics and RehabilitationOregon Health & Science UniversityPortlandOregonUSA
| | | | | | - Paolo Punsalan
- Department of Orthopaedics and RehabilitationOregon Health & Science UniversityPortlandOregonUSA
| | | | | | | | - Jung Yoo
- Department of Orthopaedics and RehabilitationOregon Health & Science UniversityPortlandOregonUSA
| | - Brian Johnstone
- Department of Orthopaedics and RehabilitationOregon Health & Science UniversityPortlandOregonUSA
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Johnstone B, Zhang N, Waldorff EI, Semler E, Dasgupta A, Betsch M, Punsalan P, Cho H, Ryaby JT, Yoo J. A Comparative Evaluation of Commercially Available Cell-Based Allografts in a Rat Spinal Fusion Model. Int J Spine Surg 2020; 14:213-221. [PMID: 32355628 DOI: 10.14444/7026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background To evaluate the comparative abilities of commercially available, viable, cellular bone allografts to promote posterolateral spinal fusion. Methods Human allografts containing live cells were implanted in the athymic rat model of posterolateral spine fusion. Three commercially available allogeneic cellular bone matrices (Trinity Evolution, Trinity ELITE and Osteocel Plus) were compared with syngeneic iliac crest bone as the control. All spines underwent radiographs, manual palpation, and micro-computed tomography (CT) analysis after excision at 6 weeks. Histological sections of randomly selected spines were subjected to semiquantitative histopathological scoring for bone formation. Results By manual palpation, posterolateral fusion was detected in 40% (6/15) of spines implanted with syngeneic bone, whereas spines implanted with Trinity Evolution and Trinity ELITE allografts yielded 71% (10/14) and 77% (10/13) fusion, respectively. Only 7% (1/14) of spines implanted with Osteocel Plus allografts were judged fused by manual palpation (statistically significantly less than ELITE, P < .0007, and Evolution, P < .0013). The mineralized cancellous bone component of the allografts confounded radiographic analysis, but Trinity Evolution (0.452 ± 0.064) and Trinity ELITE (0.536 ± 0.109) allografts produced statistically significantly higher bone fusion mass volumes measured by quantitative micro-CT than did syngeneic bone (0.292 ± 0.109, P < .0001 for ELITE and P < .003 for Evolution) and Osteocel Plus (0.258 ± 0.103, P < .0001). Semiquantitative histopathological scores supported these findings because the total bone and bone marrow scores reflected significantly better new bone and marrow formation in the Trinity groups than in the Osteocel Plus group. Conclusions The Trinity Evolution and Trinity ELITE cellular bone allografts were more effective at creating posterolateral fusion than either the Osteocel Plus allografts or syngeneic bone in this animal model. Clinical Relevance The superior fusion rate of Trinity cellular bone allografts may lead to better clinical outcome of spinal fusion surgeries.
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Affiliation(s)
- Brian Johnstone
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | | | | | | | | | - Marcel Betsch
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Paolo Punsalan
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Holly Cho
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | | | - Jung Yoo
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
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Picken A, Harriman J, Iftimia-Mander A, Johnson L, Prosser A, Quirk R, Thomas R. A Monte Carlo framework for managing biological variability in manufacture of autologous cell therapy from mesenchymal stromal cells therapies. Cytotherapy 2020; 22:227-238. [DOI: 10.1016/j.jcyt.2020.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/10/2020] [Accepted: 01/11/2020] [Indexed: 12/28/2022]
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Abstract
Bone augmentation is an extremely common procedure in implant dentistry today because of significant advancements with reactive biomaterials, a better understanding of the mechanism of action that is found with growth factors contained in platelets, and improvements in surgical techniques. The expectation is for the surgeon to place the dental implant in the position that best serves the requirements of the prosthetic restorations. With the increasing demands that patients have for ideal prosthetic results, surgeons are expected to predictably augment both hard and soft tissues to provide the anticipated esthetic and functional outcomes. Bone grafting can be performed before, during, and after the implant placement; however, these augmentation procedures come with increased cost, the risk of complications such as infection or failure, and lengthening of the total treatment time. In addition, a plethora of grafting materials are available commercially, where they are often inadequately studied, or there is minimal information regarding their predictability or long-term success, or ability to support dental implants. It is clear that although the surgical field has seen major progress since early implant surgical techniques in the 1980s, major challenges still exist with hard tissue augmentation procedures. This review will discuss these challenges that are increased and often specific to bone graft healing, and which are becoming more common as implant site development often requires bone augmentation to improve volume or contour deficiencies. The risk factors that patients may present with that will affect outcomes with bone augmentation procedures are identified, and recommendations for the prevention of complications or managing complications once they have occurred are provided.
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Affiliation(s)
- Peter K Moy
- Department of Oral & Maxillofacial Surgery, UCLA, School of Dentistry, Los Angeles, California, USA
| | - Tara Aghaloo
- Department of Oral & Maxillofacial Surgery, UCLA, School of Dentistry, Los Angeles, California, USA
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Jeschke MG, Rehou S, McCann MR, Shahrokhi S. Allogeneic mesenchymal stem cells for treatment of severe burn injury. Stem Cell Res Ther 2019; 10:337. [PMID: 31752987 PMCID: PMC6869190 DOI: 10.1186/s13287-019-1465-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 10/11/2019] [Accepted: 10/22/2019] [Indexed: 12/25/2022] Open
Abstract
The most important determinant of survival post-burn injury is wound healing. For decades, allogeneic mesenchymal stem cells (MSCs) have been suggested as a potential treatment for severe burn injuries. This report describes a patient with a severe burn injury whose wounds did not heal with over 18 months of conventional burn care. When treated with allogeneic MSCs, wound healing accelerated with no adverse treatment complications. Wound sites showed no evidence of keloids or hypertrophic formation during a 6-year follow-up period. This therapeutic use of allogeneic MSCs for large non-healing burn wounds was deemed safe and effective and has great treatment potential.
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Affiliation(s)
- Marc G Jeschke
- Sunnybrook Research Institute, Toronto, Ontario, Canada. .,Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave. D7 04, Toronto, Ontario, M4N 3M5, Canada. .,Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. .,Department of Immunology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. .,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Sarah Rehou
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave. D7 04, Toronto, Ontario, M4N 3M5, Canada
| | | | - Shahriar Shahrokhi
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave. D7 04, Toronto, Ontario, M4N 3M5, Canada.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Myerson CL, Myerson MS, Coetzee JC, Stone McGaver R, Giveans MR. Subtalar Arthrodesis with Use of Adipose-Derived Cellular Bone Matrix Compared with Autologous Bone Graft: A Multicenter, Randomized Controlled Trial. J Bone Joint Surg Am 2019; 101:1904-1911. [PMID: 31567665 DOI: 10.2106/jbjs.18.01300] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UPDATE This article was updated on November 7, 2019, because of a previous error. On page 1909, in the section entitled "Discussion," the sentence that had read "Radiographic nonunion rates of 69.2% and 45.6% were observed at 6 months for ACBM and autograft, respectively, as measured on CT scans; however, these nonunion rates do account for patients who were considered to have attained fusion according to traditional methods, including absence of pain and swelling and presence of arthrodesis on radiographs" now reads "Radiographic nonunion rates of 69.2% and 45.6% were observed at 6 months for ACBM and autograft, respectively, as measured on CT scans; however, these nonunion rates do not account for patients who were considered to have attained fusion according to traditional methods, including absence of pain and swelling and presence of arthrodesis on radiographs."An erratum has been published: J Bone Joint Surg Am. 2019 XXX. BACKGROUND Subtalar arthrodesis effectively treats subtalar joint arthritis when other interventions have failed. Nonunion is a known complication of subtalar arthrodesis, with reported rates ranging from 5% to 45%. Historically, open arthrodesis has been performed with use of autologous bone graft; however, there are inherent disadvantages to autologous bone graft, including donor-site morbidity. Mesenchymal stem cells, when placed on a cellular scaffold, have shown promise as an alternative to autologous bone graft. The purpose of this multicenter, randomized controlled trial was to assess the safety and efficacy of an adipose-derived cellular bone matrix (ACBM) composite made with live cells compared with autograft in subtalar arthrodesis. METHODS A total of 140 patients were enrolled in a prospective, randomized (1:1) controlled trial performed at 6 clinical sites in the U.S. End points, including radiographic, clinical, and functional outcomes, were assessed over 2 years of follow-up. RESULTS A total of 109 patients underwent arthrodesis with ACBM (52 patients) and autograft (57 patients). At 6 months, fusion was achieved in 16 patients (30.8%) in the ACBM group and 31 patients (54.4%) in the autograft group as measured on computed tomography (p = 0.024), and in 41 patients (78.8%) in the ACBM group and 50 patients (87.7%) in the autograft group as assessed on clinical and radiographic evaluation (p = 0.213). Quality-of-life outcome measures demonstrated significant functional improvement from baseline for both groups. Fewer cases of serious adverse events occurred in the autograft group (10.5%) compared with the ACBM group (23.1%) (p = 0.078). CONCLUSIONS In patients who require subtalar arthrodesis, the use of ACBM demonstrated lower rates of radiographic fusion compared with treatment with autograft. The nonunion rate in the autologous group, as measured on computed tomography, was high. Good clinical outcomes were achieved in spite of the high non-union rates. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- C Lucas Myerson
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Methods of Cryoprotectant Preservation: Allogeneic Cellular Bone Grafts and Potential Effects. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5025398. [PMID: 31737666 PMCID: PMC6817928 DOI: 10.1155/2019/5025398] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/20/2019] [Indexed: 12/26/2022]
Abstract
Debridement of the bone surface during a surgical fusion procedure initiates an injury response promoting a healing cascade of molecular mediators released over time. Autologous grafts offer natural scaffolding to fill the bone void and to provide local bone cells. Commercial bone grafting products such as allografts, synthetic bone mineral products, etc., are used to supplement or to replace autologous grafts by supporting osteoinductivity, osteoconductivity, and osteogenesis at the surgical site. To assure osteogenic potential, preservation of allogeneic cells with cryoprotectants has been developed to allow for long-term storage and thus delivery of viable bone cells to the surgical site. Dimethyl sulfoxide (DMSO) is an intracellular cryoprotectant commonly used because it provides good viability of the cells post-thaw. However, there is known cytotoxicity reported for DMSO when cells are stored above cryogenic temperatures. For most cellular bone graft products, the cryoprotectant is incorporated with the cells into the other mineralized bone and demineralized bone components. During thawing, the DMSO may not be sufficiently removed from allograft products compared to its use in a cell suspension where removal by washing and centrifugation is available. Therefore, both the allogeneic cell types in the bone grafting product and the local cell types at the bone grafting site could be affected as cytotoxicity varies by cell type and by DMSO content according to reported studies. Overcoming cytotoxicity may be an additional challenge in the formation of bone at a wound or surgical site. Other extracellular cryoprotectants have been explored as alternatives to DMSO which preserve without entering the cell membrane, thereby providing good cellular viability post-thaw and might abrogate the cytotoxicity concerns.
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Human Umbilical Vein Endothelial Cells (HUVECs) Co-Culture with Osteogenic Cells: From Molecular Communication to Engineering Prevascularised Bone Grafts. J Clin Med 2019; 8:jcm8101602. [PMID: 31623330 PMCID: PMC6832897 DOI: 10.3390/jcm8101602] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/12/2019] [Accepted: 09/23/2019] [Indexed: 12/21/2022] Open
Abstract
The repair of bone defects caused by trauma, infection or tumor resection is a major clinical orthopedic challenge. The application of bone grafts in orthopedic procedures is associated with a problem of inadequate vascularization in the initial phase after implantation. Meanwhile, the survival of cells within the implanted graft and its integration with the host tissue is strongly dependent on nutrient and gaseous exchange, as well as waste product removal, which are effectuated by blood microcirculation. In the bone tissue, the vasculature also delivers the calcium and phosphate indispensable for the mineralization process. The critical role of vascularization for bone healing and function, led the researchers to the idea of generating a capillary-like network within the bone graft in vitro, which could allow increasing the cell survival and graft integration with a host tissue. New strategies for engineering pre-vascularized bone grafts, that apply the co-culture of endothelial and bone-forming cells, have recently gained interest. However, engineering of metabolically active graft, containing two types of cells requires deep understanding of the underlying mechanisms of interaction between these cells. The present review focuses on the best-characterized endothelial cells-human umbilical vein endothelial cells (HUVECs)-attempting to estimate whether the co-culture approach, using these cells, could bring us closer to development and possible clinical application of prevascularized bone grafts.
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D'Souza M, Macdonald NA, Gendreau JL, Duddleston PJ, Feng AY, Ho AL. Graft Materials and Biologics for Spinal Interbody Fusion. Biomedicines 2019; 7:biomedicines7040075. [PMID: 31561556 PMCID: PMC6966429 DOI: 10.3390/biomedicines7040075] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 09/19/2019] [Accepted: 09/24/2019] [Indexed: 12/11/2022] Open
Abstract
Spinal fusion is the most widely performed procedure in spine surgery. It is the preferred treatment for a wide variety of pathologies including degenerative disc disease, spondylolisthesis, segmental instability, and deformity. Surgeons have the choice of fusing vertebrae by utilizing cages containing autografts, allografts, demineralized bone matrices (DBMs), or graft substitutes such as ceramic scaffolds. Autografts from the iliac spine are the most commonly used as they offer osteogenic, osteoinductive, and osteoconductive capabilities, all while avoiding immune system rejection. Allografts obtained from cadavers and living donors can also be advantageous as they lack the need for graft extraction from the patient. DBMs are acid-extracted organic allografts with osteoinductive properties. Ceramic grafts containing hydroxyapatite can be readily manufactured and are able to provide osteoinductive support while having a long shelf life. Further, bone-morphogenetic proteins (BMPs), mesenchymal stem cells (MSCs), synthetic peptides, and autologous growth factors are currently being optimized to assist in improving vertebral fusion. Genetic therapies utilizing viral transduction are also currently being devised. This review provides an overview of the advantages, disadvantages, and future directions of currently available graft materials. The current literature on growth factors, stem cells, and genetic therapy is also discussed.
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Affiliation(s)
- Marissa D'Souza
- School of Medicine, Mercer University School of Medicine, Macon, GA 31207, USA.
| | | | - Julian L Gendreau
- School of Medicine, Mercer University School of Medicine, Macon, GA 31207, USA.
| | - Pate J Duddleston
- School of Medicine, Mercer University School of Medicine, Macon, GA 31207, USA.
| | - Austin Y Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Shanbhag S, Suliman S, Pandis N, Stavropoulos A, Sanz M, Mustafa K. Cell therapy for orofacial bone regeneration: A systematic review and meta-analysis. J Clin Periodontol 2019; 46 Suppl 21:162-182. [DOI: 10.1111/jcpe.13049] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/17/2018] [Accepted: 10/26/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Siddharth Shanbhag
- Department of Clinical Dentistry; Center for Clinical Dental Research; University of Bergen; Bergen Norway
| | - Salwa Suliman
- Department of Clinical Dentistry; Center for Clinical Dental Research; University of Bergen; Bergen Norway
| | - Nikolaos Pandis
- Department of Orthodontics and Dentofacial Orthopedics; University of Bern; Bern Switzerland
| | - Andreas Stavropoulos
- Department of Periodontology; Faculty of Odontology; Malmö University; Malmö Sweden
| | - Mariano Sanz
- Section of Periodontology; Faculty of Odontology; University Complutense of Madrid; Madrid Spain
| | - Kamal Mustafa
- Department of Clinical Dentistry; Center for Clinical Dental Research; University of Bergen; Bergen Norway
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Hsieh PC, Buser Z, Skelly AC, Brodt ED, Brodke D, Meisel HJ, Park JB, Yoon ST, Wang JC. Allogenic Stem Cells in Spinal Fusion: A Systematic Review. Global Spine J 2019; 9:22S-38S. [PMID: 31157144 PMCID: PMC6512196 DOI: 10.1177/2192568219833336] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES To review, critically appraise, and synthesize evidence on the use of allogenic stem cell products for spine fusion compared with other bone graft materials. METHODS Systematic searches of PubMed/MEDLINE, through October 31, 2018 and of EMBASE and ClinicalTrials.gov through April 13, 2018 were conducted for literature comparing allogenic stem cell sources for fusion in the lumbar or cervical spine with other fusion methods. In the absence of comparative studies, case series of ≥10 patients were considered. RESULTS From 382 potentially relevant citations identified, 6 publications on lumbar fusion and 5 on cervical fusion met the inclusion criteria. For lumbar arthrodesis, mean Oswestry Disability Index (ODI), visual analogue scale (VAS) pain score, and fusion rates were similar for anterior lumbar interbody fusion (ALIF) using allogenic multipotent adult progenitor cells (Map3) versus recombinant human bone morphogenetic protein-2 (rhBMP-2) in the one comparative lumbar study (90% vs 92%). Across case series of allogenic stem cell products, function and pain were improved relative to baseline and fusion occurred in ≥90% of patients at ≥12 months. For cervical arthrodesis across case series, stem cell products improved function and pain compared with baseline at various time frames. In a retrospective cohort study fusion rates were not statistically different for Osteocel compared with Vertigraft allograft (88% vs 95%). Fusion rates varied across time frames and intervention products in case series. CONCLUSIONS The overall quality (strength) of evidence of effectiveness and safety of allogenic stem cells products for lumbar and cervical arthrodesis was very low, meaning that we have very little confidence that the effects seen are reflective of the true effects.
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Affiliation(s)
| | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA
| | | | | | - Darrel Brodke
- University of Utah School of Medicine, Salt Lake City, UT, USA
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Abstract
Allograft tissues are commonly used by orthopedic surgeons and are processed using a variety of technologies to increase safety and clinical use. For safety, although disease transmission is a tangible risk, this possibility has been dramatically minimized through modern tissue-processing methods. These include steps to prevent processing tissues with unacceptable bioburden through rigorous screening using donor medical and social histories along with microbial testing of recovered tissue and viral testing of donor serum. Potential bioburden is also controlled through aseptic recovery and processing methods and then reduced through disinfection steps that can include antibiotics, detergents, mechanical process, chemical solutions, and terminal sterilization. Processing steps may also include decellularization methods to lower immunogenic potential of some tissues. To enhance fusion potential of bone void fillers, demineralization steps may be used, and the resultant demineralized bone matrices may be combined with a carrier to improve handling. Bone void fillers and osteochondral allografts may also be specially processed to retain a living cellular component. To preserve relevant biological, biochemical, and physical properties of allografts for clinical use and ease of handling, a number of methods may be used which include: (1) refrigeration in media, (2) freeze-drying, (3) cryopreservation, (4) freezing, and (5) media storage at room temperature. As academic and industry research continue to drive advances, the future direction of allograft tissue likely includes injectables, coatings, cellular therapies, and combinations with other materials. The technology approaches outlined here will be further described along with future directions.
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Piuzzi NS, Dominici M, Long M, Pascual-Garrido C, Rodeo S, Huard J, Guicheux J, McFarland R, Goodrich LR, Maddens S, Robey PG, Bauer TW, Barrett J, Barry F, Karli D, Chu CR, Weiss DJ, Martin I, Jorgensen C, Muschler GF. Proceedings of the signature series symposium "cellular therapies for orthopaedics and musculoskeletal disease proven and unproven therapies-promise, facts and fantasy," international society for cellular therapies, montreal, canada, may 2, 2018. Cytotherapy 2018; 20:1381-1400. [PMID: 30316562 PMCID: PMC8487641 DOI: 10.1016/j.jcyt.2018.09.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/06/2018] [Indexed: 12/17/2022]
Abstract
The Signature Series Symposium "Cellular Therapies for Orthopaedics and Musculoskeletal Disease Proven and Unproven Therapies-Promise, Facts and Fantasy" was held as a pre-meeting of the 26th International Society for Cellular Therapy (ISCT) annual congress in Montreal, Canada, May 2, 2018. This was the first ISCT program that was entirely dedicated to the advancement of cell-based therapies for musculoskeletal diseases. Cellular therapies in musculoskeletal medicine are a source of great promise and opportunity. They are also the source of public controversy, confusion and misinformation. Patients, clinicians, scientists, industry and government share a commitment to clear communication and responsible development of the field. Therefore, this symposium convened thought leaders from around the world in a forum designed to catalyze communication and collaboration to bring the greatest possible innovation and value to patients with musculoskeletal conditions.
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Affiliation(s)
- Nicolas S Piuzzi
- Department of Orthopedic Surgery and Biomedical Engineering Cleveland Clinic, Cleveland, Ohio, USA; Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Massimo Dominici
- Laboratory of Cellular Therapy, Department of Medical and Surgical Sciences for Children & Adults, University Hospital of Modena and Reggio Emilia, Modena, Italy
| | - Marc Long
- MTF Biologics, Edison, New Jersey, USA
| | - Cecilia Pascual-Garrido
- Adult Reconstruction-Adolescent and Young Adult Hip Service, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Scott Rodeo
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York, USA
| | - Johnny Huard
- Department of Orthopaedic Surgery, UTHealth Medical School, Houston, Texas, USA; Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Jérome Guicheux
- INSERM, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Nantes University School of Dental Medicine, ONIRIS, Nantes, France; CHU Nantes, PHU4 OTONN, Nantes, France
| | - Richard McFarland
- Advanced Regenerative Manufacturing Institute, Manchester, New Hampshire, USA, and Standards Coordinating Body, Gaithersburg, Maryland, USA
| | - Laurie R Goodrich
- Orthopaedic Research Center and Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | | | - Pamela G Robey
- Skeletal Biology Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland, USA
| | - Thomas W Bauer
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, New York, New York, USA
| | - John Barrett
- Stem Cell Allogeneic Transplant Section, National Institutes of Health, Bethesda, Maryland, USA
| | - Frank Barry
- Regenerative Medicine Institute, National University of Ireland, Galway, Ireland
| | - David Karli
- Steadman Philippon Research Institute, Vail, Colorado, USA; Greyledge Technologies, LLC, Vail, Colorado, USA
| | - Constance R Chu
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Daniel J Weiss
- University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Ivan Martin
- Department of Biomedicine, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Christian Jorgensen
- Clinical Immunology and Osteoarticular Diseases Therapeutic Unit, Hôpital Lapeyronie, Montpellier, France
| | - George F Muschler
- Department of Orthopedic Surgery and Biomedical Engineering Cleveland Clinic, Cleveland, Ohio, USA.
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Pereira Chilima TD, Moncaubeig F, Farid SS. Impact of allogeneic stem cell manufacturing decisions on cost of goods, process robustness and reimbursement. Biochem Eng J 2018. [DOI: 10.1016/j.bej.2018.04.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Makino T, Tsukazaki H, Ukon Y, Tateiwa D, Yoshikawa H, Kaito T. The Biological Enhancement of Spinal Fusion for Spinal Degenerative Disease. Int J Mol Sci 2018; 19:ijms19082430. [PMID: 30126106 PMCID: PMC6121547 DOI: 10.3390/ijms19082430] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/04/2018] [Accepted: 08/14/2018] [Indexed: 12/16/2022] Open
Abstract
In this era of aging societies, the number of elderly individuals who undergo spinal arthrodesis for various degenerative diseases is increasing. Poor bone quality and osteogenic ability in older patients, due to osteoporosis, often interfere with achieving bone fusion after spinal arthrodesis. Enhancement of bone fusion requires shifting bone homeostasis toward increased bone formation and reduced resorption. Several biological enhancement strategies of bone formation have been conducted in animal models of spinal arthrodesis and human clinical trials. Pharmacological agents for osteoporosis have also been shown to be effective in enhancing bone fusion. Cytokines, which activate bone formation, such as bone morphogenetic proteins, have already been clinically used to enhance bone fusion for spinal arthrodesis. Recently, stem cells have attracted considerable attention as a cell source of osteoblasts, promising effects in enhancing bone fusion. Drug delivery systems will also need to be further developed to assure the safe delivery of bone-enhancing agents to the site of spinal arthrodesis. Our aim in this review is to appraise the current state of knowledge and evidence regarding bone enhancement strategies for spinal fusion for degenerative spinal disorders, and to identify future directions for biological bone enhancement strategies, including pharmacological, cell and gene therapy approaches.
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Affiliation(s)
- Takahiro Makino
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Hiroyuki Tsukazaki
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Yuichiro Ukon
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Daisuke Tateiwa
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Hideki Yoshikawa
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Takashi Kaito
- Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan.
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Magnus MK, Iceman KL, Roukis TS. Living Cryopreserved Bone Allograft as an Adjunct for Hindfoot Arthrodesis. Clin Podiatr Med Surg 2018; 35:295-310. [PMID: 29861013 DOI: 10.1016/j.cpm.2018.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Hindfoot arthrodesis is a frequently performed procedure by foot and ankle surgeons. The relatively high nonunion rate associated with these procedures has led surgeons to use adjunctive bone graft to help augment osseous union. Cellular bone allografts are a specific type of graft that incorporates osteoconductive, osteoinductive, and osteogenic properties while also eliminating the common disadvantages of autografts and traditional allografts. This article discusses the role of cellular bone allografts in hindfoot arthrodesis procedures, a review of current literature, and a comparison of available products.
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Affiliation(s)
- Mark K Magnus
- Gundersen Medical Foundation, Mail Stop: CO3-006A, 1900 South Avenue, La Crosse, WI 54601, USA
| | - Kelli L Iceman
- Gundersen Medical Foundation, Mail Stop: CO3-006A, 1900 South Avenue, La Crosse, WI 54601, USA
| | - Thomas S Roukis
- Orthopaedic Center, Gundersen Healthcare System, Mail Stop: CO2-006, 1900 South Avenue, La Crosse, WI 54601, USA.
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Mohammadi M, Mousavi Shaegh SA, Alibolandi M, Ebrahimzadeh MH, Tamayol A, Jaafari MR, Ramezani M. Micro and nanotechnologies for bone regeneration: Recent advances and emerging designs. J Control Release 2018; 274:35-55. [PMID: 29410062 DOI: 10.1016/j.jconrel.2018.01.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 02/08/2023]
Abstract
Treatment of critical-size bone defects is a major medical challenge since neither the bone tissue can regenerate nor current regenerative approaches are effective. Emerging progresses in the field of nanotechnology have resulted in the development of new materials, scaffolds and drug delivery strategies to improve or restore the damaged tissues. The current article reviews promising nanomaterials and emerging micro/nano fabrication techniques for targeted delivery of biomolecules for bone tissue regeneration. In addition, recent advances in fabrication of bone graft substitutes with similar properties to normal tissue along with a brief summary of current commercialized bone grafts have been discussed.
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Affiliation(s)
- Marzieh Mohammadi
- Nanotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Ali Mousavi Shaegh
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; Clinical Research Unit, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mona Alibolandi
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Ali Tamayol
- Department of Mechanical and Materials Engineering, University of Nebraska, Lincoln, Lincoln, NE 68588, USA; Biomaterials Innovation Research Center, Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02139, USA
| | - Mahmoud Reza Jaafari
- Nanotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Mohammad Ramezani
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
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Lui YF, Ip WY. Biological Evaluation of Flexible Polyurethane/Poly l-Lactic Acid Composite Scaffold as a Potential Filler for Bone Regeneration. MATERIALS 2017; 10:ma10091042. [PMID: 28902161 PMCID: PMC5615697 DOI: 10.3390/ma10091042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/19/2017] [Accepted: 08/31/2017] [Indexed: 12/28/2022]
Abstract
Degradable bone graft substitute for large-volume bone defects is a continuously developing field in orthopedics. With the advance in biomaterial in past decades, a wide range of new materials has been investigated for their potential in this application. When compared to common biopolymers within the field such as PLA or PCL, elastomers such as polyurethane offer some unique advantages in terms of flexibility. In cases of bone defect treatments, a flexible soft filler can help to establish an intimate contact with surrounding bones to provide a stable bone-material interface for cell proliferation and ingrowth of tissue. In this study, a porous filler based on segmented polyurethane incorporated with poly l-lactic acid was synthesized by a phase inverse salt leaching method. The filler was put through in vitro and in vivo tests to evaluate its potential in acting as a bone graft substitute for critical-sized bone defects. In vitro results indicated there was a major improvement in biological response, including cell attachment, proliferation and alkaline phosphatase expression for osteoblast-like cells when seeded on the composite material compared to unmodified polyurethane. In vivo evaluation on a critical-sized defect model of New Zealand White (NZW) rabbit indicated there was bone ingrowth along the defect area with the introduction of the new filler. A tight interface formed between bone and filler, with osteogenic cells proliferating on the surface. The result suggested polyurethane/poly l-lactic acid composite is a material with the potential to act as a bone graft substitute for orthopedics application.
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Affiliation(s)
- Yuk Fai Lui
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China.
| | - Wing Yuk Ip
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China.
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Use of Allogenic Mesenchymal Cellular Bone Matrix in Anterior and Posterior Cervical Spinal Fusion: A Case Series of 21 Patients. Asian Spine J 2017; 11:454-462. [PMID: 28670414 PMCID: PMC5481601 DOI: 10.4184/asj.2017.11.3.454] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 10/12/2016] [Accepted: 11/03/2016] [Indexed: 11/08/2022] Open
Abstract
Study Design Retrospective case series. Purpose To report our early experience using allogenic mesenchymal cellular bone matrix (CBM) products in cervical spine fusion. Overview of Literature Multi-level cervical fusions have historically yielded lower fusion rates than single level fusions, especially in patients with high risk medical comorbidities. At this time, significant literature in cervical fusion outcomes with this cellular allograft technology is lacking. Methods Twenty-one patients underwent either multilevel (3 or 4 level) anterior cervical discectomy and fusion, anterior cervical corpectomy and fusion, or posterior cervical fusion. ViviGen (DePuy Synthes Spine, Raynham, MA, USA), an allogenic bone matrix product, was used in addition to standard instrumentation. Radiographic evaluation was performed at 2 weeks, 12 weeks, 24 weeks and 1 year postoperative. Visual analog scale (VAS) and neck disability index (NDI) scores along with return to work and leisure activity were recorded. Results At 6 months postoperative, all patients had radiographic evidence of bone fusion regardless of age or medical comorbidities. All patients reported subjective improvement with a mean decrease in VAS from 8.3 to 1.5 and a mean decrease in NDI from 40.3% to 6.0% at 1 year. All patients also returned to work and/or regular leisure activity within 3 months. Conclusions Twenty-one patients undergoing high-risk anterior and posterior cervical spine fusion, with the use of a commercially available mesenchymal CBM product, went on to radiographic fusion and all had improvement in subjective outcomes. While further effort and research is needed to validate its widespread use, this study shows favorable use of CBM in cervical fusion for high-risk cases.
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Liu WC, Chen S, Zheng L, Qin L. Angiogenesis Assays for the Evaluation of Angiogenic Properties of Orthopaedic Biomaterials - A General Review. Adv Healthc Mater 2017; 6. [PMID: 28135051 DOI: 10.1002/adhm.201600434] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/04/2016] [Indexed: 01/07/2023]
Abstract
Vascularization is an essential process in bone formation, remodeling and regeneration during both bone development and fracture repair. Vascularization remains a big challenge directly leading to the final success of newly regenerated bone. In this review, the advantages and disadvantages of different angiogenesis assays and bone defect models are described in details for investigating revascularization of materials of interest. Unlike conventional angiogenesis study with growth factors or pharmaceutical molecules performed in two-dimension, special considerations are taken into account whether these assays can be translated for testing three-dimensional implantable devices. Over the years, accurate and quantifiable in vitro, ex vivo and in vivo assays have been extensively demonstrated to be useful in examining how new blood vessels grow. These methods can contribute to the fundamental understanding of angiogenic properties of the materials, but a bone defect model is still pivotal in order to understand the cascade actions of angiogenesis along with bone formation. Finally, angiogenesis and osteogenesis are both complex processes interacting with each other, the choice of which assay to be performed should adequately address the clinical relevance and reflect the sequence of responses of revascularization of the test materials.
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Affiliation(s)
- Wai Ching Liu
- Musculoskeletal Research Laboratory; Department of Orthopaedics & Traumatology; The Chinese University of Hong Kong; 5/F, Clinical Science Building, Prince of Wales Hospital Shatin Hong Kong SAR PR China
| | - Shihui Chen
- Musculoskeletal Research Laboratory; Department of Orthopaedics & Traumatology; The Chinese University of Hong Kong; 5/F, Clinical Science Building, Prince of Wales Hospital Shatin Hong Kong SAR PR China
- Pathology Center; Shanghai General Hospital/Faculty of Basic Medicine; Shanghai Jiao Tong University School of Medicine; Shanghai PR China
| | - Lizhen Zheng
- Musculoskeletal Research Laboratory; Department of Orthopaedics & Traumatology; The Chinese University of Hong Kong; 5/F, Clinical Science Building, Prince of Wales Hospital Shatin Hong Kong SAR PR China
| | - Ling Qin
- Musculoskeletal Research Laboratory; Department of Orthopaedics & Traumatology; The Chinese University of Hong Kong; 5/F, Clinical Science Building, Prince of Wales Hospital Shatin Hong Kong SAR PR China
- Translational Medicine R&D Center; Institute of Biomedical and Health Engineering; Shenzhen Institutes of Advanced Technology; Chinese Academy of Sciences; Shenzhen PR China
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Onizuka S, Iwata T, Park S, Nakai K, Yamato M, Okano T, Izumi Y. ZBTB16 as a Downstream Target Gene of Osterix Regulates Osteoblastogenesis of Human Multipotent Mesenchymal Stromal Cells. J Cell Biochem 2016; 117:2423-34. [PMID: 27335174 PMCID: PMC5094493 DOI: 10.1002/jcb.25634] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 06/21/2016] [Indexed: 02/06/2023]
Abstract
Human multipotent mesenchymal stromal cells (hMSCs) possess the ability to differentiate into osteoblasts, and they can be utilized as a source for bone regenerative therapy. Osteoinductive pretreatment, which induces the osteoblastic differentiation of hMSCs in vitro, has been widely used for bone tissue engineering prior to cell transplantation. However, the molecular basis of osteoblastic differentiation induced by osteoinductive medium (OIM) is still unknown. Therefore, we used a next-generation sequencer to investigate the changes in gene expression during the osteoblastic differentiation of hMSCs. The hMSCs used in this study possessed both multipotency and self-renewal ability. Whole-transcriptome analysis revealed that the expression of zinc finger and BTB domain containing 16 (ZBTB16) was significantly increased during the osteoblastogenesis of hMSCs. ZBTB16 mRNA and protein expression was enhanced by culturing the hMSCs with OIM. Small interfering RNA (siRNA)-mediated gene silencing of ZBTB16 decreased the activity of alkaline phosphatase (ALP); the expression of osteogenic genes, such as osteocalcin (OCN) and bone sialoprotein (BSP), and the mineralized nodule formation induced by OIM. siRNA-mediated gene silencing of Osterix (Osx), which is known as an essential regulator of osteoblastic differentiation, markedly downregulated the expression of ZBTB16. In addition, chromatin immunoprecipitation (ChIP) assays showed that Osx associated with the ZBTB16 promoter region containing the GC-rich canonical Sp1 sequence, which is the specific Osx binding site. These findings suggest that ZBTB16 acts as a downstream transcriptional regulator of Osx and can be useful as a late marker of osteoblastic differentiation. J. Cell. Biochem. 117: 2423-2434, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Satoru Onizuka
- Department of PeriodontologyGraduate School of Medical Dental SciencesTokyo Medical Dental University1‐5‐45 YushimaBunkyo‐kuTokyo113‐8549Japan
- Institute of Advanced Biomedical Engineering and ScienceTokyo Women's Medical University8‐1 Kawada‐choShinjuku‐kuTokyo162‐8666Japan
| | - Takanori Iwata
- Institute of Advanced Biomedical Engineering and ScienceTokyo Women's Medical University8‐1 Kawada‐choShinjuku‐kuTokyo162‐8666Japan
| | - Sung‐Joon Park
- Human Genome CenterThe Institute of Medical ScienceThe University of Tokyo4‐6‐1 ShirokanedaiMinato‐kuTokyo108‐8639Japan
| | - Kenta Nakai
- Human Genome CenterThe Institute of Medical ScienceThe University of Tokyo4‐6‐1 ShirokanedaiMinato‐kuTokyo108‐8639Japan
| | - Masayuki Yamato
- Institute of Advanced Biomedical Engineering and ScienceTokyo Women's Medical University8‐1 Kawada‐choShinjuku‐kuTokyo162‐8666Japan
| | - Teruo Okano
- Institute of Advanced Biomedical Engineering and ScienceTokyo Women's Medical University8‐1 Kawada‐choShinjuku‐kuTokyo162‐8666Japan
| | - Yuichi Izumi
- Department of PeriodontologyGraduate School of Medical Dental SciencesTokyo Medical Dental University1‐5‐45 YushimaBunkyo‐kuTokyo113‐8549Japan
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Ishida W, Elder BD, Holmes C, Lo SFL, Witham TF. Variables Affecting Fusion Rates in the Rat Posterolateral Spinal Fusion Model with Autogenic/Allogenic Bone Grafts: A Meta-analysis. Ann Biomed Eng 2016; 44:3186-3201. [PMID: 27473706 DOI: 10.1007/s10439-016-1701-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/21/2016] [Indexed: 01/14/2023]
Abstract
The rat posterolateral spinal fusion model with autogenic/allogenic bone graft (rat PFABG) has been increasingly utilized as an experimental model to assess the efficacy of novel fusion treatments. The objective of this study was to investigate the reliability of the rat PFABG model and examine the effects of different variables on spinal fusion. A web-based literature search from January, 1970 to September, 2015, yielded 26 studies, which included 40 rat PFABG control groups and 449 rats. Data regarding age, weight, sex, and strain of rats, graft volume, graft type, decorticated levels, surgical approach, institution, the number of control rats, fusion rate, methods of fusion assessment, and timing of fusion assessment were collected and analyzed. The primary outcome variable of interest was fusion rate, as evaluated by manual palpation. Fusion rates varied widely, from 0 to 96%. The calculated overall fusion rate was 46.1% with an I 2 value of 62.4, which indicated moderate heterogeneity. Weight >300 g, age >14 weeks, male rat, Sprague-Dawley strain, and autogenic coccyx grafts increased fusion rates with statistical significance. Additionally, an assessment time-point ≥8 weeks had a trend towards statistical significance (p = 0.070). Multi-regression analysis demonstrated that timing of assessment and age as continuous variables, as well as sex as a categorical variable, can predict the fusion rate with R 2 = 0.82. In an inter-institution reliability analysis, the pooled overall fusion rate was 50.0% [44.8, 55.3%], with statistically significant differences among fusion outcomes at different institutions (p < 0.001 and I 2 of 72.2). Due to the heterogeneity of fusion outcomes, the reliability of the rat PFABG model was relatively limited. However, selection of adequate variables can optimize its use as a control group in studies evaluating the efficacy of novel fusion therapies.
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Affiliation(s)
- Wataru Ishida
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans St., Room 6007, Baltimore, MD, 21287, USA
| | - Benjamin D Elder
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans St., Room 6007, Baltimore, MD, 21287, USA.
| | - Christina Holmes
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans St., Room 6007, Baltimore, MD, 21287, USA
| | - Sheng-Fu L Lo
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans St., Room 6007, Baltimore, MD, 21287, USA
| | - Timothy F Witham
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans St., Room 6007, Baltimore, MD, 21287, USA
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Bridwell KH, Anderson PA, Boden SD, Kim HJ, Vaccaro A, Wang JC. What's New in Spine Surgery. J Bone Joint Surg Am 2015; 97:1022-30. [PMID: 26085537 DOI: 10.2106/jbjs.o.00080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Keith H Bridwell
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110. E-mail address:
| | - Paul A Anderson
- University of Wisconsin, UWMF Centennial Building, 1685 Highland Avenue, 6th Floor, Madison, WI 53705-2281. E-mail address:
| | - Scott D Boden
- Emory University School of Medicine, 59 Executive Park South, Suite 3000, Atlanta, GA 30329. E-mail address:
| | - Han Jo Kim
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address:
| | - Alexander Vaccaro
- Rothman Institute at Jefferson, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107-4216. E-mail address:
| | - Jeffrey C Wang
- University of Southern California Spine Center, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033. E-mail address:
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Elboghdady I, Hassanzadeh H, Stein BE, An HS. Controversies and potential risk of mesenchymal stem cells application. ACTA ACUST UNITED AC 2015. [DOI: 10.1053/j.semss.2015.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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