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Gantenbein B, Oswald KAC, Erbach GF, Croft AS, Bermudez-Lekerika P, Strunz F, Bigdon SF, Albers CE. The bone morphogenetic protein 2 analogue L51P enhances spinal fusion in combination with BMP2 in an in vivo rat tail model. Acta Biomater 2024; 177:148-156. [PMID: 38325708 DOI: 10.1016/j.actbio.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/31/2023] [Accepted: 01/24/2024] [Indexed: 02/09/2024]
Abstract
Bone morphogenic protein 2 (BMP2) is known to induce osteogenesis and is applied clinically to enhance spinal fusion despite adverse effects. BMP2 needs to be used in high doses to be effective due to the presence of BMP2 inhibitors. L51P is a BMP2 analogue that acts by inhibition of BMP2 inhibitors. Here, we hypothesized that mixtures of BMP2 and L51P could achieve better spinal fusion outcomes regarding ossification. To test whether mixtures of both cytokines are sufficient to improve ossification, 45 elderly Wistar rats (of which 21 were males) were assigned to seven experimental groups, all which received spinal fusion surgery, including discectomy at the caudal 4-5 level using an external fixator and a porous β-tricalcium phosphate (βTCP) carrier. These βTCP carriers were coated with varying concentrations of BMP2 and L51P. X-rays were taken immediately after surgery and again six and twelve weeks post-operatively. Histological sections and µCT were analyzed after twelve weeks. Spinal fusion was assessed using X-ray, µCT and histology according to the Bridwell scale by voxel-based quantification and a semi-quantitative histological score, respectively. The results were congruent across modalities and revealed high ossification for high-dose BMP2 (10 µg), while PBS induced no ossification. Low-dose BMP2 (1 µg) or 10 µg L51P alone did not induce relevant bone formation. However, all combinations of low-dose BMP2 with L51P (1 µg + 1/5/10 µg) were able to induce similar ossificationas high-dose BMP2. These results are of high clinical relevance, as they indicate L51P is sufficient to increase the efficacy of BMP2 and thus lower the required dose for spinal fusion. STATEMENT OF SIGNIFICANCE: Spinal fusion surgery is frequently applied to treat spinal pathologies. Bone Morphogenic Protein-2 (BMP2) has been approved by the U .S. Food and Drug Administration (FDA-) and by the "Conformité Européenne" (CE)-label. However, its application is expensive and high concentrations cause side-effects. This research targets the improvement of the efficacy of BMP2 in spinal fusion surgery.
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Affiliation(s)
- Benjamin Gantenbein
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Medical Faculty, University of Bern, Bern, Switzerland; Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical Faculty, University of Bern, Bern, Switzerland.
| | - Katharina A C Oswald
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Medical Faculty, University of Bern, Bern, Switzerland
| | - Georg F Erbach
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Medical Faculty, University of Bern, Bern, Switzerland
| | - Andreas S Croft
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical Faculty, University of Bern, Bern, Switzerland; Graduate School for Cellular and Biomedical Sciences (GCB), University of Bern, Bern, Switzerland
| | - Paola Bermudez-Lekerika
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical Faculty, University of Bern, Bern, Switzerland; Graduate School for Cellular and Biomedical Sciences (GCB), University of Bern, Bern, Switzerland
| | - Franziska Strunz
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical Faculty, University of Bern, Bern, Switzerland; Graduate School for Cellular and Biomedical Sciences (GCB), University of Bern, Bern, Switzerland
| | - Sebastian F Bigdon
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Medical Faculty, University of Bern, Bern, Switzerland
| | - Christoph E Albers
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Medical Faculty, University of Bern, Bern, Switzerland
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Keum BR, Kim HJ, Kim GH, Chang DG. Osteobiologies for Spinal Fusion from Biological Mechanisms to Clinical Applications: A Narrative Review. Int J Mol Sci 2023; 24:17365. [PMID: 38139194 PMCID: PMC10743675 DOI: 10.3390/ijms242417365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/01/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
Degenerative lumbar spinal disease (DLSD), including spondylolisthesis and spinal stenosis, is increasing due to the aging population. Along with the disease severity, lumbar interbody fusion (LIF) is a mainstay of surgical treatment through decompression, the restoration of intervertebral heights, and the stabilization of motion segments. Currently, pseudoarthrosis after LIF is an important and unsolved issue, which is closely related to osteobiologies. Of the many signaling pathways, the bone morphogenetic protein (BMP) signaling pathway contributes to osteoblast differentiation, which is generally regulated by SMAD proteins as common in the TGF-β superfamily. BMP-2 and -4 are also inter-connected with Wnt/β-catenin, Notch, and FGF signaling pathways. With the potent potential for osteoinduction in BMP-2 and -4, the combination of allogenous bone and recombinant human BMPs (rhBMPs) is currently an ideal fusion material, which has equalized or improved fusion rates compared to traditional materials. However, safety issues in the dosage of BMP remain, so overcoming current limitations will provide significant advancement in spine surgery. In the future, translational research and the application of clinical study will be important to overcome the current limitations of spinal surgery.
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Affiliation(s)
- Byeong-Rak Keum
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, Cheongju 28119, Republic of Korea;
| | - Hong Jin Kim
- Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul 01757, Republic of Korea;
| | - Gun-Hwa Kim
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, Cheongju 28119, Republic of Korea;
| | - Dong-Gune Chang
- Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul 01757, Republic of Korea;
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Morton MB, Wang YY, Buckland AJ, Oehme DA, Malham GM. Lateral lumbar interbody fusion - clinical outcomes, fusion rates and complications with recombinant human bone morphogenetic protein-2. Br J Neurosurg 2023:1-7. [PMID: 37029604 DOI: 10.1080/02688697.2023.2197503] [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: 01/26/2023] [Revised: 03/03/2023] [Accepted: 03/28/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND The authors report an Australian experience of lateral lumbar interbody fusion (LLIF) with respect to clinical outcomes, fusion rates, and complications, with recombinant human bone morphogenetic protein-2 (rhBMP-2) and other graft materials. METHODS Retrospective cohort study of LLIF patients 2011-2021. LLIFs performed lateral decubitus by four experienced surgeons past their learning curve. Graft materials classified rhBMP-2 or non-rhBMP-2. Patient-reported outcomes assessed by VAS, ODI, and SF-12 preoperatively and postoperatively. Fusion rates assessed by CT postoperatively at 6 and 12 months. Complications classified minor or major. Clinical outcomes and complications analysed and compared between rhBMP-2 and non-rhBMP-2 groups. RESULTS A cohort of 343 patients underwent 437 levels of LLIF. Mean age 67 ± 11 years (range 29-89) with a female preponderance (65%). Mean BMI 29kg/m2 (18-56). Most common operated levels L3/4 (36%) and L4/5 (35%). VAS, ODI and SF-12 improved significantly from baseline. Total complication rate 15% (53/343) with minor 11% (39/343) and major 4% (14/343). Ten patients returned to OR (2-wound infection, 8-further instrumentation and decompression). Most patients (264, 77%) received rhBMP-2, the remainder a non-rhBMP-2 graft material. No significant differences between groups at baseline. No increase in minor or major complications in the rhBMP-2 group compared to the non-rhBMP-2 group respectively; (10.6% vs 13.9% [p = 0.42], 2.7% vs 8.9% [p < 0.01]). Fusion rates significantly higher in the rhBMP-2 group at 6 and 12 months (63% vs 40%, [p < 0.01], 92% vs 80%, [p < 0.02]). CONCLUSION LLIF is a safe and efficacious procedure. rhBMP-2 in LLIF produced earlier and higher fusion rates compared to available non-rhBMP-2 graft substitutes.
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Affiliation(s)
- Matthew B Morton
- Epworth Hospital, Richmond, Australia
- Faculty of Medicine, Monash University, Clayton, Australia
| | - Yi Yuen Wang
- St Vincent's Hospital, Fitzroy, Australia
- Department of Surgery, The University of Melbourne, Parkville, Australia
| | - Aaron J Buckland
- Epworth Hospital, Richmond, Australia
- Melbourne Orthopaedic Group, Windsor, Australia
- Spine and Scoliosis Research Associates Australia, Windsor, Australia
- NYU Langone Health, New York, NY, USA
| | - David A Oehme
- Epworth Hospital, Richmond, Australia
- St Vincent's Hospital, Fitzroy, Australia
| | - Gregory M Malham
- Epworth Hospital, Richmond, Australia
- Swinburne University of Technology, Hawthorn, Australia
- University of Melbourne, Parkville, Australia
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Deininger C, Wagner A, Heimel P, Salzer E, Vila XM, Weißenbacher N, Grillari J, Redl H, Wichlas F, Freude T, Tempfer H, Teuschl-Woller AH, Traweger A. Enhanced BMP-2-Mediated Bone Repair Using an Anisotropic Silk Fibroin Scaffold Coated with Bone-like Apatite. Int J Mol Sci 2021; 23:283. [PMID: 35008718 PMCID: PMC8745248 DOI: 10.3390/ijms23010283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 12/16/2022] Open
Abstract
The repair of large bone defects remains challenging and often requires graft material due to limited availability of autologous bone. In clinical settings, collagen sponges loaded with excessive amounts of bone morphogenetic protein 2 (rhBMP-2) are occasionally used for the treatment of bone non-unions, increasing the risk of adverse events. Therefore, strategies to reduce rhBMP-2 dosage are desirable. Silk scaffolds show great promise due to their favorable biocompatibility and their utility for various biofabrication methods. For this study, we generated silk scaffolds with axially aligned pores, which were subsequently treated with 10× simulated body fluid (SBF) to generate an apatitic calcium phosphate coating. Using a rat femoral critical sized defect model (CSD) we evaluated if the resulting scaffold allows the reduction of BMP-2 dosage to promote efficient bone repair by providing appropriate guidance cues. Highly porous, anisotropic silk scaffolds were produced, demonstrating good cytocompatibility in vitro and treatment with 10× SBF resulted in efficient surface coating. In vivo, the coated silk scaffolds loaded with a low dose of rhBMP-2 demonstrated significantly improved bone regeneration when compared to the unmineralized scaffold. Overall, our findings show that this simple and cost-efficient technique yields scaffolds that enhance rhBMP-2 mediated bone healing.
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Affiliation(s)
- Christian Deininger
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, 5020 Salzburg, Austria; (C.D.); (A.W.); (N.W.); (H.T.)
- Department of Orthopedics and Traumatology, Salzburg University Hospital, Paracelsus Medical University, 5020 Salzburg, Austria; (F.W.); (T.F.)
| | - Andrea Wagner
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, 5020 Salzburg, Austria; (C.D.); (A.W.); (N.W.); (H.T.)
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria; (P.H.); (E.S.); (X.M.V.); (J.G.); (H.R.)
| | - Patrick Heimel
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria; (P.H.); (E.S.); (X.M.V.); (J.G.); (H.R.)
- AUVA Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, 1200 Vienna, Austria
- Karl Donath Laboratory for Hard Tissue and Biomaterial Research, University Clinic of Dentistry, Medical University of Vienna, 1090 Vienna, Austria
| | - Elias Salzer
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria; (P.H.); (E.S.); (X.M.V.); (J.G.); (H.R.)
- Department Life Science Engineering, University of Applied Sciences Technikum Wien, 1200 Vienna, Austria
| | - Xavier Monforte Vila
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria; (P.H.); (E.S.); (X.M.V.); (J.G.); (H.R.)
- Department Life Science Engineering, University of Applied Sciences Technikum Wien, 1200 Vienna, Austria
| | - Nadja Weißenbacher
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, 5020 Salzburg, Austria; (C.D.); (A.W.); (N.W.); (H.T.)
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria; (P.H.); (E.S.); (X.M.V.); (J.G.); (H.R.)
| | - Johannes Grillari
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria; (P.H.); (E.S.); (X.M.V.); (J.G.); (H.R.)
- AUVA Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, 1200 Vienna, Austria
- Department of Biotechnology, Institute of Molecular Biotechnology, BOKU-University of Natural Resources and Life Sciences, 1180 Vienna, Austria
| | - Heinz Redl
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria; (P.H.); (E.S.); (X.M.V.); (J.G.); (H.R.)
- AUVA Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, 1200 Vienna, Austria
| | - Florian Wichlas
- Department of Orthopedics and Traumatology, Salzburg University Hospital, Paracelsus Medical University, 5020 Salzburg, Austria; (F.W.); (T.F.)
| | - Thomas Freude
- Department of Orthopedics and Traumatology, Salzburg University Hospital, Paracelsus Medical University, 5020 Salzburg, Austria; (F.W.); (T.F.)
| | - Herbert Tempfer
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, 5020 Salzburg, Austria; (C.D.); (A.W.); (N.W.); (H.T.)
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria; (P.H.); (E.S.); (X.M.V.); (J.G.); (H.R.)
| | - Andreas Herbert Teuschl-Woller
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria; (P.H.); (E.S.); (X.M.V.); (J.G.); (H.R.)
- Department Life Science Engineering, University of Applied Sciences Technikum Wien, 1200 Vienna, Austria
| | - Andreas Traweger
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, 5020 Salzburg, Austria; (C.D.); (A.W.); (N.W.); (H.T.)
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria; (P.H.); (E.S.); (X.M.V.); (J.G.); (H.R.)
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