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Proal JD, Moon AS, Kwon B. The fragility index and reverse fragility index of FDA investigational device exemption trials in spinal fusion surgery: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08317-3. [PMID: 38802596 DOI: 10.1007/s00586-024-08317-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/20/2024] [Accepted: 05/16/2024] [Indexed: 05/29/2024]
Abstract
PURPOSE FDA investigational device exemption (IDE) studies are considered a gold standard of assessing safety and efficacy of novel devices through RCTs. The fragility index (FI) has emerged as a means to assess robustness of statistically significant study results and inversely, the reverse fragility index (RFI) for non-significant differences. Previous authors have defined results as fragile if loss to follow up is greater than the FI or RFI. The aim of this study was to assess the FI, RFI, and robustness of data supplied by IDE studies in spinal surgery. METHODS This was a systematic review of the literature. Inclusion criteria included randomized controlled trials with dichotomous outcome measures conducted under IDE guidelines between 2000 and 2023. FI and RFI were calculated through successively changing events to non-events until the outcome changed to non-significance or significance, respectively. The fragility quotient (FQ) and reverse fragility quotient (RFQ) were calculated by dividing the FI and RFI, respectively, by the sample size. RESULTS Thirty-two studies met inclusion criteria with a total of 40 unique outcome measures; 240 outcomes were analyzed. Twenty-six studies reported 96 statistically significant results. The median FI was 6 (IQR: 3-9.25), and patients lost to follow up was greater than the FI in 99.0% (95/96) of results. The average FQ was 0.027. Thirty studies reported 144 statistically insignificant results and a median RFI of 6 (IQR: 4-8). The average RFQ extrapolated was 0.021, and loss to follow up was greater than the RFI in 98.6% (142/144) of results. CONCLUSIONS IDE studies in spine surgery are surprisingly fragile given their reputations, large sample sizes, and intent to establish safety in investigational devices. This study found a median FI and RFI of 6. The number of patients lost to follow-up was greater than FIand RFI in 98.8% (237/240) of reported outcomes. FQ and RFQ tell us that changes of two to three patients per hundred can flip the significance of reported outcomes. This is an important reminder of the limitations of RCTs. Analysis of fragility in future studies may help clarify the strength of the relationship between reported data and their conclusions.
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Affiliation(s)
- Joshua D Proal
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, 02111, USA.
| | - Andrew S Moon
- Department of Orthopedic Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, Tufts MC Box #306, Boston, MA, 02111, USA
| | - Brian Kwon
- New England Baptist Hospital, Department of Orthopaedic Surgery, 125 Parker Hill Ave, Boston, MA, 02120, USA
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2
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Mi B, Xiong Y, Lu L, Liao J, Liu G, Zhao Y. Macrophage-mediated fracture healing: Unraveling molecular mechanisms and therapeutic implications using hydrogel-based interventions. Biomaterials 2024; 305:122461. [PMID: 38171119 DOI: 10.1016/j.biomaterials.2023.122461] [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: 10/27/2023] [Revised: 12/21/2023] [Accepted: 12/31/2023] [Indexed: 01/05/2024]
Abstract
Fracture healing is a complex biological process that involves the orchestrated interplay of various cells and molecular signaling pathways. Among the key players, macrophages have emerged as critical regulators of fracture repair, influencing inflammation, tissue remodeling, and angiogenesis. Recent advances in hydrogel-based therapeutics have provided exciting opportunities to leverage the modulatory effects of macrophages for improving fracture healing outcomes. In the present study, we review the importance of macrophages in fracture repair and their potential therapeutic role in hydrogel-based interventions. We discuss the molecular mechanisms underlying macrophage-mediated effects on fracture healing, and how hydrogels can be utilized as a platform for macrophage modulation. Furthermore, we highlight the translation of hydrogel-based therapies from bench to bedside, including preclinical and clinical studies, and the challenges and opportunities in harnessing the therapeutic potential of macrophages in fracture repair. Overall, understanding the importance of macrophages in fracture healing and the potential of hydrogel-based therapeutics to modulate macrophage responses can pave the way for developing innovative approaches to improve fracture healing outcomes.
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Affiliation(s)
- Bobin Mi
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China; Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China; School of Chemistry, Chemical Engineering and Biotechnology, Nanyang Technological University, 637371, Singapore
| | - Yuan Xiong
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China; Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China; School of Chemistry, Chemical Engineering and Biotechnology, Nanyang Technological University, 637371, Singapore
| | - Li Lu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China; Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China
| | - Jiewen Liao
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China; Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China
| | - Guohui Liu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China; Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China.
| | - Yanli Zhao
- School of Chemistry, Chemical Engineering and Biotechnology, Nanyang Technological University, 637371, Singapore.
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3
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Raitio A, Saarinen AJ, Sinikumpu JJ, Helenius I. Biodegradable biomaterials in orthopedic surgery: A narrative review of the current evidence. Scand J Surg 2024; 113:62-70. [PMID: 37817459 DOI: 10.1177/14574969231200650] [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] [Indexed: 10/12/2023]
Abstract
BACKGROUND Biomaterials are routinely used in orthopedic surgery to fill bone defects, improve bone healing, and as degradable fixation material. A wide range of materials are currently in use, and the materials are chosen according to their bioactive properties. Osteoinductive materials stimulate bone healing by promoting osteogenesis. Osteoconductive materials facilitate bone growth on the surface of the material. Despite the many materials in use and an increasing number of published studies, randomized controlled trials on the subject are scarce. METHODS This review aims to summarize the history of biodegradable biomaterials and also the published level I evidence currently available on orthopedic biomaterials. RESULTS Most of the studies have been superiority trials with non-significant differences compared to conventional treatment options, confirming that several biomaterials are suitable treatment options for multiple indications including bone and/or tendon fixation, filling bone defects, and spinal fusion. Biomaterials help to avoid donor site complications associated with autogenous bone grafts and often eliminate the need for implant removal. However, the surgical technique may in some cases be more demanding than with conventional methods. Careful consideration of the pros and cons is therefore recommended in clinical practice. CONCLUSION Biodegradable biomaterials complement the range of available treatment options in several fields of orthopedic surgery. However, some biomaterials performed worse than expected and were not recommended for clinical use, emphasizing the need for high-quality randomized trials. It is also noteworthy that several trials included only a limited number of patients, rendering the interpretation of the results of these underpowered studies challenging.
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Affiliation(s)
- Arimatias Raitio
- Arimatias Raitio Department of Pediatric SurgeryUniversity of Turku and Turku University Hospital Turku Finland
- Turku University Hospital, Savitehtaankatu 5, 20520 Turku
| | - Antti J Saarinen
- Department of Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha-Jaakko Sinikumpu
- Department of Pediatric Surgery and Orthopedics, Clinical Medicine Research Unit, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Ilkka Helenius
- Department of Pediatric Surgery, Orthopaedics and Traumatology, University of Turku and Turku University Hospital, Turku, Finland
- Department of Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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4
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Chung AS, Ravinsky R, Kulkarni R, Hsieh PC, Arts JJ, Rodrigues-Pinto R, Wang JC, Meisel HJ, Buser Z. Comparison of Different Osteobiologics in Terms of Imaging Modalities and Time Frames for Fusion Assessment in Anterior Cervical Discectomy and Fusion: A Systematic Review. Global Spine J 2024; 14:141S-162S. [PMID: 38421332 PMCID: PMC10913913 DOI: 10.1177/21925682231157312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES The study's primary objective was to determine how osteobiologic choice affects fusion rates in patients undergoing anterior cervical discectomy and fusion (ACDF). The study's secondary objectives were to 1) determine the optimal timing of fusion assessment following ACDF and 2) determine if osteobiologic type affects the timing and optimal modality of fusion assessment. METHODS A systematic search of PubMed/MEDLINE was conducted for literature published from 2000 through October 2020 comparing anterior fusion in the cervical spine with various osteobiologics. Both comparative studies and case series of ≥10 patients were included. RESULTS A total of 74 studies met the inclusion criteria. Seventeen studies evaluated the efficacy of autograft on fusion outcomes, and 23 studies assessed the efficacy of allograft on fusion outcomes. 3 studies evaluated the efficacy of demineralized bone matrix, and seven assessed the efficacy of rhBMP-2 on fusion outcomes. Other limited studies evaluated the efficacy of ceramics and bioactive glasses on fusion outcomes, and 4 assessed the efficacy of stem cell products. Most studies utilized dynamic radiographs for the assessment of fusion. Overall, there was a general lack of supportive data to determine the optimal timing of fusion assessment meaningfully or if osteobiologic type influenced fusion timing. CONCLUSIONS Achieving fusion following ACDF appears to remain an intricate interplay between host biology and various surgical factors, including the selection of osteobiologics. While alternative osteobiologics to autograft exist and may produce acceptable fusion rates, limitations in study methodology prevent any definitive conclusions from existing literature.
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Affiliation(s)
| | - Robert Ravinsky
- Department of Orthopedic Surgery and Physical Medicine, Medical University of South Carolina, Phoenix, AZ, USA
| | - Ronit Kulkarni
- Department of Orthopedic Surgery and Physical Medicine, Medical University of South Carolina, Phoenix, AZ, USA
| | - Patrick C Hsieh
- USC Spine Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jacobus J Arts
- Laboratory for Experimental Orthopaedics, Department of Orthopaedic Surgery, CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Ricardo Rodrigues-Pinto
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- Spinal Unit (UVM), Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Jeffrey C Wang
- USC Spine Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Hans Jörg Meisel
- Department of Neurosurgery, BG Klinikum Bergmannstrost Halle, Halle, Germany
| | - Zorica Buser
- Gerling Institute, Department of Orthopedic Surgery, NYU Grossman School of Medicine, Brooklyn, NY, USA
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5
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Gordon A, Newsome F, Ahern DP, McDonnell JM, Cunniffe G, Butler JS. Iliac crest bone graft versus cell-based grafts to augment spinal fusion: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:253-263. [PMID: 37740784 DOI: 10.1007/s00586-023-07941-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/25/2023]
Abstract
INTRODUCTION Despite successful fusion rates with iliac crest bone graft (ICBG), donor-site morbidity and increased operating time remain a considerable limitation and drive the search for alternatives. In this systematic review, grafts with additional cellular supplementation were compared with ICBG for spinal arthrodesis. We compared safety, efficacy and long-term outcomes, thus providing the current and relevant evidence for orthopaedic surgeons to make informed choices regarding this rapidly developing field. METHODS An electronic literature search was conducted according to the PRISMA guidelines by two independent reviewers for articles published up to 1st March 2023 using PubMed, EMBASE and the Cochrane Central Register of Controlled Trial. Cellular allografts were not included. The following data were extracted: Number of patients, type of graft, fusion assessment method, follow-up duration, fusion rates, clinical outcomes and complications. The methodological quality of evidence (MQOE) was assessed using the Risk of Bias 2 (RoB-2) tool and Risk of Bias In Non-Randomised Studies (ROBINS) tool developed by Cochrane for evaluating bias in randomised and non-randomised studies. RESULTS Ten studies fulfiled the inclusion criteria, including 465 patients. The mean number of patients per study was 43.8 (std dev. 28.81, range 12-100). Two studies demonstrated cell-based therapy to be significantly more successful in terms of fusion rates compared to ICBG. However, the remaining eight demonstrated equivocal results. No study found that cell-based therapy was inferior. No difference was seen between the two groups in three studies who focused on degenerative cohorts. No difference in functional outcome scores was seen between the groups. A number of different preparation techniques for cell-based grafts were used throughout the studies. CONCLUSION Cell-based therapy offers a promising alternative to ICBG in spinal fusion surgery, which could help reduce the associated morbidity to patients. This review found that cell-based therapy is non-inferior to iliac crest bone graft and may offer patients an alternative treatment option with fewer complications and reduced post-operative pain. However, the literature to date is limited by heterogeneity of the cell preparation and grafting process. Future research with a unified approach to the cell preparation process is required to fully delineate the potential advantages of this technology.
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Affiliation(s)
- Aoife Gordon
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Fiona Newsome
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Daniel P Ahern
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland.
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.
- Department of Trauma and Orthopaedics, Tallaght University Hospital, Dublin, Ireland.
| | - Jake M McDonnell
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Grainne Cunniffe
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Joseph S Butler
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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6
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Bernatz JT, Fisher MWA, Pinter ZW, Sebastian AS. Controversies in Spine Surgery: Is i-Factor Superior to Bone Morphogenic Protein for Achieving Spine Fusion? Clin Spine Surg 2023; 36:224-226. [PMID: 36727969 DOI: 10.1097/bsd.0000000000001416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/13/2022] [Indexed: 02/03/2023]
Affiliation(s)
- James T Bernatz
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Miles W A Fisher
- Department of Orthopedic Surgery, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX
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Arnold PM, Vaccaro AR, Sasso RC, Goulet B, Fehlings MG, Heary RF, Janssen ME, Kopjar B. Six-Year Follow-up of a Randomized Controlled Trial of i-FACTOR Peptide-Enhanced Bone Graft Versus Local Autograft in Single-Level Anterior Cervical Discectomy and Fusion. Neurosurgery 2023; 92:725-733. [PMID: 36700705 DOI: 10.1227/neu.0000000000002290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 10/04/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Previous analyses of the US Food and Drug Administration (FDA) Investigational Device Exemption study demonstrated the superiority of i-FACTOR compared with local autograft bone in single-level anterior cervical discectomy and fusion (ACDF) at 12 and 24 months postoperatively in a composite end point of overall success. OBJECTIVE To report the final, 6-year clinical and radiological outcomes of the FDA postapproval study. METHODS Of the original 319 subjects enrolled in the Investigational Device Exemption study, 220 participated in the postapproval study (106 i-FACTOR and 114 control). RESULTS The study met statistical noninferiority success for all 4 coprimary end points. Radiographic fusion was achieved in 99% (103/104) and 98.2% (109/111) in i-FACTOR and local autograft subjects, mean Neck Disability Index improvement from baseline was 28.6 (24.8, 32.3) in the i-FACTOR and 29.2 (25.6, 32.9) in the control group, respectively (noninferiority P < .0001). The neurological success rate at 6 years was 95.9% (70/73) in i-FACTOR subjects and 93.7% (70/75) in local autograft subjects (noninferiority P < .0001). Safety outcomes were similar between the 2 groups. Secondary surgery on the same or different cervical levels occurred in 20/106 (18.9%) i-FACTOR subjects and 23/114 (20.2%) local autograft subjects ( P = .866). Secondary outcomes (pain, SF-36 physical component score and mental component score) in i-FACTOR subjects were similar to those in local autograft subjects. CONCLUSION i-FACTOR met all 4 FDA-mandated noninferiority success criteria and demonstrated safety and efficacy in single-level anterior cervical discectomy and fusion for cervical radiculopathy through 6 years postoperatively. Safety outcomes are acceptable, and the clinical and functional outcomes observed at 12 and 24 months remained at 72 months.
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Affiliation(s)
| | - Alexander R Vaccaro
- Department of Orthopaedics, Thomas Jefferson University Hospital and Rothman Institute, Philadelphia, Pennsylvania, USA
| | - Rick C Sasso
- Indiana University School of Medicine, Indiana Spine Group, Carmel, Indiana, USA
| | - Benoit Goulet
- Montreal Neurological Institute, Montreal, Quebec, Canada
| | - Michael G Fehlings
- University of Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Michael E Janssen
- Spine Education and Research Institute, Center for Spine and Orthopedics, Thornton, Colorado, USA
| | - Branko Kopjar
- Department of Health Services, University of Washington, Seattle, Washington, USA
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A Novel Approach to Treat a Rare Case of Interprosthetic Humeral Fracture with Osteosynthesis and Combined Grafting: A Case Report and Review of the Literature. J Funct Morphol Kinesiol 2022; 7:jfmk7040094. [PMID: 36412756 PMCID: PMC9680310 DOI: 10.3390/jfmk7040094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/19/2022] [Accepted: 10/20/2022] [Indexed: 12/14/2022] Open
Abstract
Interprosthetic humeral fractures (IHFs) are severe injury patterns associated with surgical issues and contradictory results. The knowledge and literature on this topic are still lacking. A 76 year-old woman was treated for a fracture occurred between the shoulder and elbow stemmed prosthesis. Severe bone loss was associated with the fracture. Treatment: Open reduction, plate fixation, and bone grafting were considered. A xenograft (used as a mechanical strut medially), a synthetic graft associated with bone growth factors, and scaffolds improved the bone healing process. Satisfactory clinical and radiological outcomes were obtained. A scoping review of the literature was also performed by the authors. Only eight papers reported IHFs with a low level of evidence. In total, eight patients were treated; one paper that reported on biomechanical aspects using finite element analysis is discussed. Conservative treatment leads to non-union, and the surgical approach is the gold standard. The osteosynthesis technique associated with bone grafting leads to the best outcomes. The use of a xenograft mechanical strut, associated with synthetic biological bone grafting, led to complete bone union at 9 months follow-up. Larger cohorts, more standardised results, and multicentric studies are mandatory in order to improve and establish a management and treatment algorithm.
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Loenen ACY, Connor J, Johnson S, Davis K, Hannigan N, Barnes T, Arts JJ, van Rietbergen B. Peptide Enhanced Bone Graft Substitute Presents Improved Short-Term Increase in Bone Volume and Construct Stiffness Compared to Iliac Crest Autologous Bone in an Ovine Lumbar Interbody Fusion Model. Global Spine J 2022; 12:1330-1337. [PMID: 33406899 PMCID: PMC9393976 DOI: 10.1177/2192568220979839] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Preclinical ovine model. OBJECTIVE To assess the in vivo efficacy and safety of the P-15 L bone graft substitute and compare its performance to autologous iliac crest bone graft (ICBG) for lumbar interbody fusion indications. METHODS Thirty skeletally mature sheep underwent lumbar interbody fusion surgery. Half of the sheep received autologous ICBG and the other half the peptide enhanced bone graft substitute (P-15 L). Following termination at 1, 3, and 6 months after surgery, the operated segments were analyzed using micro computed tomography (µCT), histology, and destructive mechanical testing. Additional systemic health monitoring was performed for the P-15 L group. RESULTS One month after surgery, there was only minor evidence of bone remodeling and residual graft material could be clearly observed within the cage. There was active bone remodeling between 1 and 3 months after surgery. At 3 months after surgery significantly denser and stiffer bone was found in the P-15 L group, whereas at 6 months, P-15 L and ICBG gave similar fusion results. The P-15 L bone graft substitute did not have any adverse effects on systemic health. CONCLUSIONS The drug device combination P-15 L was demonstrated to be effective and save for lumbar interbody fusion as evidenced by this ovine model. Compared to autologous ICBG, P-15 L seems to expedite bone formation and remodeling but in the longer-term fusion results were similar.
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Affiliation(s)
- Arjan C. Y. Loenen
- Laboratory for Experimental Orthopaedics, Department of Orthopaedic Surgery, CAPHRI, Maastricht University Medical Centre, Maastricht, the Netherlands,Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | | | | | | | | | | | - Jacobus J. Arts
- Laboratory for Experimental Orthopaedics, Department of Orthopaedic Surgery, CAPHRI, Maastricht University Medical Centre, Maastricht, the Netherlands,Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Bert van Rietbergen
- Laboratory for Experimental Orthopaedics, Department of Orthopaedic Surgery, CAPHRI, Maastricht University Medical Centre, Maastricht, the Netherlands,Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands,Bert van Rietbergen, Department of Biomedical Engineering, Eindhoven University of Technology, Buidling 15, Gemini-Zuid (4.118), PO Box 513, 5600 MB Eindhoven, the Netherlands; Groene Loper, TU Eindhoven, De Rondom 70, 5612AP Eindhoven, the Netherlands.
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10
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O’Brien MJM, Jones DM, Semciw AI, Balakumar J, Grabinski R, Roebert J, Coburn GM, Mechlenburg I, Kemp JL. Does the use of i-FACTOR bone graft affect bone healing in those undergoing periacetabular osteotomy (PAO) for developmental dysplasia of the hip (DDH)? A retrospective study. J Hip Preserv Surg 2022; 9:165-171. [PMID: 37063347 PMCID: PMC10093896 DOI: 10.1093/jhps/hnac027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/02/2022] [Accepted: 05/11/2022] [Indexed: 04/18/2023] Open
Abstract
ABSTRACT
The aims of this study were to compare, in patients with and without the use of i-FACTOR bone graft during periacetabular osteotomy (PAO) surgery for developmental dysplasia of the hip (DDH), (i) bone healing at six-weeks post-operatively (ii) rate of complications. This was a retrospective review of case records. Participants were people aged 15-50 years undergoing rectus-sparing minimally invasive PAO surgery for DDH. Group 1: patients with i-FACTOR, Group 2: No i-FACTOR. The primary outcome was the rate of bone healing on radiographs at 6 weeks. The likelihood of bone healing was compared using logistic regression with Generalised Estimating Equations (GEE) and expressed as odds ratios (95% confidence intervals (CIs; P < 0.05)). The occurrence of complications was extracted from surgical records. The i-FACTOR group had 3-times greater odds of partial/full union than those without [adjusted odds ratio (95% CIs, P-value)]: [3.265 (1.032 to 10.330, P = 0.044)]. The i-FACTOR group had 89% partial/full union at 6-weeks, compared to 69% of the non-i-FACTOR group. Half of the patients had leaking of bone graft in the i-FACTOR group versus 10% in the non-i-FACTOR group, 26% of the i-FACTOR group and 12% of the non-i-FACTOR group had neuropraxia of the lateral femoral cutaneous nerve (LFCN). Complication rates were low, and similar between groups. However, the rate of LFCN neuropraxia and bone graft leakage was higher in the i-FACTOR. These findings should be confirmed in a future prospective randomised clinical trial and include outcomes such as pain and quality of life.
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Affiliation(s)
| | | | - Adam Ivan Semciw
- Department of Physiotherapy, Podiatry, and
Prosthetics and Orthotics, La Trobe University, Melbourne, VIC 3086,
Australia
| | | | - Rafal Grabinski
- Victoria House Imaging, I-Med
Radiology, Melbourne, VIC 3141, Australia
| | - Justin Roebert
- Victoria House Imaging, I-Med
Radiology, Melbourne, VIC 3141, Australia
| | - Georgia M Coburn
- La Trobe Sport and Exercise Medicine Research
Centre, La Trobe University, Melbourne, VIC 3086, Australia
| | - Inger Mechlenburg
- Department of Orthopaedics, Aarhus University
Hospital, Aarhus 8200, Denmark
- Department of Clinical Medicine, Aarhus
University, Aarhus 8200, Denmark
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11
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Rasouli J, Fiani B, Belding J, Moore TA. Anterior Cervical Discectomy and Fusion With "Kissing" Allograft Interbodies. Cureus 2021; 13:e19499. [PMID: 34912638 PMCID: PMC8664396 DOI: 10.7759/cureus.19499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/12/2021] [Indexed: 11/22/2022] Open
Abstract
Background: There is recent evidence to suggest that the use of polyetheretherketone (PEEK) interbodies are inherently associated with a higher rate of pseudarthrosis, in particular, at the C5-6 and C6-7 levels. Herein, we describe our technique utilizing two parallel structural allografts or “kissing” allografts, designed to mitigate the risk of pseudarthrosis and subsidence at these levels. Materials and Methods: We retrospectively reviewed all anterior cervical discectomy and fusion (ACDF) procedures with “kissing” for degenerative spine pathology at a single institution between 2018 and 2019 for the C5-6 and C6-7 levels. One-year postoperative flexion/extension cervical X-rays were evaluated for evidence of radiographic pseudarthrosis and subsidence. Results: A total of 28 patients met the study criteria. Solid fusion was achieved in 93%. There were no infections or wound complications. One patient developed postoperative dysphagia that resolved at 3-months post-op. Two patients were found to have clinically asymptomatic radiographic pseudarthrosis that did not warrant intervention. One patient developed a postoperative hematoma that required surgical evacuation. Conclusions: “Kissing” allograft ACDF is a safe and effective method designed to address the intrinsically higher risk of pseudarthrosis at the C5-6 and C6-7 levels. Further prospective studies are warranted to comparatively evaluate this technique against single allograft and PEEK interbodies.
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Affiliation(s)
| | - Brian Fiani
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - John Belding
- Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, USA
| | - Timothy A Moore
- Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, USA
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Gillman CE, Jayasuriya AC. FDA-approved bone grafts and bone graft substitute devices in bone regeneration. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 130:112466. [PMID: 34702541 PMCID: PMC8555702 DOI: 10.1016/j.msec.2021.112466] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/26/2021] [Accepted: 09/24/2021] [Indexed: 12/28/2022]
Abstract
To induce bone regeneration there is a complex cascade of growth factors. Growth factors such as recombinant BMP-2, BMP-7, and PDGF are FDA-approved therapies in bone regeneration. Although, BMP shows promising results as being an alternative to autograft, it also has its own downfalls. BMP-2 has many adverse effects such as inflammatory complications such as massive soft-tissue swelling that can compromise a patient's airway, ectopic bone formation, and tumor formation. BMP-2 may also be advantageous for patients not willing to give up smoking as it shows bone regeneration success with smokers. BMP-7 is no longer an option for bone regeneration as it has withdrawn off the market. PDGF-BB grafts in studies have shown PDGF had similar fusion rates to autologous grafts and fewer adverse effects. There is also an FDA-approved bioactive molecule for bone regeneration, a peptide P-15. P-15 was found to be effective, safe, and have similar outcomes to autograft at 2 years post-op for cervical radiculopathy due to cervical degenerative disc disease. Growth factors and bioactive molecules show some promising results in bone regeneration, although more research is needed to avoid their adverse effects and learn about the long-term effects of these therapies. There is a need of a bone regeneration method of similar quality of an autograft that is osteoconductive, osteoinductive, and osteogenic. This review covers all FDA-approved bone regeneration therapies such as the "gold standard" autografts, allografts, synthetic bone grafts, and the newer growth factors/bioactive molecules. It also covers international bone grafts not yet approved in the United States and upcoming technologies in bone grafts.
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Affiliation(s)
- Cassidy E Gillman
- The Doctor of Medicine (M.D.) Program, College of Medicine and Life Sciences, The University of Toledo, Toledo, OH 43614, USA
| | - Ambalangodage C Jayasuriya
- Department of Orthopaedic Surgery, College of Medicine and Life Sciences, The University of Toledo, Toledo, OH 43614, USA.
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Thaci B, Yee R, Kim K, Vokshoor A, Johnson JP, Ament J. Cost-Effectiveness of Peptide Enhanced Bone Graft i-Factor versus Use of Local Autologous Bone in Anterior Cervical Discectomy and Fusion Surgery. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:681-691. [PMID: 34335035 PMCID: PMC8318088 DOI: 10.2147/ceor.s318589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/09/2021] [Indexed: 11/23/2022] Open
Abstract
Study Design We conducted decision analytical modeling using a Markov model to determine the ICER of i-factor compared to autograft in ACDF surgery. Objective The efficacy and safety of traditional anterior cervical discectomy and fusion (ACDF) surgery has improved with the introduction of new implants and compounds. Cost-effectiveness of these innovations remains an often-overlooked aspect of this effort. To evaluate the cost-effectiveness of i-FACTOR compared to autograft for patients undergoing ACDF surgery. Methods The patient cohort was extracted from a prospective, multicenter randomized control trial (RCT) from twenty-two North American centers. Patients randomly received either autograft (N = 154) or i-Factor (N = 165). We analyzed various real-world scenarios, including inpatient and outpatient surgical settings as well as private versus public insurances. Two primary outcome measures were assessed: cost and utility. In the base-case analysis, both health and societal system costs were evaluated. Health-related utility outcome was expressed in quality-adjusted life years (QALYs). Cost-effectiveness was expressed as an incremental cost-effectiveness ratio (ICER). Results In all scenarios, i-FACTOR reduced costs within the first year by 1.4% to 2.1%. The savings proved to be incremental over time, increasing to 3.7% over an extrapolated 10 years. The ICER at 90 days was $13,333 per QALY and became negative ("dominated") relative to the control group within one year and onwards. In a threshold sensitivity analysis, the cost of i-FACTOR could theoretically be increased 70-fold and still remain cost-effective. Conclusion The novel i-FACTOR is not only cost-effective compared to autograft in ACDF surgery but is the dominant economic strategy.
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Affiliation(s)
- Bart Thaci
- University of California, Davis, Sacramento, CA, USA
| | - Randy Yee
- Neuronomics LLC, Los Angeles, CA, USA
| | - Kee Kim
- University of California, Davis, Sacramento, CA, USA
| | - Amir Vokshoor
- Neuronomics LLC, Los Angeles, CA, USA.,Neurosurgery & Spine Group, Los Angeles, CA, USA.,Institute of Neuro Innovation, Santa Monica, CA, USA
| | | | - Jared Ament
- Neuronomics LLC, Los Angeles, CA, USA.,Neurosurgery & Spine Group, Los Angeles, CA, USA.,Institute of Neuro Innovation, Santa Monica, CA, USA.,Cedars Sinai Medical Center, Los Angeles, CA, USA
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Hsieh PC, Chung AS, Brodke D, Park JB, Skelly AC, Brodt ED, Chang K, Buser Z, Meisel HJ, Yoon ST, Wang JC. Autologous Stem Cells in Cervical Spine Fusion. Global Spine J 2021; 11:950-965. [PMID: 32964752 PMCID: PMC8258818 DOI: 10.1177/2192568220948479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES To systematically review, critically appraise and synthesize evidence on use of stem cells from autologous stem cells from bone marrow aspirate, adipose, or any other autologous sources for fusion in the cervical spine compared with other graft materials. METHODS A systematic search of PubMed/MEDLINE was conducted for literature published through October 31, 2018 and through February 20, 2020 for EMBASE and ClinicalTrials.gov comparing autologous cell sources for cervical spine fusion to other graft options. RESULTS From 36 potentially relevant citations identified, 10 studies on cervical fusion met the inclusion criteria set a priori. Two retrospective cohort studies, one comparing cancellous bone marrow (CBM) versus hydroxyapatite (HA) and the other bone marrow aspirate (BMA) combined with autograft and HA versus autograft and HA alone, were identified. No statistical differences were seen between groups in either study for improvement in function, symptoms, or fusion; however, in the study evaluating BMA, the authors reported a statistically greater fusion rate and probability of fusion over time in the BMA versus the non-BMA group. Across case series evaluating BMA, authors reported improved function and pain and fusion ranged from 84% to 100% across the studies. In general, complications were poorly reported. CONCLUSIONS The overall quality (strength) of evidence of effectiveness and safety of autologous BMA for cervical arthrodesis in the current available literature was very low. Based on currently available data, firm conclusions regarding the effectiveness or safety of BMA in cervical fusions cannot be made.
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Affiliation(s)
- Patrick C. Hsieh
- University of Southern California, Los Angeles, CA, USA,Patrick C. Hsieh, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA 90033, USA.
| | | | | | - Jong-Beom Park
- Uijongbu St. Mary’s Hospital, The Catholic University of Korea School of Medicine, Uijongbu, Korea
| | | | | | - Ki Chang
- University of Southern California, Los Angeles, CA, USA
| | - Zorica Buser
- University of Southern California, Los Angeles, CA, 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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Fiani B, Jarrah R, Shields J, Sekhon M. Enhanced biomaterials: systematic review of alternatives to supplement spine fusion including silicon nitride, bioactive glass, amino peptide bone graft, and tantalum. Neurosurg Focus 2021; 50:E10. [PMID: 34062502 DOI: 10.3171/2021.3.focus201044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal fusions are among the most common and effective spinal surgical practices; however, the current model presents some cost and safety concerns within the patient population. Therefore, enhanced biomaterials have been presented to be an innovative yet underutilized tool to supplement the success of spinal fusion surgery. Herein, the authors discuss these biomaterials, their compositions, clinical outcomes, and cost analysis through a systematic review of the literature to date. METHODS This systematic review was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria and guidelines. Article selection was performed using the PubMed electronic bibliographic databases. The search yielded 1168 articles that were assessed and filtered for relevance by the four authors. Following the screening of titles and abstracts, 62 articles were deemed significant enough for final selection. RESULTS To date, silicon nitride, bioactive glass, amino peptide bone grafts, and tantalum are all biomaterials that could have significant roles in supporting spinal fusion. Their unique compositions allow them to be biocompatible in the spine, and their mechanisms of action stimulate osteoblast formation and support fusion success. Moreover, these biomaterials also present positive clinical and cost outcomes that support their application in spinal procedures. However, further studies with longer follow-ups are necessary to fully understand these biomaterials prior to their incorporation in mainstream spinal practice. CONCLUSIONS The combination of their positive clinical outcomes, biocompatibility, and cost-effectiveness makes these biomaterials valuable, innovative, and effective treatment modalities that could revolutionize the current model of spinal fusion.
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Affiliation(s)
- Brian Fiani
- 1Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California
| | - Ryan Jarrah
- 2College of Arts and Sciences, University of Michigan-Flint
| | - Jennifer Shields
- 3College of Human Medicine, Michigan State University, East Lansing; and
| | - Manraj Sekhon
- 4William Beaumont School of Medicine, Oakland University, Rochester, Michigan
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Arnold PM, Vaccaro AR, Sasso RC, Goulet B, Fehlings MG, Heary RF, Janssen ME, Kopjar B. Two-Year Clinical and Radiological Outcomes in Patients With Diabetes Undergoing Single-Level Anterior Cervical Discectomy and Fusion. Global Spine J 2021; 11:458-464. [PMID: 32875918 PMCID: PMC8119920 DOI: 10.1177/2192568220914880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
STUDY DESIGN Secondary analysis of data from the multicenter, randomized, parallel-controlled Food and Drug Administration (FDA) investigational device exemption study. OBJECTIVE Studies on outcomes following anterior cervical discectomy and fusion (ACDF) in individuals with diabetes are scarce. We compared 24-month radiological and clinical outcomes in individuals with and without diabetes undergoing single-level ACDF with either i-FACTOR or local autologous bone. METHODS Between 2006 and 2013, 319 individuals with single-level degenerative disc disease (DDD) and no previous fusion at the index level underwent ACDF. The presence of diabetes determined the 2 cohorts. Data collected included radiological fusion evaluation, neurological outcomes, Neck Disability Index (NDI), Visual Analog Scale (VAS) scores, and the 36-Item Short Form Survey Version 2 (SF-36v2) Physical and Mental component summary scores. RESULTS There were 35 individuals with diabetes (11.1%; average body mass index [BMI] = 32.99 kg/m2; SD = 5.72) and 284 without (average BMI = 28.32 kg/m2; SD = 5.67). The number of nondiabetic smokers was significantly higher than diabetic smokers: 73 (25.70%) and 3 (8.57%), respectively. Preoperative scores of NDI, VAS arm pain, and SF-36v2 were similar between the diabetic and nondiabetic participants at baseline; however, VAS neck pain differed significantly between the cohorts at baseline (P = .0089). Maximum improvement for NDI, VAS neck and arm pain, and SF-36v2 PCS and MCS scores was seen at 6 months in both cohorts and remained stable until 24 months. CONCLUSIONS ACDF is effective for cervical radiculopathy in patients with diabetes. Diabetes is not a contraindication for patients requiring single-level surgery for cervical DDD.
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Affiliation(s)
- Paul M. Arnold
- Carle Spine Institute, IL, USA,Paul M. Arnold, Carle Spine Institute,
610 N. Lincoln Avenue, Urbana, IL 61801 USA.
| | | | - Rick C. Sasso
- Indiana University School of Medicine, Indiana Spine Group, IN, USA
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Fertala A. Three Decades of Research on Recombinant Collagens: Reinventing the Wheel or Developing New Biomedical Products? Bioengineering (Basel) 2020; 7:E155. [PMID: 33276472 PMCID: PMC7712652 DOI: 10.3390/bioengineering7040155] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/16/2020] [Accepted: 11/23/2020] [Indexed: 02/07/2023] Open
Abstract
Collagens provide the building blocks for diverse tissues and organs. Furthermore, these proteins act as signaling molecules that control cell behavior during organ development, growth, and repair. Their long half-life, mechanical strength, ability to assemble into fibrils and networks, biocompatibility, and abundance from readily available discarded animal tissues make collagens an attractive material in biomedicine, drug and food industries, and cosmetic products. About three decades ago, pioneering experiments led to recombinant human collagens' expression, thereby initiating studies on the potential use of these proteins as substitutes for the animal-derived collagens. Since then, scientists have utilized various systems to produce native-like recombinant collagens and their fragments. They also tested these collagens as materials to repair tissues, deliver drugs, and serve as therapeutics. Although many tests demonstrated that recombinant collagens perform as well as their native counterparts, the recombinant collagen technology has not yet been adopted by the biomedical, pharmaceutical, or food industry. This paper highlights recent technologies to produce and utilize recombinant collagens, and it contemplates their prospects and limitations.
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Affiliation(s)
- Andrzej Fertala
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Curtis Building, Room 501, 1015 Walnut Street, Philadelphia, PA 19107, USA
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Abstract
PURPOSE OF REVIEW To provide information on characteristics and use of various ceramics in spine fusion and future directions. RECENT FINDINGS In most recent years, focus has been shifted to the use of ceramics in minimally invasive surgeries or implementation of nanostructured surface modification features to promote osteoinductive properties. In addition, effort has been placed on the development of bioactive synthetics. Core characteristic of bioactive synthetics is that they undergo change to simulate a beneficial response within the bone. This change is based on chemical reaction and various chemical elements present in the bioactive ceramics. Recently, a synthetic 15-amino acid polypeptide bound to an anorganic bone material which mimics the cell-binding domain of type-I collagen opened a possibility for osteogenic and osteoinductive roles of this hybrid graft material. Ceramics have been present in the spine fusion arena for several decades; however, their use has been limited. The major obstacle in published literature is small sample size resulting in low evidence and a potential for bias. In addition, different physical and chemical properties of various ceramics further contribute to the limited evidence. Although ceramics have several disadvantages, they still hold a great promise as a value-based graft material with being easily available, relatively inexpensive, and non-immunogenic.
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Buser Z, Chung AS, Abedi A, Wang JC. The future of disc surgery and regeneration. INTERNATIONAL ORTHOPAEDICS 2018; 43:995-1002. [PMID: 30506089 DOI: 10.1007/s00264-018-4254-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 11/25/2018] [Indexed: 12/21/2022]
Abstract
Low back and neck pain are among the top contributors for years lived with disability, causing patients to seek substantial non-operative and operative care. Intervertebral disc herniation is one of the most common spinal pathologies leading to low back pain. Patient comorbidities and other risk factors contribute to the onset and magnitude of disc herniation. Spine fusions have been the treatment of choice for disc herniation, due to the conflicting evidence on conservative treatments. However, re-operation and costs have been among the main challenges. Novel technologies including cage surface modifications, biologics, and 3D printing hold a great promise. Artificial disc replacement has demonstrated reduced rates of adjacent segment degeneration, need for additional surgery, and better outcomes. Non-invasive biological approaches are focused on cell-based therapies, with data primarily from preclinical settings. High-quality comparative studies are needed to evaluate the efficacy and safety of novel technologies and biological therapies.
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Affiliation(s)
- Zorica Buser
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA.
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo St, HC4 - #5400A, Los Angeles, CA, 90033, USA.
| | | | - Aidin Abedi
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
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Lin W, Ha A, Boddapati V, Yuan W, Riew KD. Diagnosing Pseudoarthrosis After Anterior Cervical Discectomy and Fusion. Neurospine 2018; 15:194-205. [PMID: 31352693 PMCID: PMC6226130 DOI: 10.14245/ns.1836192.096] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 09/19/2018] [Indexed: 12/18/2022] Open
Abstract
Radiographic confirmation of fusion after anterior cervical discectomy and fusion (ACDF) surgery is a critical aspect of determining surgical success. However, there is a lack of established diagnostic radiographic parameters for pseudoarthrosis. The purpose of this study is to summarize the findings of previous studies, review the advantages and disadvantages of frequently employed diagnostic criteria, and present our recommended protocol of fusion assessment. This study identified randomized controlled trials, case-control studies, and prospective and retrospective cohort studies reporting on spinal fusion and how successful fusion after ACDF. Among the 39 articles reviewed, bridging bone across the operated levels on static radiographs was the most commonly used criteria to confirm fusion (31 of 39, 79%). Dynamic flexion-extension radiographs were used to assess for interspinous movement (ISM) (22 of 39, 56.4%) and change in Cobb angle (12 of 39, 30.8%). Computed tomography (CT) based findings (21 of 39, 53.8%) were employed in ambiguous cases with improved sensitivity and specificity. Reconstructed CT scans were used to assess for intragraft bridging bone and extragraft bridging bone (ExGBB). ExGBB were proved to have the highest diagnostic sensitivity and specificity for pseudoarthrosis detection when compared to all other radiographic criteria. The ISM <1 mm on dynamic flexion-extension radiographs had high diagnostic sensitivity and specificity as well. After our reviewing, we recommend using dynamic lateral flexion-extension cervical spine radiographs at 150% magnificationin which the interspinous motion <1 mm and superjacent interspinous motion ≥4 mm confirms fusion. In ambiguous cases, we recommend using reconstructed CT scans to evaluate for ExGBB.
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Affiliation(s)
- Wenbo Lin
- Department of Orthopedic, Changzheng Hospital, Second Military Medical University, Shang Hai, China
| | - Alex Ha
- Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital, New York-Presbyterian Healthcare System, New York, NY, USA
| | - Venkat Boddapati
- Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital, New York-Presbyterian Healthcare System, New York, NY, USA
| | - Wen Yuan
- Department of Orthopedic, Changzheng Hospital, Second Military Medical University, Shang Hai, China
| | - K Daniel Riew
- Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital, New York-Presbyterian Healthcare System, New York, NY, USA
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