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Omi M, Koneru T, Lyu Y, Haraguchi A, Kamiya N, Mishina Y. Increased BMP-Smad signaling does not affect net bone mass in long bones. Front Physiol 2023; 14:1145763. [PMID: 37064883 PMCID: PMC10101206 DOI: 10.3389/fphys.2023.1145763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023] Open
Abstract
Bone morphogenetic proteins (BMPs) have been used for orthopedic and dental application due to their osteoinductive properties; however, substantial numbers of adverse reactions such as heterotopic bone formation, increased bone resorption and greater cancer risk have been reported. Since bone morphogenetic proteins signaling exerts pleiotropic effects on various tissues, it is crucial to understand tissue-specific and context-dependent functions of bone morphogenetic proteins. We previously reported that loss-of-function of bone morphogenetic proteins receptor type IA (BMPR1A) in osteoblasts leads to more bone mass in mice partly due to inhibition of bone resorption, indicating that bone morphogenetic protein signaling in osteoblasts promotes osteoclast function. On the other hand, hemizygous constitutively active (ca) mutations for BMPR1A (caBmpr1awt/+) in osteoblasts result in higher bone morphogenetic protein signaling activity and no overt skeletal changes in adult mice. Here, we further bred mice for heterozygous null for Bmpr1a (Bmpr1a+/−) and homozygous mutations of caBmpr1a (caBmpr1a+/+) crossed with Osterix-Cre transgenic mice to understand how differences in the levels of bone morphogenetic protein signaling activity specifically in osteoblasts contribute to bone phenotype. We found that Bmpr1a+/−, caBmpr1awt/+ and caBmpr1a+/+ mice at 3 months of age showed no overt bone phenotypes in tibiae compared to controls by micro-CT and histological analysis although BMP-Smad signaling is increased in both caBmpr1awt/+ and caBmpr1a+/+ tibiae and decreased in the Bmpr1a+/− mice compared to controls. Gene expression analysis demonstrated that slightly higher levels of bone formation markers and resorption markers along with levels of bone morphogenetic protein-Smad signaling, however, there was no significant changes in TRAP positive cells in tibiae. These findings suggest that changes in bone morphogenetic protein signaling activity within differentiating osteoblasts does not affect net bone mass in the adult stage, providing insights into the concerns in the clinical setting such as high-dose and unexpected side effects of bone morphogenetic protein application.
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Affiliation(s)
- Maiko Omi
- Department of Biologic and Materials Sciences and Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, United States
| | - Tejaswi Koneru
- Department of Biologic and Materials Sciences and Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, United States
| | - Yishan Lyu
- Department of Biologic and Materials Sciences and Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, United States
| | - Ai Haraguchi
- Department of Biologic and Materials Sciences and Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, United States
| | - Nobuhiro Kamiya
- Department of Budo and Sport Studies, Faculty of Budo and Sport Studies, Tenri University, Nara, Japan
| | - Yuji Mishina
- Department of Biologic and Materials Sciences and Prosthodontics, University of Michigan School of Dentistry, Ann Arbor, MI, United States
- *Correspondence: Yuji Mishina,
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Jiang F, Qi X, Wu X, Lin S, Shi J, Zhang W, Jiang X. Regulating macrophage-MSC interaction to optimize BMP-2-induced osteogenesis in the local microenvironment. Bioact Mater 2023; 25:307-318. [PMID: 36844362 PMCID: PMC9947106 DOI: 10.1016/j.bioactmat.2023.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 02/12/2023] Open
Abstract
Bone morphogenetic protein (BMP-2) has been approved by the FDA to promote bone regeneration, but uncertain osteogenic effect and dose-dependent side effects may occur. Osteoimmunomodulation plays an important role in growth factor-based osteogenesis. Here, we explored how proinflammatory signals affect the dose-dependent osteogenic potential of BMP-2. We observed that the expression level of local IL-1β did not increase with the dose of BMP-2 in the mouse osteogenesis model. A low dose of BMP-2 could not promote new bone formation, but trigger the release of IL-1β from M1 macrophages. As the dose of BMP-2 increased, the IL-1β expression and M1 infiltration in local microenvironment were inhibited by IL-1Ra from MSCs under osteogenic differentiation induced by BMP-2, and new bone tissues formed, even excessively. Anti-inflammatory drugs (Dexamethasone, Dex) promoted osteogenesis via inhibiting M1 polarization and enhancing BMP-2-induced MSC osteo-differentiation. Thus, we suggest that the osteogenic effect of BMP-2 involves macrophage-MSC interaction that is dependent on BMP-2 dose and based on IL-1R1 ligands, including IL-1β and IL-1Ra. The dose of BMP-2 could be reduced by introducing immunoregulatory strategies.
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Affiliation(s)
- Fei Jiang
- Department of Prosthodontics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No.639, Zhizaoju Road, Shanghai, 200011, China
- College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, No.639, Zhizaoju Road, Shanghai, 200011, China
- Jiangsu Key Laboratory of Oral Diseases, Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing Medical University, No. 140, Han Zhong Road, Nanjing, 210029, China
- Department of General Dentistry, Affiliated Hospital of Stomatology, Nanjing Medical University, No. 136, Han Zhong Road, Nanjing, 210029, China
| | - Xuanyu Qi
- Department of Prosthodontics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No.639, Zhizaoju Road, Shanghai, 200011, China
- College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, No.639, Zhizaoju Road, Shanghai, 200011, China
| | - Xiaolin Wu
- Department of Prosthodontics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No.639, Zhizaoju Road, Shanghai, 200011, China
- College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, No.639, Zhizaoju Road, Shanghai, 200011, China
| | - Sihan Lin
- Department of Prosthodontics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No.639, Zhizaoju Road, Shanghai, 200011, China
- College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, No.639, Zhizaoju Road, Shanghai, 200011, China
| | - Junfeng Shi
- Department of Prosthodontics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No.639, Zhizaoju Road, Shanghai, 200011, China
- College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, No.639, Zhizaoju Road, Shanghai, 200011, China
| | - Wenjie Zhang
- Department of Prosthodontics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No.639, Zhizaoju Road, Shanghai, 200011, China
- College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, No.639, Zhizaoju Road, Shanghai, 200011, China
| | - Xinquan Jiang
- Department of Prosthodontics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No.639, Zhizaoju Road, Shanghai, 200011, China
- College of Stomatology, Shanghai Jiao Tong University, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, No.639, Zhizaoju Road, Shanghai, 200011, China
- Corresponding author. Department of Prosthodontics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No.639, Zhizaoju Road, Shanghai, 200011, China.
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Lambrechts MJ, Siegel N, Karamian BA, Fredericks DJ, Curran J, Safran J, Canseco JA, Woods BI, Kaye D, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. A Short-Term Assessment of Lumbar Sagittal Alignment Parameters in Patients Undergoing Anterior Lumbar Interbody Fusion. Spine (Phila Pa 1976) 2022; 47:1620-1626. [PMID: 35867592 DOI: 10.1097/brs.0000000000004430] [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: 04/14/2022] [Accepted: 06/04/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To determine if intraoperative on-table lumbar lordosis (LL) and segmental lordosis (SL) coincide with perioperative change in lordosis. SUMMARY OF BACKGROUND DATA Improvements in sagittal alignment are believed to correlate with improvements in clinical outcomes. Thus, it is important to establish whether intraoperative radiographs predict postoperative improvements in LL or SL. MATERIALS AND METHODS Electronic medical records were reviewed for patients ≥18 years old who underwent single-level and two-level anterior lumbar interbody fusion with posterior instrumentation between 2016 and 2020. LL, SL, and the lordosis distribution index were compared between preoperative, intraoperative, and postoperative radiographs using paired t tests. A linear regression determined the effect of subsidence on SL and LL. RESULTS A total of 118 patients met inclusion criteria. Of those, 75 patients had one-level fusions and 43 had a two-level fusion. LL significantly increased following on-table positioning [delta (Δ): 5.7°, P <0.001]. However, LL significantly decreased between the intraoperative to postoperative radiographs at two to six weeks (Δ: -3.4°, P =0.001), while no change was identified between the intraoperative and more than three-month postoperative radiographs (Δ: -1.6°, P =0.143). SL was found to significantly increase from the preoperative to intraoperative radiographs (Δ: 10.9°, P <0.001), but it subsequently decreased at the two to six weeks follow up (Δ: -2.7, P <0.001) and at the final follow up (Δ: -4.1, P <0.001). On linear regression, cage subsidence/allograft resorption was predictive of the Δ SL (β=0.55; 95% confidence interval: 0.16-0.94; P =0.006), but not LL (β=0.10; 95% confidence interval: -0.44 to 0.65; P =0.708). CONCLUSION Early postoperative radiographs may not accurately reflect the improvement in LL seen on intraoperative radiographic imaging, but they are predictive of long-term lumbar sagittal alignment. Each millimeter of cage subsidence or allograft resorption reduces SL by 0.55°, but subsidence does not significantly affect LL. LEVELS OF EVIDENCE 4.
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Affiliation(s)
- Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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Bordukalo-Nikšić T, Kufner V, Vukičević S. The Role Of BMPs in the Regulation of Osteoclasts Resorption and Bone Remodeling: From Experimental Models to Clinical Applications. Front Immunol 2022; 13:869422. [PMID: 35558080 PMCID: PMC9086899 DOI: 10.3389/fimmu.2022.869422] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/28/2022] [Indexed: 11/18/2022] Open
Abstract
In response to mechanical forces and the aging process, bone in the adult skeleton is continuously remodeled by a process in which old and damaged bone is removed by bone-resorbing osteoclasts and subsequently is replaced by new bone by bone-forming cells, osteoblasts. During this essential process of bone remodeling, osteoclastic resorption is tightly coupled to osteoblastic bone formation. Bone-resorbing cells, multinuclear giant osteoclasts, derive from the monocyte/macrophage hematopoietic lineage and their differentiation is driven by distinct signaling molecules and transcription factors. Critical factors for this process are Macrophage Colony Stimulating Factor (M-CSF) and Receptor Activator Nuclear Factor-κB Ligand (RANKL). Besides their resorption activity, osteoclasts secrete coupling factors which promote recruitment of osteoblast precursors to the bone surface, regulating thus the whole process of bone remodeling. Bone morphogenetic proteins (BMPs), a family of multi-functional growth factors involved in numerous molecular and signaling pathways, have significant role in osteoblast-osteoclast communication and significantly impact bone remodeling. It is well known that BMPs help to maintain healthy bone by stimulating osteoblast mineralization, differentiation and survival. Recently, increasing evidence indicates that BMPs not only help in the anabolic part of bone remodeling process but also significantly influence bone catabolism. The deletion of the BMP receptor type 1A (BMPRIA) in osteoclasts increased osteoblastic bone formation, suggesting that BMPR1A signaling in osteoclasts regulates coupling to osteoblasts by reducing bone-formation activity during bone remodeling. The dual effect of BMPs on bone mineralization and resorption highlights the essential role of BMP signaling in bone homeostasis and they also appear to be involved in pathological processes in inflammatory disorders affecting bones and joints. Certain BMPs (BMP2 and -7) were approved for clinical use; however, increased bone resorption rather than formation were observed in clinical applications, suggesting the role BMPs have in osteoclast activation and subsequent osteolysis. Here, we summarize the current knowledge of BMP signaling in osteoclasts, its role in osteoclast resorption, bone remodeling, and osteoblast–osteoclast coupling. Furthermore, discussion of clinical application of recombinant BMP therapy is based on recent preclinical and clinical studies.
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Affiliation(s)
- Tatjana Bordukalo-Nikšić
- Laboratory for Mineralized Tissues, Center for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Vera Kufner
- Laboratory for Mineralized Tissues, Center for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Slobodan Vukičević
- Laboratory for Mineralized Tissues, Center for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
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Villavicencio AT, Nelson EL, Rajpal S, Beasley K, Burneikiene S. Prospective, randomized, double-blinded clinical trial comparing PEEK and allograft spacers in patients undergoing transforaminal lumbar interbody fusion surgeries. Spine J 2022; 22:84-94. [PMID: 34116214 DOI: 10.1016/j.spinee.2021.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/30/2021] [Accepted: 06/01/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Allograft and polyether-ether-ketone (PEEK) radiographic, biomechanical, histological properties have been extensively studied and both spacers have their advantages and shortcomings. There are no comparative randomized or double-blinded spinal fusion clinical trials reported to date. PURPOSE The study's primary objective was to prospectively investigate clinical and radiological outcomes in patients undergoing lumbar interbody fusions and randomized to receive either PEEK or structural bone allografts. STUDY DESIGN/ SETTING A prospective, randomized, double-blinded clinical trial was initiated at a single center. PATIENT SAMPLE A total of 138 patients were enrolled, randomized and 121 patients completed the study. OUTCOME MEASURES The primary clinical outcome parameters were scored from standardized patient-reported questionnaires. The severity of lower back and leg pain was evaluated using the 11-point Visual Analog Scale (VAS). The Oswestry Disability Questionnaire was used to evaluate chronic disability and activities of daily living. Health-related quality of life and functional outcomes were assessed using Health-related Quality of Life Questionnaire (SF-36 v2). Two scores within the scoring algorithm were analyzed: Physical Component (PCS) and Mental Component Summary (MCS). The primary radiological outcomes included restoration and maintenance of vertebral body height, lumbar sagittal and segmental alignment, and fusion status. METHODS All patients were followed for 2 years ± 2 months; radiographic and clinical outcomes were assessed at 3, 6, 12 and 24 months with an additional follow-up at 3 weeks for radiographic assessment. RESULTS A total of 138 patients undergoing transforaminal lumbar interbody fusions (TLIF) were randomized (1:1) to receive either cortical allograft or PEEK interbody lordotic spacers. Although no differences were detected between the allograft and PEEK patient groups at any of the follow-up time points, there was a highly significant (p<.0001) improvement in all clinical outcome measures. Overall, evidence of radiographic fusion was achieved in 118 (97.5%) patients at the 24 months follow-up. Three patients, all in the allograft group, had pseudoarthrosis and underwent revision surgeries. Postoperative improvement of sagittal alignment, anterior (ABH) or posterior body height (PBH) was initially achieved, but it was mainly lost or reduced at the final follow-up and there were no statistically significant differences between the groups. At the end of the study, improvement and maintenance of lumbar lordosis were achieved in 43.3% and 49.2% patients and segmental alignment in 38.3% and 36.1% for the allograft and PEEK patient groups, respectively. Similarly, ABH was improved and maintained in 28.3% and 36.1% patients and PBH in 28.3% and 44.3% for the allograft and PEEK groups, respectively. CONCLUSIONS Although allograft-assisted surgeries may have reduced fusion rates, the study findings demonstrated that TLIF surgery with two different types of cages and in conjunction with rhBMP-2 resulted in similar radiological or clinical outcomes and a highly statistically significant improvement in all clinical outcome measures at the end of the study regardless of the randomization group.
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Affiliation(s)
- Alan T Villavicencio
- Boulder Neurosurgical Associates, 4743 Arapahoe Avenue, Suite 202, Boulder, CO 80303, USA; Justin Parker Neurological Institute, Boulder, CO 80303, USA
| | - E Lee Nelson
- Boulder Neurosurgical Associates, 4743 Arapahoe Avenue, Suite 202, Boulder, CO 80303, USA
| | - Sharad Rajpal
- Boulder Neurosurgical Associates, 4743 Arapahoe Avenue, Suite 202, Boulder, CO 80303, USA; Justin Parker Neurological Institute, Boulder, CO 80303, USA
| | - Kara Beasley
- Boulder Neurosurgical Associates, 4743 Arapahoe Avenue, Suite 202, Boulder, CO 80303, USA
| | - Sigita Burneikiene
- Boulder Neurosurgical Associates, 4743 Arapahoe Avenue, Suite 202, Boulder, CO 80303, USA; Justin Parker Neurological Institute, Boulder, CO 80303, USA.
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Ismail T, Haumer A, Lunger A, Osinga R, Kaempfen A, Saxer F, Wixmerten A, Miot S, Thieringer F, Beinemann J, Kunz C, Jaquiéry C, Weikert T, Kaul F, Scherberich A, Schaefer DJ, Martin I. Case Report: Reconstruction of a Large Maxillary Defect With an Engineered, Vascularized, Prefabricated Bone Graft. Front Oncol 2021; 11:775136. [PMID: 34938659 PMCID: PMC8685218 DOI: 10.3389/fonc.2021.775136] [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] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/15/2021] [Indexed: 11/14/2022] Open
Abstract
The reconstruction of complex midface defects is a challenging clinical scenario considering the high anatomical, functional, and aesthetic requirements. In this study, we proposed a surgical treatment to achieve improved oral rehabilitation and anatomical and functional reconstruction of a complex defect of the maxilla with a vascularized, engineered composite graft. The patient was a 39-year-old female, postoperative after left hemimaxillectomy for ameloblastic carcinoma in 2010 and tumor-free at the 5-year oncological follow-up. The left hemimaxillary defect was restored in a two-step approach. First, a composite graft was ectopically engineered using autologous stromal vascular fraction (SVF) cells seeded on an allogenic devitalized bone matrix. The resulting construct was further loaded with bone morphogenic protein-2 (BMP-2), wrapped within the latissimus dorsi muscle, and pedicled with an arteriovenous (AV) bundle. Subsequently, the prefabricated graft was orthotopically transferred into the defect site and revascularized through microvascular surgical techniques. The prefabricated graft contained vascularized bone tissue embedded within muscular tissue. Despite unexpected resorption, its orthotopic transfer enabled restoration of the orbital floor, separation of the oral and nasal cavities, and midface symmetry and allowed the patient to return to normal diet as well as to restore normal speech and swallowing function. These results remained stable for the entire follow-up period of 2 years. This clinical case demonstrates the safety and the feasibility of composite graft engineering for the treatment of complex maxillary defects. As compared to the current gold standard of autologous tissue transfer, this patient’s benefits included decreased donor site morbidity and improved oral rehabilitation. Bone resorption of the construct at the ectopic prefabrication site still needs to be further addressed to preserve the designed graft size and shape.
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Affiliation(s)
- Tarek Ismail
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland.,Department of Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexander Haumer
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland.,Department of Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexander Lunger
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
| | - Rik Osinga
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland.,Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland
| | - Alexandre Kaempfen
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland.,Department of Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Franziska Saxer
- Department of Orthopedic Surgery, University Hospital Basel, Basel, Switzerland
| | - Anke Wixmerten
- Department of Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Sylvie Miot
- Department of Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Florian Thieringer
- Clinic for Craniomaxillofacial and Oral Surgery, University Hospital Basel, Basel, Switzerland
| | - Joerg Beinemann
- Clinic for Craniomaxillofacial and Oral Surgery, University Hospital Basel, Basel, Switzerland
| | - Christoph Kunz
- Clinic for Craniomaxillofacial and Oral Surgery, University Hospital Basel, Basel, Switzerland
| | - Claude Jaquiéry
- Clinic for Craniomaxillofacial and Oral Surgery, University Hospital Basel, Basel, Switzerland
| | - Thomas Weikert
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Felix Kaul
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Arnaud Scherberich
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland.,Department of Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Dirk J Schaefer
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland.,Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland
| | - Ivan Martin
- Department of Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
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Yamaguchi JT, Weiner JA, Minardi S, Greene AC, Ellenbogen DJ, Hallman MJ, Shah VP, Weisz KM, Jeong S, Nandurkar T, Yun C, Hsu WK, Hsu EL. Characterizing the host response to rhPDGF-BB in a rat spinal arthrodesis model. JOR Spine 2021; 4:e1173. [PMID: 35005440 PMCID: PMC8717117 DOI: 10.1002/jsp2.1173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 09/09/2021] [Accepted: 09/16/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Due to the constraints surrounding autograft bone, surgeons have turned to osteoinductive agents to augment spinal fusion. Reports of complications and questionable efficacy slowed the adoption of these alternatives. Recombinant human platelet-derived growth factor B homodimer (rhPDGF-BB) has been Food and Drug Administration (FDA)-approved (Augment) to promote fusion in other areas of orthopedics, but its characterization in spine fusion has not yet been tested. The purpose of this study is to characterize the host response to PDGF-BB in vivo. METHODS Eighty female Fischer rats underwent L4-5 posterolateral fusion using one of four implant types: (a) iliac crest syngeneic allograft harvested from syngeneic donors, (b) β-TCP/bovine collagen matrix (β-TCP/Col) with sodium acetate buffer, (c) β-TCP/Col with 0.3 mg/mL "low dose," or (d) β-TCP/Col with 3.0 mg/mL "high dose" of rhPDGF-BB. Animals underwent magnetic resonance imaging (MRI) and serum cytokine quantification at 4, 7, 10, and 21 days, postoperatively. Tissues were processed for immunofluorescence staining for Ki67 and von Willebrand factor (vWF) to assess neovascularization. RESULTS MRI demonstrated no differences in fluid accumulation among the four treatment groups at any of the time points. Serum cytokine analysis showed no clinically significant differences between treatment groups in 20 of the 27 cytokines. Inflammatory cytokines IFN-γ, IL-1β, IL-18, MCP-1, MIP-1α, TNF-α were not induced by rhPDGF-BB. Histology showed no differences in cell infiltration, and Ki67 and vWF immunofluorescence staining was similar among groups. CONCLUSIONS rhPDGF-BB delivered with a β-TCP/Col matrix exerts no exaggerated systemic or local host inflammatory response when compared to iliac crest syngeneic allograft bone or the control carrier. rhPDGF-BB mixed with a β-TCP/Col matrix could be a viable and safe biologic alternative to syngeneic allograft in spine fusion. Further studies need to be performed to evaluate efficacy in this setting.
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Affiliation(s)
- Jonathan T. Yamaguchi
- Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
- Simpson Querrey InstituteFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Joseph A. Weiner
- Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Silvia Minardi
- Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
- Simpson Querrey InstituteFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Allison C. Greene
- Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
- Simpson Querrey InstituteFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - David J. Ellenbogen
- Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
- Simpson Querrey InstituteFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Mitchell J. Hallman
- Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
- Simpson Querrey InstituteFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Vivek P. Shah
- Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
- Simpson Querrey InstituteFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Kevin M. Weisz
- Department of Orthopaedic SurgeryWilliam Beuamont HospitalRoyal OakMichiganUSA
| | - Soyeon Jeong
- Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
- Simpson Querrey InstituteFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Tejas Nandurkar
- Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
- Simpson Querrey InstituteFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Chawon Yun
- Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
- Simpson Querrey InstituteFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Wellington K. Hsu
- Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
- Simpson Querrey InstituteFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Erin L. Hsu
- Department of Orthopaedic SurgeryFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
- Simpson Querrey InstituteFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
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8
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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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9
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Bullock G, Atkinson J, Gentile P, Hatton P, Miller C. Osteogenic Peptides and Attachment Methods Determine Tissue Regeneration in Modified Bone Graft Substitutes. J Funct Biomater 2021; 12:22. [PMID: 33807267 PMCID: PMC8103284 DOI: 10.3390/jfb12020022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 01/01/2023] Open
Abstract
The inclusion of biofunctional molecules with synthetic bone graft substitutes has the potential to enhance tissue regeneration during treatment of traumatic bone injuries. The clinical use of growth factors has though been associated with complications, some serious. The use of smaller, active peptides has the potential to overcome these problems and provide a cost-effective, safe route for the manufacture of enhanced bone graft substitutes. This review considers the design of peptide-enhanced bone graft substitutes, and how peptide selection and attachment method determine clinical efficacy. It was determined that covalent attachment may reduce the known risks associated with growth factor-loaded bone graft substitutes, providing a predictable tissue response and greater clinical efficacy. Peptide choice was found to be critical, but even within recognised families of biologically active peptides, the configurations that appeared to most closely mimic the biological molecules involved in natural bone healing processes were most potent. It was concluded that rational, evidence-based design of peptide-enhanced bone graft substitutes offers a pathway to clinical maturity in this highly promising field.
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Affiliation(s)
- George Bullock
- School of Clinical Dentistry, The University of Sheffield, Sheffield S10 2TA, UK; (G.B.); (J.A.); (C.M.)
| | - Joss Atkinson
- School of Clinical Dentistry, The University of Sheffield, Sheffield S10 2TA, UK; (G.B.); (J.A.); (C.M.)
| | - Piergiorgio Gentile
- School of Engineering, Newcastle University, Stephenson Building, Newcastle upon Tyne NE1 7RU, UK;
| | - Paul Hatton
- School of Clinical Dentistry, The University of Sheffield, Sheffield S10 2TA, UK; (G.B.); (J.A.); (C.M.)
| | - Cheryl Miller
- School of Clinical Dentistry, The University of Sheffield, Sheffield S10 2TA, UK; (G.B.); (J.A.); (C.M.)
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10
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Philipp T, Radoslovich SS, Yoo JU. Risk Factors Associated With Femoral Ring Allograft Breakage in ALIF. Global Spine J 2021; 11:57-62. [PMID: 32875836 PMCID: PMC7734263 DOI: 10.1177/2192568219890294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN This is a retrospective chart review. OBJECTIVES To identify the incidence of, and variables correlated with, femoral ring allograft (FRA) fracture following anterior lumbar interbody fusion (ALIF). METHODS All patients who underwent ALIF using FRAs at an academic institution over 10 years were included. Postoperative radiographs were reviewed by both the primary and senior authors; fracture and no-fracture groups were created for comparison. Patient and surgical characteristics were extracted from electronic medical records. Frequency data comparisons were performed using contingency table analysis; comparisons of means were analyzed for continuous variables. A multivariate linear regression model was developed using screw use, graft height <12 mm, index level, and weight as variables. RESULTS A total of 76 FRAs in 59 patients were identified, 13 (17%) of which fractured. Age, sex, smoking status, use of buttress screws, weight, index level, and presence of spondylolisthesis were not correlated with incidence of fracture (P > .05). There was a significant correlation between the height of FRA and incidence of fracture; 2% (1/52) of grafts ≥12 mm and 50% (12/24) of grafts <12 mm fractured (P < .0001). Using ordinary least-squares regression, this result was independent of patient weight, use of screws, and index level. Of 10 patients, 9 did not require revision surgery to achieve fusion. CONCLUSIONS Graft height was the only variable correlated with incidence of FRA fracture. Graft height <12 mm is an independent risk factor for FRA fracture in patients undergoing ALIF, and their use should be avoided in ALIF procedures.
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Affiliation(s)
| | - Stephanie S. Radoslovich
- Oregon Health & Science University, Portland, OR, USA,Stephanie S. Radoslovich, Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, 3181 S W Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Jung U. Yoo
- Oregon Health & Science University, Portland, OR, USA
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11
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Kamiya N, Atsawasuwan P, Joiner DM, Waldorff EI, Goldstein S, Yamauchi M, Mishina Y. Controversy of physiological vs. pharmacological effects of BMP signaling: Constitutive activation of BMP type IA receptor-dependent signaling in osteoblast lineage enhances bone formation and resorption, not affecting net bone mass. Bone 2020; 138:115513. [PMID: 32603910 PMCID: PMC7423725 DOI: 10.1016/j.bone.2020.115513] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 12/17/2022]
Abstract
Bone morphogenetic proteins (BMPs) were first described over 50 years ago as potent inducers of ectopic bone formation when administrated subcutaneously. Preclinical studies have extensively examined the osteoinductive properties of BMPs in vitro and new bone formation in vivo. BMPs (BMP-2, BMP-7) have been used in orthopedics over 15 years. While osteogenic function of BMPs has been widely accepted, our previous studies demonstrated that loss-of-function of BMP receptor type IA (BMPR1A), a potent receptor for BMP-2, increased net bone mass by significantly inhibiting bone resorption in mice, indicating a positive role of BMP signaling in bone resorption. The physiological role of BMPs (i.e. osteogenic vs. osteoclastogenic) is still largely unknown. The purpose of this study was to investigate the physiological role of BMP signaling in endogenous long bones during adult stages. For this purpose, we conditionally and constitutively activated the Smad-dependent canonical BMP signaling thorough BMPR1A in osteoblast lineage cells using the mutant mice (Col1CreER™:caBmpr1a). Because trabecular bones were largely increased in the loss-of-function mouse study for BMPR1A, we hypothesized that the augmented BMP signaling would affect endogenous trabecular bones. In the mutant bones, the Smad phosphorylation was enhanced within physiological level three-fold while the resulting gross morphology, bodyweights, bone mass/shape/length, serum calcium/phosphorus levels, collagen cross-link patterns, and healing capability were all unchanged. Interestingly, we found; 1) increased expressions of both bone formation and resorption markers in femoral bones, 2) increased osteoblast and osteoclast numbers together with dynamic bone formation parameters by trabecular bone histomorphometry, 3) modest bone architectural phenotype with reduced bone quality (i.e. reduced trabecular bone connectivity, larger diametric size but reduced cortical bone thickness, and reduced bone mechanical strength), and 4) increased expression of SOST, a downstream target of the Smad-dependent BMPR1A signaling, in the mutant bones. This study is clinically insightful because gain-of-function of BMP signaling within a physiological window does not increase bone mass while it alters molecular and cellular aspects of osteoblast and osteoclast functions as predicted. These findings help explain the high-doses of BMPs (i.e. pharmacological level) in clinical settings required to substantially induce a bone formation, concurrent with potential unexpected side effects (i.e. bone resorption, inflammation) presumably due to a broader population of cell-types exposed to the high-dose BMPs rather than osteoblastic lineage cells.
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Affiliation(s)
- Nobuhiro Kamiya
- Department of Biologic and Materials Sciences, School of Dentistry, University of Michigan, Ann Arbor, MI 48109-1078, USA; Faculty of Budo and Sport Studies, Tenri University, Nara 6320071, Japan; Center for Excellence in Hip Disorders, Texas Scottish Rite Hospital for Children, Dallas, TX 75219, USA.
| | - Phimon Atsawasuwan
- School of Dentistry, University of North Carolina, Chapel Hill, NC 27599, USA; College of Dentistry, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Danese M Joiner
- Department of Orthopaedic Surgery, Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Erik I Waldorff
- Department of Orthopaedic Surgery, Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Steve Goldstein
- Department of Orthopaedic Surgery, Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Mitsuo Yamauchi
- School of Dentistry, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Yuji Mishina
- Department of Biologic and Materials Sciences, School of Dentistry, University of Michigan, Ann Arbor, MI 48109-1078, USA.
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12
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Is Multilevel Anterior Lumbar Interbody Fusion (ALIF) Superior to Pedicle Subtraction Osteotomy (PSO) for Degenerative Lumbar Deformity? Clin Spine Surg 2020; 33:1-4. [PMID: 30932932 DOI: 10.1097/bsd.0000000000000817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Rajadurai J, Lovric V, Mobbs RJ, Choy WJ, Walsh WR. The use of demineralised bone fibres (DBF) in conjunction with supercritical carbon dioxide (SCCO 2) treated allograft in anterior lumbar interbody fusion (ALIF). JOURNAL OF SPINE SURGERY 2019; 5:589-595. [PMID: 32043009 DOI: 10.21037/jss.2019.10.04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Spinal fusion is a common procedure for the treatment of various spinal pathologies. Since the early days, spinal fusion has been carried out with the use of bone grafts as interbody spacers. With the development of synthetic interbody implants, bone grafts were used to facilitate fusion. Although autograft provides the best outcomes for fusion, allografts have been sought after due to donor site morbidity and other shortcomings. Currently, a vast variety of demineralised bone matrix (DBM) products are available with their methods of processing and preparation impacting their properties and clinical outcomes. Demineralised bone fibres (DBF), a form a DBM can be easily packed into implants when mixed with other substances such as allograft bone and patient's blood providing a scaffold for the mixture. We report two cases of anterior lumbar interbody fusion (ALIF) utilising a titanium-polyetheretherketone (PEEK) interbody cage filled with DBF, allograft and patient's blood with a maximum of 12 months follow-up outcome.
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Affiliation(s)
- Jeremy Rajadurai
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia.,Prince of Wales Private Hospital, Randwick, NSW, Australia
| | - Vedran Lovric
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,Surgical and Orthopaedics Research Lab (SORL), Prince of Wales Hospital, Randwick, Australia
| | - Ralph J Mobbs
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia.,Prince of Wales Private Hospital, Randwick, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,Surgical and Orthopaedics Research Lab (SORL), Prince of Wales Hospital, Randwick, Australia
| | - Wen Jie Choy
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,Surgical and Orthopaedics Research Lab (SORL), Prince of Wales Hospital, Randwick, Australia
| | - William R Walsh
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,Surgical and Orthopaedics Research Lab (SORL), Prince of Wales Hospital, Randwick, Australia
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14
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Is NO the Answer? The Nitric Oxide Pathway Can Support Bone Morphogenetic Protein 2 Mediated Signaling. Cells 2019; 8:cells8101273. [PMID: 31635347 PMCID: PMC6830101 DOI: 10.3390/cells8101273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/14/2019] [Accepted: 10/16/2019] [Indexed: 12/20/2022] Open
Abstract
The growth factor bone morphogenetic protein 2 (BMP2) plays an important role in bone development and repair. Despite the positive effects of BMP2 in fracture healing, its use is associated with negative side effects and poor cost effectiveness, partly due to the large amounts of BMP2 applied. Therefore, reduction of BMP2 amounts while maintaining efficacy is of clinical importance. As nitric oxide (NO) signaling plays a role in bone fracture healing and an association with the BMP2 pathway has been indicated, this study aimed to investigate the relationship of BMP2 and NO pathways and whether NO can enhance BMP2-induced signaling and osteogenic abilities in vitro. To achieve this, the stable BMP reporter cell line C2C12BRELuc was used to quantify BMP signaling, and alkaline phosphatase (ALP) activity and gene expression were used to quantify osteogenic potency. C2C12BRELuc cells were treated with recombinant BMP2 in combination with NO donors and substrate (Deta NONOate, SNAP & L-Arginine), NOS inhibitor (LNAME), soluble guanylyl cyclase (sGC) inhibitor (LY83583) and activator (YC-1), BMP type-I receptor inhibitor (LDN-193189), or protein kinase A (PKA) inhibitor (H89). It was found that the NOS enzyme, direct NO application, and sGC enhanced BMP2 signaling and improved BMP2 induced osteogenic activity. The application of a PKA inhibitor demonstrated that BMP2 signaling is enhanced by the NO pathway via PKA, underlining the capability of BMP2 in activating the NO pathway. Collectively, this study proves the ability of the NO pathway to enhance BMP2 signaling.
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15
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Buttermann G, Hollmann S, Arpino JM, Ferko N. Value of single-level circumferential fusion: a 10-year prospective outcomes and cost-effectiveness analysis comparing posterior facet versus pedicle screw fixation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:360-373. [PMID: 31583439 DOI: 10.1007/s00586-019-06165-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/24/2019] [Accepted: 09/23/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare the clinical and economic outcomes of facet versus pedicle screw instrumentation for single-level circumferential lumbar spinal fusion. METHODS Outcomes included self-assessment of back and leg pain, pain drawing, ODI, pain medication usage, and procedure success. The CEA was based on the 10-year data collected, and the base-case was from a US payer perspective. Costs included the index surgery, additional surgeries, outpatient/ED visits, and medications. To determine quality-adjusted life years (QALYs), ODI scores were used to predict SF-6D utilities. Sensitivity analyses were performed from a modified payer perspective including device costs and from a societal perspective including productivity loss. Discounted and undiscounted incremental costs and QALYs were calculated. Bootstrapping was performed to estimate the distribution of incremental costs and effects. RESULTS Clinical improvement was significant from pre-op to 10-year follow-up for both groups (p < 0.01 for all outcomes scales). Outcomes were significantly better for back pain and ODI for the facet versus pedicle group at all follow-up periods > 1 year (p < 0.05). In the CEA base-case, facets had more QALYs (0.68) and lower costs (- $8650) per person compared with pedicle screws. Therefore, facets were dominant (i.e., provided cost savings and greater QALYs) compared with pedicle screws. Facets had a 97% probability of being below a willingness-to-pay threshold of $20,000 per QALY gained and were estimated to be dominant over pedicle screws in 84% of the simulations. CONCLUSION One-level circumferential spinal fusion using facet screws was clinically superior and provided cost savings compared with pedicle screw instrumentation in the USA.
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Affiliation(s)
- Glenn Buttermann
- Midwest Spine & Brain Institute, 1950 Curve Crest Boulevard, Stillwater, MN, 55082, USA.
| | | | | | - Nicole Ferko
- Cornerstone Research Group, Burlington, ON, Canada
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16
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Kakuta A, Tanaka T, Chazono M, Komaki H, Kitasato S, Inagaki N, Akiyama S, Marumo K. Effects of micro-porosity and local BMP-2 administration on bioresorption of β-TCP and new bone formation. Biomater Res 2019; 23:12. [PMID: 31372237 PMCID: PMC6660686 DOI: 10.1186/s40824-019-0161-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/17/2019] [Indexed: 01/19/2023] Open
Abstract
Background It has been reported that the microporous structure of calcium phosphate (CaP) ceramics is important to osteoconduction. Bone morphogenetic protein-2 (BMP-2) has been shown to be a promising alternative to bone grafting and a therapeutic agent promoting bone regeneration when delivered locally. The aim of this study was to evaluate the effects of micro-porosity within beta-tricalcium phosphate (β-TCP) cylinders and local BMP-2 administration on β-TCP resorption and new bone formation. Methods Bilateral cylindrical bone defects were created in rabbit distal femora, and the defects were filled with β-TCP. Rabbits were divided into 3 groups; defects were filled with a β-TCP cylinder with a total of approximately 60% porosity (Group A: 13.4% micro- and 46.9% macropore, Group B: 38.5% micro- and 20.3% macropore, Group C: the same micro- and macro-porosity as in group B supplemented with BMP-2). Rabbits were sacrificed 4, 8, 12, and 24 weeks postoperatively. Results The number of TRAP-positive cells and new bone formation in group B were significantly greater than those in group A at every period. The amount of residual β-TCP in group C was less than that in group B at all time periods, resulting in significantly more new bone formation in group C at 8 and 12 weeks. The number of TRAP-positive cells in group C was maximum at 4 weeks. Conclusions These results suggest that the amount of submicron microporous structure and local BMP-2 administration accelerated both osteoclastic resorption of β-TCP and new bone formation, probably through a coupling-like phenomenon between resorption and new bone formation.
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Affiliation(s)
- Atsuhito Kakuta
- 1Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-0003 Japan
| | - Takaaki Tanaka
- 1Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-0003 Japan.,Department of Orthopaedic Surgery, NHO Utsunomiya National Hospital, 2160 Shimo-Okamoto, Utsunomiya City, Tochigi 329-1193 Japan
| | - Masaaki Chazono
- 1Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-0003 Japan.,Department of Orthopaedic Surgery, NHO Utsunomiya National Hospital, 2160 Shimo-Okamoto, Utsunomiya City, Tochigi 329-1193 Japan
| | - Hirokazu Komaki
- 1Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-0003 Japan
| | - Seiichiro Kitasato
- 1Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-0003 Japan
| | - Naoya Inagaki
- 1Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-0003 Japan
| | - Shoshi Akiyama
- 1Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-0003 Japan
| | - Keishi Marumo
- 1Department of Orthopaedic Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-0003 Japan
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17
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Li G, Li P, Chen Q, Thu HE, Hussain Z. Current Updates on Bone Grafting Biomaterials and Recombinant Human Growth Factors Implanted Biotherapy for Spinal Fusion: A Review of Human Clinical Studies. Curr Drug Deliv 2019; 16:94-110. [PMID: 30360738 DOI: 10.2174/1567201815666181024142354] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 08/01/2018] [Accepted: 10/18/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Owing to their great promise in the spinal surgeries, bone graft substitutes have been widely investigated for their safety and clinical potential. By the current advances in the spinal surgery, an understanding of the precise biological mechanism of each bone graft substitute is mandatory for upholding the induction of solid spinal fusion. OBJECTIVE The aim of the present review is to critically discuss various surgical implications and level of evidence of most commonly employed bone graft substitutes for spinal fusion. METHOD Data was collected via electronic search using "PubMed", "SciFinder", "ScienceDirect", "Google Scholar", "Web of Science" and a library search for articles published in peer-reviewed journals, conferences, and e-books. RESULTS Despite having exceptional inherent osteogenic, osteoinductive, and osteoconductive features, clinical acceptability of autografts (patient's own bone) is limited due to several perioperative and postoperative complications i.e., donor-site morbidities and limited graft supply. Alternatively, allografts (bone harvested from cadaver) have shown great promise in achieving acceptable bone fusion rate while alleviating the donor-site morbidities associated with implantation of autografts. As an adjuvant to allograft, demineralized bone matrix (DBM) has shown remarkable efficacy of bone fusion, when employed as graft extender or graft enhancer. Recent advances in recombinant technologies have made it possible to implant growth and differentiation factors (bone morphogenetic proteins) for spinal fusion. CONCLUSION Selection of a particular bone grafting biotherapy can be rationalized based on the level of spine fusion, clinical experience and preference of orthopaedic surgeon, and prevalence of donor-site morbidities.
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Affiliation(s)
- Guanbao Li
- Department of Minimally Invasive Spine Surgery, Yulin City Orthopaedic Hospital of Traditional Chinese Medicine and Western Medicine, NO.597, Jiaoyu Road, Yulin, Guangxi, 537000, China
| | - Pinquan Li
- Department of Minimally Invasive Spine Surgery, Yulin City Orthopaedic Hospital of Traditional Chinese Medicine and Western Medicine, NO.597, Jiaoyu Road, Yulin, Guangxi, 537000, China
| | - Qiuan Chen
- Department of Minimally Invasive Spine Surgery, Yulin City Orthopaedic Hospital of Traditional Chinese Medicine and Western Medicine, NO.597, Jiaoyu Road, Yulin, Guangxi, 537000, China
| | - Hnin Ei Thu
- Department of Pharmacology and Dental Therapeutics, Faculty of Dentistry, Lincoln University College, Jalan Stadium, SS 7/15, Kelana Jaya, 47301 Petaling Jaya, Selangor, Malaysia
| | - Zahid Hussain
- Department of Pharmaceutics, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Puncak Alam Campus, Bandar Puncak Alam 42300, Selangor, Malaysia
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18
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Affiliation(s)
- Ameer Elbuluk
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
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19
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Grgurevic L, Oppermann H, Pecin M, Erjavec I, Capak H, Pauk M, Karlovic S, Kufner V, Lipar M, Bubic Spoljar J, Bordukalo-Niksic T, Maticic D, Peric M, Windhager R, Sampath TK, Vukicevic S. Recombinant Human Bone Morphogenetic Protein 6 Delivered Within Autologous Blood Coagulum Restores Critical Size Segmental Defects of Ulna in Rabbits. JBMR Plus 2018; 3:e10085. [PMID: 31131338 DOI: 10.1002/jbm4.10085] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/29/2018] [Accepted: 12/16/2018] [Indexed: 12/21/2022] Open
Abstract
BMP2 and BMP7, which use bovine Achilles tendon-derived absorbable collagen sponge and bovine bone collagen as scaffold, respectively, have been approved as bone graft substitutes for orthopedic and dental indications. Here, we describe an osteoinductive autologous bone graft substitute (ABGS) that contains recombinant human BMP6 (rhBMP6) dispersed within autologous blood coagulum (ABC) scaffold. The ABGS is created as an injectable or implantable coagulum gel with rhBMP6 binding tightly to plasma proteins within fibrin meshwork, as examined by dot-blot assays, and is released slowly as an intact protein over 6 to 8 days, as assessed by ELISA. The biological activity of ABGS was examined in vivo in rats (Rattus norvegicus) and rabbits (Oryctolagus cuniculus). In a rat subcutaneous implant assay, ABGS induced endochondral bone formation, as observed by histology and micro-CT analyses. In the rabbit ulna segmental defect model, a reproducible and robust bone formation with complete bridging and restoration of the defect was observed, which is dose dependent, as determined by radiographs, micro-CT, and histological analyses. In ABGS, ABC scaffold provides a permissive environment for bone induction and contributes to the use of lower doses of rhBMP6 compared with BMP7 in bovine bone collagen as scaffold. The newly formed bone undergoes remodeling and establishes cortices uniformly that is restricted to implant site by bridging with host bone. In summary, ABC carrier containing rhBMP6 may serve as an osteoinductive autologous bone graft substitute for several orthopedic applications that include delayed and nonunion fractures, anterior and posterior lumbar interbody fusion, trauma, and nonunions associated with neurofibromatosis type I.
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Affiliation(s)
- Lovorka Grgurevic
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
| | | | - Marko Pecin
- Clinics for Surgery, Orthopedics, and Ophthalmology School of Veterinary Medicine University of Zagreb Zagreb Croatia
| | - Igor Erjavec
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
| | - Hrvoje Capak
- Department of Radiology School of Veterinary Medicine University of Zagreb Zagreb Croatia
| | - Martina Pauk
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
| | - Sven Karlovic
- Faculty of Food Technology and Biotechnology University of Zagreb Zagreb Croatia
| | - Vera Kufner
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
| | - Marija Lipar
- Clinics for Surgery, Orthopedics, and Ophthalmology School of Veterinary Medicine University of Zagreb Zagreb Croatia
| | - Jadranka Bubic Spoljar
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
| | | | - Drazen Maticic
- Clinics for Surgery, Orthopedics, and Ophthalmology School of Veterinary Medicine University of Zagreb Zagreb Croatia
| | - Mihaela Peric
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
| | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery Medical University of Vienna Vienna Austria
| | | | - Slobodan Vukicevic
- Laboratory for Mineralized Tissues School of Medicine University of Zagreb Zagreb Croatia
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Ide M, Yamada K, Kaneko K, Sekiya T, Kanai K, Higashi T, Saito T. Combined teriparatide and denosumab therapy accelerates spinal fusion following posterior lumbar interbody fusion. Orthop Traumatol Surg Res 2018; 104:1043-1048. [PMID: 30179720 DOI: 10.1016/j.otsr.2018.07.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 07/09/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Previous studies reported that teriparatide (recombinant human parathyroid hormone) accelerated spinal fusion following posterior lumbar inter-body fusion surgery, and combination therapy using teriparatide and denosumab increased bone marrow density more than teriparatide alone. The purpose of this study is to evaluate the influence of combination therapy with teriparaide and denosumab on spinal fusion after posterior lumbar interbody fusion. MATERIALS AND METHODS Sixteen osteoporotic patients with lumbar canal stenosis were randomly divided into two treatment groups, a teriparatide group (n=8; 20μg of teriparatide daily alone, administered from a month before surgery to 12 months after surgery) and a combination group (n=8; 20μg of teriparatide administered daily from a month before surgery to 12 months after surgery with 60mg denosumab every 6 months, administered at 2 and 8 months following surgery). All patients underwent posterior lumbar interbody fusion with local bone grafts. At 3, 6, 9, and 12 months following surgery, bone mineral density at the femoral neck was measured, and biochemical markers were obtained for bone turnover for all cases. Clinical findings were quantified using the Japanese Orthopedic Association scores before surgery, and at 6 and 12 months following surgery. Fusion rates were measured using computed tomography images before surgery, and 6 and 12 months following surgery. RESULTS Alkaline phosphatase in the teriparatide group increased more than in the combination group at 3 months following surgery (p<0.05). Femoral neck BMD increased more in the combination group than in the teriparatide group at 12 months following surgery. The combination group achieved higher fusion rates than the teriparatide group at 6 months following surgery. CONCLUSIONS Combination therapy with teriparatide and denosumab increased bone mineral density more than teriparatide alone, and accelerated spinal fusion following posterior lumbar interbody fusion.
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Affiliation(s)
- Manabu Ide
- Department of Orthopedic Surgery, Yokohama City University, Fukuura 3-9, Kanazawa-ku, Yokohama-shi, 236-0004 Kanagawa, Japan.
| | - Katsutaka Yamada
- Department of Orthopedic Surgery, Yokohama City University, Fukuura 3-9, Kanazawa-ku, Yokohama-shi, 236-0004 Kanagawa, Japan
| | - Kanichirou Kaneko
- Department of Orthopedic Surgery, Yokohama City University, Fukuura 3-9, Kanazawa-ku, Yokohama-shi, 236-0004 Kanagawa, Japan
| | - Tatsuhiro Sekiya
- Department of Orthopedic Surgery, Yokohama City University, Fukuura 3-9, Kanazawa-ku, Yokohama-shi, 236-0004 Kanagawa, Japan
| | - Kenzo Kanai
- Department of Orthopedic Surgery, Yokohama City University, Fukuura 3-9, Kanazawa-ku, Yokohama-shi, 236-0004 Kanagawa, Japan
| | - Takayuki Higashi
- Department of Orthopedic Surgery, Yokohama City University, Fukuura 3-9, Kanazawa-ku, Yokohama-shi, 236-0004 Kanagawa, Japan
| | - Tomoyuki Saito
- Department of Orthopedic Surgery, Yokohama City University, Fukuura 3-9, Kanazawa-ku, Yokohama-shi, 236-0004 Kanagawa, Japan
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Bone morphogenetic proteins in fracture repair. INTERNATIONAL ORTHOPAEDICS 2018; 42:2619-2626. [DOI: 10.1007/s00264-018-4153-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 09/07/2018] [Indexed: 12/19/2022]
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Beger B, Blatt S, Pabst AM, Hansen T, Goetz H, Al-Nawas B, Ziebart T. Biofunctionalization of synthetic bone substitutes with angiogenic stem cells: Influence on regeneration of critical-size bone defects in an in vivo murine model. J Craniomaxillofac Surg 2018; 46:1601-1608. [PMID: 30196861 DOI: 10.1016/j.jcms.2018.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 05/23/2018] [Accepted: 06/01/2018] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The aim of this study was to investigate the influence of human bone marrow-derived endothelial progenitor cells (EPC) on vascularization and bone regeneration in combination with a bone-substitute material (BSM) in a critical-size bone defect in a murine model. Critical-size bone defects were performed and the defects were filled according to the group membership. MATERIALS AND METHODS Eighteen rats were randomized in two experimental groups: BSM (BoneCeramic) with/without EPC biofunctionalization, and a control group without BSM and EPC. Calvaria bone defects were performed and the defects were filled according to the group membership. After 8 weeks, qualitative tissue response of newly formed bone mass was analyzed by histology, cone beam CT (CBCT) and micro-CT (μCT) scans. Occurrence of tumor masses due to EPC vascularization in peripheral organs was investigated microscopically in histological slides of liver and kidney. RESULTS The combination of EPC and BSM showed smaller bone defects in the CT scans and the histological evaluation as the single use of BSM without EPC by trend (p = 0.067). Further, a higher amount of blood vessels could be found in histological slices of BSM in combination with EPC. No inflammatory response or tumor formation could be found. CONCLUSION These findings confirm the biocompatibility of the used BSM and provide evidence that the combination of BSM with EPC might be effective for bone vascularization and regeneration. Using EPC in augmentation sites might overall lead to faster and better bone regeneration and should be further investigated in future studies.
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Affiliation(s)
- Benjamin Beger
- Department of Oral- and Maxillofacial Surgery, (Head: Univ.-Prof. Dr. Dr. B. Al-Nawas), University Medical Center, Augustusplatz 2, 55131, Mainz, Germany.
| | - Sebastian Blatt
- Department of Oral- and Maxillofacial Surgery, (Head: Univ.-Prof. Dr. Dr. B. Al-Nawas), University Medical Center, Augustusplatz 2, 55131, Mainz, Germany
| | - Andreas Max Pabst
- Department of Oral- and Maxillofacial Surgery, (Head: Prof. Dr. Dr. R. Werkmeister), Federal Armed Forces Hospital, Rübenacherstrasse 170, 56072, Koblenz, Germany
| | - Torsten Hansen
- Institute of Pathology, (Head: Prof. Dr. T. Hansen), Clinic Lippe, Röntgenstrasse 18, 32756, Detmold, Germany
| | - Hermann Goetz
- Biomaterials in Medicine (BioAPP), (Head: Univ.-Prof. Dr. Dr. B. Al-Nawas), University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Bilal Al-Nawas
- Department of Oral- and Maxillofacial Surgery, (Head: Univ.-Prof. Dr. Dr. B. Al-Nawas), University Medical Center, Augustusplatz 2, 55131, Mainz, Germany
| | - Thomas Ziebart
- Department of Oral- and Maxillofacial Surgery, (Head: Univ.-Prof. Dr. Dr. A. Neff), University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
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Karikari IO, Metz LN. Preventing Pseudoarthrosis and Proximal Junctional Kyphosis. Neurosurg Clin N Am 2018; 29:365-374. [DOI: 10.1016/j.nec.2018.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Huang CY, Yeh KT, Yu TC, Lee RP, Chen IH, Peng CH, Liu KL, Wang JH, Wu WT. Surgical results of a one-stage combined anterior lumbosacral fusion and posterior percutaneous pedicle screw fixation. Tzu Chi Med J 2018; 30:20-23. [PMID: 29643712 PMCID: PMC5883832 DOI: 10.4103/tcmj.tcmj_186_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objectives: Lumbosacral fusion through either an anterior or a posterior approach to achieve good lordosis and stability is always a challenging surgical operation and is often accompanied by a higher rate of pseudarthrosis than when other lumbar segments are involved. This study evaluated the clinical and radiological results of lumbosacral fusions achieved through a combined anterior and posterior approach. Materials and Methods: From June 2008 to 2012, 20 patients who had L5–S1 instability and stenosis were consecutively treated, first by anterior interbody fusion using an allogenous strut bone graft through the pararectus approach and then by posterior pedicle screw fixation. A minimum of 1-year of clinical and radiological follow-up was conducted. Intraoperative blood loss, surgical time, and any surgery-related complications were recorded. Clinical outcomes were assessed using a visual analog scale (VAS) and the patient's Oswestry Disability Index (ODI) score. After 1 year, radiological outcomes were assessed by analyzing pelvic incidence, lumbar lordosis, and segmental lordosis using static plain films, while fusion stability was assessed using dynamic plain films. Results: The mean operative time and blood loss were 215 min and 325 cc, respectively. After 1 year, the VAS and ODI scores had significantly improved, and stable fusion with good lordotic curvature was obtained in all cases. Conclusion: The surgical results of the combined procedure are satisfactory in terms of the functional and radiological outcomes. Our method offers advantages regarding both anterior fusion and posterior fixation.
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Affiliation(s)
- Chien-Yuan Huang
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Kuang-Ting Yeh
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tzai-Chiu Yu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ru-Ping Lee
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
| | - Ing-Ho Chen
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Cheng-Huan Peng
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Kuan-Lin Liu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Jen-Hung Wang
- Department of Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Wen-Tien Wu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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Alobaidaan R, Cohen JR, Lord EL, Buser Z, Yoon ST, Youssef JA, Park JB, Brodke DS, Wang JC, Meisel HJ. Complication Rates in Posterior Lumbar Interbody Fusion (PLIF) Surgery With Human Bone Morphogenetic Protein 2: Medicare Population. Global Spine J 2017; 7:770-773. [PMID: 29238641 PMCID: PMC5721992 DOI: 10.1177/2192568217696695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study among Medicare beneficiaries who underwent posterior lumbar interbody fusion (PLIF) surgery. OBJECTIVE To identify the complication rates associated with the use of bone morphogenetic protein 2 (BMP2) in PLIF. Human BMP2 is commonly used in the "off-label" manner for various types of spine fusion procedures, including PLIF. However, recent studies have reported potential complications associated with the recombinant human BMP2 (rhBMP2) use in the posterior approach. METHODS Medicare records within the PearlDiver database were queried for patients undergoing PLIF procedure with and without rhBMP2 between 2005 and 2010. We evaluated complications within 1 year postoperatively. Chi-square was used to compare the complication rates between the 2 groups. RESULTS A total of 8609 patients underwent PLIF procedure with or without rhBMP2. Individual complication rates in the rhBMP2 group ranged from 0.45% to 7.68% compared with 0.65% to 10.99 in the non-rhBMP2 group. Complication rates for cardiac, pulmonary, lumbosacral neuritis, infection, wound, and urinary tract (include acute kidney failure and post-operative complications) were significantly lower in the rhBMP2 group (P < .05). There was no difference in the rates of central nervous system complications or radiculitis between the 2 groups. CONCLUSION Our data showed that the patients who received rhBMP2 had lower complication rates compared to the non-rhBMP2 group. However, use of rhBMP2 was associated with a higher rate of pseudarthrosis. We did not observe any difference in radiculitis and central nervous system complications between the groups.
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Affiliation(s)
| | | | | | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA,Zorica Buser, Department of Orthopaedic Surgery, Elaine Stevely Hoffman Medical Research Center, Keck School of Medicine, University of Southern California, HMR 710, 2011 Zonal Avenue, Los Angeles, CA 90033, USA.
| | | | - Jim A. Youssef
- Durango Orthopedic Associates, Spine Colorado, Durango, CO, USA
| | - Jong-Beom Park
- Uijongbu St Mary’s Hospital, The Catholic University of Korea, Uijongbu, Korea
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Lee DD, Kim JY. A comparison of radiographic and clinical outcomes of anterior lumbar interbody fusion performed with either a cellular bone allograft containing multipotent adult progenitor cells or recombinant human bone morphogenetic protein-2. J Orthop Surg Res 2017; 12:126. [PMID: 28841904 PMCID: PMC5574155 DOI: 10.1186/s13018-017-0618-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 07/11/2017] [Indexed: 11/29/2022] Open
Abstract
Background Both the map3 Cellular Allogeneic Bone Graft® and recombinant human bone morphogenetic protein 2 (rhBMP-2, Infuse®) were developed to provide an alternative to iliac crest autograft, thus eliminating the morbidity associated with its harvest. The recent literature concerning adverse events associated with the use of rhBMP-2, however, highlights the need for a safe and effective alternative. The multipotent adult progenitor cells (MAPC) found in map3 allograft may provide this alternative. The purpose of this study is to report 1-year outcomes of patients treated via anterior lumbar interbody fusion (ALIF) using either map3 Cellular Allogeneic Bone Graft or rhBMP-2 for bony fusion. Methods This was a retrospective evaluation of 41 patients treated via ALIF with either map3 or rhBMP-2 in a polyetheretherketone cage with posterior stabilization at 1, 2, or 3 consecutive levels (L3-S1). Patients were equally divided between treatment groups. The Oswestry Disability Index (ODI) and visual analog scores (VAS) for pain were documented as part of the standard of care. An independent radiologist assessed bridging of bone, disc height, and lordosis. Primary outcome measures included radiographic analysis of fusion by plain film and CTs. Secondary clinical outcomes included visual analogue scale for neck and arm pain and low back disability index scores. Results The overall fusion rate was 91%, with no significant difference between groups. Improvements in ODI and VAS were observed among all patients (p < 0.001), with no significant difference between groups for ODI (p = 0.966) or VAS (p = 0.251). There was no significant difference in terms of changes to disc height and lordosis between groups (p < 0.05). The rhBMP-2 group had increased post-operative complications when compared to the map3 group, but the low numbers precluded statistical analysis. Conclusion Improvements in radiographic and clinical findings were observed in both treatment groups one-year postoperatively. Map3 allograft demonstrated equivalent fusion rates to rhBMP-2. A review of surgical supply costs at the treatment facility favored map3 allograft for the treatment of patients with DDD undergoing an ALIF in 1–3 levels compared to rhBMP-2. Further studies to evaluate long-term outcomes and post-operative complications are required.
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Affiliation(s)
| | - John Yongmin Kim
- Desert Orthopaedic Center, 2800 E Desert Inn Rd, Las Vegas, NV, 89121, USA
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Kang DG, Hsu WK, Lehman RA. Complications Associated With Bone Morphogenetic Protein in the Lumbar Spine. Orthopedics 2017; 40:e229-e237. [PMID: 27992640 DOI: 10.3928/01477447-20161213-06] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 05/24/2016] [Indexed: 02/03/2023]
Abstract
Complications associated with the use of recombinant human bone morphogenetic protein in the lumbar spine include retrograde ejaculation, ectopic bone formation, vertebral osteolysis and subsidence, postoperative radiculitis, and hematoma and seroma. These complications are controversial and remain widely debated. This article discusses the reported complications and possible implications for the practicing spine surgeon. Understanding the complications associated with the use of recombinant human bone morphogenetic protein and the associated controversies allows for informed decision making by both the patient and the surgeon. [Orthopedics. 2017; 40(2):e229-e237.].
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Bae HW, Patel VV, Sardar ZM, Badura JM, Pradhan BB, Seim HB, Turner AS, Toth JM. Transient Local Bone Remodeling Effects of rhBMP-2 in an Ovine Interbody Spine Fusion Model. J Bone Joint Surg Am 2016; 98:2061-2070. [PMID: 28002369 DOI: 10.2106/jbjs.16.00345] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a powerful osteoinductive morphogen capable of stimulating the migration of mesenchymal stem cells (MSCs) to the site of implantation and inducing the proliferation and differentiation of these MSCs into osteoblasts. Vertebral end-plate and vertebral body resorption has been reported after interbody fusion with high doses of rhBMP-2. In this study, we investigated the effects of 2 rhBMP-2 doses on peri-implant bone resorption and bone remodeling at 7 time points in an end-plate-sparing ovine interbody fusion model. METHODS Twenty-one female sheep underwent an end-plate-sparing discectomy followed by interbody fusion at L2-L3 and L4-L5 using a custom polyetheretherketone (PEEK) interbody fusion device. The PEEK interbody device was filled with 1 of 2 different doses of rhBMP-2 on an absorbable collagen sponge (ACS): 0.13 mg (1×) or 0.90 mg (7×). Bone remodeling and interbody fusion were assessed via high-resolution radiography and histological analyses at 1, 2, 3, 4, 8, 12, and 20 weeks postoperatively. RESULTS Peri-implant bone resorption peaked between 3 and 8 weeks in both the 1× and the 7× rhBMP-2/ACS-dose group. Osteoclastic activity and corresponding peri-implant bone resorption was dose-dependent, with moderate-to-marked resorption at the 7×-dose level and less resorption at the 1×-dose level. Both dose (p < 0.0007) and time (p < 0.0025) affected bone resorption significantly. Transient bone-resorption areas were fully healed by 12 weeks. Osseous bridging was seen at all but 1 spinal level at 12 and at 20 weeks. CONCLUSIONS In the ovine end-plate-sparing interbody fusion model, rhBMP-2 dose-dependent osteoclastic resorption is a transient phenomenon that peaks at 4 weeks postoperatively. CLINICAL RELEVANCE Using the U.S. Food and Drug Administration (FDA)-approved rhBMP-2 concentration and matching the volume of rhBMP-2/ACS with the volume of desired bone formation within the interbody construct may limit the occurrence of transient bone resorption.
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Affiliation(s)
- Hyun W Bae
- 1Spine Center, Department of Surgery (H.W.B.), Cedars-Sinai Medical Center (Z.M.S.), Los Angeles, California 2Department of Orthopaedic and Spine Surgery, University of Colorado Health Sciences Center, Aurora, Colorado 3Medtronic Sofamor Danek, Inc., Memphis, Tennessee 4Risser Orthopaedic Group, Pasadena, California 5Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado 6Department of Orthopaedic Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin
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Kerolus M, Turel MK, Tan L, Deutsch H. Stand-alone anterior lumbar interbody fusion: indications, techniques, surgical outcomes and complications. Expert Rev Med Devices 2016; 13:1127-1136. [PMID: 27792409 DOI: 10.1080/17434440.2016.1254039] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Anterior lumbar interbody fusion (ALIF) is a well-established technique to achieve lumbar spine fusion with various indications including degenerative disk disease, spondylolisthesis, recurrent disk herniation, adjacent level disease, pseudoarthrosis, as well as being used as part of the overall strategy to restore sagittal balance. ALIF can be an extremely useful tool in any spine surgeon's armamentarium. However, like any surgical procedure, proper patient selection is key to success. A solid understanding of the biomechanics, careful surgical planning, along with clear knowledge of the advantages and disadvantages of stand-alone ALIF will ensure optimal clinical outcome. Stand-alone ALIF may be a suitable surgical option in carefully selected patients that can provide good clinical results and adequate fusion rates without the need for posterior instrumentation. Areas covered: A brief overview of the indications, techniques, biomechanics, surgical outcome and complications of stand-alone ALIF is provided in this article with a review of the pertinent literature. Expert commentary: In this review we discuss the clinical evidence of using a stand-alone ALIF compared to other fusion techniques of the lumbar spine. The development of interbody cages with integrated screws has increased the arthrodesis rate and improved clinical outcomes while decreasing morbidity and operative time.
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Affiliation(s)
- Mena Kerolus
- a Department of Neurosurgery , Rush University Medical Center , Chicago , IL , USA
| | - Mazda K Turel
- a Department of Neurosurgery , Rush University Medical Center , Chicago , IL , USA
| | - Lee Tan
- a Department of Neurosurgery , Rush University Medical Center , Chicago , IL , USA
| | - Harel Deutsch
- a Department of Neurosurgery , Rush University Medical Center , Chicago , IL , USA
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Hsu WK. Recombinant Human Bone Morphogenetic Protein-2 in Spine Surgery. JBJS Rev 2016; 2:01874474-201406000-00002. [PMID: 27500718 DOI: 10.2106/jbjs.rvw.m.00107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Wellington K Hsu
- 1Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 North St. Clair Street, Suite 1350, Chicago, IL 60611
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James AW, LaChaud G, Shen J, Asatrian G, Nguyen V, Zhang X, Ting K, Soo C. A Review of the Clinical Side Effects of Bone Morphogenetic Protein-2. TISSUE ENGINEERING PART B-REVIEWS 2016; 22:284-97. [PMID: 26857241 DOI: 10.1089/ten.teb.2015.0357] [Citation(s) in RCA: 660] [Impact Index Per Article: 82.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Bone morphogenetic protein-2 (BMP-2) is currently the only Food and Drug Administration (FDA)-approved osteoinductive growth factor used as a bone graft substitute. However, with increasing clinical use of BMP-2, a growing and well-documented side effect profile has emerged. This includes postoperative inflammation and associated adverse effects, ectopic bone formation, osteoclast-mediated bone resorption, and inappropriate adipogenesis. Several large-scale studies have confirmed the relative frequency of adverse events associated with the clinical use of BMP-2, including life-threatening cervical spine swelling. In fact, the FDA has issued a warning of the potential life-threatening complications of BMP-2. This review summarizes the known adverse effects of BMP-2, including controversial areas such as tumorigenesis. Next, select animal models that replicate BMP-2's adverse clinical effects are discussed. Finally, potential molecules to mitigate the adverse effects of BMP-2 are reviewed. In summary, BMP-2 is a potent osteoinductive cytokine that has indeed revolutionized the bone graft substitute market; however, it simultaneously has accrued a worrisome side effect profile. Better understanding of these adverse effects among both translational scientists and clinicians will help determine the most appropriate and safe use of BMP-2 in the clinical setting.
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Affiliation(s)
- Aaron W James
- 1 Department of Orthopaedic Surgery and the Orthopaedic Hospital Research Center, UCLA and Orthopaedic Hospital, University of California , Los Angeles, Los Angeles, California.,2 Section of Orthodontics, Division of Growth and Development, School of Dentistry, University of California , Los Angeles, Los Angeles, California.,3 Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California
| | - Gregory LaChaud
- 1 Department of Orthopaedic Surgery and the Orthopaedic Hospital Research Center, UCLA and Orthopaedic Hospital, University of California , Los Angeles, Los Angeles, California.,2 Section of Orthodontics, Division of Growth and Development, School of Dentistry, University of California , Los Angeles, Los Angeles, California.,3 Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California
| | - Jia Shen
- 2 Section of Orthodontics, Division of Growth and Development, School of Dentistry, University of California , Los Angeles, Los Angeles, California
| | - Greg Asatrian
- 2 Section of Orthodontics, Division of Growth and Development, School of Dentistry, University of California , Los Angeles, Los Angeles, California
| | - Vi Nguyen
- 3 Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California
| | - Xinli Zhang
- 2 Section of Orthodontics, Division of Growth and Development, School of Dentistry, University of California , Los Angeles, Los Angeles, California
| | - Kang Ting
- 2 Section of Orthodontics, Division of Growth and Development, School of Dentistry, University of California , Los Angeles, Los Angeles, California
| | - Chia Soo
- 1 Department of Orthopaedic Surgery and the Orthopaedic Hospital Research Center, UCLA and Orthopaedic Hospital, University of California , Los Angeles, Los Angeles, California.,4 Division of Plastic and Reconstructive Surgery, Department of Surgery, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California
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Bone morphogenetic protein use in spine surgery-complications and outcomes: a systematic review. INTERNATIONAL ORTHOPAEDICS 2016; 40:1309-19. [PMID: 26961193 DOI: 10.1007/s00264-016-3149-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 02/25/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE Because of significant complications related to the use of autologous bone grafts in spinal fusion surgery, bone substitutes and growth factors such as bone morphogenetic protein (BMP) have been developed. One of them, recombinant human (rh) BMP-2, has been approved by the Food and Drug Administration (FDA) for use under precise conditions. However, rhBMP-2-related side effects have been reported, used in FDA-approved procedures, but also in off-label use.A systematic review of clinical data was conducted to analyse the rhBMP-2-related adverse events (AEs), in order to assess their prevalence and the associated surgery practices. METHODS Medline search with keywords "bone morphogenetic protein 2", "lumbar spine", "anterolateral interbody fusion" (ALIF) and the filter "clinical trial". FDA published reports were also included. Study assessment was made by authors (experienced spine surgeons), based on quality of study designs and level of evidence. RESULTS Extensive review of randomised controlled trials (RCTs) and controlled series published up to the present point, reveal no evidence of a significant increase of AEs related to rhBMP-2 use during ALIF surgeries, provided that it is used following FDA guidelines. Two additional RCTs performed with rhBMP-2 in combination with allogenic bone dowels reported increased bone remodelling in BMP-treated patients. This AE was transient and had no consequence on the clinical outcome of the patients. No other BMP-related AEs were reported in these studies. CONCLUSIONS This literature review confirms that the use of rhBMP-2 following FDA-approved recommendations (i.e. one-level ALIF surgery with an LT-cage) is safe. The rate of complications is low and the AEs had been identified by the FDA during the pre-marketing clinical trials. The clinical efficiency of rhBMP-2 is equal or superior to that of allogenic or autologous bone graft in respect to fusion rate, low back pain disability, patient satisfaction and rate of re-operations. For all other off-label use, the safety and effectiveness of rhBMP-2 have not been established, and further RCTs with high level of evidence are required.
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Bougioukli S, Jain A, Sugiyama O, Tinsley BA, Tang AH, Tan MH, Adams DJ, Kostenuik PJ, Lieberman JR. Combination therapy with BMP-2 and a systemic RANKL inhibitor enhances bone healing in a mouse critical-sized femoral defect. Bone 2016; 84:93-103. [PMID: 26723577 PMCID: PMC4903101 DOI: 10.1016/j.bone.2015.12.052] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 12/08/2015] [Accepted: 12/22/2015] [Indexed: 11/26/2022]
Abstract
Recombinant human BMP-2 (rhBMP-2) is a potent osteoinductive agent, but has been associated not only with bone formation, but also osteoclastogenesis and bone resorption. Osteoprotegerin (OPG) is a RANKL inhibitor that blocks differentiation and function of osteoclasts. We hypothesized that the combination of local BMP-2 (recombinant protein or a product of gene therapy) plus systemic OPG-Fc is more effective than BMP-2 alone in promoting bone repair. To test this hypothesis we used a mouse critical-sized femoral defect model. Col2.3eGFP (osteoblastic marker) male mice were treated with rhBMP-2 (group I), rhBMP-2 and systemic OPG (group II), rhBMP-2 and delayed administration of OPG (group III), mouse BM cells transduced with a lentiviral vector containing the BMP-2 gene (LV-BMP-2; group IV), LV-BMP-2 and systemic OPG (group V), a carrier alone (group VI) and administration of OPG alone (group VII). All bone defects treated with BMP-2 (alone or combined with OPG) healed, whereas minimal bone formation was noted in animals treated with the carrier alone or OPG alone. MicroCT analysis showed that bone volume (BV) in rhBMP-2+OPG and LV-BMP-2+OPG groups was significantly higher compared to rhBMP-2 alone (p<0.01) and LV-BMP-2 alone (p<0.001). Similar results were observed in histomorphometry, with rhBMP-2 alone defects exhibiting significantly lower bone area (B.Ar) compared to rhBMP-2+OPG defects (p<0.005) and LV-BMP-2 defects having a significantly lower B.Ar compared to all BMP-2+OPG treated groups (p≤0.01). TRAP staining demonstrated a major osteoclast response in the groups that did not receive OPG (rhBMP-2, LV-BMP-2 and sponge alone) beginning as early as 7days post-operatively. In conclusion, we demonstrated that locally delivered BMP-2 (recombinant protein or gene therapy) in combination with systemically administered OPG improved bone healing compared to BMP-2 alone in a mouse critical-sized bone defect. These data indicate that osteoclasts can diminish healing responses to BMP-2 and that RANKL inhibition may thus accentuate BMP-2 efficacy.
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Affiliation(s)
- Sofia Bougioukli
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ashish Jain
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut Health, Farmington, CT, USA
| | - Osamu Sugiyama
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Brian A Tinsley
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut Health, Farmington, CT, USA
| | - Amy H Tang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Matthew H Tan
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Douglas J Adams
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut Health, Farmington, CT, USA
| | - Paul J Kostenuik
- Phylon Pharma Services, Newbury Park, CA, USA; Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Nayef L, Mekhail M, Benameur L, Rendon JS, Hamdy R, Tabrizian M. A combinatorial approach towards achieving an injectable, self-contained, phosphate-releasing scaffold for promoting biomineralization in critical size bone defects. Acta Biomater 2016; 29:389-397. [PMID: 26478471 DOI: 10.1016/j.actbio.2015.10.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/10/2015] [Accepted: 10/14/2015] [Indexed: 12/18/2022]
Abstract
An injectable, guanosine 5'-diphosphate (GDP)-crosslinked chitosan sponge was investigated as a drug delivery system (DDS) for accelerating biomineralization in critical size bone defects (CSBDs). Two approaches were examined both individually, and in combination, in order to achieve this goal. The first approach involved the encapsulation and release of Bone Morphogenetic Protein 7 (BMP-7), a powerful mineralization stimulant. Results confirmed that the rapid gelation of the chitosan sponge prompted high encapsulation of BMP-7 and provided a controlled release over a period of 30 days with no burst release. The second approach was aimed at encapsulating pyrophosphatase (PPtase) in the chitosan sponge to cleave pyrophosphate (PPi) - a mineralization inhibitor and a degradation by-product of the chitosan sponge - into phosphate ions (Pi). PPtase was successfully encapsulated in the chitosan sponge and was able to completely eliminate PPi from the media by cleaving them to Pi. Chitosan sponges releasing Pi into the media were shown to increase overall biomineralization fourfold as compared to controls, an amount equivalent to biomineralization caused by direct injection of 1μg of free BMP-7 to the cells. Even though the combined encapsulation of 1μg BMP-7 and PPtase in the sponges did not demonstrate an additional increase in biomineralization, encapsulation of low concentrations of BMP-7 can promote mesenchymal stem cell migration into the sponge after application in vivo. The findings suggest that the sponge-PPtase system likely allows excellent bone regeneration with lower concentrations of BMP-7, reducing risks and expense of the treatment. STATEMENT OF SIGNIFICANCE There are bone defects, known as critical size defects, which do not heal on their own and require a therapeutic intervention. The current commercially-available therapies use large quantities of growth factors, such as Bone Morphogenetic Proteins (BMPs), which makes them expensive and a source for a myriad of unwanted side effects. In this manuscript we demonstrate, for the first time, the use of an injectable chitosan-based sponge that contains no inorganic components, but can nonetheless act as a source of phosphate ions to improve bone mineralization. We also demonstrate that this sponge can entrap small concentrations of BMP-7 and provide controlled release over time. The ability to release phosphate ions and low concentrations of BMP-7 makes this therapeutic intervention clinically-relevant, affordable, and safe.
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Tinsley BA, Dukas A, Pensak MJ, Adams DJ, Tang AH, Ominsky MS, Ke HZ, Lieberman JR. Systemic Administration of Sclerostin Antibody Enhances Bone Morphogenetic Protein-Induced Femoral Defect Repair in a Rat Model. J Bone Joint Surg Am 2015; 97:1852-9. [PMID: 26582615 DOI: 10.2106/jbjs.o.00171] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recombinant human bone morphogenetic protein (rhBMP)-2 is a potent osteoinductive agent; however, its clinical use has been reduced because of safety and efficacy concerns. In preclinical studies involving a critical-sized defect in a rat model, sclerostin antibody (Scl-Ab) treatment increased bone formation within the defect but did not result in reliable healing. The purpose of the current study was to evaluate bone repair of a critical-sized femoral defect in a rat model with use of local implantation of rhBMP-2 combined with systemic administration of Scl-Ab. METHODS A critical-sized femoral defect was created in rats randomized into three treatment groups: local rhBMP-2 and systemic Scl-Ab (Scl + BMP), local rhBMP-2 alone, and collagen sponge alone (operative control). The Scl + BMP group received local rhBMP-2 (10 μg) on a collagen sponge placed within the defect intraoperatively and then twice weekly injections of Scl-Ab (25 mg/kg) administered postoperatively. The femora were evaluated at twelve weeks with use of radiography, microcomputed tomography (microCT), histomorphometric analysis, and biomechanical testing. RESULTS At twelve weeks, all Scl + BMP and rhBMP-2 only samples were healed. No femora healed in the operative control group. Histomorphometric analysis demonstrated more bone in the Scl + BMP samples than in the samples treated with rhBMP-2 alone (p = 0.029) and the control samples (p = 0.003). MicroCT revealed that the Scl + BMP group had a 90% greater bone volume within the defect region compared with the rhBMP-2 group and a 350% greater bone volume compared with the operative control group (p < 0.001). Biomechanical testing showed that the group treated with Scl + BMP had greater torsional strength and rigidity compared with the rhBMP-2 group (p < 0.001 and p = 0.047) and the intact femoral control group (p < 0.001). Torque to failure was lower in the rhBMP-2 group compared with the intact femoral control group (p < 0.002). Mean energy to failure was higher in the Scl + BMP samples compared with the rhBMP-2 only samples (p = 0.001). CONCLUSIONS In a critical-sized femoral defect in a rat model, local rhBMP-2 combined with systemic administration of Scl-Ab resulted in more robust healing that was stronger and more rigid than results for rhBMP-2 alone and intact nonoperative femora. CLINICAL RELEVANCE Our study demonstrated that combining an osteoinductive agent with a systemically administered antibody that promotes bone formation can enhance bone repair and has potential as a therapeutic regimen in humans.
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Affiliation(s)
- Brian A Tinsley
- Department of Orthopaedic Surgery, University of Connecticut Health Center, MARB 4th floor, 263 Farmington Avenue, Farmington, CT 06030. E-mail address for B.A. Tinsley:
| | - Alex Dukas
- Department of Orthopaedic Surgery, University of Connecticut Health Center, MARB 4th floor, 263 Farmington Avenue, Farmington, CT 06030. E-mail address for B.A. Tinsley:
| | - Michael J Pensak
- Department of Orthopaedic Surgery, University of Connecticut Health Center, MARB 4th floor, 263 Farmington Avenue, Farmington, CT 06030. E-mail address for B.A. Tinsley:
| | - Douglas J Adams
- Department of Orthopaedic Surgery, University of Connecticut Health Center, MARB 4th floor, 263 Farmington Avenue, Farmington, CT 06030. E-mail address for B.A. Tinsley:
| | - Amy H Tang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Los Angeles, CA 90033
| | - Michael S Ominsky
- Department of Metabolic Disorders, Amgen, Inc., 1 Amgen Center Drive, Thousand Oaks, CA 91320
| | - Hua Zhu Ke
- Bone Research, UCB Pharma, 208 Bath Road, Slough, Berkshire, SL1 3WE, United Kingdom
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Los Angeles, CA 90033
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Sánchez-Duffhues G, Hiepen C, Knaus P, Ten Dijke P. Bone morphogenetic protein signaling in bone homeostasis. Bone 2015; 80:43-59. [PMID: 26051467 DOI: 10.1016/j.bone.2015.05.025] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 04/11/2015] [Accepted: 05/20/2015] [Indexed: 01/06/2023]
Abstract
Bone morphogenetic proteins (BMPs) are cytokines belonging to the transforming growth factor-β (TGF-β) superfamily. They play multiple functions during development and tissue homeostasis, including regulation of the bone homeostasis. The BMP signaling pathway consists in a well-orchestrated manner of ligands, membrane receptors, co-receptors and intracellular mediators, that regulate the expression of genes controlling the normal functioning of the bone tissues. Interestingly, BMP signaling perturbation is associated to a variety of low and high bone mass diseases, including osteoporosis, bone fracture disorders and heterotopic ossification. Consistent with these findings, in vitro and in vivo studies have shown that BMPs have potent effects on the activity of cells regulating bone function, suggesting that manipulation of the BMP signaling pathway may be employed as a therapeutic approach to treat bone diseases. Here we review the recent advances on BMP signaling and bone homeostasis, and how this knowledge may be used towards improved diagnosis and development of novel treatment modalities. This article is part of a Special Issue entitled "Muscle Bone Interactions".
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Affiliation(s)
- Gonzalo Sánchez-Duffhues
- Department of Molecular Cell Biology and Cancer Genomics Centre Netherlands, Leiden University Medical Center, The Netherlands
| | - Christian Hiepen
- Institute for Chemistry and Biochemistry, Freie Universität Berlin, Berlin, Germany; Berlin Brandenburg School of Regenerative Therapies (BSRT), Charité Universitätsmedizin, Berlin, Germany
| | - Petra Knaus
- Institute for Chemistry and Biochemistry, Freie Universität Berlin, Berlin, Germany; Berlin Brandenburg School of Regenerative Therapies (BSRT), Charité Universitätsmedizin, Berlin, Germany.
| | - Peter Ten Dijke
- Department of Molecular Cell Biology and Cancer Genomics Centre Netherlands, Leiden University Medical Center, The Netherlands.
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Gupta A, Kukkar N, Sharif K, Main BJ, Albers CE, III SFEA. Bone graft substitutes for spine fusion: A brief review. World J Orthop 2015; 6:449-456. [PMID: 26191491 PMCID: PMC4501930 DOI: 10.5312/wjo.v6.i6.449] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 04/17/2015] [Accepted: 05/18/2015] [Indexed: 02/06/2023] Open
Abstract
Bone graft substitutes are widely used in the field of orthopedics and are extensively used to promote vertebral fusion. Fusion is the most common technique in spine surgery and is used to treat morbidities and relieve discomfort. Allograft and autograft bone substitutes are currently the most commonly used bone grafts to promote fusion. These approaches pose limitations and present complications to the patient. Numerous alternative bone graft substitutes are on the market or have been developed and proposed for application. These options have attempted to promote spine fusion by enhancing osteogenic properties. In this review, we reviewed biology of spine fusion and the current advances in biomedical materials and biological strategies for application in surgical spine fusion. Our findings illustrate that, while many bone graft substitutes perform well as bone graft extenders, only osteoinductive proteins (recombinant bone morphogenetic proteins-2 and osteogenic protein-1) provide evidence for use as both bone enhancers and bone substitutes for specific types of spinal fusion. Tissue engineered hydrogels, synthetic polymer composites and viral based gene therapy also holds the potential to be used for spine fusion in future, though warrants further investigation to be used in clinical practice.
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Pobloth AM, Duda GN, Giesecke MT, Dienelt A, Schwabe P. High-dose recombinant human bone morphogenetic protein-2 impacts histological and biomechanical properties of a cervical spine fusion segment: results from a sheep model. J Tissue Eng Regen Med 2015; 11:1514-1523. [PMID: 26053675 DOI: 10.1002/term.2049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/20/2015] [Accepted: 04/29/2015] [Indexed: 11/11/2022]
Abstract
The 'off-label' use of high-dose recombinant human bone morphogenetic protein-2 (rhBMP-2) in lumbar and cervical fusion leads to heterotopic bone formation and vertebral osteolysis. These radiographically assessed side-effects in patients were frequently associated with an over-dosage of BMP-2. However, little is so far known about the histological, functional or biomechanical tissue consequences of over-dosage of rhBMP-2 in these specific clinical situations. We hypothesized that a high dose of rhBMP-2 in cervical spinal fusion could induce substantial alterations in bone, leading to mechanical impairment. An anterior cervical spinal fusion (C3-C4 ACDF) model in 16 sheep (aged > 2.5 years; n = 8/group) was used to quantify the consequences of a high rhBMP-2 dose (6 mg rhBMP-2) on fusion tissue compared to the 'gold standard' of autologous, cancellous bone graft. The fusion site was assessed by radiography after 0, 8 and 12 weeks. Biomechanical non-destructive testing and (immuno)histological and histomorphometrical analyses were performed 12 weeks postoperatively. Although high-dose rhBMP-2 treatment led to an advanced radiological fusion result compared to autograft treatment, heterotopic bone formation and vertebral bone resorption were induced simultaneously. Histological evaluation unveiled highly active bone-forming processes ventral to the fusion segment after 12 weeks, while radiolucent areas showed still a partial loss of regular trabecular structure, with rare signs of remodelling and restoration. Despite qualitative alteration of the trabecular bone structure within the fusion site, the massive anterior heterotopic bone formation led to a substantial increase in mechanical stiffness compared to the autograft group. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Anne-Marie Pobloth
- Julius Wolff Institute and Centre for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Germany.,Berlin-Brandenburg Centre for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Germany
| | - Georg N Duda
- Julius Wolff Institute and Centre for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Germany.,Berlin-Brandenburg Centre for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Germany
| | - Moritz T Giesecke
- Centre for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Germany
| | - Anke Dienelt
- Julius Wolff Institute and Centre for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Germany.,Berlin-Brandenburg Centre for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Germany
| | - Philipp Schwabe
- Centre for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Germany
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Martin BI, Lurie JD, Deyo RA, Tosteson AN, Farrokhi FR, Mirza SK. Use of bone morphogenetic protein among patients undergoing fusion for degenerative diagnoses in the United States, 2002 to 2012. Spine J 2015; 15:692-9. [PMID: 25523380 PMCID: PMC4375057 DOI: 10.1016/j.spinee.2014.12.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 12/03/2014] [Accepted: 12/05/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Use of bone morphogenetic protein (BMP) as an adjunct to spinal fusion surgery proliferated after Food and Drug Administration (FDA) approval in 2002. Major safety concerns emerged in 2008. PURPOSE The purpose of this study was to examine whether published concerns about the safety of BMP altered clinical practice. STUDY DESIGN/SETTING The study design involved the analysis of the National Inpatient Sample from 2002 through 2012. PATIENT SAMPLE Adults (older than 20 years) undergoing an elective fusion operation for common degenerative diagnoses were identified using codes from the International Classification of Diseases, ninth revision, Clinical Modification. OUTCOME MEASURES Outcome measures were proportion of cervical and lumbar fusion operations, over time, that involved BMP. METHODS We aggregated the data into a monthly time series and reported the proportion of cervical and lumbar fusion operations, over time, that involved BMP. Autoregressive Integrated Moving Average, a regression model for time series data, was used to test whether there was a statistically significant change in the overall rate of BMP use after an FDA Public Health Notification in 2008. RESULTS Use of BMP in spinal fusion procedures increased rapidly until 2008, involving up to 45.2% of lumbar and 13.5% of cervical fusions. Bone morphogenetic protein use significantly decreased after the 2008 FDA Public Health Notification and revelations of financial payments to surgeons involved in the pivotal FDA-approved trials. For lumbar fusion, the average annual increase was 7.9 percentage points per year from 2002 to 2008, followed by an average annual decrease of 11.7 percentage points thereafter (p≤.001). Use of BMP in cervical fusion increased 2.0% per year until the FDA Public Health Notification, followed by a 2.8% per year decrease (p=.035). CONCLUSIONS Use of BMP in spinal fusion surgery declined subsequent to published safety concerns and revelations of financial conflicts of interest for investigators involved in the pivotal clinical trials.
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Affiliation(s)
- Brook I. Martin
- The Dartmouth Institute for Health Policy and Clinical Practice; and of The Department of Orthopaedic Surgery at Dartmouth-Hitchcock Medical Center, One Medical Center Dr., Lebanon, NH 03756, (603) 653-9167,
| | - Jon D. Lurie
- Departments of Medicine, Orthopaedics, and of The Dartmouth Institute, One Medical Center Dr. Lebanon, NH 03756, (603) 653-3575,
| | - Richard A. Deyo
- Department of Family Medicine, Department of Medicine, Department of Public Health & Preventive Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR. 97239, (503) 494-1694,
| | - Anna N.A. Tosteson
- Departments of Medicine, and Community and Family Medicine, and The Dartmouth Institute, One Medical Center Dr. Lebanon, NH 03756, (603) 653-3519,
| | - Farrokh Reza Farrokhi
- Virginia Mason Medical Center, 1100 9th Ave; Mail stop X7-NS; Seattle, WA 98111, 206-223-7525,
| | - Sohail K. Mirza
- Professor of Orthopaedic Surgery, and The Dartmouth Institute, Chair, Department of Orthopaedics, One Medical Center Dr. Lebanon, NH 03756, (603) 653-6090,
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Vavken J, Mameghani A, Vavken P, Schaeren S. Complications and cancer rates in spine fusion with recombinant human bone morphogenetic protein-2 (rhBMP-2). 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 2015; 25:3979-3989. [PMID: 25772092 DOI: 10.1007/s00586-015-3870-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 02/05/2015] [Accepted: 03/08/2015] [Indexed: 01/20/2023]
Abstract
PURPOSE To quantitatively synthesize the available best evidence for general complications, heterotopic ossification (HO), retrograde ejaculation, cervical swelling, and cancer rates with the use of rhBMP-2 in lumbar and cervical spine fusion. METHODS We conducted an online search for relevant controlled trials and extracted data on the abovementioned endpoints. Studies were eligible for inclusion if they reported on spinal fusion with rhBMP-2 in humans. Publication bias and heterogeneity were assessed mathematically. These data were synthesized in a meta-analysis using DerSimonian-Laird random effects modeling to calculate pooled odds ratios. RESULTS We identified 26 studies reporting on a total of 184,324 patients (28,815 experimental, 155,509 controls) with a mean age of 51.1 ± 1.8 years. There was a significantly higher risk of general complications with rhBMP-2 compared to iliac crest bone graft (ICBG) with an odds ratio (OR) of 1.78 (95 %CI 1.20-2.63), (p = 0.004). The odds ratio for HO was 5.57 (95 %CI 1.90-16.36), (p = 0.002), for retrograde ejaculation 3.31 (95 %CI 1.20-9.09), (p = 0.020), and for cervical swelling 4.72 (95 %CI 1.42-15.67), (p = 0.011), all significantly higher in the rhBMP-2 group. The pooled odds ratio for new onset of tumor was 1.35 (95 %CI 0.93-1.96), which represents no statistically significant difference between the groups (p = 0.111). CONCLUSION rhBMP-2 is associated with a higher rate of general complications as well as retrograde ejaculation, HO, and cervical tissue swelling in spine fusion. There is a slightly increased risk of new onset of tumors, however, without statistical significance.
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Affiliation(s)
- Julia Vavken
- Spine Surgery, University Hospital of Basel, University of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Alexander Mameghani
- Spine Surgery, University Hospital of Basel, University of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Patrick Vavken
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Population and Development Studies, Harvard School of Public Health, Boston, MA, USA
| | - Stefan Schaeren
- Spine Surgery, University Hospital of Basel, University of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
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Charles LF, Woodman JL, Ueno D, Gronowicz G, Hurley MM, Kuhn LT. Effects of low dose FGF-2 and BMP-2 on healing of calvarial defects in old mice. Exp Gerontol 2015; 64:62-9. [PMID: 25681640 DOI: 10.1016/j.exger.2015.02.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/30/2015] [Accepted: 02/10/2015] [Indexed: 02/06/2023]
Abstract
There is an age-associated reduction in the bone healing activity of bone morphogenetic protein-2 (BMP-2) that is currently addressed by administering higher doses of BMP-2 in elderly patients. The unwanted medical complications from high dose BMP-2 motivated this investigation to determine whether the addition of a low dose of fibroblast growth factor 2 (FGF-2) could enhance the ability of a lower dose of BMP-2 to heal calvarial bone defects in old mice (18-20 months old). FGF-2 (5 ng) and BMP-2 (2 μg) were administered by a controlled release two-phase biomaterial scaffold placed into the bone defect. FGF-2 released more rapidly and completely in vitro than BMP-2 (40% vs 2%). In vivo, both BMP-2 and FGF-2+BMP-2 groups formed more new bone in calvarial defects than scaffold alone (p < 0.001) or FGF-2 only groups (p < 0.01). The overall total volume of new bone was not statistically increased by the addition of FGF-2 to BMP-2 as measured by microCT, but the pattern of bone deposition was different. In old mice, but not young, there was enhanced bony fill in the central bone defect area when the BMP-2 was supplemented with FGF-2. Histological analysis of the center of the defect revealed an increased bone volume (%BV/TV (p = 0.004)) from the addition of FGF-2. These studies suggest that combining a low dose of FGF-2 with a low dose of BMP-2 has the potential to increase bone healing in old mice relative to BMP-2 alone.
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Affiliation(s)
- Lyndon F Charles
- Department of Reconstructive Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Jessica L Woodman
- Department of Reconstructive Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Daisuke Ueno
- Unit of Oral and Maxillofacial Implantology, Tsurumi University School of Dental Medicine, Yokohama, Japan
| | - Gloria Gronowicz
- Department of Surgery, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Marja M Hurley
- Department of Medicine, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Liisa T Kuhn
- Department of Reconstructive Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA.
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Radiological evaluation of anterior lumbar fusion using PEEK cages with adjacent vertebral autograft in spinal deformity long fusion surgeries. 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 2015; 24:791-9. [PMID: 25618451 DOI: 10.1007/s00586-014-3745-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 12/25/2014] [Accepted: 12/25/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this study was to evaluate the radiographic characteristics of polyetheretherketone (PEEK) cages packed with adjacent vertebral autograft material in lumbar anterior lumbar interbody fusion (ALIF) in spinal deformity long fusion surgeries. METHODS This is a retrospective radiographic study. From April 2008 to April 2012, 40 patients (5 males and 35 females, mean age 67 ± 9 years) with coronal and/or sagittal spine deformities underwent staged corrective surgery combined with lumbar ALIF using PEEK cages at the L3-L4, L4-L5 or L5-S1 segment with posterior long (≥ 4 levels) instrumentation. The mean follow-up time was 27.5 months (13-49 months). We examined the interbody fusion rate and cage subsidence at 3 months postoperatively and final follow-up. Additionally, we evaluated the distance of cage migration at final follow-up and the improvement in lumbar lordosis. The rate of "collapse" of the adjacent vertebra where the autograft was harvested was assessed at the final follow-up. Finally, we examined the cage-related postoperative complications in this series. RESULTS Solid interbody fusion was achieved in 96.4 % (81/84) of the levels at the final follow-up. A mild forward cage migration was observed, and the mean migration distance at final follow-up was 0.83 mm in L3/4, 0.36 mm in L4/5 and 0.55 mm in L5/S1. There was cage subsidence observed in 8.3 % (7/84) of the levels. In all patients, the PEEK cage maintained a significant increase in segmental lordosis at all postoperative visits. However, a mild reduction in segmental lordosis still occurred with time. The adjacent lumbar vertebral bodies where the autografts were harvested appeared to be intact in height radiologically at the final follow-up. There were no postoperative complications due to bone harvesting or cage insertion. Proximal junctional kyphosis was found in one patient who underwent a subsequent revision surgery. CONCLUSIONS The use of lumbar ALIF with PEEK cages and adjacent vertebral autografts in spinal deformity long fusion surgeries is an effective and safe procedure. The allograft filler is safe and effective in maintaining the shape of harvested vertebrae. Additional long-term follow-up studies are needed to further justify its use.
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Abstract
Retrospective radiographic analysis.To determine the fusion rate of stand-alone lateral lumbar interbody fusion (LLIF). Biomechanical studies have indicated that LLIF may be more stable than anterior or transforaminal lumbar interbody fusion. Early clinical reports of stand-alone LLIF have shown success in obtaining fusion and indirectly decompressing nerve roots. A consecutive case series of stand-alone LLIF was analyzed with chart and radiographic review. Non-union was determined by symptomatology consistent with non-union and absence of bridging bone on the CT scan. Thirty-nine levels of stand alone LLIF were performed in 23 patients. Eleven patients received 1-level surgery, 7 patients received 2-level surgery, 3 patients received 3-level surgery, and 1 patient received 4-level surgery. Excluding 1 infected case, we analyzed 37 levels of stand alone LLIF in 22 patients. Non-union incidence was 7 levels in 6 patients. Non-union rate was 7/37 (19%) per level and 6/22 (27%) per patient. While our study population was relatively low, a non-union rate of 19% to 27% is concerning for modern spine surgery. Currently in our practice, we occasionally still perform stand-alone LLIF utilizing 22 mm wide grafts in low-demand levels in non-smoking and non-osteoporotic patients. However, in a majority of patients, we provide supplemental fixation: bilateral pedicle screws in most patients and unilateral pedicle screws or spinous process plates in some patients.
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Affiliation(s)
- Robert Watkins
- From the Marina Spine Center, Marina del Rey, CA (RW, RW-III); and University of Southern California, Los Angeles, CA (RH)
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Kaiser MG, Groff MW, Watters WC, Ghogawala Z, Mummaneni PV, Dailey AT, Choudhri TF, Eck JC, Sharan A, Wang JC, Dhall SS, Resnick DK. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 16: bone graft extenders and substitutes as an adjunct for lumbar fusion. J Neurosurg Spine 2014; 21:106-32. [PMID: 24980593 DOI: 10.3171/2014.4.spine14325] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In an attempt to enhance the potential to achieve a solid arthrodesis and avoid the morbidity of harvesting autologous iliac crest bone (AICB) for a lumbar fusion, numerous alternatives have been investigated. The use of these fusion adjuncts has become routine despite a lack of convincing evidence demonstrating a benefit to justify added costs or potential harm. Potential alternatives to AICB include locally harvested autograft, calcium-phosphate salts, demineralized bone matrix (DBM), and the family of bone morphogenetic proteins (BMPs). In particular, no option has created greater controversy than the BMPs. A significant increase in the number of publications, particularly with respect to the BMPs, has taken place since the release of the original guidelines. Both DBM and the calciumphosphate salts have demonstrated efficacy as a graft extender or as a substitute for AICB when combined with local autograft. The use of recombinant human BMP-2 (rhBMP-2) as a substitute for AICB, when performing an interbody lumbar fusion, is considered an option since similar outcomes have been observed; however, the potential for heterotopic bone formation is a concern. The use of rhBMP-2, when combined with calcium phosphates, as a substitute for AICB, or as an extender, when used with local autograft or AICB, is also considered an option as similar fusion rates and clinical outcomes have been observed. Surgeons electing to use BMPs should be aware of a growing body of literature demonstrating unique complications associated with the use of BMPs.
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Affiliation(s)
- Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
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A collagen-hydroxyapatite scaffold allows for binding and co-delivery of recombinant bone morphogenetic proteins and bisphosphonates. Acta Biomater 2014; 10:2250-8. [PMID: 24456759 DOI: 10.1016/j.actbio.2014.01.016] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 12/16/2013] [Accepted: 01/14/2014] [Indexed: 01/28/2023]
Abstract
An emerging paradigm in orthopedics is that a bone-healing outcome is the product of the anabolic (bone-forming) and catabolic (bone-resorbing) outcomes. Recently, surgical and tissue engineering strategies have emerged that combine recombinant human bone morphogenetic proteins (rhBMPs) and bisphosphonates (BPs) in order to maximize anabolism and minimize catabolism. Collagen-based scaffolds that are the current surgical standard can bind rhBMPs, but not BPs. We hypothesized that a biomimetic collagen-hydroxyapatite (CHA) scaffold would bind both agents and produce superior in vivo outcomes. Consistent with this concept, in vitro elution studies utilizing rhBMP-2 ELISA assays and scintillation counting of (14)C-radiolabeled zoledronic acid (ZA) confirmed delayed release of both agents from the CHA scaffold. Next, scaffolds were tested for their capacity to form ectopic bone after surgical implantation into the rat hind limb. Using CHA, a significant 6-fold increase in bone volume was seen in rhBMP-2/ZA groups compared to rhBMP-2 alone, confirming the ability of ZA to enhance rhBMP-2 bone formation. CHA scaffolds were found to be capable of generating mineralized tissue in the absence of rhBMP-2. This study has implications for future clinical treatments of critical bone defects. It demonstrates the relative advantages of co-delivering anabolic and anti-catabolic agents using a multicomponent scaffold system.
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Flouzat-Lachaniette CH, Ghazanfari A, Bouthors C, Poignard A, Hernigou P, Allain J. Bone union rate with recombinant human bone morphogenic protein-2 versus autologous iliac bone in PEEK cages for anterior lumbar interbody fusion. INTERNATIONAL ORTHOPAEDICS 2014; 38:2001-7. [DOI: 10.1007/s00264-014-2301-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 02/09/2014] [Indexed: 11/29/2022]
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Incidence and outcome of graft resorption in anterior lumbar interbody fusion: using femoral ring allografts and recombinant human bone morphogenetic protein-2. Spine (Phila Pa 1976) 2014; 39:374-80. [PMID: 24299714 DOI: 10.1097/brs.0000000000000145] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To determine the incidence of resorption after anterior lumbar interbody fusion (ALIF) and its effect on outcome. SUMMARY OF BACKGROUND DATA Recombinant human bone morphogenetic protein-2 (rhBMP-2) used in ALIF has been associated with a 0.5% to 82% incidence of resorption. This has been described as either a complication or part of the natural history. We postulate that early resorption (≤4 mo) in ALIF using femoral ring allograft augmented with rhBMP-2 supplemented with posterior instrumentation has no effect on outcome. METHODS Institutional review board-approved retrospective 60 chart cohort study of ALIF using femoral ring allograft-augmented rhBMP-2 supplemented with posterior instrumentation from May 5, 2005, to April 6, 2010. Two groups were based upon the presence or absence of early graft resorption (≤4 mo). Patients were seen prior to surgery and postoperatively until 29 ± 20 months (last visit). Follow-up visual analogue scale pain scores and radiographical evidence of fusion were measured and compared between the 2 groups. RESULTS Sixty patients, 27 females and 33 males had follow-up for 29 ± 20 months. Group 1 (33 patients, 45 levels) and group 2 (27 patients, 36 levels) were identical in age (P = 0.62), sex distribution (P = 0.43), preoperative pain score (P = 0.63), and in the rhBMP-2 dose per level (P = 0.77). There were no significant group differences in postoperative visual analogue scale scores but a trend to higher fusion rate in group 1 was seen (P = 0.07) at 6 months. There was a 40% incidence of early resorption with no significant differences in visual analogue scale scores or fusion rate between both groups. CONCLUSION There is a 40% incidence of early resorption (≤4 mo) that had no significant effect on pain score or fusion rate. Resorption should be considered part of the fusion process and not necessarily a complication. LEVEL OF EVIDENCE 3.
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Kodera R, Miyazaki M, Yoshiiwa T, Kawano M, Kaku N, Tsumura H. Manipulation of anabolic and catabolic responses with bone morphogenetic protein and zoledronic acid in a rat spinal fusion model. Bone 2014; 58:26-32. [PMID: 24103577 DOI: 10.1016/j.bone.2013.09.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 09/25/2013] [Accepted: 09/27/2013] [Indexed: 11/23/2022]
Abstract
Bone fusion involves a complex set of regulated signaling pathways that control the formation of new bone matrix and the resorption of damaged bone matrix at the surgical site. It has been reported that systemically administering a single dose of zoledronic acid (ZA) at the optimal time increases the strength of the bone morphogenetic protein (BMP)-mediated callus. In the present study, we aimed to investigate the effect of BMP-2 and ZA in a rat spinal model. Sixty-seven rats were divided into 6 groups: group I (n=11) animals were implanted with a carrier alone, group II (n=12) animals were implanted with a carrier and a subcutaneous injection of ZA was administered 2weeks after surgery, group III (n=12) animals were implanted with a carrier containing 1μg of rhBMP-2, group IV (n=12) animals were implanted with a carrier containing 1μg of rhBMP-2 and a subcutaneous injection of ZA was administered 2weeks after surgery, group V (n=10) animals were implanted with a carrier containing 3μg of rhBMP-2, and group VI (n=10) animals were implanted with a carrier containing 3μg of rhBMP-2 and a subcutaneous injection of ZA was administered 2weeks after surgery. The rats were euthanized after 6weeks, and their spines were explanted and assessed by manual palpation, radiography, high-resolution micro-computerized tomography (micro-CT), and histologic analysis. The fusion rates in group VI (60%) were considerably higher than those in the groups I (0%), II (0%), III (12.5%), IV (20.8%), and V (35%), (P<0.05). Additionally, the radiographic scores of group VI were higher than those in the other groups, (P<0.05). In micro-CT analysis, the tissue and bone volumes of the callus were significantly higher in group VI than those in the other groups, (P<0.05). The trabecular number was significantly higher and the trabecular spacing was significantly lower in group VI than those in the other groups, (P<0.05). The combination of rhBMP-2 and ZA administered systemically as a single dose at the optimal time was efficacious in our rat spinal fusion model. Our results suggest that this combination facilitates spinal fusion and has potential clinical application.
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Affiliation(s)
- Ryuzo Kodera
- Department of Orthopaedic Surgery, Oita University, Oita, Japan
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The clinical use of bone morphogenetic proteins revisited: a novel biocompatible carrier device OSTEOGROW for bone healing. INTERNATIONAL ORTHOPAEDICS 2013; 38:635-47. [PMID: 24352822 DOI: 10.1007/s00264-013-2201-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 11/12/2013] [Indexed: 01/01/2023]
Abstract
PURPOSE The purpose of this study was to revise the clinical use of commercial BMP2 (Infuse) and BMP7 (Osigraft) based bone devices and explore the mechanism of action and efficacy of low BMP6 doses in a novel whole blood biocompatible device OSTEOGROW. METHODS Complications from the clinical use of BMP2 and BMP7 have been systemically reviewed in light of their role in bone remodeling. BMP6 function has been assessed in Bmp6-/- mice by μCT and skeletal histology, and has also been examined in mesenchymal stem cells (MSC), hematopoietic stem cells (HSC) and osteoclasts. Safety and efficacy of OSTEOGROW have been assessed in rats and rabbits. RESULTS Clinical use issues of BMP2 and BMP7 have been ascribed to the limited understanding of their role in bone remodeling at the time of device development for clinical trials. BMP2 and BMP7 in bone devices significantly promote bone resorption leading to osteolysis at the endosteal surfaces, while in parallel stimulating exuberant bone formation in surrounding tissues. Unbound BMP2 and BMP7 in bone devices precipitate on the bovine collagen and cause inflammation and swelling. OSTEOGROW required small amounts of BMP6, applied in a biocompatible blood coagulum carrier, for stimulating differentiation of MSCs and accelerated healing of critical size bone defects in animals, without bone resorption and inflammation. BMP6 decreased the number of osteoclasts derived from HSC, while BMP2 and BMP7 increased their number. CONCLUSIONS Current issues and challenges with commercial bone devices may be resolved by using novel BMP6 biocompatible device OSTEOGROW, which will be clinically tested in metaphyseal bone fractures, compartments where BMP2 and BMP7 have not been effective.
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