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Rajkovic CJ, Tracz JA, DeMordaunt T, Davidar AD, Perdomo-Pantoja A, Judy BF, Zhang KY, Hernandez VN, Lin J, Lazzari JL, Cottrill E, Witham TF. Synthesis and evaluation of a novel vancomycin-infused, biomimetic bone graft using a rat model of spinal implant-associated infection. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100323. [PMID: 38746017 PMCID: PMC11091687 DOI: 10.1016/j.xnsj.2024.100323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/05/2024] [Accepted: 04/06/2024] [Indexed: 05/16/2024]
Abstract
Background Postoperative infection is a complication of spinal fusion surgery resulting in increased patient morbidity. Strategies including intraoperative application of powdered vancomycin have been proposed to reduce the incidence of infection; however, such antimicrobial effects are short-lived. Methods Instrumentation of the L4-L5 vertebrae was performed mimicking pedicle screw and rod fixation in 30 rats. Titanium instrumentation inoculated with either PBS or 1×105 CFU bioluminescent MRSA, along with biomimetic bone grafts infused with varying concentrations of vancomycin and 125 µg of rhBMP-2 (BioMim-rhBMP-2-VCM) were implanted prior to closure. Infection was quantified during the six-week postoperative period using bioluminescent imaging. Arthrodesis was evaluated using micro-CT. Results Infected animals receiving a bone graft infused with low-dose (0.18 mg/g) or high-dose vancomycin (0.89 mg/g) both exhibited significantly lower bioluminescent signal over the six-week postoperative period than control animals inoculated with MRSA and implanted with bone grafts lacking vancomycin (p=.019 and p=.007, respectively). Both low and high-dose vancomycin-infused grafts also resulted in a statistically significant reduction in average bioluminescence when compared to control animals (p=.027 and p=.047, respectively), independent of time. MicroCT analysis of animals from each group revealed pseudoarthrosis only in the control group, suggesting a correlation between infection and pseudoarthrosis. MRSA-inoculated control animals also had significantly less bone volume formation on micro-CT than the PBS-inoculated control cohort (p<.001), the MRSA+low-dose vancomycin-infused bone graft cohort (p<.001), and the MRSA+high-dose vancomycin-infused bone graft cohort (p<.001). Conclusion BioMim-rhBMP-2-VCM presents a novel tissue engineering approach to simultaneously promoting arthrodesis and antimicrobial prophylaxis in spinal fusion. Despite mixed evidence of potential osteotoxicity of vancomycin reported in literature, BioMim-rhBMP-2-VCM preserved arthrodesis and osteogenesis with increasing vancomycin loading doses due to the graft's osteoinductive composition.
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Affiliation(s)
- Christian J Rajkovic
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Jovanna A Tracz
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Trevor DeMordaunt
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Alexander Perdomo-Pantoja
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
- Department of Neurosurgery, Washington University in St. Louis School of Medicine, 660 S. Euclid Avenue Campus Box 8057, St. Louis, MO 63110, United States
| | - Brendan F Judy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Kevin Yang Zhang
- Department of Pathology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Vaughn N Hernandez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Jessica Lin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Julianna L Lazzari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
- Department of Orthopaedic Surgery, Duke University School of Medicine, DUMC Box 104002, Durham, NC 27710, United States
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
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Morse KW, Moore H, Kumagai H, Hahn W, Koo A, Meyers KN, Bouxsein ML, Brooks DJ, Lanske B, Iyer S, Cunningham M. Abaloparatide Enhances Fusion and Bone Formation in a Rabbit Spinal Arthrodesis Model. Spine (Phila Pa 1976) 2022; 47:1607-1612. [PMID: 35943233 PMCID: PMC10024932 DOI: 10.1097/brs.0000000000004452] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/21/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective randomized placebo controlled animal trial. OBJECTIVE Determine the effect of daily subcutaneous abaloparatide injection on the intervertebral fusion rate in rabbits undergoing posterolateral fusion. STUDY OF BACKGROUND DATA Despite the wide utilization of spine fusion, pseudarthrosis remains prevalent, and results in increased morbidity. Abaloparatide is a novel analog of parathyroid hormone-related peptide (1-34) and has shown efficacy in a rat posterolateral spine fusion model to increase fusion rates. The effect of abaloparatide on the fusion rate in a larger animal model remains unknown. MATERIALS AND METHODS A total of 24 skeletally mature New Zealand White male rabbits underwent bilateral posterolateral spine fusion. Following surgery, the rabbits were randomized to receive either saline as control or abaloparatide subcutaneous injection daily. Specimens underwent manual assessment of fusion, radiographic analysis with both x-ray and high-resolution peripheral quantitative computed tomography, and biomechanical assessment. RESULTS Rabbits that received abaloparatide had a 100% (10/10) fusion rate compared with 45% (5/11) for controls ( P <0.02) as assessed by manual palpation. Radiographic analysis determined an overall mean fusion score of 4.17±1.03 in the abaloparatide group versus 3.39±1.21 for controls ( P <0.001). The abaloparatide group also had a greater volume of bone formed with a bone volume of 1209±543 mm 3 compared with 551±152 mm 3 ( P <0.001) for controls. The abaloparatide group had significantly greater trabecular bone volume fraction and trabecular thickness and lower specific bone surface and connectivity density in the adjacent levels when compared with controls. Abaloparatide treatment did not impact trabecular number or separation. There were no differences in biomechanical testing in flexion, extension, or lateral bending ( P >0.05) between groups. CONCLUSIONS Abaloparatide significantly increased the fusion rate in a rabbit posterolateral fusion model as assessed by manual palpation. In addition, there were marked increases in the radiographic evaluation of fusion.
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Affiliation(s)
- Kyle W. Morse
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Harold Moore
- Weill Cornell Medical College, New York, NY, USA
| | - Hiroshi Kumagai
- Department of Orthopaedic Surgery, Tsukuba Memorial Hospital, Tsukuba, Japan
| | - William Hahn
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Kathleen N. Meyers
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Mary L. Bouxsein
- Center for Advanced Orthopaedic Studies, Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA
| | - Daniel J. Brooks
- Center for Advanced Orthopaedic Studies, Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Sravisht Iyer
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Matthew Cunningham
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
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Raad M, Ortiz-Babilonia C, Hassanzadeh H, Puvanesarajah V, Kebaish K, Jain A. Cost-utility Analysis of Neoadjuvant Teriparatide Therapy in Osteopenic Patients Undergoing Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2022; 47:1121-1127. [PMID: 35797582 DOI: 10.1097/brs.0000000000004409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/10/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cost-utility analysis study. OBJECTIVE This study aims to evaluate the cost-utility of neoadjuvant teriparatide therapy in osteopenic patients undergoing adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA There is increasing evidence supporting preoperative use of anabolic agents such as teriparatide for preoperative optimization of ASD patients with poor bone density. However, such treatments are associated with added costs. To our knowledge, the cost-utility of teriparatide in osteopenic patients undergoing ASD surgery has not been established. MATERIALS AND METHODS A decision-analysis model was developed for a hypothetical 68-year-old female patient with osteopenia ( T score <-1.0) undergoing a T11 to pelvis instrumented spinal fusion for ASD. A comprehensive literature review was conducted to create estimates for event probabilities, costs, and quality adjusted life years at each node. Key model assumptions were that administration of a 4-month preoperative teriparatide course reduced 2-year postoperative reoperation rates [for pseudarthrosis from 5% to 2.5% and for proximal junctional failure (PJF) from 15% to 5%]. Monte Carlo simulations were used to calculate the mean incremental cost utility ratio and incremental net monetary benefits. One-way sensitivity analysis was used to estimate the contribution of individual parameters to uncertainty in the model. RESULTS Teriparatide was the favored strategy in 82% of the iterations. The mean incremental cost utility ratio for the teriparatide strategy was negative (higher net benefit, lower net cost), and lower than the willingness-to-pay threshold of $50,000 per quality adjusted life year. Teriparatide use was associated with a mean incremental net monetary benefit of $3,948. One-way sensitivity analysis demonstrated that the factors with the greatest impact on the model were the incidence of PJF in the no teriparatide group, the duration and monthly cost of treatment, and the cost of reoperation due to PJF. CONCLUSIONS Neoadjuvant teriparatide is a cost-effective strategy to reduce postoperative complications in patients with osteopenia undergoing ASD surgery.
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Affiliation(s)
- Micheal Raad
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Carlos Ortiz-Babilonia
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
- Department of Orthopaedic Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | | | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
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Abe T, Miyazaki M, Ishihara T, Kanezaki S, Tsubouchi Y, Tsumura H. Optimal intermittent administration interval of parathyroid hormone 1-34 for bone morphogenetic protein-induced bone formation in a rat spinal fusion model. JOR Spine 2021; 4:e1168. [PMID: 34611590 PMCID: PMC8479526 DOI: 10.1002/jsp2.1168] [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] [Received: 02/25/2021] [Revised: 07/16/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Both bone morphogenetic protein 2 (BMP-2) and teriparatide (parathyroid hormone [PTH] 1-34) are used to enhance bone healing. There is still no established opinion regarding the optimum dose and administration method. We investigated the optimal administration method for the combination of BMP-2 and PTH 1-34 in a rat spinal fusion model. METHODS Group I was implanted with a control carrier. Groups II, III, and IV were implanted with a carrier containing 3 μg of recombinant human BMP-2 (rhBMP-2). In addition, following implantation, PTH 1-34 injections were administered to Group III thrice a week (total, 180 μg/kg/week) and Group IV six times a week (total, 180 μg/kg/week). The rats were euthanized after 8 weeks, and their spines were explanted; assessed by manual palpation, radiographs, and high-resolution micro-computed tomography (micro-CT); and subjected to histological analysis. Serum markers of bone metabolism were also analyzed. RESULTS Manual palpation tests showed that the fusion rates in Groups III and IV were considerably higher than those in Group I. They also had higher radiographic scores than Group I and II. Micro-CT analysis revealed Tb.Th in the Group IV had higher values than that in the Group I, II, III with significant differences and Tb.Sp in the Group IV had lower values than that in the Group I, II, III with significant differences. Serum marker analysis revealed that Group IV had higher osteocalcin and lower tartrate-resistant acid phosphatase-5b than Group III. Histological analysis indicated that Group IV had enhanced trabecular bone structure. CONCLUSIONS Frequent administration of PTH may be better in making thicker and strengthening the trabecular bone structure in newly formed bone in the rat spinal fusion model using insufficient BMP-2.
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Affiliation(s)
- Tetsutaro Abe
- Faculty of Medicine, Department of Orthopedic SurgeryOita UniversityOitaJapan
| | - Masashi Miyazaki
- Faculty of Medicine, Department of Orthopedic SurgeryOita UniversityOitaJapan
| | - Toshinobu Ishihara
- Faculty of Medicine, Department of Orthopedic SurgeryOita UniversityOitaJapan
| | - Shozo Kanezaki
- Faculty of Medicine, Department of Orthopedic SurgeryOita UniversityOitaJapan
| | | | - Hiroshi Tsumura
- Faculty of Medicine, Department of Orthopedic SurgeryOita UniversityOitaJapan
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Drakopoulos P, Flevas DA, Galanopoulos IP, Lepetsos P, Zafeiris C. Off-Label Use of Teriparatide in Spine. Cureus 2021; 13:e16522. [PMID: 34430132 PMCID: PMC8376240 DOI: 10.7759/cureus.16522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2021] [Indexed: 11/12/2022] Open
Abstract
Teriparatide belongs to osteo-anabolic compounds and has been used in recent years to treat patients with osteoporosis, with the benefits of increased bone density. Its osteo-anabolic action has led to the investigation of the use of teriparatide for the improvement of bone quality. Apart from the enhancement of fracture union, teriparatide has been extensively studied in the promotion of fusion rate after spinal fusion. This study summarizes the preclinical and clinical results of the off-label use of teriparatide in the spine, and specifically its intermittent administration after instrumented spinal arthrodesis along with its impact on the spinal bone quality and spinal bone mineral density.
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Affiliation(s)
- Panagiotis Drakopoulos
- Laboratory for the Research of the Musculoskeletal System, University of Athens, KAT Hospital, Athens, GRC.,Orthopaedics, Thriasio General Hospital, Athens, GRC
| | - Dimitrios A Flevas
- Arthroscopy and Orthopaedic Surgery, Metropolitan General Hospital, Athens, GRC
| | | | | | - Christos Zafeiris
- Orthopaedics and Spine Surgery, Metropolitan General Hospital, Athens, GRC
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Arlt H, Besschetnova T, Ominsky MS, Fredericks DC, Lanske B. Effects of systemically administered abaloparatide, an osteoanabolic PTHrP analog, as an adjuvant therapy for spinal fusion in rats. JOR Spine 2021; 4:e1132. [PMID: 33778406 PMCID: PMC7984001 DOI: 10.1002/jsp2.1132] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/26/2020] [Accepted: 11/04/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Abaloparatide is a parathyroid hormone receptor agonist that increases bone formation and reduces vertebral and nonvertebral fracture risk in women with postmenopausal osteoporosis. Animal studies indicate abaloparatide stimulates vertebral bone formation and enhances bony bridging and biomechanical stability of fracture calluses. AIMS The current study is evaluating the potential utility for abaloparatide as an adjunct therapy for spinal fusions. MATERIAL AND METHODS The effects of 14 or 28 days of daily subcutaneous injections of abaloparatide (20 μg/kg/d) or vehicle were evaluated in 32 male Sprague-Dawley rats starting 1 day after noninstrumented posterolateral fusion (PLF) with bone autograft. Fusion mass microarchitecture was analyzed by micro-computed tomography (micro-CT) and serum markers of bone formation and bone resorption were evaluated. Motion segments were scored in a blinded manner as fused or unfused by postmortem radiography and manual palpation. RESULTS Abaloparatide-treated rats showed higher bone formation (serum osteocalcin) at day 14 and 28 compared with vehicle controls, without increases in the bone resorption marker serum TRACP-5b. Micro-CT showed greater trabecular number in fusion masses from the abaloparatide group vs vehicle controls at day 14. Manual palpation and radiography indicated no fusions in either group at day 14, whereas 25% of vehicle-treated rats and 50% of abaloparatide-treated rats had bilateral fusion at day 28. DISCUSSION AND CONCLUSION In summary, this rat PLF model showed that abaloparatide treatment was associated with higher levels of the bone formation marker osteocalcin, improved fusion mass architecture, and a non- significant 2-fold higher fusion rate compared with vehicle.
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Affiliation(s)
- Heike Arlt
- Research & DevelopmentRadius Health, Inc.WalthamMassachusettsUSA
| | | | | | - Douglas C. Fredericks
- Department of Orthopedics and RehabilitationUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | - Beate Lanske
- Research & DevelopmentRadius Health, Inc.WalthamMassachusettsUSA
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Yu T, Zheng L, Chen G, Wang N, Wang X, Song C, Yan J, Xi C. A Study to Compare the Efficacy of a Biodegradable Dynamic Fixation System With Titanium Devices in Posterior Spinal Fusion Between Articular Processes in a Canine Model. J Biomech Eng 2021; 143:031010. [PMID: 33210131 DOI: 10.1115/1.4049154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Indexed: 11/08/2022]
Abstract
The objective of this study was to apply a biodegradable dynamic fixation system (BDFS) for lumbar fusion between articular processes and compare the fusion results and biomechanical changes with those of conventional rigid fixation. Twenty-four mongrel dogs were randomly assigned to 2 groups and subjected to either posterior lumbar fusion surgery with a BDFS or titanium rods (TRs) at the L5-L6 segments. Six animals in each group were sacrificed at 8 or 16 weeks. Fusion conditions were evaluated by computed tomography (CT), manual palpation, biomechanical tests, and histological analysis. Biomechanical tests were performed at the L4-7 (for range of motion (ROM)) and L5-6 (for fusion stiffness) segments. Histological examination was performed on organs, surrounding tissues, and the fused area. The magnesium alloy components maintained their initial shape 8 weeks after the operation, but the meshing teeth were almost completely degraded at 16 weeks. The biomechanical analysis revealed an increased lateral bending ROM at 8 weeks and axial torsion ROM at 16 weeks. The L4-5 extension-flexion ROMs in the BDFS group were 2.29 ± 0.86 deg and 3.17 ± 1.08 deg at 16 weeks, respectively, compared with 3.22 ± 0.56 deg and 5.55 ± 1.84 deg in TR group. However, both groups showed similar fusion results. The BDFS design is suitable, and its degradation in vivo is safe. The BDFS can be applied for posterior lumbar fusion between articular processes to complete the fusion well. Additionally, the BDFS can reduce the decline in lateral motion and hypermotion of the cranial adjacent segment in flexion-extension motion.
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Affiliation(s)
- Tailong Yu
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, No. 246, Xuefu Road, Harbin, Heilongjiang 150001, China
| | - Leyu Zheng
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, No. 246, Xuefu Road, Harbin, Heilongjiang 150001, China
| | - Guanghua Chen
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, No. 246, Xuefu Road, Harbin, Heilongjiang 150001, China
| | - Nanxiang Wang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, No. 600, Tianhe Road, Tianhe District, Guangzhou, Guangdong 510000, China
| | - Xiaoyan Wang
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, No. 246, Xuefu Road, Harbin, Heilongjiang 150001, China
| | - Chengchao Song
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, No. 246, Xuefu Road, Harbin, Heilongjiang 150001, China
| | - Jinglong Yan
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, Xuefu Road 246#, Harbin, Heilongjiang 150001, China
| | - Chunyang Xi
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, Xuefu Road 246#, Harbin, Heilongjiang 150001, China
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Yolcu YU, Zreik J, Alvi MA, Wanderman NR, Carlson BC, Nassr A, Fogelson JL, Elder BD, Freedman BA, Bydon M. Use of teriparatide prior to lumbar fusion surgery lowers two-year complications for patients with poor bone health. Clin Neurol Neurosurg 2020; 198:106244. [PMID: 32980798 DOI: 10.1016/j.clineuro.2020.106244] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Poor bone health can create challenges in management which are amplified for patients undergoing spinal fusion. Although previously shown to improve outcomes postoperatively, the impact of preoperative teriparatide use on long-term complications remains unclear. In this study, we investigated the complication rates within two years of surgery for osteoporotic and osteopenic patients using teriparatide prior to lumbar fusion procedures. METHODS Patients with poor bone health undergoing any lumbar fusion surgery at a single institution between 2008 and 2018 were identified and subsequently divided into two groups as teriparatide and non-teriparatide group. Baseline demographics, patient and surgery related factors, and two-year complications were collected through a retrospective chart review. Multivariable logistic regression was performed to evaluate the association between teriparatide usage and development of any related postoperative complication. RESULTS A total of 42 and 114 patients were identified for the teriparatide and non-teriparatide groups, respectively. The median age (IQR) for the teriparatide group was 62 years (55.8-68.8), while the non-teriparatide group had a median (IQR) age of 70 years (64-75.8). Overall, there were no statistically significant differences in terms of individual complications between the groups. However, on adjusted regression analysis, teriparatide use was associated with significantly lower odds of related complications for lumbar fusion patients (p = 0.049). CONCLUSION Teriparatide use prior to lumbar fusion procedures resulted in reduced rate of osteoporosis-related complications within two years postoperatively. Results suggest improved outcomes might be seen in patients with osteopenia and osteoporosis when pre-treating with teriparatide.
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Affiliation(s)
- Yagiz U Yolcu
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jad Zreik
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mohammed Ali Alvi
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Bayard C Carlson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Benjamin D Elder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
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Holmes C, Elder BD, Ishida W, Perdomo-Pantoja A, Locke J, Cottrill E, Lo SFL, Witham TF. Comparing the efficacy of syngeneic iliac and femoral allografts with iliac crest autograft in a rat model of lumbar spinal fusion. J Orthop Surg Res 2020; 15:410. [PMID: 32933551 PMCID: PMC7490887 DOI: 10.1186/s13018-020-01936-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/31/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Despite widespread use of femoral-sourced allografts in clinical spinal fusion procedures and the increasing interest in using femoral reamer-irrigator-aspirator (RIA) autograft in clinical bone grafting, few studies have examined the efficacy of femoral grafts compared to iliac crest grafts in spinal fusion. The objective of this study was to directly compare the use of autologous iliac crest with syngeneic femoral and iliac allograft bone in the rat model of lumbar spinal fusion. METHODS Single-level bilateral posterolateral intertransverse process lumbar spinal fusion surgery was performed on Lewis rats divided into three experimental groups: iliac crest autograft, syngeneic iliac crest allograft, and syngeneic femoral allograft bone. Eight weeks postoperatively, fusion was evaluated via microCT analysis, manual palpation, and histology. In vitro analysis of the colony-forming and osteogenic capacity of bone marrow cells derived from rat femurs and hips was also performed to determine whether there was a correlation with the fusion efficacy of these graft sources. RESULTS Although no differences were observed between groups in CT fusion mass volumes, iliac allografts displayed an increased number of radiographically fused fusion masses and a higher rate of bilateral fusion via manual palpation. Histologically, hip-derived grafts showed better integration with host bone than femur derived ones, likely associated with the higher concentration of osteogenic progenitor cells observed in hip-derived bone marrow. CONCLUSIONS This study demonstrates the feasibility of using syngeneic allograft bone in place of autograft bone within inbred rat fusion models and highlights the need for further study of femoral-derived grafts in fusion.
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Affiliation(s)
- Christina Holmes
- Department of Chemical and Biomedical Engineering, Florida A&M University-Florida State University College of Engineering, Tallahassee, FL, USA.
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA.
| | | | - Wataru Ishida
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | | | - John Locke
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Ethan Cottrill
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Sheng-Fu L Lo
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Timothy F Witham
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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10
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Abstract
Since FDA approval in 2002, teriparatide has gained popularity as an anabolic therapy for the treatment of osteoporosis. Animal studies have suggested a role for teriparatide in spine surgery. Several recent studies have demonstrated adjunctive use of teriparatide in osteoporotic patients undergoing spine fusions improves fusion rates, decreases time to union, and decreases osteoporosis-related complications such as proximal junctional kyphosis. On the basis of the available literature, we outline an algorithm for the use of teriparatide in spine surgery.
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11
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Yolcu Y, Alvi M, Wanderman N, Carlson B, Sebastian A, Bydon M, Freedman B. Effect of teriparatide use on bone mineral density and spinal fusion: a narrative review of animal models. Int J Neurosci 2018; 129:814-820. [PMID: 30587048 DOI: 10.1080/00207454.2018.1564051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose of the study: Teriparatide (Human recombinant Parathyroid Hormone 1-34) is an anabolic agent that is frequently used in patients with osteoporosis and has been extensively investigated with animal model and clinical studies in current literature. The purpose of the study was to evaluate the impact of teriparatide on bone mineral density and fusion. Materials and methods: The findings from preclinical studies that have investigated the role of teriparatide in animal models are summarized in presented review. Results: Overall, the studies show an improvement in bone mineral density and increased fusion rates for osteoporotic animals undergoing spine fusion with teriparatide use. Conclusion: Further studies should be conducted for unanswered questions, such as teriparatide use before surgery, the effect on cervical fusion and surgery related complications.
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Affiliation(s)
- Yagiz Yolcu
- a Mayo Clinic Neuro-Informatics Laboratory , Mayo Clinic , Rochester , MN , USA.,b Department of Neurologic Surgery , Mayo Clinic , Rochester , MN , USA
| | - Mohammed Alvi
- a Mayo Clinic Neuro-Informatics Laboratory , Mayo Clinic , Rochester , MN , USA.,b Department of Neurologic Surgery , Mayo Clinic , Rochester , MN , USA
| | - Nathan Wanderman
- c Department of Orthopaedic Surgery , Mayo Clinic , Rochester , MN , USA
| | - Bayard Carlson
- c Department of Orthopaedic Surgery , Mayo Clinic , Rochester , MN , USA
| | - Arjun Sebastian
- c Department of Orthopaedic Surgery , Mayo Clinic , Rochester , MN , USA
| | - Mohamad Bydon
- a Mayo Clinic Neuro-Informatics Laboratory , Mayo Clinic , Rochester , MN , USA.,b Department of Neurologic Surgery , Mayo Clinic , Rochester , MN , USA
| | - Brett Freedman
- c Department of Orthopaedic Surgery , Mayo Clinic , Rochester , MN , USA
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Lina IA, Ishida W, Liauw JA, Lo SFL, Elder BD, Perdomo-Pantoja A, Theodros D, Witham TF, Holmes C. A mouse model for the study of transplanted bone marrow mesenchymal stem cell survival and proliferation in lumbar spinal fusion. 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 2018; 28:710-718. [PMID: 30511246 DOI: 10.1007/s00586-018-5839-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 10/21/2018] [Accepted: 11/25/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE Bone marrow aspirate has been successfully used alongside a variety of grafting materials to clinically augment spinal fusion. However, little is known about the fate of these transplanted cells. Herein, we develop a novel murine model for the in vivo monitoring of implanted bone marrow cells (BMCs) following spinal fusion. METHODS A clinical-grade scaffold was implanted into immune-intact mice undergoing spinal fusion with or without freshly isolated BMCs from either transgenic mice which constitutively express the firefly luciferase gene or syngeneic controls. The in vivo survival, distribution and proliferation of these luciferase-expressing cells was monitored via bioluminescence imaging over a period of 8 weeks and confirmed via immunohistochemistry. MicroCT imaging was performed 8 weeks to assess fusion. RESULTS Bioluminescence imaging indicated transplanted cell survival and proliferation over the first 2 weeks, followed by a decrease in cell numbers, with transplanted cell survival still evident at the end of the study. New bone formation and increased fusion mass volume were observed in mice implanted with cell-seeded scaffolds. CONCLUSIONS By enabling the tracking of transplanted bone marrow-derived cells during spinal fusion in vivo, this mouse model will be integral to developing a deeper understanding of the biological processes underlying spinal fusion in future studies. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Ioan A Lina
- Department of Otolaryngology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wataru Ishida
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1550 Orleans St, Rm 2M-51, Baltimore, MD, 21287, USA
| | - Jason A Liauw
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1550 Orleans St, Rm 2M-51, Baltimore, MD, 21287, USA
| | - Sheng-Fu L Lo
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1550 Orleans St, Rm 2M-51, Baltimore, MD, 21287, USA
| | - Benjamin D Elder
- Department of Neurological Surgery, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Alexander Perdomo-Pantoja
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1550 Orleans St, Rm 2M-51, Baltimore, MD, 21287, USA
| | - Debebe Theodros
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1550 Orleans St, Rm 2M-51, Baltimore, MD, 21287, USA
| | - Timothy F Witham
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1550 Orleans St, Rm 2M-51, Baltimore, MD, 21287, USA
| | - Christina Holmes
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1550 Orleans St, Rm 2M-51, Baltimore, MD, 21287, USA.
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Kim SM, Rhyu KH, Lim SJ. Salvage of failed osteosynthesis for an atypical subtrochanteric femoral fracture associated with long-term bisphosphonate treatment using a 95° angled blade plate. Bone Joint J 2018; 100-B:1511-1517. [PMID: 30418051 DOI: 10.1302/0301-620x.100b11.bjj-2018-0306.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment. PATIENTS AND METHODS Between October 2008 and July 2016, 14 patients with failed osteosynthesis of an atypical subtrochanteric femoral fracture were treated with a blade plate (atypical group). Their mean age was 67.8 years (60 to 74); all were female. During the same period, 21 patients with failed osteosynthesis of a typical subtrochanteric fracture underwent restabilization using a blade plate (typical group). Outcome variables included the time of union, postoperative complications, Harris Hip Score, and Sanders functional rating scale. RESULTS In the atypical group, union was achieved in 12 patients (85.7%) at a mean of 8.4 months (4 to 12). The mean follow-up was 31.2 months (12 to 92) The plate broke in one patient requiring further stabilization with a longer plate and strut-allograft. Another patient with failure of fixation and varus angulation at the fracture site declined further surgery. In the typical group, union was achieved in 18 patients (85.7%) at a mean of 7.9 months (4 to 12). There was no difference in the mean Harris Hip Score between the two groups (83.1 points vs 86.8 points; p = 0.522) at the time of final follow-up. Sanders functional rating scores were good or excellent in 78.6% of the atypical group and in 81.0% of the typical group. CONCLUSION The 95° angled blade plate was shown to be an effective fixation modality for nonunion of atypical subtrochanteric fractures with a high rate of union and functional improvement, comparable to those after fractures not associated with bisphosphonate treatment. Cite this article: Bone Joint J 2018;100-B:1511-17.
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Affiliation(s)
- S M Kim
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University School of Medicine, Seoul, South Korea
| | - K H Rhyu
- Department of Orthopedic Surgery, Kyung Hee University Hospital, College of Medicine, Kyung-Hee University, Seoul, South Korea
| | - S J Lim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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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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Holmes CA, Ishida W, Elder BD, Lo SFL, Chen YA, Kim E, Locke J, Taylor M, Witham TF. The Effects of High-Dose Parathyroid Hormone Treatment on Fusion Outcomes in a Rabbit Model of Posterolateral Lumbar Spinal Fusion Alone and in Combination with Bone Morphogenetic Protein 2 Treatment. World Neurosurg 2018; 115:e366-e374. [DOI: 10.1016/j.wneu.2018.04.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/07/2018] [Accepted: 04/09/2018] [Indexed: 01/21/2023]
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16
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Liu Y, Levack AE, Marty E, Or O, Samuels BP, Redko M, Lane JM. Anabolic agents: what is beyond osteoporosis? Osteoporos Int 2018; 29:1009-1022. [PMID: 29627891 PMCID: PMC5949085 DOI: 10.1007/s00198-018-4507-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 03/23/2018] [Indexed: 02/06/2023]
Abstract
Osteoporosis is a common skeletal disorder characterized by low bone mass, which leads to reduced bone strength and an increased risk of fractures. Anabolic agents have been shown to improve bone mass and decrease fracture risk in osteoporosis patients by directly stimulating osteoblasts to produce new bone. Currently, two anabolic agents are available in the USA: recombinantly produced teriparatide (TPTD), which is the fully active (1-34) amino active sequence of human parathyroid hormone (PTH), and abaloparatide (APTD), a synthetic analog of parathyroid hormone-related peptide (PTHrP). At present, both agents are approved only for treatment of patients with osteoporosis at high risk of fracture. Nonetheless, their anabolic properties have led to off-label application in additional settings which include spine fusion, osteonecrosis of the jaw, arthroplasty, and fracture healing. In this article, we summarize available scientific literature regarding the efficacy, effectiveness, and safety of TPTD in these off-label settings.
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Affiliation(s)
- Y Liu
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA
| | - A E Levack
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA
| | - E Marty
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA
| | - O Or
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedic Surgery, Hadassah Medical Center, 91120, Jerusalem, Israel
| | - B P Samuels
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA
| | - M Redko
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA
| | - J M Lane
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA.
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Oliveira ORGD, Martins SPR, Lima WGD, Gomes MM. O uso de proteínas morfogenéticas ósseas (BMP) e pseudoartroses, uma revisão de literatura. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.03.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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18
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Kim SM, Kang KC, Kim JW, Lim SJ, Hahn MH. Current Role and Application of Teriparatide in Fracture Healing of Osteoporotic Patients: A Systematic Review. J Bone Metab 2017; 24:65-73. [PMID: 28326303 PMCID: PMC5357614 DOI: 10.11005/jbm.2017.24.1.65] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 01/08/2023] Open
Abstract
Background The use of osteoanabolic agents to facilitate fracture healing has been of heightened interest to the field of orthopaedic trauma. This study aimed to evaluate the evidence of teriparatide for fracture healing and functional recovery in osteoporotic patients. Methods We performed a literature search in PubMed, EMBASE, Web of Science, and the Cochrane Library using terms including “Fracture” [tiab] AND “Teriparatide [tiab] OR “PTH” [tiab]. Results This systematic review included 6 randomized clinical trials, 4 well-controlled retrospective studies, and 1 retrospective post hoc subgroup analysis. Fracture location was 2 in pelvis, 3 in proximal femur, 1 in distal femur, 1 in shoulder, 2 in wrist and 2 in spine. The use of teriparatide yielded positive effects on radiographic bone healing in 6 studies, but was not associated with better radiographic outcome in 3. In terms of functional recovery, teriparatide injection was related with decrease in pain or shorter time to mobilization in 6 studies, but not related with pain numerical scale and mobility in 3. Conclusions Our findings suggest that teriparatide provide selective advantages to fracture healing or functional recovery in the management of osteoporotic fractures. A better understanding of the role of teriparatide on osteoporotic fractures requires greater evidences from large volume prospective trials.
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Affiliation(s)
- Sang-Min Kim
- Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, Korea
| | - Kyung-Chung Kang
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Kyung Hee University, Seoul, Korea
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Seung-Jae Lim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung Hoon Hahn
- Department of Orthopaedics, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Cheonan, Korea
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Ishida W, Elder BD, Holmes C, Lo SFL, Witham TF. Variables Affecting Fusion Rates in the Rat Posterolateral Spinal Fusion Model with Autogenic/Allogenic Bone Grafts: A Meta-analysis. Ann Biomed Eng 2016; 44:3186-3201. [PMID: 27473706 DOI: 10.1007/s10439-016-1701-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/21/2016] [Indexed: 01/14/2023]
Abstract
The rat posterolateral spinal fusion model with autogenic/allogenic bone graft (rat PFABG) has been increasingly utilized as an experimental model to assess the efficacy of novel fusion treatments. The objective of this study was to investigate the reliability of the rat PFABG model and examine the effects of different variables on spinal fusion. A web-based literature search from January, 1970 to September, 2015, yielded 26 studies, which included 40 rat PFABG control groups and 449 rats. Data regarding age, weight, sex, and strain of rats, graft volume, graft type, decorticated levels, surgical approach, institution, the number of control rats, fusion rate, methods of fusion assessment, and timing of fusion assessment were collected and analyzed. The primary outcome variable of interest was fusion rate, as evaluated by manual palpation. Fusion rates varied widely, from 0 to 96%. The calculated overall fusion rate was 46.1% with an I 2 value of 62.4, which indicated moderate heterogeneity. Weight >300 g, age >14 weeks, male rat, Sprague-Dawley strain, and autogenic coccyx grafts increased fusion rates with statistical significance. Additionally, an assessment time-point ≥8 weeks had a trend towards statistical significance (p = 0.070). Multi-regression analysis demonstrated that timing of assessment and age as continuous variables, as well as sex as a categorical variable, can predict the fusion rate with R 2 = 0.82. In an inter-institution reliability analysis, the pooled overall fusion rate was 50.0% [44.8, 55.3%], with statistically significant differences among fusion outcomes at different institutions (p < 0.001 and I 2 of 72.2). Due to the heterogeneity of fusion outcomes, the reliability of the rat PFABG model was relatively limited. However, selection of adequate variables can optimize its use as a control group in studies evaluating the efficacy of novel fusion therapies.
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Affiliation(s)
- Wataru Ishida
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans St., Room 6007, Baltimore, MD, 21287, USA
| | - Benjamin D Elder
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans St., Room 6007, Baltimore, MD, 21287, USA.
| | - Christina Holmes
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans St., Room 6007, Baltimore, MD, 21287, USA
| | - Sheng-Fu L Lo
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans St., Room 6007, Baltimore, MD, 21287, USA
| | - Timothy F Witham
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans St., Room 6007, Baltimore, MD, 21287, USA
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20
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Oliveira ORGD, Martins SPR, Lima WGD, Gomes MM. The use of bone morphogenetic proteins (BMP) and pseudarthrosis, a literature review. Rev Bras Ortop 2016; 52:124-140. [PMID: 28409128 PMCID: PMC5380784 DOI: 10.1016/j.rboe.2016.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/07/2016] [Indexed: 11/29/2022] Open
Abstract
Bone morphogenetic proteins (BMP) are multi-functional growth factors to promote bone healing with the proposal of less morbidity compared to the usual methods of bone graft harvest. Pseudoarthrosis occur when the fusion attempt fails, a solid fusion is not achieved, or there is motion across the segment leading to it, and it can be clinically symptomatic as pain, deformity, neurocompression, or hardware failure. BMPs are used at spinal fusion as a tool for the treatment of degenerative, traumatic, neoplastic and infectious conditions of the spine. This review shows that the use of BMPS is effective and secure when compared with iliac crest bone graft (ICGB); however, depending of the location of usage (cervical spine, lumbar spine or sacrum) and the medical status of the patient (presence of comorbidities, tobacco usage), it is more likely to exhibit complications. Therefore, the use of these proteins must be an informed decision of patient and physician preferences.
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21
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Huang TW, Chuang PY, Lin SJ, Lee CY, Huang KC, Shih HN, Lee MS, Hsu RWW, Shen WJ. Teriparatide Improves Fracture Healing and Early Functional Recovery in Treatment of Osteoporotic Intertrochanteric Fractures. Medicine (Baltimore) 2016; 95:e3626. [PMID: 27175673 PMCID: PMC4902515 DOI: 10.1097/md.0000000000003626] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Osteoporotic intertrochanteric fractures result in serious health problems and decrease health-related quality of life (HRQoL). Faster time-to-union is important for early return to daily activities and reduction of complications. Teriparatide has been shown to accelerate fracture healing, but the literature is sparse on this topic. The aim of this study is to assess whether teriparatide accelerates fracture healing.Between 2008 and 2014, patients with osteoporotic intertrochanteric fractures who underwent surgical interventions were enrolled in this retrospective cohort study. Group 1 included patients who were not on any osteoporosis medication prior to fracture and who postoperatively received only calcium and vitamin D; patients in Group 2 were not on any osteoporosis medication prior to fracture, and received teriparatide and calcium and vitamin D postoperatively. Patients in Group 3 were those who were on alendronate prior to fracture and postfracture received teriparatide as well as calcium and vitamin D. Demographics, time-to-union, HRQoL (short-form health survey [SF]-12 physical component summary [PCS] and SF-12 mental component summary [MCS]), morbidities, mortalities, and radiographic and functional outcomes between groups were compared.A total of 189 patients were enrolled in this study. There were 83 patients in Group 1, 47 patients in Group 2, and 59 patients in Group 3. A significantly shorter time-to-union was found in the teriparatide-treated groups (mean, 13.6, 12.3, and 10.6 weeks, respectively [P = 0.002]). With regard to SF-12 PCS, the scores were significantly better in teriparatide-treated groups at 3 months (mean, 19, 28, and 29, respectively [P = 0.002]) and 6 months (mean, 28, 37, and 38, respectively [P = 0.008]). Similar inter-group differences were noted when comparing the pain scores, the ability to get around the house, the ability to get out of the house, and the ability to go shopping at 3 and 6 months. Complications and mortality were also markedly reduced in the teriparatide-treated groups.Postoperative use of teriparatide for 6 months appears to be an effective adjunct therapy in the treatment of patients with osteoporotic intertrochanteric fractures. However, because of the limited power of the study, a prospective, randomized, large-scale cohort study is still required for determining the efficacy of teriparatide.
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Affiliation(s)
- Tsan-Wen Huang
- From the Department of Orthopedic Surgery (T-WH, P-YC, S-JL, C-YL, K-CH, RW-WH) and Sports Medicine Center (RW-WH), Chang Gung Memorial Hospital, Chiayi, Taiwan; Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan (MSL); Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan (H-NS); Chang Gung University, Taoyuan, Taiwan (T-WH, K-CH, H-NS, MSL, RW-WH); and Po-Cheng Orthopedic Institute, Kaohsiung (W-JS), Taiwan
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Abstract
Over 50 million Americans have low bone mass. Poor bone quality is known to complicate spinal fusion surgery, which relies on strong bony purchase to be effective. Unfortunately, many spine surgeons do not perform routine workups for either osteoporosis or osteomalacia. Effective screening and risk factor assessment can allow for appropriate medical management of osteoporosis in the perioperative setting, improving outcomes. Medical management can be grouped into several different categories: vitamins and minerals, bisphosphonates, recombinant parathyroid hormone, estrogen replacement or modification, inhibitors of receptor activator of nuclear factor κ-B ligand (RANKL), and calcitonin. Calcium and vitamin D supplements are the least expensive to prescribe, with minimal side effects and promising animal studies, and thus should be provided to most osteoporotic patients. Recombinant parathyroid hormone can also be considered, as clinical studies have demonstrated impressive results in spine fusion patients. Bisphosphonates, estrogen therapy or selective estrogen receptor modulators, and calcitonin should all be avoided in this patient population given unproven benefit and potentially harmful side-effect profiles. Denosumab is potentially an option, but may not be first line given the general lack of supporting data for its use in perioperative management of spine surgery patients.
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Zhou Z, Tian FM, Gou Y, Wang P, Zhang H, Song HP, Shen Y, Zhang YZ, Zhang L. Enhancement of Lumbar Fusion and Alleviation of Adjacent Segment Disc Degeneration by Intermittent PTH(1-34) in Ovariectomized Rats. J Bone Miner Res 2016; 31:828-38. [PMID: 26542457 DOI: 10.1002/jbmr.2736] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 10/27/2015] [Accepted: 11/03/2015] [Indexed: 01/07/2023]
Abstract
Osteoporosis, which is prevalent in postmenopausal or aged populations, is thought to be a contributing factor to adjacent segment disc degeneration (ASDD), and the incidence and extent of ASDD may be augmented by osteopenia. Parathyroid hormone (PTH) (1-34) has already been shown to be beneficial in osteoporosis, lumbar fusion and matrix homeostasis of intervertebral discs. However, whether PTH(1-34) has a reversing or retarding effect on ASDD in osteopenia has not been confirmed. In the present study, we evaluated the effects of intermittent PTH(1-34) on ASDD in an ovariectomized (OVX) rat model. One hundred 3-month-old female Sprague-Dawley rats underwent L4 -L5 posterolateral lumbar fusion (PLF) with spinous-process wire fixation 4 weeks after OVX surgery. Control groups were established accordingly. PTH(1-34) was intermittently administered immediately after PLF surgery and lasted for 8 weeks using the following groups (n = 20) (V = vehicle): Sham+V, OVX+V, Sham+PLF+V, OVX+PLF+V, OVX+PLF+PTH. The fused segments showed clear evidence of eliminated motion on the fusion-segment based on manual palpation. Greater new bone formation in histology was observed in PTH-treated animals compared to the control group. The extent of ASDD was significantly increased by ovariotomy. Intermittent PTH(1-34) significantly alleviated ASDD by preserving disc height, microvessel density, relative area of vascular buds, endplate thickness and the relative area of endplate calcification. Moreover, protein expression results showed that PTH(1-34) not only inhibited matrix degradation by decreasing MMP-13, ADAMTS-4 and Col-I, but also promote matrix synthesis by increasing Col-II and Aggrecan. In conclusion, PTH(1-34), which effectively improves lumbar fusion and alleviates ASDD in ovariectomized rats, may be a potential candidate to ameliorate the prognosis of lumbar fusion in osteopenia.
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Affiliation(s)
- Zhuang Zhou
- Department of Orthopedic Surgery, The Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Fa-Ming Tian
- Medical Research Center, North China University of Science and Technology, Tangshan, China
| | - Yu Gou
- Department of Orthopedic Surgery, The Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Peng Wang
- Department of Orthopedic Surgery, The Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Heng Zhang
- Department of Orthopedic Surgery, The Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Hui-Ping Song
- Department of Orthopedic Surgery, The Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Yong Shen
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ying-Ze Zhang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Liu Zhang
- Department of Orthopedic Surgery, The Affiliated Hospital of North China University of Science and Technology, Tangshan, China
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Effect of teriparatide on unstable pertrochanteric fractures. BIOMED RESEARCH INTERNATIONAL 2015; 2015:568390. [PMID: 25756046 PMCID: PMC4338378 DOI: 10.1155/2015/568390] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 01/12/2015] [Accepted: 01/12/2015] [Indexed: 11/18/2022]
Abstract
We retrospectively analyzed the radiographic and clinical outcomes of unstable pertrochanteric fractures (AO/OTA 31-A2) in 44 patients who underwent dynamic hip screw (DHS) fixation and compared the results with 29 patients who received teriparatide in addition to DHS fixation. A significantly shorter time for fracture healing was recorded in the teriparatide-treated group than in the control group. Rates of lag screw sliding, femoral shortening, and varus collapse were all significantly reduced in the teriparatide-treated group. There were no significant differences with regard to superficial wound infection, pneumonia, urinary tract infection, mortality, malunion, and cutting of the lag screw. The mean overall mobility scores were significantly better in the teriparatide-treated group at 3 and 6 months (P < 0.001 and P < 0.001, resp.) but not at 12 months or the last follow-up. The pain scores were also significantly better in the teriparatide-treated group at 3 and 6 months (P = 0.040 and P = 0.041, resp.) but not at 12 months or the last follow-up. Teriparatide improves radiographic outcomes and yields better clinical outcomes at 3 and 6 months postoperatively. The improvement in union time may be important for elderly populations with unstable pertrochanteric fractures to enable them to return to daily activities and reduce morbidity and mortality.
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