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Cheers GM, Weimer LP, Neuerburg C, Arnholdt J, Gilbert F, Thorwächter C, Holzapfel BM, Mayer-Wagner S, Laubach M. Advances in implants and bone graft types for lumbar spinal fusion surgery. Biomater Sci 2024; 12:4875-4902. [PMID: 39190323 DOI: 10.1039/d4bm00848k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/28/2024]
Abstract
The increasing prevalence of spinal disorders worldwide necessitates advanced treatments, particularly interbody fusion for severe cases that are unresponsive to non-surgical interventions. This procedure, especially 360° lumbar interbody fusion, employs an interbody cage, pedicle screw-and-rod instrumentation, and autologous bone graft (ABG) to enhance spinal stability and promote fusion. Despite significant advancements, a persistent 10% incidence of non-union continues to result in compromised patient outcomes and escalated healthcare costs. Innovations in lumbar stabilisation seek to mimic the properties of natural bone, with evolving implant materials like titanium (Ti) and polyetheretherketone (PEEK) and their composites offering new prospects. Additionally, biomimetic cages featuring precisely engineered porosities and interconnectivity have gained traction, as they enhance osteogenic differentiation, support osteogenesis, and alleviate stress-shielding. However, the limitations of ABG, such as harvesting morbidities and limited fusion capacity, have spurred the exploration of sophisticated solutions involving advanced bone graft substitutes. Currently, demineralised bone matrix and ceramics are in clinical use, forming the basis for future investigations into novel bone graft substitutes. Bioglass, a promising newcomer, is under investigation despite its observed rapid absorption and the potential for foreign body reactions in preclinical studies. Its clinical applicability remains under scrutiny, with ongoing research addressing challenges related to burst release and appropriate dosing. Conversely, the well-documented favourable osteogenic potential of growth factors remains encouraging, with current efforts focused on modulating their release dynamics to minimise complications. In this evidence-based narrative review, we provide a comprehensive overview of the evolving landscape of non-degradable spinal implants and bone graft substitutes, emphasising their applications in lumbar spinal fusion surgery. We highlight the necessity for continued research to improve clinical outcomes and enhance patient well-being.
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Affiliation(s)
- Giles Michael Cheers
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany.
| | - Lucas Philipp Weimer
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany.
| | - Carl Neuerburg
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany.
| | - Jörg Arnholdt
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany.
| | - Fabian Gilbert
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany.
| | - Christoph Thorwächter
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany.
| | - Boris Michael Holzapfel
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany.
| | - Susanne Mayer-Wagner
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany.
| | - Markus Laubach
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany.
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000, Australia
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Lambrechts MJ, Issa TZ, Mazmudar A, Lee Y, Toci GR, D’Antonio ND, Schilken M, Lingenfelter K, Kepler CK, Schroeder GD, Vaccaro AR. Cellular Bone Matrix in Spine Surgery - Are They Worth the Risk: A Systematic Review. Global Spine J 2024; 14:1070-1081. [PMID: 37773001 PMCID: PMC11192114 DOI: 10.1177/21925682231205099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
STUDY DESIGN Systematic Review. OBJECTIVE To review the literature for complications and outcomes after the implantation of cellular bone matrix (CBM) during spine fusion. METHODS The PubMed database was queried from inception to January 31, 2023 for any articles that discussed the role of and identified a specific CBM in spinal fusion procedures. Adverse events, reoperations, methods, and fusion rates were collected from all studies and reported. RESULTS Six hundred articles were identified, of which 19 were included that reported outcomes of 7 different CBM products. Seven studies evaluated lumbar fusion, 11 evaluated cervical fusion, and 1 study reported adverse events of a single CBM product. Only 4 studies were comparative studies while others were limited to case series. Fusion rates ranged from 68% to 98.7% in the lumbar spine and 87% to 100% in the cervical spine, although criteria for radiographic fusion was variable. While 7 studies reported no adverse events, there was no strict consensus on what constituted a complication. One study reported catastrophic disseminated tuberculosis from donor contaminated CBM. The authors of 14 studies had conflicts of interest with either the manufacturer or distributor for their analyzed CBM. CONCLUSIONS Current evidence regarding the use of cellular bone matrix as an osteobiologic during spine surgery is weak and limited to low-grade non-comparative studies subject to industry funding. While reported fusion rates are high, the risk of severe complications should not be overlooked. Further large clinical trials are required to elucidate whether the CBMs offer any benefits that outweigh the risks.
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Affiliation(s)
- Mark J. Lambrechts
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Tariq Z. Issa
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Aditya Mazmudar
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Yunsoo Lee
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory R. Toci
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Meghan Schilken
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Gregory D. Schroeder
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R. Vaccaro
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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Mohanty S, Sardar ZM, Hassan FM, Lombardi JM, Lehman RA, Lenke LG. Impact of Teriparatide on Complications and Patient-Reported Outcomes of Patients Undergoing Long Spinal Fusion According to Bone Density. J Bone Joint Surg Am 2024; 106:206-217. [PMID: 37973052 DOI: 10.2106/jbjs.23.00272] [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] [Indexed: 11/19/2023]
Abstract
BACKGROUND Surgery for adult spinal deformity (ASD) poses substantial risks, including the development of symptomatic pseudarthrosis, which is twice as prevalent among patients with osteoporosis compared with those with normal bone mineral density (BMD). Limited data exist on the impact of teriparatide, an osteoanabolic compound, in limiting the rates of reoperation and pseudarthrosis after treatment of spinal deformity in patients with osteoporosis. METHODS Osteoporotic patients on teriparatide (OP-T group) were compared with patients with osteopenia (OPE group) and those with normal BMD. OP-T patients were matched with OPE patients and patients with normal BMD at a 1:2:2 ratio. All patients had a minimum 2-year follow-up and underwent posterior spinal fusion (PSF) involving >7 instrumented levels. The primary outcome was the 2-year reoperation rate. Secondary outcomes included pseudarthrosis with or without implant failure, proximal junctional kyphosis (PJK), and changes in patient-reported outcomes (PROs). Clinical outcomes were analyzed using conditional logistic regression. Changes in PROs were analyzed using a mixed-effects model. RESULTS Five hundred and forty patients (52.6% normal BMD, 32.9% OPE, 14.4% OP-T) were included. In the unmatched cohort, 2-year reoperation rates (odds ratio [OR] = 0.45 [95% confidence interval (CI): 0.20 to 0.91]) and pseudarthrosis rates (OR = 0.25 [95% CI: 0.08 to 0.61]) were significantly lower in the OP-T group than the OPE group. Seventy-eight patients in the OP-T group were matched to 156 patients in the OPE group. Among these matched patients, at 2 years, 23.1% (36) in the OPE group versus 11.5% (9) in the OP-T group had a reoperation (OR = 0.45, p = 0.0188), 21.8% (34) versus 6.4% (5) had pseudarthrosis with or without implant failure (OR = 0.25, p = 0.0048), and 6.4% (10) versus 7.7% (6) had PJK (OR = 1.18, p = 0.7547), respectively. At 2 years postoperatively, PROs were better among OP-T patients than OPE patients. Subsequently, 78 patients in the OP-T group were matched to 156 patients in the normal BMD group. Among these matched patients, there was no significant difference in 2-year reoperation (OR = 0.85 [95% CI: 0.37 to 1.98]), pseudarthrosis (OR = 0.51 [95% CI: 0.181 to 1.44]), and PJK rates (OR = 0.77 [95% CI: 0.28 to 2.06). CONCLUSIONS Osteoporotic patients on teriparatide demonstrated lower reoperation and symptomatic pseudarthrosis rates 2 years postoperatively compared with osteopenic patients. Moreover, patient-reported and clinical outcomes for osteoporotic patients on teriparatide were not different from those for patients with normal BMD. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sarthak Mohanty
- Department of Orthopaedic Surgery, Och Spine Hospital, Columbia University Irving Medical Center, New York, NY
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Daldal I, Senkoylu A, Degim IT, Ilbasmıs Tamer S, Omeroglu S, Akarca Dizakar SO, Celik HH, Uzuner MB, Kurtoglu A, Yapar D, Yapar A. The combined use of carbon nanotubes with synthetic ceramics enhances posterolateral fusion: an experimental study in a rat spinal fusion model. Spine Deform 2023; 11:805-814. [PMID: 36750546 DOI: 10.1007/s43390-023-00659-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/29/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE The aim of the present study was to evaluate the effectiveness of carbon nanotubes (CNTs)/ HA-tricalcium phosphate (TCP) composite in a posterolateral spinal fusion model. METHODS At first, CNTs and CNTs/HA-TCP composites were prepared. Twenty adult male Sprague Dawley rats were randomized into four groups with five rats in each group. Decortication was carried out in standard manner in all animals. Group 1 (only decortication), group 2 (CNTs), group 3 (HA-TCP) and group 4 (CNTs/HA-TCP) were formed. Eight weeks later, all animals were killed and obtained fusion segments were evaluated by manual palpation, histomorphometry and micro-computed tomography (mCT). RESULTS In all evaluations, highest fusion values were obtained in Group 4. In mCT investigations, bone volume/ tissue volume (BV/TV) ratio was found to be significantly higher in composite group (group 4) only compared to ceramic group (group 3) (p < 0.001). Although in Group 2, in which only CNTs were used, the ratio was found to be statistically significantly higher than group 1(p < 0.001), the difference was not considered as significant in terms of fusion and in addition in group 2, CNTs were completely surrounded by fibrous tissue, i.e., no bone formation was observed. CONCLUSIONS The CNTs/HA-TCP composite is a promising synthetic bone graft substitute for spinal fusion. Although CNTs are inadequate in producing spinal fusion when they are used alone, due to their high biocompatibility due to their high biocompatibility, and multiple effect on bone regeneration, they seem to increase fusion rates significantly when they are used in combination with ceramic-based synthetic grafts.
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Affiliation(s)
- Ismail Daldal
- Department of Orthopedics and Traumatology, Medicana İnternational İstanbul Hospital, İstanbul, Turkey
| | - Alpaslan Senkoylu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ismail Tuncer Degim
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Biruni University, Istanbul, Turkey
| | - Sibel Ilbasmıs Tamer
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Gazi University, Ankara, Turkey
| | - Suna Omeroglu
- Department of Histology and Embryology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | | | - Hakan Hamdi Celik
- Department of Anatomy, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Muhammet Bora Uzuner
- Department of Anatomy, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Alper Kurtoglu
- Sakarya University Training and Research Hospital, Sakarya, Turkey
| | - Dilek Yapar
- Department of Public Health, Ministry of Health, Antalya, Turkey
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Aliekber Yapar
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey.
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Hsieh MK, Liu MY, Tsai TT, Lai PL, Tai CL. Biomechanical Comparison of Different Numbers and Configurations of Cross-Links in Long-Segment Spinal Fixation-An Experimental Study in a Porcine Model. Global Spine J 2023; 13:25-32. [PMID: 33511875 PMCID: PMC9837523 DOI: 10.1177/2192568221990646] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
STUDY DESIGN Biomechanical study. OBJECTIVE Cross-links are a type of common clinical spinal instrumentation. However, the effects of the position and number of cross-links have never been investigated in long-segment spinal fixation, and the variables have not been optimized. We conducted an in vitro biomechanical study by using a porcine long-segment spinal model with 5 different crosslink configurations to determine the optimal construct for clinical practice. METHODS Five modalities with paired segmental screws from T15-L5 were tested in 20 porcine spines. The spines without cross-links composed the control group, Group A; those with a single cross-link from L2-3 composed Group B; those with 2 cross-links from L1-2 and L3-4 composed Group C; those with 2 cross-links from T15-L1 and L4-5 composed Group D; and those with 3 cross-links from T15-L1, L2-3 and L4-5 composed Group E. Spinal stiffnesses in flexion, extension, lateral bending, and axial rotation were compared among 5 different cross-link configurations in 5-level porcine spinal units. RESULTS Flexional, extensional and lateral bending stiffnesses did not significantly change with an increasing number of cross-links or positions in the construct. Axial stiffness was significantly increased with 2 cross-links compared to one (P < 0.05) and with placement more distant from the center of the long spinal fixation construct (P < 0.05). CONCLUSIONS Two cross-links individually placed proximal and distal from the center of a construct is an optimal and efficient configuration to achieve biomechanical stability in non-rigid lumbar spines undergoing long-level fixation.
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Affiliation(s)
- Ming-Kai Hsieh
- Department of Orthopaedic Surgery, Spine
Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung
University College of Medicine, Taoyuan
| | - Mu-Yi Liu
- Ph.D. Program in Biomedical Engineering,
Collage of Engineering, Chang Gung University, Taoyuan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine
Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung
University College of Medicine, Taoyuan
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine
Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung
University College of Medicine, Taoyuan,Po-Liang Lai, Department of Orthopaedic
Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial
Hospital and Chang Gung University College of Medicine, Taoyuan.
| | - Ching-Lung Tai
- Department of Orthopaedic Surgery, Spine
Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung
University College of Medicine, Taoyuan,Graduate Institute of Biomedical
Engineering, Chang Gung University, Taoyuan,Ching-Lung Tai, Department of Orthopaedic
Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial
Hospital and Chang Gung University College of Medicine, Taoyuan; Graduate
Institute of Biomedical Engineering, Chang Gung University, Taoyuan.
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Kim YH, Ha KY, Kim YS, Kim KW, Rhyu KW, Park JB, Shin JH, Kim YY, Lee JS, Park HY, Ko J, Kim SI. Lumbar Interbody Fusion and Osteobiologics for Lumbar Fusion. Asian Spine J 2022; 16:1022-1033. [PMID: 36573302 PMCID: PMC9827209 DOI: 10.31616/asj.2022.0435] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 12/28/2022] Open
Abstract
Lumbar interbody fusion (LIF) is an excellent treatment option for a number of lumbar diseases. LIF can be performed through posterior, transforaminal, anterior, and lateral or oblique approaches. Each technique has its own pearls and pitfalls. Through LIF, segmental stabilization, neural decompression, and deformity correction can be achieved. Minimally invasive surgery has recently gained popularity and each LIF procedure can be performed using minimally invasive techniques to reduce surgery-related complications and improve early postoperative recovery. Despite advances in surgical technology, surgery-related complications after LIF, such as pseudoarthrosis, have not yet been overcome. Although autogenous iliac crest bone graft is the gold standard for spinal fusion, other bone substitutes are available to enhance fusion rate and reduce complications associated with bone harvest. This article reviews the surgical procedures and characteristics of each LIF and the osteobiologics utilized in LIF based on the available evidence.
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Affiliation(s)
- Young-Hoon Kim
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee-Yong Ha
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Youn-Soo Kim
- Department of Orthopaedic Surgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Ki-Won Kim
- Department of Orthopaedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee-Won Rhyu
- Department of Orthopaedic Surgery, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Jae-Hyuk Shin
- Department of Orthopaedic Surgery, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Young-Yul Kim
- Department of Orthopaedic Surgery, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Jun-Seok Lee
- Department of Orthopaedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Youl Park
- Department of Orthopaedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jaeryong Ko
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea,Corresponding author: Sang-Il Kim Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6775, Fax: +82-2-535-9837, E-mail:
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Griffoni C, Tedesco G, Canella V, Nataloni A, Zerbi A, Tosini G, Gasbarrini A, Barbanti-Brodano G. Ceramic bone graft substitute (Mg-HA) in spinal fusion: A prospective pilot study. Front Bioeng Biotechnol 2022; 10:1050495. [PMID: 36532576 PMCID: PMC9748738 DOI: 10.3389/fbioe.2022.1050495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 10/28/2022] [Indexed: 04/14/2024] Open
Abstract
Background: Iliac crest bone graft (ICBG) is considered the gold standard for spine surgical procedures to achieve a successful fusion due to its known osteoinductive and osteoconductive properties. However, complications related to harvesting procedure and donor site morbidity have been largely reported in the literature, favoring the development of a wide range of alternative products to be used as bone graft extenders or substitutes for spine fusion. Among all, ceramic-based biomaterials have been widely studied and employed in the last years as bone graft substitutes. Methods: We report here the results of a prospective pilot study aimed to evaluating the grade of ossification obtained by the use of an Mg-doped hydroxyapatite (HA) product to achieve postero-lateral fusion in degenerative spine diseases. Results: Results show a successful degree of fusion of about 62% at the 12-month follow-up and an improvement of quality of life and health status following surgery, as evaluated by clinical scores (ODI, VAS, and EQ-5L). No adverse events related to the material were reported. Conclusion: The present pilot study shows the effectiveness and the safety profile of an Mg-doped HA bone graft substitute used to achieve postero-lateral fusion in the treatment of degenerative spine diseases, laying down the basis for further larger clinical investigations.
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Affiliation(s)
- Cristiana Griffoni
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Tedesco
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | | | - Alberto Zerbi
- Istituti Clinici Iseni, Fondazione Iseni y Nervi, Lonate Pozzolo, Italy
| | - Giovanni Tosini
- Department of Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Fenton-White HA. Trailblazing: the historical development of the posterior lumbar interbody fusion (PLIF). Spine J 2021; 21:1528-1541. [PMID: 33757870 DOI: 10.1016/j.spinee.2021.03.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 02/23/2021] [Accepted: 03/16/2021] [Indexed: 02/03/2023]
Abstract
Today, the posterior lumbar interbody fusion (PLIF), and related methods of fusion, represent the gold standard in spinal arthrodesis. However, despite the PLIF being first performed in the 1940s, its reputation was marked by animosity for the next fifty years. Only due to the extraordinary talent and perseverance from a small group of pioneers, was the operation eventually appreciated to be an ideal fusion technique. This process of popularization has assisted the surgical community to better recognize the complexities of spinal biomechanics and has encouraged the momentum of success in modern spinal surgery. Neither the complete origins of the technique, nor the remarkable story of its propagation, have previously been reported.
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Wang TY, Than KD. Commentary: Osteobiologics. Oper Neurosurg (Hagerstown) 2021; 21:S10-S11. [PMID: 34128061 DOI: 10.1093/ons/opaa403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/25/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Timothy Y Wang
- Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Khoi D Than
- Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Lo WC, Tsai LW, Yang YS, Chan RWY. Understanding the Future Prospects of Synergizing Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery with Ceramics and Regenerative Cellular Therapies. Int J Mol Sci 2021; 22:3638. [PMID: 33807361 PMCID: PMC8037583 DOI: 10.3390/ijms22073638] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 12/14/2022] Open
Abstract
Transforaminal lumber interbody fusion (TLIF) is the last resort to address the lumber degenerative disorders such as spondylolisthesis, causing lower back pain. The current surgical intervention for these abnormalities includes open TLIF. However, in recent years, minimally invasive TLIF (MIS-TLIF) has gained a high momentum, as it could minimize the risk of infection, blood loss, and post-operative complications pertaining to fusion surgery. Further advancement in visualizing and guiding techniques along with grafting cage and materials are continuously improving the safety and efficacy of MIS-TLIF. These assistive techniques are also playing a crucial role to increase and improve the learning curve of surgeons. However, achieving an appropriate output through TLIF still remains a challenge, which might be synergized through 3D-printing and tissue engineering-based regenerative therapy. Owing to their differentiation potential, biomaterials such as stem/progenitor cells may contribute to restructuring lost or damaged tissues during MIS-TLIF, and this therapeutic efficacy could be further supplemented by platelet-derived biomaterials, leading to improved clinical outcomes. Thus, based on the above-mentioned strategies, we have comprehensively summarized recent developments in MIS-TLIF and its possible combinatorial regenerative therapies for rapid and long-term relief.
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Affiliation(s)
- Wen-Cheng Lo
- Department of Surgery, Division of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (Y.-S.Y.); (R.W.Y.C.)
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
| | - Lung-Wen Tsai
- Department of Medical Education and Research, Taipei Medical University Hospital, Taipei 11031, Taiwan;
| | - Yi-Shan Yang
- Department of Surgery, Division of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (Y.-S.Y.); (R.W.Y.C.)
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
| | - Ryan Wing Yuk Chan
- Department of Surgery, Division of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (Y.-S.Y.); (R.W.Y.C.)
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
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Abstract
PURPOSE OF REVIEW Biologic bone graft materials continue to be an important component of various spinal fusion procedures. Given the known risks and morbidity of harvesting iliac crest bone graft, the historical gold standard for spinal fusion, these biologic materials serve the purpose of improving both the efficacy and safety of spinal fusion procedures. Recent advances in biomedical and materials sciences have enabled the design of many novel materials that have shown promise as effective bone graft materials. This review will discuss current research pertaining to several of these materials, including functionalized peptide amphiphiles and other nanocomposites, novel demineralized bone matrix applications, 3D-printed materials, and Hyperelastic Bone®, among others. RECENT FINDINGS Recent investigation has demonstrated that novel technologies, including nanotechnology and 3D printing, can be used to produce biomaterials with significant osteogenic potential. Notably, peptide amphiphile nanomaterials functionalized to bind BMP-2 have demonstrated significant bone regenerative capacity in a pre-clinical rodent posterolateral lumbar fusion (PLF) model. Additionally, 3D-printed Hyperelastic Bone® has demonstrated promising bone regenerative capacity in several in vivo animal models. Composite materials such as TrioMatrix® (demineralized bone matrix, hydroxyapatite, and nanofiber-based collagen scaffold) have also demonstrated significant osteogenic potential in both in vitro and in vivo settings. Advances in materials science and engineering have allowed for the design and implementation of several novel biologic materials, including nanocomposites, 3D-printed materials, and various biologic composites. These materials provide significant bone regenerative capacity and have the potential to be alternatives to other bone graft materials, such as autograft and BMP-2, which have known complications.
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Affiliation(s)
- Mark A Plantz
- Department of Orthopaedic Surgery, Northwestern University - Feinberg School of Medicine, 676 N. St. Clair St. #1350, Chicago, IL, 60611, USA
| | - Wellington K Hsu
- Department of Orthopaedic Surgery, Northwestern University - Feinberg School of Medicine, 676 N. St. Clair St. #1350, Chicago, IL, 60611, USA
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Smith KA, Russo GS, Vaccaro AR, Arnold PM. Scientific, Clinical, Regulatory, and Economic Aspects of Choosing Bone Graft/Biological Options in Spine Surgery. Neurosurgery 2020; 84:827-835. [PMID: 30032187 DOI: 10.1093/neuros/nyy322] [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: 03/12/2018] [Accepted: 06/17/2018] [Indexed: 01/07/2023] Open
Abstract
Spinal arthrodesis is a major element of the spinal surgeon's practice. To attain successful fusion rates, attention must be paid to spinal segment immobilization and proper selection of bone graft. Autogenous bone graft (ie, ICBG), the "gold standard," with or without graft extenders and enhancers provides the foundation for most spinal fusions. ABG is the only graft option containing all 3 factors of new bone growth: osteoconductivity, osteoinductivity, and osteogenicity. While many bone graft alternatives function well as bone graft extenders, only growth factors proteins (ie, rhBMP-2 or OP-2) function as bone graft enhancers and substitutes. The search for optimal hybrid interbody cages, bone graft substitutes, autogenous or allogenic stem cells, and nanostructure scaffolds for release of growth factors continues.
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Affiliation(s)
- Kyle A Smith
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Glenn S Russo
- Department of Orthopedics, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexander R Vaccaro
- Department of Orthopedics, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
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Yoo JS, Ahn J, Patel DS, Hrynewycz NM, Brundage TS, Singh K. An evaluation of biomaterials and osteobiologics for arthrodesis achievement in spine surgery. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S168. [PMID: 31624734 PMCID: PMC6778273 DOI: 10.21037/atm.2019.06.80] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/23/2019] [Indexed: 12/31/2022]
Abstract
An increasing variety of orthobiologic materials, including autologous and allogeneic bone graft, bone marrow aspirate, demineralized bone matrix, ceramics, and growth factors are available to the spine surgeon. Although autologous bone graft remains the gold standard material, concerns for failure in achieving fusion have prompted evaluation of current and new biologic materials. As such, this review attempts to summarize the available biologic materials with their pertinent characteristics, advantages, disadvantages, and primary uses.
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Affiliation(s)
- Joon S Yoo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Junyoung Ahn
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Dillon S Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nadia M Hrynewycz
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Thomas S Brundage
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Greene AC, Hsu WK. Orthobiologics in minimally invasive lumbar fusion. JOURNAL OF SPINE SURGERY 2019; 5:S11-S18. [PMID: 31380488 DOI: 10.21037/jss.2019.04.15] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Minimally invasive (MI) spine surgery continues to gain popularity with patients and surgeons for its potential to decrease operative time and avoid complications commonly associated with open surgery. In the face of a changing surgical landscape, selecting the appropriate implant material to be used in MI lumbar fusion procedures will remain critically important. Various orthobiologic materials are available for use, including autologous and allogeneic bone graft, bone marrow aspirate (BMA), demineralized bone matrix (DBM), ceramics, and growth factors. The purpose of this review is to summarize the use and efficacy of currently available products, as well as highlight the development of novel therapeutic options.
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Affiliation(s)
- Allison C Greene
- Northwestern University Department of Orthopaedic Surgery, Chicago, IL, USA.,Simpson Querrey Institute, Northwestern University, Chicago, IL, USA
| | - Wellington K Hsu
- Northwestern University Department of Orthopaedic Surgery, Chicago, IL, USA.,Simpson Querrey Institute, Northwestern University, Chicago, IL, USA
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Steen G. An inception cohort study of patients in a military clinic treated for lower back pain with lumbar fusion and SIGNAFUSE® with a systematic review of the literature. Surg Case Rep 2018. [DOI: 10.31487/j.scr.2018.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Use of synthetic bone graft substitutes for spinal fusion has increased sharply over the past 20 years. SIGNAFUSE® is one such synthetic graft material that provides an osteostimulatory effect for spinal fusion. Because clinical trials are not required for commercialization of synthetic bone graft substitutes in the United States, fusion rates attained using SIGNAFUSE for lumbar fusion are not well documented. The goal of the current study is to determine the rate of spinal fusion in a military clinic following lumbar fusion surgery augmented with SIGNAFUSE.
Methods: We report a retrospective chart review of 8 patients who received lumbar spinal fusion surgery augmented with SIGNAFUSE. All patients were assessed by computed tomographic (CT) imaging at least 1-year post-surgery to determine whether bony fusion had occurred. We also systematically reviewed literature sources that report fusion rate following spinal fusion surgery, for broader context.
Results: An average of 1.6 spinal levels were treated with SIGNAFUSE-loaded interbody cages. All patients had stabilization hardware via pedicle screws or integrated cage fixation. Seven of 8 patients successfully fused, for an overall fusion rate of 87.5% (95% confidence interval: 47.4% to 99.7%). Systematic review of 26 recent publications that included 1,126 patients treated with synthetic bone graft showed that the overall fusion rate in the literature is 84.4%.
Conclusions: Fusion was achieved in 87.5% of patients treated with SIGNAFUSE. This is comparable to the fusion rate in a systematic review of 1,126 patients treated with synthetic bone graft materials.
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Abstract
STUDY DESIGN Laboratory study. OBJECTIVE Mesenchymal stem cells (MSCs) derived from whole bone marrow aspirate (BMA) and MSCs derived from density-gradient centrifugation were isolated from vertebral bodies and cultured under either hypoxic or normoxic conditions to evaluate their biological characteristics and HOX and TALE signature able to improve spinal surgery procedures. SUMMARY OF BACKGROUND DATA The use of spinal fusion procedures has increased over the last decades; however, failed fusion still remains an important problem. Clinician and researchers focused their attention on the therapeutic potential of bone marrow MSCs and several methods for their isolation and cultivation have been developed. However, the best source and techniques are still debated. METHODS MSCs morphology, surface markers, colony-forming-units, and three lineage differentiation through quantitative real-time PCR (qPCR) were evaluated. Additionally, gene expression analysis of HOX and TALE signatures during osteogenic differentiation were analyzed. RESULTS Our study showed that MSCs derived from whole BMA were successfully isolated and when cultured under hypoxic condition presented greater proliferation, larger colonies, and differentiated onto osteogenic and chondrogenic lineage with greater ability, while adipogenic differentiation was less efficient. Results also revealed that MSCs, differently isolated and cultured, expressed different level of HOX and TALE signatures and that HOXB8 were up-regulated with greater efficiency in MSCs derived from whole BMA under hypoxia. CONCLUSION Our data indicated that hypoxic preconditioning of MSCs derived from whole BMA exhibited more suitable biological characteristics and different level of HOX and TALE gene activation. We, therefore, concluded that vertebral body MSCs derived from whole BMA may provide alternative sources of MSCs for tissue engineering applications for spine surgery. LEVEL OF EVIDENCE N/A.
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Thorpe AA, Bach FC, Tryfonidou MA, Le Maitre CL, Mwale F, Diwan AD, Ito K. Leaping the hurdles in developing regenerative treatments for the intervertebral disc from preclinical to clinical. JOR Spine 2018; 1:e1027. [PMID: 31463447 PMCID: PMC6686834 DOI: 10.1002/jsp2.1027] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 06/07/2018] [Accepted: 06/28/2018] [Indexed: 12/11/2022] Open
Abstract
Chronic back and neck pain is a prevalent disability, often caused by degeneration of the intervertebral disc. Because current treatments for this condition are less than satisfactory, a great deal of effort is being applied to develop new solutions, including regenerative strategies. However, the path from initial promising idea to clinical use is fraught with many hurdles to overcome. Many of the keys to success are not necessarily linked to science or innovation. Successful translation to clinic will also rely on planning and awareness of the hurdles. It will be essential to plan your entire path to clinic from the outset and to do this with a multidisciplinary team. Take advice early on regulatory aspects and focus on generating the proof required to satisfy regulatory approval. Scientific demonstration and societal benefits are important, but translation cannot occur without involving commercial parties, which are instrumental to support expensive clinical trials. This will only be possible when intellectual property can be protected sufficiently to support a business model. In this manner, commercial, societal, medical, and scientific partners can work together to ultimately improve patient health. Based on literature surveys and experiences of the co-authors, this opinion paper presents this pathway, highlights the most prominent issues and hopefully will aid in your own translational endeavors.
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Affiliation(s)
- Abbey A. Thorpe
- Biomolecular Sciences Research CentreSheffield Hallam UniversitySheffieldUK
| | - Frances C. Bach
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary MedicineUtrecht UniversityUtrechtthe Netherlands
| | - Marianna A. Tryfonidou
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary MedicineUtrecht UniversityUtrechtthe Netherlands
| | | | - Fackson Mwale
- Department of SurgeryMcGill UniversityMontrealCanada
| | - Ashish D. Diwan
- Spine Service, Department of Orthopaedic SurgerySt. George & Sutherland Clinical School, University of New South WalesSydneyAustralia
| | - Keita Ito
- Orthopaedic Biomechanics Division, Department of Biomedical EngineeringEindhoven University of TechnologyEindhoventhe Netherlands
- Department of OrthopedicsUniversity Medical Centre UtrechtUtrechtthe Netherlands
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18
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Spinal Biologics in Minimally Invasive Lumbar Surgery. Minim Invasive Surg 2018; 2018:5230350. [PMID: 29850240 PMCID: PMC5907390 DOI: 10.1155/2018/5230350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 02/25/2018] [Indexed: 12/28/2022] Open
Abstract
As the use of minimally invasive spine (MIS) fusion approaches continues to grow, increased scrutiny is being placed on its outcomes and efficacies against traditional open fusion surgeries. While there are many factors that contribute to the success of achieving spinal arthrodesis, selecting the optimal fusion biologic remains a top priority. With an ever-expanding market of bone graft substitutes, it is important to evaluate each of their use as it pertains to MIS techniques. This review will summarize the important characteristics and properties of various spinal biologics used in minimally invasive lumbar surgeries and compare their fusion rates via a systematic review of published literature.
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Smith WR, Hudson PW, Ponce BA, Rajaram Manoharan SR. Nanotechnology in orthopedics: a clinically oriented review. BMC Musculoskelet Disord 2018; 19:67. [PMID: 29499666 PMCID: PMC5833027 DOI: 10.1186/s12891-018-1990-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 02/23/2018] [Indexed: 12/15/2022] Open
Abstract
The utility of nanotechnology in medicine, specifically within the field of orthopedics, is a topic of extensive research. Our review provides a unique comprehensive overview of the current and potential future uses of nanotechnology with respect to orthopedic sub-specialties. Nanotechnology offers an immense assortment of novel applications, most notably the use of nanomaterials as scaffolds to induce a more favorable interaction between orthopedic implants and native bone. Nanotechnology has the capability to revolutionize the diagnostics and treatment of orthopedic surgery, however the long-term health effects of nanomaterials are poorly understood and extensive research is needed regarding clinical safety.
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Affiliation(s)
- Walter Ryan Smith
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13 St. South, Birmingham, AL 35205 USA
| | - Parke William Hudson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13 St. South, Birmingham, AL 35205 USA
| | - Brent Andrew Ponce
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13 St. South, Birmingham, AL 35205 USA
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Hsu WK, Goldstein CL, Shamji MF, Cho SK, Arnold PM, Fehlings MG, Mroz TE. Novel Osteobiologics and Biomaterials in the Treatment of Spinal Disorders. Neurosurgery 2017; 80:S100-S107. [PMID: 28350951 DOI: 10.1093/neuros/nyw085] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 01/11/2017] [Indexed: 12/12/2022] Open
Abstract
Spinal osteobiologics have evolved substantially in this century after the development of many product categories such as growth factors, allograft, and stem cells. The indications for the use of novel biologics within spine surgery are rapidly expanding as the mechanism of each is elucidated. While the knowledge base of bone morphogenetic protein increases with each subsequent year, the application of new nanotechnology and cell-based strategies are being reported. This review will discuss the most recent data in novel osteobiologics, and where we could use future study.
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Affiliation(s)
- Wellington K Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Mohammed F Shamji
- Department of Orthopaedic Surgery, University of Toronto, Toronto, Canada
| | - Sam K Cho
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, New York
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Missouri
| | - Michael G Fehlings
- Department of Orthopaedic Surgery, University of Toronto, Toronto, Canada
| | - Tom E Mroz
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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21
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Guzman JZ, Merrill RK, Kim JS, Overley SC, Dowdell JE, Somani S, Hecht AC, Cho SK, Qureshi SA. Bone morphogenetic protein use in spine surgery in the United States: how have we responded to the warnings? Spine J 2017; 17:1247-1254. [PMID: 28456674 DOI: 10.1016/j.spinee.2017.04.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/18/2017] [Accepted: 04/24/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been widely adopted as a fusion adjunct in spine surgery since its approval in 2002. A number of concerns regarding adverse effects and potentially devastating complications of rhBMP-2 use led to a Food and Drug Administration (FDA) advisory issued in 2008 cautioning its use, and a separate warning about its potential complications was published by The Spine Journal in 2011. PURPOSE To compare trends of rhBMP-2 use in spine surgery after the FDA advisory in 2008 and The Spine Journal warning in 2011. STUDY DESIGN Retrospective cross-sectional study using a national database. PATIENT SAMPLE All patients from 2002 to 2013 who underwent spinal fusion surgery at an institution participating in the Nationwide Inpatient Sample (NIS). OUTCOME MEASURES Proportion of spinal fusion surgeries using rhBMP-2. METHODS We queried the NIS from 2002 to 2013 and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes to identify spinal fusion procedures and those that used rhBMP-2. Procedures were subdivided into primary and revision fusions, and by region of the spine. Cervical and lumbosacral fusions were further stratified into anterior and posterior approaches. The percentage of cases using BMP was plotted across time. A linear regression was fit to the data from quarter 3 of 2008 (FDA advisory) through quarter 1 of 2011, and a separate regression was fit to the data from quarter 2 of 2011 (The Spine Journal warning) onward. The slopes of these regression lines were statistically compared to determine differences in trends. No funding was received to conduct this study, and no authors had any relevant conflicts of interest. RESULTS A total of 4,167,079 patients in the NIS underwent spinal fusion between 2002 and 2013. We found a greater decrease in rhBMP-2 use after The Spine Journal warning compared with the FDA advisory for all fusion procedures (p=.006), primary fusions (p=.006), and revision fusions (p=.004). Lumbosacral procedures also experienced a larger decline in rhBMP-2 use after The Spine Journal article as compared with the FDA warning (p=.0008). This pattern was observed for both anterior and posterior lumbosacral fusions (p≤.0001 for both). Anterior cervical fusion was the only procedure that demonstrated a decline in rhBMP-2 use after the FDA advisory that was statistically greater than after The Spine Journal article (p=.02). CONCLUSIONS Warnings sanctioned through the spine literature may have a greater influence on practice of the spine surgery community as compared with advisories issued by the FDA.Comprehensive guidelines regarding safe and effective use of rhBMP-2 must be established.
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Affiliation(s)
- Javier Z Guzman
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th St, 4th Floor, New York, NY 10029, USA
| | - Robert K Merrill
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th St, 4th Floor, New York, NY 10029, USA
| | - Jun S Kim
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th St, 4th Floor, New York, NY 10029, USA
| | - Samuel C Overley
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th St, 4th Floor, New York, NY 10029, USA
| | - James E Dowdell
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th St, 4th Floor, New York, NY 10029, USA
| | - Sulaiman Somani
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th St, 4th Floor, New York, NY 10029, USA
| | - Andrew C Hecht
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th St, 4th Floor, New York, NY 10029, USA
| | - Samuel K Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th St, 4th Floor, New York, NY 10029, USA
| | - Sheeraz A Qureshi
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th St, 4th Floor, New York, NY 10029, USA.
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A new bioinspired collagen-hydroxyapatite bone graft substitute in adult scoliosis surgery: results at 3-year follow-up. J Appl Biomater Funct Mater 2017; 15:e262-e270. [PMID: 28604992 PMCID: PMC6379889 DOI: 10.5301/jabfm.5000366] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2017] [Indexed: 12/11/2022] Open
Abstract
Background Spinal fusion is a common procedure used for surgical treatment of spinal
deformity. In recent years, many bone graft substitutes (BGS) have been
developed to provide good arthrodesis when the available autologous bone
harvested from the patient is not enough. The aim of this study was to
analyze the use of a new-generation composite material (RegenOss) made of
Mg-hydroxyapatite nanoparticles nucleated on type I collagen to obtain long
posterolateral fusion in adult scoliosis surgery. Methods A total of 41 patients who underwent spinal fusion for the treatment of adult
scoliosis were retrospectively analyzed. According to Lenke classification,
visual analog scale (VAS) score and Oswestry Disability Index (ODI) score,
radiographic rates of bone union were evaluated before surgery and at 6, 12
and 36 months of follow-up. Fusion was considered to be successful when
criteria for Lenke grade A or B were satisfied. Patient-related risk factors
were considered for the evaluation of the final outcome. Results At 36-month follow-up, radiographic evidence of spinal fusion was present in
the majority of patients (95.1%). A time-dependent statistically significant
improvement was evidenced after surgery for all clinical outcomes evaluated.
Based on the demographic data collected, there were no statistically
significant factors determining fusion. The correction of deformity was
maintained at different time points. No intraoperative or postoperative
complications were recorded. Conclusions The present study demonstrated that RegenOss can safely be used to achieve
good arthrodesis when associated with autologous bone graft to obtain long
spinal fusion in the treatment of adult scoliosis.
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Abstract
Orthobiologics are biologic devices or products used in orthopedic surgery to augment or enhance bone formation. The use of orthobiologics in pediatric orthopedics is less frequent than in other orthopedic subspecialties, mainly due to the naturally abundant healing potential and bone formation in children compared with adults. However, orthobiologics are used in certain situations in pediatric orthopedics, particularly in spine and foot surgery. Other uses have been reported in conjunction with specific procedures involving the tibia and pelvis. The use of bioabsorable implants to stabilize children's fractures is an emerging concept but has limited supporting data.
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Affiliation(s)
- Robert F Murphy
- Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB 708, Charleston, SC 29492, USA.
| | - James F Mooney
- Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB 708, Charleston, SC 29492, USA
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Pierannunzii L, Zagra L. Bone grafts, bone graft extenders, substitutes and enhancers for acetabular reconstruction in revision total hip arthroplasty. EFORT Open Rev 2017; 1:431-439. [PMID: 28461922 PMCID: PMC5367522 DOI: 10.1302/2058-5241.160025] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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
Acetabular bone loss is a relevant concern for surgeons dealing with a failed total hip arthroplasty. Since the femoral head is no longer available, allografts represent the first choice for most reconstructive solutions, either as a structural buttress or impacted bone chips. Even though fresh-frozen bone is firmly recommended for structural grafts, freeze-dried and/or irradiated bone may be used alternatively for impaction grafting. Indeed, there are some papers on freeze-dried or irradiated bone impaction grafting, but their number is limited, as is the number of cases. Xenografts do not represent a viable option based on the poor available evidence but bioactive bioceramics such as hydroxyapatite and biphasic calcium phosphates are suitable bone graft extenders or even substitutes for acetabular impaction grafting. Bone-marrow-derived mesenchymal stem cells and demineralised bone matrix seem to act as reliable bone graft enhancers, i.e. adjuvant therapies able to improve the biological performance of standard bone grafts or substitutes. Among these therapies, platelet-rich plasma and bone morphogenetic proteins need to be investigated further before any recommendations can be made.
Cite this article: EFORT Open Rev 2016;1:431-439. DOI:10.1302/2058-5241.160025
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Affiliation(s)
| | - Luigi Zagra
- IRCCS Galeazzi Orthopedic Institute, Milan, Italy
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25
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Rodriguez RU, Kemper N, Breathwaite E, Dutta SM, Huber A, Murchison A, Chen S, Hsu EL, Hsu WK, Francis MP. Demineralized bone matrix fibers formable as general and custom 3D printed mold-based implants for promoting bone regeneration. Biofabrication 2016; 8:035007. [DOI: 10.1088/1758-5090/8/3/035007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
OBJECT Failed solid bony fusion, or pseudarthrosis, is a well-known complication of lumbar arthrodesis. Recent advances in radiographic technology, biologics, instrumentation, surgical technique, and understanding of the local biology have all aided in the prevention and treatment of pseudarthrosis. Here, the current literature on the diagnosis and management of lumbar pseudarthroses is reviewed. METHODS A systematic literature review was conducted using the MEDLINE and Embase databases in order to search for the current radiographie diagnosis and surgical treatment methods published in the literature (1985 to present). Inclusion criteria included: 1) published in English; 2) level of evidence I-III; 3) diagnosis of degenerative lumbar spine conditions and/or history of lumbar spine fusion surgery; and 4) comparative studies of 2 different surgical techniques or comparative studies of imaging modality versus surgical exploration. RESULTS Seven studies met the inclusion criteria for current radiographie imaging used to diagnose lumbar pseudarthrosis. Plain radiographs and thin-cut CT scans were the most common method for radiographie diagnosis. PET has been shown to be a valid imaging modality for monitoring in vivo active bone formation. Eight studies compared the surgical techniques for managing and preventing failed lumbar fusion. The success rates for the treatment of pseudarthrosis are enhanced with the use of rigid instrumentation. CONCLUSIONS Spinal fusion rates have improved secondary to advances in biologies, instrumentation, surgical techniques, and understanding of local biology. Treatment of lumbar pseudarthrosis includes a variety of surgical options such as replacing loose instrumentation, use of more potent biologies, and interbody fusion techniques. Prevention and recognition are important tenets in the algorithm for the management of spinal pseudarthrosis.
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Affiliation(s)
- Danielle S Chun
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and
| | - Kevin C Baker
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | - Wellington K Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and
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Zhang Y, Shuang Y, Fu H, Zhou W, Qian L, Dai J, Miron RJ. Characterization of a shorter recombinant polypeptide chain of bone morphogenetic protein 2 on osteoblast behaviour. BMC Oral Health 2015; 15:171. [PMID: 26715589 PMCID: PMC4696268 DOI: 10.1186/s12903-015-0154-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 12/16/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Recombinant bone morphogenetic protein two (rhBMP2) has been utilised for a variety of clinical applications in orthopaedic surgery and dental procedures. Despite its widespread use, concerns have been raised regarding its short half-life and transient bioactivity in vivo. Recent investigation aimed at developing rhBMP2 synthesized from a shorter polypeptide chain (108 amino acids) has been undertaken. METHODS The osteopromotive properties of BMP2 were investigated on cell behaviour. Five concentrations of rhBMP2_108 including 10, 50, 100, 200 and 500 ng/ml were compared to a commercially available rhBMP2 (100 ng/ml). Each of the working concentrations of rhBMP2_108 were investigated on MC3T3-E1 osteoblasts for their ability to induce osteoblast recruitment, proliferation and differentiation as assessed by alkaline phosphatase (ALP) staining, alizarin red staining, and real-time PCR for genes encoding ALP, osteocalcin (OCN), collagen-1 (COL-1) and Runx2. RESULTS The results demonstrate that all concentrations of rhBMP2_108 significantly improved cell recruitment and proliferation of osteoblasts at 5 days post seeding. Furthermore, rhBMP2_108 had the most pronounced effects on osteoblast differentiation. It was found that rhBMP2_108 had over a four fold significant increase in ALP activity at seven and 14 days post-seeding and the concentrations ranging from 50 to 200 ng/ml demonstrated the most pronounced effects. Analysis of real-time PCR for genes encoding ALP, OCN, COL-1 and Runx2 further confirmed dose-dependant increases at 14 days post-seeding. Furthermore, alizarin red staining demonstrated a concentration dependant increase in staining at 14 days. CONCLUSION The results from the present study demonstrate that this shorter polypeptide chain of rhBMP2_108 is equally as bioactive as commercially available rhBMP2 for the recruitment of progenitor cells by facilitating their differentiation towards the osteoblast lineage. Future in vivo study are necessary to investigate its bioactivity.
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Affiliation(s)
- Yufeng Zhang
- The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, 237 Luoyu Road, Wuhan, 430079, People's Republic of China.
- Department of Oral Implantology, School of Stomatology, Wuhan University, Wuhan, 430079, China.
| | - Yang Shuang
- The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, 237 Luoyu Road, Wuhan, 430079, People's Republic of China.
| | - Hang Fu
- Hangzhou JIuyuan Gene Engineering Co, Ltd;East of No.8 Street, Hangzhou Econ. and Tech. Development Zone, Hangzhou, China Hangzhou China, 310018, China.
| | - Wei Zhou
- Hangzhou JIuyuan Gene Engineering Co, Ltd;East of No.8 Street, Hangzhou Econ. and Tech. Development Zone, Hangzhou, China Hangzhou China, 310018, China.
| | - Li Qian
- Hangzhou JIuyuan Gene Engineering Co, Ltd;East of No.8 Street, Hangzhou Econ. and Tech. Development Zone, Hangzhou, China Hangzhou China, 310018, China.
| | - Jing Dai
- The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, 237 Luoyu Road, Wuhan, 430079, People's Republic of China.
| | - Richard J Miron
- The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, 237 Luoyu Road, Wuhan, 430079, People's Republic of China.
- Department of Oral Surgery and Stomatology, University of Bern, Freiburgstrasse 7, Bern, 3010, Switzerland.
- Department of Periodontology, School of Dental Medicine, University of Bern, Freiburgstrasse 7, Bern, 3010, Switzerland.
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