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Bergin SM, Crutcher CL, Keeler C, Rocos B, Haglund MM, Michael Guo H, Gottfried ON, Richardson WJ, Than KD. Osteoimmunology: Interactions With the Immune System in Spinal Fusion. Int J Spine Surg 2023; 17:S9-S17. [PMID: 38050073 PMCID: PMC10753333 DOI: 10.14444/8556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023] Open
Abstract
Spinal fusion is important for the clinical success of patients undergoing surgery, and the immune system plays an increasingly recognized role. Osteoimmunology is the study of the interactions between the immune system and bone. Inflammation impacts the osteogenic, osteoconductive, and osteoinductive properties of bone grafts and substitutes and ultimately influences the success of spinal fusion. Macrophages have emerged as important cells for coordinating the immune response following spinal fusion surgery, and macrophage-derived cytokines impact each phase of bone graft healing. This review explores the cellular and molecular immune processes that regulate bone homeostasis and healing during spinal fusion.
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Affiliation(s)
- Stephen M Bergin
- Department of Neurosurgery, Division of Spine, Duke University, Durham, NC, USA
| | - Clifford L Crutcher
- Department of Neurosurgery, Division of Spine, Duke University, Durham, NC, USA
| | - Carolyn Keeler
- Department of Neurosurgery, Division of Spine, Duke University, Durham, NC, USA
| | - Brett Rocos
- Department of Orthopedic Surgery, Division of Spine, Duke University, Durham, NC, USA
| | - Michael M Haglund
- Department of Neurosurgery, Division of Spine, Duke University, Durham, NC, USA
| | - H Michael Guo
- Department of Orthopedic Surgery, Division of Spine, Duke University, Durham, NC, USA
| | - Oren N Gottfried
- Department of Neurosurgery, Division of Spine, Duke University, Durham, NC, USA
| | - William J Richardson
- Department of Orthopedic Surgery, Division of Spine, Duke University, Durham, NC, USA
| | - Khoi D Than
- Department of Neurosurgery, Division of Spine, Duke University, Durham, NC, USA
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van Dijk LA, Janssen NG, Nurmohamed SJ, Muradin MSM, Longoni A, Bakker RC, de Groot FG, de Bruijn JD, Gawlitta D, Rosenberg AJWP. Osteoinductive calcium phosphate with submicron topography as bone graft substitute for maxillary sinus floor augmentation: A translational study. Clin Oral Implants Res 2023; 34:177-195. [PMID: 36645164 DOI: 10.1111/clr.14028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The aim of this study was the preclinical and clinical evaluation of osteoinductive calcium phosphate with submicron surface topography as a bone graft substitute for maxillary sinus floor augmentation (MSFA). MATERIAL AND METHODS A preclinical sheep model of MSFA was used to compare a calcium phosphate with submicron needle-shaped topography (BCPN , MagnetOs Granules, Kuros Biosciences BV) to a calcium phosphate with submicron grain-shaped topography (BCPG ) and autologous bone graft (ABG) as controls. Secondly, a 10-patient, prospective, randomized, controlled trial was performed to compare BCPN to ABG in MSFA with two-stage implant placement. RESULTS The pre-clinical study demonstrated that both BCPN and BCPG were highly biocompatible, supported bony ingrowth with direct bone apposition against the material, and exhibited bone formation as early as 3 weeks post-implantation. However, BCPN demonstrated significantly more bone formation than BCPG at the study endpoint of 12 weeks. Only BCPN reached an equivalent amount of bone formation in the available space and a greater proportion of calcified material (bone + graft material) in the maxillary sinus compared to the "gold standard" ABG after 12 weeks. These results were validated in a small prospective clinical study, in which BCPN was found comparable to ABG in implant stability, bone height, new bone formation in trephine core biopsies, and overall clinical outcome. CONCLUSION This translational work demonstrates that osteoinductive calcium phosphates are promising bone graft substitutes for MSFA, whereas their bone-forming potential depends on the design of their surface features. Netherlands Trial Register, NL6436.
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Affiliation(s)
- Lukas A van Dijk
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Regenerative Medicine Center Utrecht, Utrecht, the Netherlands
- Kuros Biosciences BV, Bilthoven, the Netherlands
| | - Nard G Janssen
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Silke J Nurmohamed
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marvick S M Muradin
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Alessia Longoni
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Regenerative Medicine Center Utrecht, Utrecht, the Netherlands
| | - Robbert C Bakker
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Joost D de Bruijn
- Kuros Biosciences BV, Bilthoven, the Netherlands
- School of Materials Science and Engineering, Queen Mary University of London, London, UK
| | - Debby Gawlitta
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Regenerative Medicine Center Utrecht, Utrecht, the Netherlands
| | - Antoine J W P Rosenberg
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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Safety and Efficacy of Stand-Alone Bioactive Glass Injectable Putty or Granules in Posterior Vertebral Fusion for Adolescent Idiopathic and Non-Idiopathic Scoliosis. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020398. [PMID: 36832526 PMCID: PMC9955925 DOI: 10.3390/children10020398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023]
Abstract
Posterior spinal fusion (PSF) is the standard procedure for the treatment of severe scoliosis. PSF is a standard procedure that combines posterior instrumentation with bone grafting and/or bone substitutes to enhance fusion. The aim of this retrospective study was to evaluate and compare the post-operative safety and efficiency of stand-alone bioactive glass putty and granules in posterior spine fusion for scoliosis in a paediatric cohort. A total of 43 children and adolescents were included retrospectively. Each patient's last follow-up was performed at 24 months and included clinical and radiological evaluations. Pseudarthrosis was defined as a loss of correction measuring >10° of Cobb angle between the pre-operative and last follow-up measurements. There was no significant loss of correction between the immediate post-operative timepoint and the 24-month follow-up. There was no sign of non-union, implant displacement or rod breakage. Bioactive glass in the form of putty or granules is an easily handled biomaterial but still a newcomer on the market. This study shows that the massive use of bioactive glass in posterior fusion, when combined with proper surgical planning, hardware placement and correction, is effective in providing good clinical and radiological outcomes.
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Physico-Chemical Characteristics and Posterolateral Fusion Performance of Biphasic Calcium Phosphate with Submicron Needle-Shaped Surface Topography Combined with a Novel Polymer Binder. MATERIALS 2022; 15:ma15041346. [PMID: 35207887 PMCID: PMC8880136 DOI: 10.3390/ma15041346] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 12/04/2022]
Abstract
A biphasic calcium phosphate with submicron needle-shaped surface topography combined with a novel polyethylene glycol/polylactic acid triblock copolymer binder (BCP-EP) was investigated in this study. This study aims to evaluate the composition, degradation mechanism and bioactivity of BCP-EP in vitro, and its in vivo performance as an autograft bone graft (ABG) extender in a rabbit Posterolateral Fusion (PLF) model. The characterization of BCP-EP and its in vitro degradation products showed that the binder hydrolyses rapidly into lactic acid, lactide oligomers and unaltered PEG (polyethylene glycol) without altering the BCP granules and their characteristic submicron needle-shaped surface topography. The bioactivity of BCP-EP after immersion in SBF revealed a progressive surface mineralization. In vivo, BCP-EP was assessed in a rabbit PLF model by radiography, manual palpation, histology and histomorphometry up to 12 weeks post-implantation. Twenty skeletally mature New Zealand (NZ) White Rabbits underwent single-level intertransverse process PLF surgery at L4/5 using (1) autologous bone graft (ABG) alone or (2) by mixing in a 1:1 ratio with BCP-EP (BCP-EP/ABG). After 3 days of implantation, histology showed the BCP granules were in direct contact with tissues and cells. After 12 weeks, material resorption and mature bone formation were observed, which resulted in solid fusion between the two transverse processes, following all assessment methods. BCP-EP/ABG showed comparable fusion rates with ABG at 12 weeks, and no graft migration or adverse reaction were noted at the implantation site nor in distant organs.
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Øvrebø Ø, Perale G, Wojciechowski JP, Echalier C, Jeffers JRT, Stevens MM, Haugen HJ, Rossi F. Design and clinical application of injectable hydrogels for musculoskeletal therapy. Bioeng Transl Med 2022; 7:e10295. [PMID: 35600661 PMCID: PMC9115710 DOI: 10.1002/btm2.10295] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 11/25/2022] Open
Abstract
Musculoskeletal defects are an enormous healthcare burden and source of pain and disability for individuals. With an aging population, the proportion of individuals living with these medical indications will increase. Simultaneously, there is pressure on healthcare providers to source efficient solutions, which are cheaper and less invasive than conventional technology. This has led to an increased research focus on hydrogels as highly biocompatible biomaterials that can be delivered through minimally invasive procedures. This review will discuss how hydrogels can be designed for clinical translation, particularly in the context of the new European Medical Device Regulation (MDR). We will then do a deep dive into the clinically used hydrogel solutions that have been commercially approved or have undergone clinical trials in Europe or the United States. We will discuss the therapeutic mechanism and limitations of these products. Due to the vast application areas of hydrogels, this work focuses only on treatments of cartilage, bone, and the nucleus pulposus. Lastly, the main steps toward clinical translation of hydrogels as medical devices are outlined. We suggest a framework for how academics can assist small and medium MedTech enterprises conducting the initial clinical investigation and post‐market clinical follow‐up required in the MDR. It is evident that the successful translation of hydrogels is governed by acquiring high‐quality pre‐clinical and clinical data confirming the device mechanism of action and safety.
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Affiliation(s)
- Øystein Øvrebø
- Department of Chemistry, Materials and Chemical Engineering “Giulio Natta”Politecnico di MilanoMilanoItaly
- Department of BiomaterialsInstitute of Clinical Dentistry, University of OsloOsloNorway
- Material Biomimetic ASOslo Science ParkOsloNorway
| | - Giuseppe Perale
- Industrie Biomediche Insubri SAMezzovico‐ViraSwitzerland
- Faculty of Biomedical SciencesUniversity of Southern SwitzerlandLuganoSwitzerland
- Ludwig Boltzmann Institute for Experimental and Clinical TraumatologyViennaAustria
| | - Jonathan P. Wojciechowski
- Department of MaterialsImperial College LondonLondonUK
- Department of BioengineeringImperial College LondonLondonUK
- Institute of Biomedical EngineeringImperial College LondonLondonUK
| | - Cécile Echalier
- Department of MaterialsImperial College LondonLondonUK
- Department of BioengineeringImperial College LondonLondonUK
- Institute of Biomedical EngineeringImperial College LondonLondonUK
- Hybrid Technology Hub, Centre of ExcellenceInstitute of Basic Medical Science, University of OsloOsloNorway
| | | | - Molly M. Stevens
- Department of MaterialsImperial College LondonLondonUK
- Department of BioengineeringImperial College LondonLondonUK
- Institute of Biomedical EngineeringImperial College LondonLondonUK
| | - Håvard J. Haugen
- Department of BiomaterialsInstitute of Clinical Dentistry, University of OsloOsloNorway
- Material Biomimetic ASOslo Science ParkOsloNorway
| | - Filippo Rossi
- Department of Chemistry, Materials and Chemical Engineering “Giulio Natta”Politecnico di MilanoMilanoItaly
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Walsh WR, Pelletier M, Wills D, Wang T, Bannigan S, Vizesi F. Undercut macrostructure topography on and within an interbody cage improves biomechanical stability and interbody fusion. Spine J 2020; 20:1876-1886. [PMID: 32645503 DOI: 10.1016/j.spinee.2020.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The interface and interactions between an interbody cage, graft material, and host bone can all participate in the fusion. Shortcomings of Poly(aryl-ether-ether-ketone) interbody cages have been addressed with novel titanium surfaces. Titanium surfaces paired with macroscale topography features on the endplates and within the aperture may provide additional benefits. PURPOSE To evaluate the influence of cage design parameters on interbody fusion in a large animal preclinical model. STUDY DESIGN/SETTING A comparative preclinical large animal model was performed to evaluate how macroscale topography features of an interbody cage can facilitate early integration between the host bone, graft material, and interbody cage and these effects on biomechanical stability and fusion. METHODS Forty single level interbody fusions (L4-L5) using iliac crest autograft and bilateral pedicle screw fixation were performed in adult sheep to evaluate the effect of undercut macrostructure topography features of an interbody cage on the endplates and within the aperture. Fusions were evaluated at 6 and 12 weeks (n=10 per group) using radiography, microcomputed tomography, biomechanical integrity, and histology endpoints. RESULTS The presence of the undercut macrostructures present on the endplates and within the aperture statistically improved biomechanical integrity at 6 and 12 weeks compared with controls. Microcomputed tomography and histology demonstrated bony interdigitation within the endplate and aperture features contributing to the improvement in properties. CONCLUSIONS The present study demonstrates that Poly(aryl-ether-ether-ketone) implants with titanium surfaces can be augmented by undercut macrostructures present on the endplates and within the aperture to provide opportunities for a series of anchoring points that, with new bone formation and remodelling, result in earlier and improved biomechanical integrity of the treated level. CLINICAL SIGNIFICANCE This preclinical study showed that bone interdigitation with the undercut macrostructures present on the endplates and within the aperture resulted in improved fusion and biomechanical stability in a clinically relevant spinal fusion model. Future clinical study is warranted to evaluate such implants' performance in humans.
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Affiliation(s)
- William R Walsh
- Surgical & Orthopedic Research Laboratories, Prince of Wales Clinical, UNSW Sydney, Level 1, Clinical Sciences Building, Gate 6, Avoca St, Sydney, NSW 2031, Australia.
| | | | - Dan Wills
- Surgical & Orthopedic Research Laboratories, Prince of Wales Clinical, UNSW Sydney, Level 1, Clinical Sciences Building, Gate 6, Avoca St, Sydney, NSW 2031, Australia
| | - Tian Wang
- Surgical & Orthopedic Research Laboratories, Prince of Wales Clinical, UNSW Sydney, Level 1, Clinical Sciences Building, Gate 6, Avoca St, Sydney, NSW 2031, Australia
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Zhao H, Liang G, Liang W, Li Q, Huang B, Li A, Qiu D, Jin D. In vitro and in vivo evaluation of the pH-neutral bioactive glass as high performance bone grafts. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2020; 116:111249. [PMID: 32806287 DOI: 10.1016/j.msec.2020.111249] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/18/2022]
Abstract
Osteogenic and angiogenic properties are two most valued factors for bone grafting materials. Biomedical materials with synergistic promotion effects on these two properties would be highly desirable. In this study, we showed that a recently developed pH-neutral bioactive glass (PSC) possessed such characteristics. Compared to two classical biomaterials, 45S5 bioactive glass and beta-tricalcium phosphate (β-TCP), PSC markedly improved BMSCs' proliferation, migration and mineralization as well as their osteogenic and angiogenic differentiation. In vivo, PSC showed better performance on inducing bone regeneration than both 45S5 and β-TCP, as featured by elevated bone mineral density (BMD) and new bone areas. PSC also significantly promoted new blood vessels formation compared with those in control groups. Furthermore, we revealed that PSC induced osteogenic and angiogenic differentiation of BMSCs through the PI3K/Akt/HIF-1α pathway, which had not been reported before. This synergistic effect of the PI3K/Akt/HIF-1α pathway on osteogenesis and angiogenic differentiation of BMSCs suggested that biomedical materials may promote new bone formation through multiple signal pathways, thus shedding light on the future development of materials with better performance.
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Affiliation(s)
- Huiyu Zhao
- Academy of Orthopedics, Guangdong Province, Orthopaedic Hospital of Guangdong Province, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510665, People's Republic of China
| | - Guojun Liang
- Academy of Orthopedics, Guangdong Province, Orthopaedic Hospital of Guangdong Province, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510665, People's Republic of China
| | - Wenquan Liang
- Academy of Orthopedics, Guangdong Province, Orthopaedic Hospital of Guangdong Province, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510665, People's Republic of China
| | - Qingchu Li
- Academy of Orthopedics, Guangdong Province, Orthopaedic Hospital of Guangdong Province, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510665, People's Republic of China
| | - Bin Huang
- Academy of Orthopedics, Guangdong Province, Orthopaedic Hospital of Guangdong Province, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510665, People's Republic of China
| | - Ailing Li
- Beijing National Laboratory for Molecular Sciences, CAS Research/Education Center for Excellence in Molecular Sciences, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, People's Republic of China
| | - Dong Qiu
- Beijing National Laboratory for Molecular Sciences, CAS Research/Education Center for Excellence in Molecular Sciences, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, People's Republic of China; University of Chinese Academy of Sciences, Beijing 100190, People's Republic of China.
| | - Dadi Jin
- Academy of Orthopedics, Guangdong Province, Orthopaedic Hospital of Guangdong Province, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510665, People's Republic of China.
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