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Laubach M, Herath B, Bock N, Suresh S, Saifzadeh S, Dargaville BL, McGovern J, Wille ML, Hutmacher DW, Medeiros Savi F. In vivo characterization of 3D-printed polycaprolactone-hydroxyapatite scaffolds with Voronoi design to advance the concept of scaffold-guided bone regeneration. Front Bioeng Biotechnol 2023; 11:1272348. [PMID: 37860627 PMCID: PMC10584154 DOI: 10.3389/fbioe.2023.1272348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/20/2023] [Indexed: 10/21/2023] Open
Abstract
Three-dimensional (3D)-printed medical-grade polycaprolactone (mPCL) composite scaffolds have been the first to enable the concept of scaffold-guided bone regeneration (SGBR) from bench to bedside. However, advances in 3D printing technologies now promise next-generation scaffolds such as those with Voronoi tessellation. We hypothesized that the combination of a Voronoi design, applied for the first time to 3D-printed mPCL and ceramic fillers (here hydroxyapatite, HA), would allow slow degradation and high osteogenicity needed to regenerate bone tissue and enhance regenerative properties when mixed with xenograft material. We tested this hypothesis in vitro and in vivo using 3D-printed composite mPCL-HA scaffolds (wt 96%:4%) with the Voronoi design using an ISO 13485 certified additive manufacturing platform. The resulting scaffold porosity was 73% and minimal in vitro degradation (mass loss <1%) was observed over the period of 6 months. After loading the scaffolds with different types of fresh sheep xenograft and ectopic implantation in rats for 8 weeks, highly vascularized tissue without extensive fibrous encapsulation was found in all mPCL-HA Voronoi scaffolds and endochondral bone formation was observed, with no adverse host-tissue reactions. This study supports the use of mPCL-HA Voronoi scaffolds for further testing in future large preclinical animal studies prior to clinical trials to ultimately successfully advance the SGBR concept.
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Affiliation(s)
- Markus Laubach
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, Australia
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich, Munich, Germany
| | - Buddhi Herath
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, Australia
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- Jamieson Trauma Institute, Metro North Hospital and Health Service, Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
| | - Nathalie Bock
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, Australia
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- Max Planck Queensland Centre (MPQC) for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD, Australia
| | - Sinduja Suresh
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, Australia
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- Biomechanics and Spine Research Group at the Centre of Children’s Health Research, Queensland University of Technology, Brisbane, QLD, Australia
| | - Siamak Saifzadeh
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, Australia
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- Medical Engineering Research Facility, Queensland University of Technology, Chermside, QLD, Australia
| | - Bronwin L. Dargaville
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- Max Planck Queensland Centre (MPQC) for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD, Australia
| | - Jacqui McGovern
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- Max Planck Queensland Centre (MPQC) for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD, Australia
- ARC Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology, Brisbane, QLD, Australia
| | - Marie-Luise Wille
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, Australia
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- Max Planck Queensland Centre (MPQC) for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD, Australia
| | - Dietmar W. Hutmacher
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, Australia
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- Max Planck Queensland Centre (MPQC) for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD, Australia
- ARC Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology, Brisbane, QLD, Australia
| | - Flavia Medeiros Savi
- Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD, Australia
- Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD, Australia
- Max Planck Queensland Centre (MPQC) for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD, Australia
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Noh T, Zakaria H, Massie L, Ogasawara CT, Lee GA, Chedid M. Bone Marrow Aspirate in Spine Surgery: Case Series and Review of the Literature. Cureus 2021; 13:e20309. [PMID: 35028210 PMCID: PMC8748018 DOI: 10.7759/cureus.20309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 12/02/2022] Open
Abstract
Background With the modernization of biotechnology, there has been a concerted effort to create novel biomaterials to promote arthrodesis for spine surgery. The novel use of the stem cells from bone marrow aspirate (BMA) to augment spine surgery is a burgeoning field because these cells are considered to be both osteoinductive and osteogenic. We sought to review the evidence behind the use of BMAs in spinal fusions and report the results of our own case series. Methods PubMed and EMBASE databases were searched for studies that investigated the use of stem cells for spine surgery. For our own case series, the medical records of 150 consecutive patients who underwent a lumbar spinal fusion with BMA were retrospectively reviewed for adverse events (AEs) for up to two years after surgery. Results In our case series, there were no AEs identified in 49% of our patients. Of the identified AEs, 61% were unrelated to the use of BMA (e.g., UTI and heart failure), with the remaining 39% likely unrelated to its use (e.g., back pain and anemia). There was a 92.8% arthrodesis rate with the use of BMA. Conclusions We reviewed the rationale, basic science, and clinical science for BMA usage in spine surgery and concluded that BMA is safe for use in spine surgery and is associated with a high rate of arthrodesis.
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Buser Z, Hsieh P, Meisel HJ, Skelly AC, Brodt ED, Brodke DS, Park JB, Yoon ST, Wang J. Use of Autologous Stem Cells in Lumbar Spinal Fusion: A Systematic Review of Current Clinical Evidence. Global Spine J 2021; 11:1281-1298. [PMID: 33203241 PMCID: PMC8453670 DOI: 10.1177/2192568220973190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES To systematically review, critically appraise and synthesize evidence on use of autologous stem cells sources for fusion in the lumbar spine. METHODS A systematic search of PubMed/MEDLINE, EMBASE and ClinicalTrials.gov through February 20, 2020 was conducted comparing autologous cell grafts to other biologics for lumbar spine fusion. The focus was on studies comparing distinct patient groups. RESULTS From 343 potentially relevant citations, 15 studies met the inclusion criteria set a priori. Seven studies compared distinct patient groups, with BMA being used in combination with allograft or autograft not as a standalone material. No economic evaluations were identified. Most observational studies were at moderately high risk of bias. When used for primary lumbar fusion, no statistical differences in outcomes or complications were seen between BMA+autograft/or +allograft compared to autograft/allograft alone. Compared with allograft, data from a RCT suggested statistically better fusion and lower complication rates with concentrated BMA+allograft. When used in revisions, no differences in outcomes were seen between BMA+allograft and either autograft or rh-BMP-2 but fusion rates were lower with BMA+allograft, leading to additional revision surgery. CONCLUSIONS There was substantial heterogeneity across studies in patient populations, sample size, biologic combinations, and surgical characteristics making direct comparisons difficult. The overall quality of evidence for fusion rates and the safety of BMA in lumbar fusion procedures was considered very low, with studies being at moderately high or high risk of bias.
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Affiliation(s)
- Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, CA, USA,Zorica Buser, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo St., HC4-5400A, Los Angeles, CA 90033, USA.
| | - Patrick Hsieh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, CA, USA
| | | | | | | | - Darrel S. Brodke
- Department of Orthopaedics, University of Utah School of Medicine, Salt Lake, UT, USA
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, Uijongbu St. Mary’s Hospital, The Catholic University of Korea School of Medicine, Uijongbu, Korea
| | - S. Tim Yoon
- Department of Orthopedics, Emory Spine Center, Emory University, Atlanta, GA, USA
| | - Jeffrey Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, CA, USA
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Paré A, Charbonnier B, Tournier P, Vignes C, Veziers J, Lesoeur J, Laure B, Bertin H, De Pinieux G, Cherrier G, Guicheux J, Gauthier O, Corre P, Marchat D, Weiss P. Tailored Three-Dimensionally Printed Triply Periodic Calcium Phosphate Implants: A Preclinical Study for Craniofacial Bone Repair. ACS Biomater Sci Eng 2020; 6:553-563. [PMID: 32158932 PMCID: PMC7064275 DOI: 10.1021/acsbiomaterials.9b01241] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Finding alternative strategies for the regeneration of craniofacial bone defects (CSD), such as combining a synthetic ephemeral calcium phosphate (CaP) implant and/or active substances and cells, would contribute to solving this reconstructive roadblock. However, CaP's architectural features (i.e., architecture and composition) still need to be tailored, and the use of processed stem cells and synthetic active substances (e.g., recombinant human bone morphogenetic protein 2) drastically limits the clinical application of such approaches. Focusing on solutions that are directly transposable to the clinical setting, biphasic calcium phosphate (BCP) and carbonated hydroxyapatite (CHA) 3D-printed disks with a triply periodic minimal structure (TPMS) were implanted in calvarial critical-sized defects (rat model) with or without addition of total bone marrow (TBM). Bone regeneration within the defect was evaluated, and the outcomes were compared to a standard-care procedure based on BCP granules soaked with TBM (positive control). After 7 weeks, de novo bone formation was significantly greater in the CHA disks + TBM group than in the positive controls (3.33 mm3 and 2.15 mm3, respectively, P=0.04). These encouraging results indicate that both CHA and TPMS architectures are potentially advantageous in the repair of CSDs and that this one-step procedure warrants further clinical investigation.
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Affiliation(s)
- Arnaud Paré
- INSERM, U 1229, Laboratoire Regenerative Medicine and Skeleton (RMeS), 1 place Alexis Ricordeau, Nantes F - 44042, France
- Service de Chirurgie Maxillo faciale, Plastique et Brulés, Hôpital Trousseau, CHU de Tours, Avenue de la République, Chambray-lès-Tours F – 37170, France
- Université de Tours, UFR Médecine, 2 boulevard Tonnellé, Tours F - 37000, France
- Université́ de Nantes, UFR Odontologie, 1 place Alexis Ricordeau, Nantes F - 44042, France
| | - Baptiste Charbonnier
- Mines Saint-Etienne, Univ Lyon, Univ Jean Monnet, INSERM, U 1059 Sainbiose, Centre CIS, 158 Cours Fauriel, CS 62362, Saint-Etienne F – 42023, France
| | - Pierre Tournier
- INSERM, U 1229, Laboratoire Regenerative Medicine and Skeleton (RMeS), 1 place Alexis Ricordeau, Nantes F - 44042, France
- Université́ de Nantes, UFR Odontologie, 1 place Alexis Ricordeau, Nantes F - 44042, France
| | - Caroline Vignes
- INSERM, U 1229, Laboratoire Regenerative Medicine and Skeleton (RMeS), 1 place Alexis Ricordeau, Nantes F - 44042, France
| | - Joëlle Veziers
- INSERM, U 1229, Laboratoire Regenerative Medicine and Skeleton (RMeS), 1 place Alexis Ricordeau, Nantes F - 44042, France
| | - Julie Lesoeur
- INSERM, U 1229, Laboratoire Regenerative Medicine and Skeleton (RMeS), 1 place Alexis Ricordeau, Nantes F - 44042, France
| | - Boris Laure
- Service de Chirurgie Maxillo faciale, Plastique et Brulés, Hôpital Trousseau, CHU de Tours, Avenue de la République, Chambray-lès-Tours F – 37170, France
- Université de Tours, UFR Médecine, 2 boulevard Tonnellé, Tours F - 37000, France
| | - Hélios Bertin
- Université́ de Nantes, UFR Odontologie, 1 place Alexis Ricordeau, Nantes F - 44042, France
- Service de chirurgie Maxillo-faciale et stomatologie, CHU de Nantes, 1 place Alexis Ricordeau, Nantes F - 44093, France
| | - Gonzague De Pinieux
- Université de Tours, UFR Médecine, 2 boulevard Tonnellé, Tours F - 37000, France
- Service d’Anatomo-cyto-pathologie, Hôpital Trousseau, CHU de Tours, Avenue de la République, Chambray-lès-Tours F – 37000, France
| | - Grégory Cherrier
- Université de Tours, UFR Médecine, 2 boulevard Tonnellé, Tours F - 37000, France
- Service d’Anatomo-cyto-pathologie, Hôpital Trousseau, CHU de Tours, Avenue de la République, Chambray-lès-Tours F – 37000, France
| | - Jérome Guicheux
- INSERM, U 1229, Laboratoire Regenerative Medicine and Skeleton (RMeS), 1 place Alexis Ricordeau, Nantes F - 44042, France
- Université́ de Nantes, UFR Odontologie, 1 place Alexis Ricordeau, Nantes F - 44042, France
| | - Olivier Gauthier
- INSERM, U 1229, Laboratoire Regenerative Medicine and Skeleton (RMeS), 1 place Alexis Ricordeau, Nantes F - 44042, France
- Université́ de Nantes, UFR Odontologie, 1 place Alexis Ricordeau, Nantes F - 44042, France
- ONIRIS Nantes-Atlantic College of Veterinary Medicine, Centre de rechecherche et d’investigation préclinique (CRIP), 101 route de Gachet, Nantes F - 44300, France
| | - Pierre Corre
- INSERM, U 1229, Laboratoire Regenerative Medicine and Skeleton (RMeS), 1 place Alexis Ricordeau, Nantes F - 44042, France
- Université́ de Nantes, UFR Odontologie, 1 place Alexis Ricordeau, Nantes F - 44042, France
- Service de chirurgie Maxillo-faciale et stomatologie, CHU de Nantes, 1 place Alexis Ricordeau, Nantes F - 44093, France
| | - David Marchat
- Mines Saint-Etienne, Univ Lyon, Univ Jean Monnet, INSERM, U 1059 Sainbiose, Centre CIS, 158 Cours Fauriel, CS 62362, Saint-Etienne F – 42023, France
| | - Pierre Weiss
- INSERM, U 1229, Laboratoire Regenerative Medicine and Skeleton (RMeS), 1 place Alexis Ricordeau, Nantes F - 44042, France
- Université́ de Nantes, UFR Odontologie, 1 place Alexis Ricordeau, Nantes F - 44042, France
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Salamanna F, Giavaresi G, Contartese D, Bigi A, Boanini E, Parrilli A, Lolli R, Gasbarrini A, Barbanti Brodano G, Fini M. Effect of strontium substituted ß-TCP associated to mesenchymal stem cells from bone marrow and adipose tissue on spinal fusion in healthy and ovariectomized rat. J Cell Physiol 2019; 234:20046-20056. [PMID: 30950062 DOI: 10.1002/jcp.28601] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 03/11/2019] [Accepted: 03/19/2019] [Indexed: 01/05/2023]
Abstract
Despite alternatives to autogenous bone graft for spinal fusion have been investigated, it has been shown that osteoconductive materials alone do not give a rate of fusion comparable with autogenous bone. This study analyzed a strontium substituted ß-tricalcium phosphate (Sr-ßTCP) associated with syngeneic, unexpanded, and undifferentiated mesenchymal stem cells from bone marrow (BMSC) or adipose tissue (ADSC) as a new tissue engineering approach for spinal fusion procedures. A posterolateral fusion was performed in 15 ovariectomized (OVX) and 15 sham-operated (SHAM) Inbred rats. Both SHAM and OVX animals were divided into three groups: Sr-ßTCP, Sr-ßTCP + BMCSs, and Sr-ßTCP + ADSCs. Animals were euthanized 8 weeks after surgery and the spines evaluated by manual palpation, micro-CT, and histology. For both SHAM and OVX animals, the fusion tissue in the Sr-ßTCP + BMSCs group was more solid. This effect was significantly higher in OVX animals by comparing the Sr-ßTCP + BMCSs group with Sr-ßTCP + ADSCs. Radiographical score, based on micro-CT 2D image, highlighted that the Sr-ßTCP + BMCSs group presented a similar fusion to Sr-ßTCP and higher than Sr-ßTCP + ADSCs in both SHAM and OVX animals. Micro-CT 3D parameters did not show significant differences among groups. Histological score showed significantly higher fusion in Sr-ßTCP + BMSCs group than Sr-ßTCP and Sr-ßTCP + ADSCs, for both SHAM and OVX animals. In conclusion, our results suggest that addition of BMSCs to a Sr-ßTCP improve bone formation and fusion, both in osteoporotic and nonosteoporotic animal, whereas spinal fusion is not enhanced in rats treated with Sr-ßTCP + ADSCs. Thus, for conducting cells therapy in spinal surgery BMSCs still seems to be a better choice compared with ADSCs.
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Affiliation(s)
- Francesca Salamanna
- Laboratory of Preclinical and Surgical Studies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gianluca Giavaresi
- Laboratory of Preclinical and Surgical Studies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Deyanira Contartese
- Laboratory of Preclinical and Surgical Studies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Adriana Bigi
- Department of Chemistry "G.Ciamician", University of Bologna, Bologna, Italy
| | - Elisa Boanini
- Department of Chemistry "G.Ciamician", University of Bologna, Bologna, Italy
| | - Annapaola Parrilli
- Laboratory of Preclinical and Surgical Studies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Roberta Lolli
- Laboratory of Preclinical and Surgical Studies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Gasbarrini
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giovanni Barbanti Brodano
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Milena Fini
- Laboratory of Biomechanics and Technological Innovation, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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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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Morris MT, Tarpada SP, Cho W. Bone graft materials for posterolateral fusion made simple: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:1856-1867. [DOI: 10.1007/s00586-018-5511-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 01/24/2018] [Accepted: 02/03/2018] [Indexed: 12/30/2022]
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Ofluoglu AE, Erdogan U, Aydogan M, Cevik OM, Ofluoglu O. Anterior cervical fusion with interbody cage containing beta-tricalcium phosphate: Clinical and radiological results. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:197-200. [PMID: 28351516 PMCID: PMC6197468 DOI: 10.1016/j.aott.2017.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/26/2016] [Accepted: 11/01/2016] [Indexed: 12/11/2022]
Abstract
Aim Beta tricalcium phosphate (beta-TCP) is an osteoconductive, resorbable material. Its clinical effectiveness has been proved in many indications. This study was clinical and radiographic study report obtained in patients undergoing anterior cervical discectomy and fusion ACDF in which PEEK cages were filled beta-TCP in an injectable form. Material and methods Between January 2010 and June 2011, 16 consecutive patients underwent ACDF using PEEK cages with beta-TCP. The cohort compromised 10 men and 6 women with a mean age of 45.2 years. The surgery was performed when the patient had myelopathy or radiculopathy with progressive neurological deficit, or failure of conservative treatment (a minimum of 3 months). The patients were evaluated by Odom criteria preoperatively and postoperative 3rd, 6th, 12th and 24th months. Preop and postop pain was evaluated with visual analogue scala (VAS). Disc height and fusion success rates were evaluated. Results Preoperative average VAS score was 7.9 (7–10) for neck pain and 8 (7–10) for arm pain. At the final follow-up, these scores became 1.5 and 1.4 for neck and arm pain, respectively. The average improvement rate was 81% for neck pain and 82.5% for arm pain. Postop ODOM's criteria main rate was 3.4. Bone fusion was achieved in 14 segments (70%) at 3rd month, 19 segments (95%) at 12th month follow-up assessment. Conclusion Clinical and radiological results revealed that B-TCP is a good alternative synthetic fusion material for cervical interbody fusion. Level of evidence: Level IV, therapeutic study.
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Affiliation(s)
- Ali Ender Ofluoglu
- Bakirkoy Research and Training Hospital for Neurology, Neurosurgery and Psychiatry, Neurosurgery Clinic, Istanbul, Turkey
| | - Uzay Erdogan
- Department of Neurosurgery, Bakirkoy Research and Training Hospital for Neurology Neurosurgery and Psychiartry, Istanbul, Turkey.
| | | | - Orhun Mete Cevik
- Bakirkoy Prof.Dr. Mazhar Training and Research Hospital for Neurology, Neurosurgery and Psychiatry, Bakirkoy, Istanbul, Turkey
| | - Onder Ofluoglu
- Bahcesehir University, Göztepe Medical Park Hospital, Orthopedic and Traumatology Department, Istanbul, Turkey
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Mesenchymal Stem Cells for the Treatment of Spinal Arthrodesis: From Preclinical Research to Clinical Scenario. Stem Cells Int 2017; 2017:3537094. [PMID: 28286524 PMCID: PMC5327761 DOI: 10.1155/2017/3537094] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 01/05/2017] [Indexed: 02/07/2023] Open
Abstract
The use of spinal fusion procedures has rapidly augmented over the last decades and although autogenous bone graft is the “gold standard” for these procedures, alternatives to its use have been investigated over many years. A number of emerging strategies as well as tissue engineering with mesenchymal stem cells (MSCs) have been planned to enhance spinal fusion rate. This descriptive systematic literature review summarizes the in vivo studies, dealing with the use of MSCs in spinal arthrodesis surgery and the state of the art in clinical applications. The review has yielded promising evidence supporting the use of MSCs as a cell-based therapy in spinal fusion procedures, thus representing a suitable biological approach able to reduce the high cost of osteoinductive factors as well as the high dose needed to induce bone formation. Nevertheless, despite the fact that MSCs therapy is an interesting and important opportunity of research, in this review it was detected that there are still doubts about the optimal cell concentration and delivery method as well as the ideal implantation techniques and the type of scaffolds for cell delivery. Thus, further inquiry is necessary to carefully evaluate the clinical safety and efficacy of MSCs use in spine fusion.
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Buser Z, Brodke DS, Youssef JA, Meisel HJ, Myhre SL, Hashimoto R, Park JB, Tim Yoon S, Wang JC. Synthetic bone graft versus autograft or allograft for spinal fusion: a systematic review. J Neurosurg Spine 2016; 25:509-516. [PMID: 27231812 DOI: 10.3171/2016.1.spine151005] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The purpose of this review was to compare the efficacy and safety of synthetic bone graft substitutes versus autograft or allograft for the treatment of lumbar and cervical spinal degenerative diseases. Multiple major medical reference databases were searched for studies that evaluated spinal fusion using synthetic bone graft substitutes (either alone or with an autograft or allograft) compared with autograft and allograft. Randomized controlled trials (RCT) and cohort studies with more than 10 patients were included. Radiographic fusion, patient-reported outcomes, and functional outcomes were the primary outcomes of interest. The search yielded 214 citations with 27 studies that met the inclusion criteria. For the patients with lumbar spinal degenerative disease, data from 19 comparative studies were included: 3 RCTs, 12 prospective, and 4 retrospective studies. Hydroxyapatite (HA), HA+collagen, β-tricalcium phosphate (β-TCP), calcium sulfate, or polymethylmethacrylate (PMMA) were used. Overall, there were no differences between the treatment groups in terms of fusion, functional outcomes, or complications, except in 1 study that found higher rates of HA graft absorption. For the patients with cervical degenerative conditions, data from 8 comparative studies were included: 4 RCTs and 4 cohort studies (1 prospective and 3 retrospective studies). Synthetic grafts included HA, β-TCP/HA, PMMA, and biocompatible osteoconductive polymer (BOP). The PMMA and BOP grafts led to lower fusion rates, and PMMA, HA, and BOP had greater risks of graft fragmentation, settling, and instrumentation problems compared with iliac crest bone graft. The overall quality of evidence evaluating the potential use and superiority of the synthetic biological materials for lumbar and cervical fusion in this systematic review was low or insufficient, largely due to the high potential for bias and small sample sizes. Thus, definitive conclusions or recommendations regarding the use of these synthetic materials should be made cautiously and within the context of the limitations of the evidence.
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Affiliation(s)
- Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Darrel S Brodke
- Department of Orthopedics, University of Utah School of Medicine, Salt Lake City, Utah
| | | | | | | | | | - Jong-Beom Park
- Department of Orthopaedic Surgery, Uijongbu St. Mary's Hospital, The Catholic University of Korea School of Medicine, Uijongbu, Korea; and
| | - S Tim Yoon
- Department of Orthopedics, Emory Spine Center, Emory University, Atlanta, Georgia
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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11
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Corre P, Merceron C, Longis J, Khonsari R, Pilet P, thi TN, Battaglia S, Sourice S, Masson M, Sohier J, Espitalier F, Guicheux J, Weiss P. Direct comparison of current cell-based and cell-free approaches towards the repair of craniofacial bone defects - A preclinical study. Acta Biomater 2015; 26:306-17. [PMID: 26283163 DOI: 10.1016/j.actbio.2015.08.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 07/09/2015] [Accepted: 08/13/2015] [Indexed: 12/27/2022]
Abstract
For craniofacial bone defect repair, several alternatives to bone graft (BG) exist, including the combination of biphasic calcium phosphate (BCP) biomaterials with total bone marrow (TBM) and bone marrow-derived mesenchymal stromal cells (MSCs), or the use of growth factors like recombinant human bone morphogenic protein-2 (RhBMP-2) and various scaffolds. Therefore, clinicians might be unsure as to which approach will offer their patients the most benefit. Here, we aimed to compare different clinically relevant bone tissue engineering methods in an "all-in-one" study in rat calvarial defects. TBM, and MSCs committed or not, and cultured in two- or three-dimensions were mixed with BCP and implanted in bilateral parietal bone defects in rats. RhBMP-2 and BG were used as positive controls. After 7 weeks, significant de novo bone formation was observed in rhBMP-2 and BG groups, and in a lesser amount, when BCP biomaterials were mixed with TBM or committed MSCs cultured in three-dimensions. Due to the efficacy and safety of the TBM/BCP combination approach, we recommend this one-step procedure for further clinical investigation. STATEMENT OF SIGNIFICANCE For craniofacial repair, total bone marrow (BM) and BM mesenchymal stem cell (MSC)-based regenerative medicine have shown to be promising in alternative to bone grafting (BG). Therefore, clinicians might be unsure as to which approach will offer the most benefit. Here, BM and MSCs committed or not were mixed with calcium phosphate ceramics (CaP) and implanted in bone defects in rats. RhBMP-2 and BG were used as positive controls. After 7 weeks, significant bone formation was observed in rhBMP-2 and BG groups, and when CaP were mixed with BM or committed MSCs. Since the BM-based procedure does not require bone harvest or cell culture, but provides de novo bone formation, we recommend consideration of this strategy for craniofacial applications.
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12
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Coathup MJ, Edwards TC, Samizadeh S, Lo WJ, Blunn GW. The effect of an alginate carrier on bone formation in a hydroxyapatite scaffold. J Biomed Mater Res B Appl Biomater 2015; 104:1328-35. [PMID: 26118665 DOI: 10.1002/jbm.b.33395] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 01/12/2015] [Accepted: 02/08/2015] [Indexed: 12/23/2022]
Abstract
This study investigated the osteoconductive properties of a porous hydroxyapatite (HA) scaffold manufactured using a novel technique similar to the bread-making process, alone and in combination with an alginate polysaccharide fiber gel (HA/APFG putty) and autologous bone marrow aspirate (BMA). The hypothesis was that the HA/APFG putty would be as osteoconductive as granular HA and that the presence of BMA would further enhance bone formation in an ovine femoral condyle critical defect model. Thirty-six defects were created and either (1) porous HA granules, (2) HA/APFG putty, or (3) HA/APFG putty + BMA were implanted. After retrieval at 6 and 12 weeks, image analysis techniques were used to quantify bone apposition rates, new bone area, bone-HA scaffold contact, and implant resorption. At 6 weeks postsurgery, significantly lower bone apposition rates were observed in the HA/APFG putty group when compared to the HA (p = 0.014) and HA/APFG putty + BMA (p = 0.014) groups. At 12 weeks, significantly increased amounts of new bone formation were measured within the HA scaffold (33.56 ± 3.53%) when compared to both the HA/APFG putty (16.69 ± 2.7%; p = 0.043) and the defects containing HA/APFG putty + BMA (19.31 ± 3.8%; p = 0.043). The use of an APFG gel as a carrier for injectable CaP bone substitute materials delayed bone formation in this model compared to HA granules alone which enhanced bone formation especially within the interconnected smaller pores. Our results also showed that the addition of autologous BMA did not further enhance its osteoconductive properties. Further study is required to optimize the degradation rate of this APFG binding agent before using as a directly injectable material for repair of bone defect. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 104B: 1328-1335, 2016.
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Affiliation(s)
- Melanie J Coathup
- Division of Surgery and Interventional Science, John Scales Centre for Biomedical Engineering, Institute of Orthopaedics and Musculoskeletal Science, University College London, The Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7, 4LP, UK.
| | - Thomas C Edwards
- Division of Surgery and Interventional Science, John Scales Centre for Biomedical Engineering, Institute of Orthopaedics and Musculoskeletal Science, University College London, The Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7, 4LP, UK
| | - Sorousheh Samizadeh
- Division of Surgery and Interventional Science, John Scales Centre for Biomedical Engineering, Institute of Orthopaedics and Musculoskeletal Science, University College London, The Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7, 4LP, UK
| | - Wei-Jen Lo
- Department of Research and Development, Wollaton Medical Consultancy Ltd., Nottingham, NG8, 2RN, UK
| | - Gordon W Blunn
- Division of Surgery and Interventional Science, John Scales Centre for Biomedical Engineering, Institute of Orthopaedics and Musculoskeletal Science, University College London, The Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7, 4LP, UK
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13
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Nickoli MS, Hsu WK. Ceramic-based bone grafts as a bone grafts extender for lumbar spine arthrodesis: a systematic review. Global Spine J 2014; 4:211-6. [PMID: 25083364 PMCID: PMC4111951 DOI: 10.1055/s-0034-1378141] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/25/2014] [Indexed: 01/28/2023] Open
Abstract
Study Design Systematic review. Objective Ceramic-based bone grafts have been widely utilized to reduce the need for iliac crest bone grafting given the complications associated with the harvest of iliac crest autograft. As a family, ceramics vary widely based on differences in composition, manufacturing, porosity, and structure, which may ultimately affect their efficacy. This article reviews the current data of ceramics used in different environments in the lumbar spine to achieve arthrodesis. Methods Medline, EMBASE, and Cochrane Central Register of Controlled Trials were searched for publications from 1980 to 2013 involving ceramic-based bone grafts in the lumbar spine. Variables such as age of patients, volume of ceramic, procedure, time to evaluation, method of evaluation, specific composition of ceramic, adjuncts used with ceramic products, type of fusion, and fusion rate were compared using a multivariate logistic regression model. Results Thirty studies with 1,332 patients met the final inclusion criteria. The overall fusion rate for all ceramic products as a bone graft extender in the lumbar spine was 86.4%. Age, gender, method of evaluation (plain radiographs, computed tomography, or combination), or specific ceramic product did not significantly affect fusion rate. Ceramics used in combination with local autograft resulted in significantly higher fusion rates compared with all other adjuncts, and bone marrow aspirate and platelet concentrates resulted in significantly lower fusion rates. Conclusions Ceramic-based bone grafts represent a promising bone graft extender in lumbar spine fusion when an osteoinductive stimulus, such as local bone graft is available.
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Affiliation(s)
- Michael S. Nickoli
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States,Address for correspondence Michael Nickoli, MD 676 N. Saint ClairSuite 1350, Chicago, IL 60611United States
| | - Wellington K. Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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Corre P, Merceron C, Vignes C, Sourice S, Masson M, Durand N, Espitalier F, Pilet P, Cordonnier T, Mercier J, Remy S, Anegon I, Weiss P, Guicheux J. Determining a clinically relevant strategy for bone tissue engineering: an "all-in-one" study in nude mice. PLoS One 2013; 8:e81599. [PMID: 24349093 PMCID: PMC3862877 DOI: 10.1371/journal.pone.0081599] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 10/15/2013] [Indexed: 11/20/2022] Open
Abstract
Purpose Autologous bone grafting (BG) remains the standard reconstruction strategy for large craniofacial defects. Calcium phosphate (CaP) biomaterials, such as biphasic calcium phosphate (BCP), do not yield consistent results when used alone and must then be combined with cells through bone tissue engineering (BTE). In this context, total bone marrow (TBM) and bone marrow-derived mesenchymal stem cells (MSC) are the primary sources of cellular material used with biomaterials. However, several other BTE strategies exist, including the use of growth factors, various scaffolds, and MSC isolated from different tissues. Thus, clinicians might be unsure as to which method offers patients the most benefit. For this reason, the aim of this study was to compare eight clinically relevant BTE methods in an “all-in-one” study. Methods We used a transgenic rat strain expressing green fluorescent protein (GFP), from which BG, TBM, and MSC were harvested. Progenitor cells were then mixed with CaP materials and implanted subcutaneously into nude mice. After eight weeks, bone formation was evaluated by histology and scanning electron microscopy, and GFP-expressing cells were tracked with photon fluorescence microscopy. Results/Conclusions Bone formation was observed in only four groups. These included CaP materials mixed with BG or TBM, in which abundant de novo bone was formed, and BCP mixed with committed cells grown in two- and three-dimensions, which yielded limited bone formation. Fluorescence microscopy revealed that only the TBM and BG groups were positive for GFP expressing-cells, suggesting that these donor cells were still present in the host and contributed to the formation of bone. Since the TBM-based procedure does not require bone harvest or cell culture techniques, but provides abundant de novo bone formation, we recommend consideration of this strategy for clinical applications.
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Affiliation(s)
- Pierre Corre
- INSERM (Institut National de la Santé et de la Recherche Médicale), UMR (Unité Mixte de Recherche) 791, center for osteoarticular and dental tissue engineering, Université de Nantes, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Clinique de Stomatologie et de Chirurgie maxillo-faciale, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 4, Nantes, France
- * E-mail:
| | - Christophe Merceron
- INSERM (Institut National de la Santé et de la Recherche Médicale), UMR (Unité Mixte de Recherche) 791, center for osteoarticular and dental tissue engineering, Université de Nantes, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 4, Nantes, France
| | - Caroline Vignes
- INSERM (Institut National de la Santé et de la Recherche Médicale), UMR (Unité Mixte de Recherche) 791, center for osteoarticular and dental tissue engineering, Université de Nantes, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 4, Nantes, France
| | - Sophie Sourice
- INSERM (Institut National de la Santé et de la Recherche Médicale), UMR (Unité Mixte de Recherche) 791, center for osteoarticular and dental tissue engineering, Université de Nantes, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 4, Nantes, France
| | - Martial Masson
- INSERM (Institut National de la Santé et de la Recherche Médicale), UMR (Unité Mixte de Recherche) 791, center for osteoarticular and dental tissue engineering, Université de Nantes, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 4, Nantes, France
| | - Nicolas Durand
- INSERM (Institut National de la Santé et de la Recherche Médicale), UMR (Unité Mixte de Recherche) 791, center for osteoarticular and dental tissue engineering, Université de Nantes, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Clinique d'Oto-Rhino-Laryngologie et de Chirurgie cervico-faciale, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 4, Nantes, France
| | - Florent Espitalier
- INSERM (Institut National de la Santé et de la Recherche Médicale), UMR (Unité Mixte de Recherche) 791, center for osteoarticular and dental tissue engineering, Université de Nantes, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Clinique d'Oto-Rhino-Laryngologie et de Chirurgie cervico-faciale, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 4, Nantes, France
| | - Paul Pilet
- INSERM (Institut National de la Santé et de la Recherche Médicale), UMR (Unité Mixte de Recherche) 791, center for osteoarticular and dental tissue engineering, Université de Nantes, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 4, Nantes, France
| | - Thomas Cordonnier
- INSERM (Institut National de la Santé et de la Recherche Médicale), UMR (Unité Mixte de Recherche) 791, center for osteoarticular and dental tissue engineering, Université de Nantes, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 4, Nantes, France
| | - Jacques Mercier
- Centre Hospitalier Universitaire de Nantes, Clinique de Stomatologie et de Chirurgie maxillo-faciale, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 4, Nantes, France
| | - Séverine Remy
- INSERM, UMR 1064, Centre pour la recherche en transplantation et immunologie et Plate-forme Transgenic Rats Nantes, Institut de Transplantation Urologie-Néphrologie (ITUN), Nantes, France
| | - Ignacio Anegon
- INSERM, UMR 1064, Centre pour la recherche en transplantation et immunologie et Plate-forme Transgenic Rats Nantes, Institut de Transplantation Urologie-Néphrologie (ITUN), Nantes, France
| | - Pierre Weiss
- INSERM (Institut National de la Santé et de la Recherche Médicale), UMR (Unité Mixte de Recherche) 791, center for osteoarticular and dental tissue engineering, Université de Nantes, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 4, Nantes, France
| | - Jérôme Guicheux
- INSERM (Institut National de la Santé et de la Recherche Médicale), UMR (Unité Mixte de Recherche) 791, center for osteoarticular and dental tissue engineering, Université de Nantes, Nantes, France
- Centre Hospitalier Universitaire de Nantes, Pôle Hospitalo-Universitaire 4, Nantes, France
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Khashan M, Inoue S, Berven SH. Cell based therapies as compared to autologous bone grafts for spinal arthrodesis. Spine (Phila Pa 1976) 2013; 38:1885-91. [PMID: 23873235 DOI: 10.1097/brs.0b013e3182a3d7dc] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To compare the clinical outcome of cell based grafts combined with bone extenders to autologous bone grafts. SUMMARY OF BACKGROUND DATA Alternative graft options that combine mesenchymal stem cells (MSCs) and bone marrow aspirate (BMA) with synthetic or allograft scaffolds have been recently used in several animal and clinical studies. METHODS This systematic review of the literature addresses the following key questions (KQs): (1) Does the use of MSCs or BMA combined with synthetic or allograft extenders contribute to thoracolumbar fusion rates that are comparable with the rates achieved by the use of iliac crest graft? (2) Are these fusion rates comparable with those of local bone graft (LBG)? (3) Does the addition of MSCs or BMA to iliac crest bone graft or LBG contribute to better throracolumbar fusion rates? (4) Are the cervical spine fusion outcomes achieved by the use of SCM or BMA with synthetic or allograft scaffolds comparable with the iliac crest bone graft or LBG outcomes? (5) Was there any difference in terms of fusion rates, when MSCs were compared with BMA? RESULTS For KQ1, 4 level II, III studies used iliac crest bone graft as control. The results of these studies were inconsistent, and the overall body of evidence was found insufficient. Three, level II, III studies were identified for KQ2. Comparable fusion rates were demonstrated between LBG and BMA combined with calcium phosphate or collagen carrier. The overall body of evidence was found weak. For KQ3, one level III study was found. No significant difference was found in the fusion rates. No studies met the criteria for KQ4, 5. CONCLUSION The currently available evidence is insufficient to support the use of MSCs or BMA combined with synthetic or allograft materials as a substitute or supplementary graft to autologous bone graft. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Morsi Khashan
- *Orthopedic Surgery Department, University of California-San Francisco, San Francisco, CA †Department of Orthopedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
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16
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Hsu WK, Nickoli MS, Wang JC, Lieberman JR, An HS, Yoon ST, Youssef JA, Brodke DS, McCullough CM. Improving the clinical evidence of bone graft substitute technology in lumbar spine surgery. Global Spine J 2012; 2:239-48. [PMID: 24353975 PMCID: PMC3864464 DOI: 10.1055/s-0032-1315454] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 03/02/2012] [Indexed: 11/20/2022] Open
Abstract
Bone graft substitutes have been used routinely for spine fusion for decades, yet clinical evidence establishing comparative data remains sparse. With recent scrutiny paid to the outcomes, complications, and costs associated with osteobiologics, a need to improve available data guiding efficacious use exists. We review the currently available clinical literature, studying the outcomes of various biologics in posterolateral lumbar spine fusion, and establish the need for a multicenter, independent osteobiologics registry.
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Affiliation(s)
- Wellington K. Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Address for correspondence and reprint requests Wellington K. Hsu, M.D. Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine676 N. St. Clair Street, #1350Chicago, IL 60611
| | - M. S. Nickoli
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - J. C. Wang
- Department of Orthopaedic Surgery, UCLA Comprehensive Spine Center, Santa Monica, California
| | - J. R. Lieberman
- University of Connecticut Medical Center, Farmington, Connecticut
| | - H. S. An
- Rush University Medical Center, Chicago, Illinois
| | | | | | | | - C. M. McCullough
- Resources for Medical Education and Collaboration, Durango, Colorado
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Silicate-substituted calcium phosphate as a bone graft substitute in surgery for adolescent idiopathic scoliosis. 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 2012; 22 Suppl 2:S185-94. [PMID: 22948551 DOI: 10.1007/s00586-012-2485-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 08/12/2012] [Accepted: 08/13/2012] [Indexed: 10/27/2022]
Abstract
STUDY DESIGN AND OBJECTIVE The purpose of this prospective clinical study is to evaluate the clinical and radiographic outcomes using a silicate-substituted calcium phosphate (Si-CaP) as a bone graft substitute in surgery for adolescent idiopathic scoliosis (AIS). In posterior corrective surgery for AIS, harvesting autologous bone from the iliac crest still represents the gold standard to augment the local bone graft though it is comparatively invasive and associated with donor site morbidity. Si-CaP enriched with bone marrow aspirate (BMA) might be an appropriate bone graft extender to overcome these difficulties. METHODS Eighteen female and three male patients with AIS who underwent corrective posterior instrumentation were observed clinically and radiographically for a minimum of 24 months. In all cases, 20-40 ml Si-CaP granules (ACTIFUSE) mixed with BMA from vertebral bodies was used to extend the local bone graft. Fusion was assessed by standardized conventional radiographs regarding loss of correction and implant failure. Clinical outcome was evaluated with use of the Scoliosis Research Society-22 patient Questionnaire (SRS-22) and a Visual Analog Scale (VAS) for back pain. RESULTS Cobb angle of major curves averaged 63° preoperatively, 22° after surgery, and 24° at final follow-up, with a maximum loss of correction of 7° recorded after 4 months. No adverse effects related to the study material had been observed. In all patients, there was no evidence of implant failure, and formation of an increasingly densifying 'fusion mass' was visible, as assessed by conventional radiography. VAS score for back pain averaged 1.7 before surgery, 2.3 at discharge, and 1.5 at final follow-up. Outcome assessment using the SRS-22 revealed a significantly enhanced overall health-related quality of life (84 vs. 74 % before surgery; P = 0.0005) due to a significant improvement of the domains 'self image' (77 vs. 59 %; P = 0.0002) and 'pain' (88 vs. 80 %; P = 0.02). Patients' management satisfaction averaged 93 %. CONCLUSIONS Si-CaP augmented with BMA from vertebral bodies seems to prove an effective, safe, and easy to handle bone graft extender in scoliosis surgery and thus a suitable alternative to bone harvesting procedures.
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Odri GA, Hami A, Pomero V, Seite M, Heymann D, Bertrand-Vasseur A, Skalli W, Delecrin J. Development of a per-operative procedure for concentrated bone marrow adjunction in postero-lateral lumbar fusion: radiological, biological and clinical assessment. 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 2012; 21:2665-72. [PMID: 22639299 DOI: 10.1007/s00586-012-2375-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 04/07/2012] [Accepted: 05/10/2012] [Indexed: 12/13/2022]
Abstract
PURPOSE Addition of bone marrow to the bone graft in the postero-lateral lumbar arthrodesis is a widely used technique. Bone marrow brings stem cells and growth factors contained in the platelets, favorable for bone growth. Adjunction of concentrated bone marrow should create better conditions and may increase bone growth. METHODS Simple blind randomized clinical, prospective, monocentric trial was conducted. Fifteen patients underwent lumbar arthrodesis. During surgery, a fraction of the bone marrow harvested was centrifuged. One side received this concentrate with autologous bone and ceramics; the other side received the same graft with unconcentrated bone marrow. A quantitative study, realised with a volume calculating software on CT-scan images, determined the cortical bone volume in the graft post-operatively and at 3 months. The osteoprogenitor cells, nucleated cells and platelet concentrations were determined. RESULTS The biological study found an average concentration of six times for the nucleated cells, 3.5 times for the platelets and 2.2 times for the osteoprogenitor cells. The comparison of the mean cortical bone volumes post-operatively and at 3 months was not significantly different. CONCLUSIONS Despite the concentration obtained, there was no increase of bone growth by adding concentrated bone marrow. However, the number of stem cells in bone marrow was low and maybe a stronger concentration is needed to obtain a difference. The 3D reconstruction of the graft and the analysis of the graft's volume using a novel software was efficient according to the similarity of the graft's volume post-operatively in all patients.
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Affiliation(s)
- G A Odri
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU Hôtel Dieu, 1 Place Alexis Ricordeau, 44093, Nantes Cedex 1, France.
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Evaluation of autologous platelet concentrate for intertransverse lumbar 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 2011; 20 Suppl 3:361-6. [PMID: 21786039 DOI: 10.1007/s00586-011-1904-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 03/16/2011] [Accepted: 06/29/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The aim of the study was to analyze if the adding of autologous platelet concentrate (APC) to a mixture of local autograft plus tricalcium phosphate and hidroxiapatite (TCP/HA) would improve the fusion rate in posterolateral lumbar fusion. MATERIALS AND METHODS A prospective, controlled, blinded, non-randomized clinical trial was carried out in 107 patients affected by degenerative lumbar pathology. The study group consisted of 67 patients, in which autologous platelet concentration was added to a mixture of autologous local bone graft and TCP/HA. A control group of 40 patients with same pathology and surgical technique but without APC addition was used to compare the fusion mass obtained. By means of plain X-rays, a blinded evaluation of the intertransverse fusion mass quality at twelve and twenty-four months was made according to type A (bilateral uniform mass), type B (unilateral uniform mass) and type C (irregular or lack bilateral mass). Patients with type C were regarded as pseudoarthrosis. RESULTS In the study group 17 patients had lack or irregular fusion mass (25.4%) versus three patients in the control group (7.5%), which was statistically significant. CONCLUSIONS This study shows that the adding of autologous platelet concentration to a mixture of autologous bone graft plus TCP/HA has decreased our rates of posterolateral lumbar fusion.
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Park JH, Choi CG, Jeon SR, Rhim SC, Kim CJ, Roh SW. Radiographic Analysis of Instrumented Posterolateral Fusion Mass Using Mixture of Local Autologous Bone and b-TCP (PolyBone®) in a Lumbar Spinal Fusion Surgery. J Korean Neurosurg Soc 2011; 49:267-72. [PMID: 21716898 DOI: 10.3340/jkns.2011.49.5.267] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Revised: 04/17/2011] [Accepted: 05/08/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Although iliac crest autograft is the gold standard for lumbar fusion, the morbidity of donor site leads us to find an alternatives to replace autologous bone graft. Ceramic-based synthetic bone grafts such as hydroxyapatite (HA) and b-tricalcium phosphate (b-TCP) provide scaffolds similar to those of autologous bone, are plentiful and inexpensive, and are not associated with donor morbidity. The present report describes the use of Polybone® (Kyungwon Medical, Korea), a beta-tricalcium phosphate, for lumbar posterolateral fusion and assesses clinical and radiological efficacy as a graft material. METHODS This study retrospectively analyzed data from 32 patients (11 men, 21 women) who underwent posterolateral fusion (PLF) using PolyBone® from January to August, 2008. Back and leg pain were assessed using a Numeric Rating Scale (NRS), and clinical outcome was assessed using the Oswestry Disability Index (ODI). Serial radiological X-ray follow up were done at 1, 3, 6 12 month. A computed tomography (CT) scan was done in 12 month. Radiological fusion was assessed using simple anterior-posterior (AP) X-rays and computed tomography (CT). The changes of radiodensity of fusion mass showed on the X-ray image were analyzed into 4 stages to assess PLF status. RESULTS The mean NRS scores for leg pain and back pain decreased over 12 months postoperatively, from 8.0 to 1.0 and from 6.7 to 1.7, respectively. The mean ODI score also decreased from 60.5 to 17.7. X-rays and CT showed that 25 cases had stage IV fusion bridges at 12 months postoperatively (83.3% success). The radiodensity of fusion mass on X-ray AP image significantly changed at 1 and 6 months. CONCLUSION The present results indicate that the use of a mixture of local autologous bone and PolyBone® results in fusion rates comparable to those using autologous bone and has the advantage of reduced morbidity. In addition, the graft radiodensity ratio significantly changed at postoperative 1 and 6 months, possibly reflecting the inflammatory response and stabilization.
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Affiliation(s)
- Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
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Brydone AS, Meek D, Maclaine S. Bone grafting, orthopaedic biomaterials, and the clinical need for bone engineering. Proc Inst Mech Eng H 2011; 224:1329-43. [PMID: 21287823 DOI: 10.1243/09544119jeim770] [Citation(s) in RCA: 211] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
As the population ages, the number of operations performed on bone is expected to increase. Diseases such as arthritis, tumours, and trauma can lead to defects in the skeleton requiring an operation to replace or restore the lost bone. Surgeons can use autografts, allografts, and/or bone graft substitutes to restore areas of bone loss. Surgical implants are also used in addition or in isolation to replace the diseased bone. This review considers the application of available bone grafts in different clinical settings. It also discusses recently introduced bioactive biomaterials and highlights the clinical difficulties and technological deficiencies that exist in our current surgical practice.
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Affiliation(s)
- A S Brydone
- Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF, UK
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Efficacy of silicate-substituted calcium phosphate ceramic in posterolateral instrumented lumbar fusion. Spine (Phila Pa 1976) 2010; 35:E1058-63. [PMID: 20479699 DOI: 10.1097/brs.0b013e3181df196f] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN/SETTING Retrospective review of a consecutive, nonrandomized series operated on by 2 surgeons. OBJECTIVE To evaluate the clinical and radiographic effectiveness of a silicated hydroxyapatite ceramic as a bone graft substitute in a series of patients undergoing posterolateral instrumented lumbar fusion. SUMMARY OF BACKGROUND DATA Newer-generation synthetic ceramics have been refined to maximize their host-graft interaction and stimulation of new tissue formation, including silicate-substitution. METHODS An independent radiologist interpreted the computed tomography images at 6, 12, and 24 months after surgery. Forty-two patients with 1- or 2-level lumbar degenerative disorders underwent posterior laminectomy (when indicated) and posterolateral fusion with instrumentation. Surgical levels included 15 patients who underwent 2-level and 27 single-level fusion procedures (57 levels operated on in total). RESULTS The average back pain scores improved from 5.6 ± 2.5 preoperative to 2.1 ± 2.5 at follow-up (P < 0.05). Similar results were seen with leg pain improvement from 5.8 ± 2.5 to 1.4 ± 1.9 (P < 0.05). At 6 months, 35% of levels revealed fusion, which increased to 76.2% and 76.5% at 12 and 24 months, respectively. No evidence of ectopic bone formation or osteolysis was noted. CONCLUSION In this study, a silicated calcium phosphate-based ceramic has been shown to be effective as a graft substitute and eliminate the need for autogenous iliac crest bone graft. The results confirm radiographic healing in posterolateral instrumented lumbar fusion at 24-months follow-up. The clinical outcomes also substantiate significant pain improvement consistent with published data in the literature compared with other bone graft alternatives.
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Abstract
In spinal fusion procedures, the local bone that is resected serves as the base bone graft for attaining biological fusion. The local bone is frequently not sufficient and requires supplementary grafting. Autologous bone transplantation is still regarded as the gold standard but might cause additional complications; also, autograft resources are limited. Alternatively, allografts and a wide variety of different bone substitutes are available.The bone substitutes currently used in scoliosis surgery are presented, and their clinical significance is elucidated by a review of the literature. Furthermore, our own experiences and clinical practice are compared with those in the literature and are critically discussed. The recently growing number of scientific publications reporting on bone substitutes reflects the immense interest and relevance of this issue. In scoliosis surgery, calcium phosphate ceramics together with bone marrow aspirate are increasingly applied.Although harvesting of autologous bone continues to be the accepted standard to extend the local autograft in scoliosis surgery, there is a clear trend toward the use of bone substitutes.
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Vadalà G, Di Martino A, Tirindelli MC, Denaro L, Denaro V. Use of autologous bone marrow cells concentrate enriched with platelet-rich fibrin on corticocancellous bone allograft for posterolateral multilevel cervical fusion. J Tissue Eng Regen Med 2009; 2:515-20. [PMID: 18972577 DOI: 10.1002/term.121] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The outcomes of posterolateral multilevel spine fusion in difficult clinical settings, such as in an aged multi-diseased osteoporotic patient, remain unpredictable. The osteoprogenitor cells in bone marrow decrease with ageing without losing their osteogeneic potential. Autologous bone marrow cells (BMCs) from iliac crest aspirate can be concentrated in the operating room and platelet-rich fibrin (PRF) can be obtained from a peripheral blood as a source of autologous osteoprogenitor cells and growth factors, respectively. We present the case of an 88 year-old multi-diseased osteoporotic patient affected by cervical stenosis and subjected to C3--C7 posterior decompression, instrumentation and posterolateral fusion, using an intraoperative 'tissue-engineered' composite made of corticocancellous bone allograft augmented with autologous BMCs concentrate from iliac crest aspirate enriched with PRF from peripheral blood. Lateral dynamic X-rays and CT scan showed consolidation signs at 3 months follow-up, with solid C3--C7 fusion at 6 months follow-up. This paper describes a simple and effective method for potentially improving the fusion rate in aged osteoporotic patients by using corticocancellous bone allograft augmented with autologous BMCs concentrate from the iliac crest, enriched with PRF from peripheral blood, rapidly obtained before the surgical procedure.
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Affiliation(s)
- Gianluca Vadalà
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
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Bansal S, Chauhan V, Sharma S, Maheshwari R, Juyal A, Raghuvanshi S. Evaluation of hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate as a bone graft substitute for posterolateral spinal fusion. Indian J Orthop 2009; 43:234-9. [PMID: 19838344 PMCID: PMC2762171 DOI: 10.4103/0019-5413.49387] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Autologous cancellous bone is the most effective biological graft material. However, harvest of autologous bone is associated with significant morbidity. Since porous hydroxyapatite and beta-tricalcium phosphate are biodegradable materials and can be replaced by bone tissue, but it lacks osteogenic property. We conducted a study to assess their use as a scaffold and combine them with bone marrow aspirate for bone regeneration using its osteogenic property for posterolateral spinal fusion on one side and autologous bone graft on the other side and compare them radiologically in terms of graft incorporation and fusion. MATERIALS AND METHODS Thirty patients with unstable dorsal and lumbar spinal injuries who needed posterior stabilization and fusion were evaluated in this prospective study from October 2005 to March 2008. The posterior stabilization was done using pedicle screw and rod assembly, and fusion was done using hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate as a bone graft substitute over one side of spine and autologous bone graft obtained from iliac crest over other side of spine. The patients were followed up to a minimum of 12 months. Serial radiographs were done at an interval of 3, 6, and 12 months and CT scan was done at one year follow-up. Graft incorporation and fusion were assessed at each follow-up. The study was subjected to statistical analysis using chi-square and kappa test to assess graft incorporation and fusion. RESULTS At the end of the study, radiological graft incorporation and fusion was evident in all the patients on the bone graft substitute side and in 29 patients on the autologous bone graft side of the spine (P > 0.05). One patient showed lucency and breakage of distal pedicle screw in autologous bone graft side. The interobserver agreement (kappa) had an average of 0.72 for graft incorporation, 0.75 for fusion on radiographs, and 0.88 for the CT scan findings. CONCLUSION Hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate seems to be a promising alternative to conventional autologous iliac bone graft for posterolateral spinal fusion.
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Affiliation(s)
- Sanjay Bansal
- Department of Orthopaedic Surgery, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Jollygrant, Doiwala, Dehradun- Uttarakhand-248 140, India
| | - Vijendra Chauhan
- Department of Orthopaedic Surgery, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Jollygrant, Doiwala, Dehradun- Uttarakhand-248 140, India,Address for correspondence: Dr. Vijendra Chauhan, Department of Orthopaedics, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Jollygrant, Doiwala, Dehradun- Uttarakhand - 248 140, India. E-mail:
| | - Sansar Sharma
- Department of Orthopaedic Surgery, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Jollygrant, Doiwala, Dehradun- Uttarakhand-248 140, India
| | - Rajesh Maheshwari
- Department of Orthopaedic Surgery, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Jollygrant, Doiwala, Dehradun- Uttarakhand-248 140, India
| | - Anil Juyal
- Department of Orthopaedic Surgery, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Jollygrant, Doiwala, Dehradun- Uttarakhand-248 140, India
| | - Shailendra Raghuvanshi
- Department of Radiodiagnosis, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Jollygrant, Doiwala, Dehradun- Uttarakhand-248 140, India
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