1
|
Cheng CT, Vyas PS, McClain EJ, Hoelen TCA, Arts JJC, McLaughlin C, Altman DT, Yu AK, Cheng BC. The Osteogenic Peptide P-15 for Bone Regeneration: A Narrative Review of the Evidence for a Mechanism of Action. Bioengineering (Basel) 2024; 11:599. [PMID: 38927835 PMCID: PMC11200470 DOI: 10.3390/bioengineering11060599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/22/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024] Open
Abstract
Bone regeneration is a complex multicellular process involving the recruitment and attachment of osteoprogenitors and their subsequent differentiation into osteoblasts that deposit extracellular matrixes. There is a growing demand for synthetic bone graft materials that can be used to augment these processes to enhance the healing of bone defects resulting from trauma, disease or surgery. P-15 is a small synthetic peptide that is identical in sequence to the cell-binding domain of type I collagen and has been extensively demonstrated in vitro and in vivo to enhance the adhesion, differentiation and proliferation of stem cells involved in bone formation. These events can be categorized into three phases: attachment, activation and amplification. This narrative review summarizes the large body of preclinical research on P-15 in terms of these phases to describe the mechanism of action by which P-15 improves bone formation. Knowledge of this mechanism of action will help to inform the use of P-15 in clinical practice as well as the development of methods of delivering P-15 that optimize clinical outcomes.
Collapse
Affiliation(s)
- Cooper T. Cheng
- Neuroscience Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, USA; (C.T.C.); (P.S.V.); (C.M.)
| | - Praveer S. Vyas
- Neuroscience Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, USA; (C.T.C.); (P.S.V.); (C.M.)
| | - Edward James McClain
- Neuroscience Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, USA; (C.T.C.); (P.S.V.); (C.M.)
| | - Thomáy-Claire Ayala Hoelen
- Department of Orthopedic Surgery and CAPHRI Research School, Maastricht University Medical Center (MUMC+), P.O. Box 616 Maastricht, The Netherlands; (T.-C.A.H.); (J.J.C.A.)
| | - Jacobus Johannes Chris Arts
- Department of Orthopedic Surgery and CAPHRI Research School, Maastricht University Medical Center (MUMC+), P.O. Box 616 Maastricht, The Netherlands; (T.-C.A.H.); (J.J.C.A.)
| | - Colin McLaughlin
- Neuroscience Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, USA; (C.T.C.); (P.S.V.); (C.M.)
| | - Daniel T. Altman
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, USA;
| | - Alexander K. Yu
- Department of Neurosurgery, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, USA;
| | - Boyle C. Cheng
- Neuroscience Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, USA; (C.T.C.); (P.S.V.); (C.M.)
| |
Collapse
|
2
|
Dickson RP, Dingell DA. Urgent Need for Regulatory Oversight of Human Cells, Tissues, and Cellular and Tissue-Based Products. JAMA 2024; 331:1703-1704. [PMID: 38696201 DOI: 10.1001/jama.2024.6834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
This Viewpoint discusses the death of a patient caused by unregulated biological products and efforts to encourage federal government oversight of such products.
Collapse
Affiliation(s)
- Robert P Dickson
- Washtenaw County Tuberculosis Program, Ypsilanti, Michigan
- University of Michigan Medical School, Ann Arbor
| | | |
Collapse
|
3
|
Hubbell PJ, Roth B, Block JE. Comparative Evaluation of Mineralized Bone Allografts for Spinal Fusion Surgery. J Funct Biomater 2023; 14:384. [PMID: 37504879 PMCID: PMC10381653 DOI: 10.3390/jfb14070384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/19/2023] [Accepted: 07/19/2023] [Indexed: 07/29/2023] Open
Abstract
The primary objective of this review is to evaluate whether the degree of processing and the clinical utility of commercially available mineralized bone allografts for spine surgery meet the 2020 US Food and Drug Administration's (FDA) guideline definitions for minimal manipulation and homologous use, respectively. We also assessed the consistency of performance of these products by examining the comparative postoperative radiographic fusion rates following spine surgery. Based on the FDA's criteria for determining whether a structural allograft averts regulatory oversight and classification as a drug/device/biologic, mineralized bone allografts were judged to meet the Agency's definitional descriptions for minimal manipulation and homologous use when complying with the American Association of Tissue Banks' (AATB) accredited guidelines for bone allograft harvesting, processing, storing and transplanting. Thus, these products do not require FDA medical device clearance. Radiographic fusion rates achieved with mineralized bone allografts were uniformly high (>85%) across three published systematic reviews. Little variation was found in the fusion rates irrespective of anatomical location, allograft geometry, dimensions or indication, and in most cases, the rates were similar to those for autologous bone alone. Continued utilization of mineralized bone allografts should be encouraged across all spine surgery applications where supplemental grafts and/or segmental stability are required to support mechanically solid arthrodeses.
Collapse
Affiliation(s)
- Paul J Hubbell
- Southern Pain and Neurologic, 3939 Houma Blvd., Building 2, Suite 6, Metairie, LA 70006, USA
| | - Brandon Roth
- AZ Pain Doctors, 14420 W Meeker Blvd., Building A, Ste. 211, Sun City West, AZ 85375, USA
| | - Jon E Block
- Independent Consultant, 2210 Jackson Street, Suite 401, San Francisco, CA 94115, USA
| |
Collapse
|
4
|
Arnold PM, Vaccaro AR, Sasso RC, Goulet B, Fehlings MG, Heary RF, Janssen ME, Kopjar B. Six-Year Follow-up of a Randomized Controlled Trial of i-FACTOR Peptide-Enhanced Bone Graft Versus Local Autograft in Single-Level Anterior Cervical Discectomy and Fusion. Neurosurgery 2023; 92:725-733. [PMID: 36700705 DOI: 10.1227/neu.0000000000002290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 10/04/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Previous analyses of the US Food and Drug Administration (FDA) Investigational Device Exemption study demonstrated the superiority of i-FACTOR compared with local autograft bone in single-level anterior cervical discectomy and fusion (ACDF) at 12 and 24 months postoperatively in a composite end point of overall success. OBJECTIVE To report the final, 6-year clinical and radiological outcomes of the FDA postapproval study. METHODS Of the original 319 subjects enrolled in the Investigational Device Exemption study, 220 participated in the postapproval study (106 i-FACTOR and 114 control). RESULTS The study met statistical noninferiority success for all 4 coprimary end points. Radiographic fusion was achieved in 99% (103/104) and 98.2% (109/111) in i-FACTOR and local autograft subjects, mean Neck Disability Index improvement from baseline was 28.6 (24.8, 32.3) in the i-FACTOR and 29.2 (25.6, 32.9) in the control group, respectively (noninferiority P < .0001). The neurological success rate at 6 years was 95.9% (70/73) in i-FACTOR subjects and 93.7% (70/75) in local autograft subjects (noninferiority P < .0001). Safety outcomes were similar between the 2 groups. Secondary surgery on the same or different cervical levels occurred in 20/106 (18.9%) i-FACTOR subjects and 23/114 (20.2%) local autograft subjects ( P = .866). Secondary outcomes (pain, SF-36 physical component score and mental component score) in i-FACTOR subjects were similar to those in local autograft subjects. CONCLUSION i-FACTOR met all 4 FDA-mandated noninferiority success criteria and demonstrated safety and efficacy in single-level anterior cervical discectomy and fusion for cervical radiculopathy through 6 years postoperatively. Safety outcomes are acceptable, and the clinical and functional outcomes observed at 12 and 24 months remained at 72 months.
Collapse
Affiliation(s)
| | - Alexander R Vaccaro
- Department of Orthopaedics, Thomas Jefferson University Hospital and Rothman Institute, Philadelphia, Pennsylvania, USA
| | - Rick C Sasso
- Indiana University School of Medicine, Indiana Spine Group, Carmel, Indiana, USA
| | - Benoit Goulet
- Montreal Neurological Institute, Montreal, Quebec, Canada
| | - Michael G Fehlings
- University of Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Michael E Janssen
- Spine Education and Research Institute, Center for Spine and Orthopedics, Thornton, Colorado, USA
| | - Branko Kopjar
- Department of Health Services, University of Washington, Seattle, Washington, USA
| |
Collapse
|
5
|
McVeigh LG, Zaazoue MA, Lane BC, Voorhies JM, Bradbury J. Management and outcomes of surgical site tuberculosis infection due to infected bone graft in spine surgery: a single-institution experience and 1-year postoperative follow-up. J Neurosurg Spine 2023; 38:281-292. [PMID: 36272124 DOI: 10.3171/2022.7.spine22534] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In 2021, several patients across the United States received bone allograft contaminated with Mycobacterium tuberculosis (TB). TB is typically a pulmonary infection with many possible extrapulmonary manifestations, including skeletal tuberculosis. However, TB is a rare causative organism of postoperative surgical site infection. Iatrogenic skeletal TB infections are not widely reported in the medical literature; therefore, treatment and associated outcomes are relatively unknown. In this series, the authors report 6 cases of patients who received a mesenchymal stem cell-enhanced bone graft infected with TB at their institution, including the clinical courses, imaging findings, management plans, and outcomes at 1 year postoperatively. METHODS A retrospective review was performed of 6 consecutive patients who underwent spinal fusion surgery at the authors' institution and received bone graft from a lot contaminated with TB. Collected data included patient demographic characteristics, indications for surgery, surgical procedures performed, timing of contamination discovery, medical treatment, and follow-up information including reoperation, healing progress, and imaging findings. RESULTS Five of 6 patients (83.3%) eventually tested positive for TB via interferon-gamma release assay or wound culture. They experienced significant complications, including surgical site infections with neck swelling, pain, dysphagia, and wound dehiscence. Extensive soft-tissue infection was common; however, significant bony involvement was not observed. Surgical wound debridement was required in 4 patients, and all patients received medical management with standard RIPE (rifampin, isoniazid pyrazinamide, pyridoxine, and ethambutol) therapy for 8 weeks with extension of rifampin and isoniazid for scheduled 12 months. All patients (excluding 1 patient who died of COVID-19) showed signs of improvement with adequately healing wounds at the most recent follow-up at a median (range) of 12 (6-13) months postoperatively. To date, no patients have developed pulmonary TB. CONCLUSIONS Direct inoculation with TB via contaminated bone grafts resulted in a high rate of severe soft-tissue infection, although extensive skeletal and pulmonary involvement has not been observed at 1 year postoperatively; this review includes the longest reported follow-up period for this TB outbreak. Medical management remains the mainstay of therapy for these patients, with most patients showing recovery with oral antibiotic therapy. The severity of these infections arising from mesenchymal stem cell-containing bone allografts that undergo an alternative sterilization process than standard allografts raises concerns regarding the added risks of infection, which should be weighed against the expected benefits of these grafts.
Collapse
|
6
|
Kiapour A, Seim HB, Atkinson BL, Lalor PA, Block JE. Bone Mineralization and Spinal Fusion Evaluation of a Truss-based Interbody Fusion Device: Ovine Finite Element Analysis with Confirmatory In Vivo Outcomes. Spine (Phila Pa 1976) 2022; 47:E319-E327. [PMID: 34593736 PMCID: PMC8912963 DOI: 10.1097/brs.0000000000004256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Finite element analysis (FEA) and in vivo ovine spinal interbody fusion study. OBJECTIVE To determine comparative load-induced strain amplitudes, bone mineralization and fusion outcomes associated with different diameter struts in a truss-based interbody fusion device. SUMMARY OF BACKGROUND DATA Additive manufacturing technology has been employed to develop implants that actively participate in the fusion process. The truss device enables the optimal transfer of compressive and tensile stresses via the struts. Mechanobiologic principles postulate that strut diameter can be regulated to allow different magnitudes of strain distribution within the struts which may affect fusion rates. METHODS Modeling of strain distributions as a function of strut diameter (0.75, 1.0, 1.25, and 1.5 mm) employed FEA that simulated physiologic loading conditions. A confirmatory in vivo ovine lumbar spinal interbody fusion study compared fusion scores and bone histomorphometric variables for cages with 0.75 and 1.5 mm strut diameters. Outcomes were compared at 3-, 6-, and 12-month follow-up intervals. RESULTS FEA showed an inverse association between strut diameter and peak strain amplitude. Cages with 1.0, 1.25, and 1.5 mm struts had peak strain values that were 36%, 60%, and 73% lower than the 0.75 mm strut strain value. In vivo results showed the mean fusion score for the 0.75 mm diameter strut cage was significantly greater by 3-months versus the 1.5 mm strut cage, and remained significantly higher at each subsequent interval (P < 0.001 for all comparisons). Fusion rates were 95%, 100%, and 100% (0.75 mm) and 72.7%, 86.4%, and 95.8% (1.5 mm) at 3, 6, and 12 months. Thinner struts had greater mineralized bone tissue and less fibrous/chondral tissue than the thicker struts at each follow-up. CONCLUSION Validating FEA estimates, cages with smaller diameter struts exhibited more rapid fusion consolidation and more aggressive osseointegration compared with cages with larger diameters struts.Level of Evidence: 4.
Collapse
Affiliation(s)
- Ali Kiapour
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | | | | | | |
Collapse
|
7
|
Ashukina N, Maltseva V, Vorontsov P, Danyshchuk Z, Nikolchenko O, Korzh M, Korzh M. Histological evaluation of the incorporation and remodeling of structural allografts in critical size metaphyseal femur defects in rats of different ages. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2022; 63:349-356. [PMID: 36374140 PMCID: PMC9804061 DOI: 10.47162/rjme.63.2.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Insufficient bone regeneration is a common issue for patients with extensive bone damage, therefore the use of allografts is required. With increasing life expectancy, there is a higher risk of bone repair issues after fractures or orthopedic surgical intervention. We studied incorporation and remodeling of structural allografts in critical size metaphyseal femur defects in 52 rats aged 3-month-old and 12-month-old who underwent surgeries creating a bone defect, which was either filled with a structural allograft (3-month-old - 3moAllo; 12-month-old - 12moAllo) or left empty (3-month-old - 3moE; 12-month-old - 12moE). Histological analyses were performed 14, 28 and 90 days after the surgery. The percentage of bone and fibrous tissues, and allograft relative to the defect area was evaluated. The transmission electron microscopy was carried out 14 days after allograft implantation. When the defect was empty, slower bone regeneration was observed in 12moE rats versus 3moE, leading to sufficient irregularities in the anatomic structure of the femur 90 days after the surgery. When a structural allograft was used, the area of the fibrous tissue was larger in the defects of 12moAllo compared with 3moAllo rats 90 days after surgery. No age-related differences were found in the allograft remodeling and structures of the osteocytes, osteoblasts, and osteoclasts over the observation period. Evident issues with bone regeneration were found in critical size defects both of 12moE and 12moAllo rats. However, the allograft use allowed the bone maintaining anatomic structure 90 days after the surgery.
Collapse
Affiliation(s)
- Nataliya Ashukina
- Laboratory of Connective Tissue Morphology, Sytenko Institute of Spine and Joint Pathology, National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine;
| | - Valentyna Maltseva
- Laboratory of Connective Tissue Morphology, Sytenko
Institute of Spine and Joint Pathology, National Academy of Medical Sciences of
Ukraine, Kharkiv, Ukraine
| | - Petro Vorontsov
- Department of Transplantology and Experimental Modeling
with an Experimental Biological Clinic, Sytenko Institute of Spine and Joint
Pathology, National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine
| | - Zinaida Danyshchuk
- Laboratory of Connective Tissue Morphology, Sytenko
Institute of Spine and Joint Pathology, National Academy of Medical Sciences of
Ukraine, Kharkiv, Ukraine
| | - Olga Nikolchenko
- Department of Transplantology and Experimental Modeling
with an Experimental Biological Clinic, Sytenko Institute of Spine and Joint
Pathology, National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine
| | - Mykola Korzh
- Department of Emergency Traumatology and Reconstructive
Surgery, Sytenko Institute of Spine and Joint Pathology, National Academy of Medical
Sciences of Ukraine, Kharkiv, Ukraine
| | | | | | | | | | | | | |
Collapse
|
8
|
Gillman CE, Jayasuriya AC. FDA-approved bone grafts and bone graft substitute devices in bone regeneration. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 130:112466. [PMID: 34702541 PMCID: PMC8555702 DOI: 10.1016/j.msec.2021.112466] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/26/2021] [Accepted: 09/24/2021] [Indexed: 12/28/2022]
Abstract
To induce bone regeneration there is a complex cascade of growth factors. Growth factors such as recombinant BMP-2, BMP-7, and PDGF are FDA-approved therapies in bone regeneration. Although, BMP shows promising results as being an alternative to autograft, it also has its own downfalls. BMP-2 has many adverse effects such as inflammatory complications such as massive soft-tissue swelling that can compromise a patient's airway, ectopic bone formation, and tumor formation. BMP-2 may also be advantageous for patients not willing to give up smoking as it shows bone regeneration success with smokers. BMP-7 is no longer an option for bone regeneration as it has withdrawn off the market. PDGF-BB grafts in studies have shown PDGF had similar fusion rates to autologous grafts and fewer adverse effects. There is also an FDA-approved bioactive molecule for bone regeneration, a peptide P-15. P-15 was found to be effective, safe, and have similar outcomes to autograft at 2 years post-op for cervical radiculopathy due to cervical degenerative disc disease. Growth factors and bioactive molecules show some promising results in bone regeneration, although more research is needed to avoid their adverse effects and learn about the long-term effects of these therapies. There is a need of a bone regeneration method of similar quality of an autograft that is osteoconductive, osteoinductive, and osteogenic. This review covers all FDA-approved bone regeneration therapies such as the "gold standard" autografts, allografts, synthetic bone grafts, and the newer growth factors/bioactive molecules. It also covers international bone grafts not yet approved in the United States and upcoming technologies in bone grafts.
Collapse
Affiliation(s)
- Cassidy E Gillman
- The Doctor of Medicine (M.D.) Program, College of Medicine and Life Sciences, The University of Toledo, Toledo, OH 43614, USA
| | - Ambalangodage C Jayasuriya
- Department of Orthopaedic Surgery, College of Medicine and Life Sciences, The University of Toledo, Toledo, OH 43614, USA.
| |
Collapse
|
9
|
Hunt JP, Begley MR, Block JE. Truss implant technology™ for interbody fusion in spinal degenerative disorders: profile of advanced structural design, mechanobiologic and performance characteristics. Expert Rev Med Devices 2021; 18:707-715. [PMID: 34160337 DOI: 10.1080/17434440.2021.1947244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Interbody fusion devices are customarily used in fusion of the anterior spinal column for treatment of degenerative disc disease. Their traditional role is to reestablish and maintain intervertebral disc height, contain bone graft and provide mechanical support for the spine while osseointegration takes place. Utilizing the principles of mechanobiology, a unique biokinetic interbody fusion device has been developed that employs an advanced structural design to facilitate and actively participate in the fusion consolidation process.Areas covered: This article profiles and characterizes 4WEB Medical's Truss Implant Technology™ which includes a range of 3D-printed titanium spinal interbody implants and non-spinal implants whose design is based on truss structures enabled by advances in additive manufacturing. Four main areas of the implant design and functionality are detailed: bio-architecture, mechanobiologic underpinnings, bioactive surface features, and subsidence resistance. Pre-clinical and clinical examples are provided to describe and specify the bioactive roles and contributions of each design feature.Expert opinion: The distinct and unique combination of features incorporated within the truss cage design results in a biokinetic implant that actively participates in the bone healing cascade and fusion process.
Collapse
Affiliation(s)
| | - Matthew R Begley
- Department of Engineering, University of California, Santa Barbara, Santa Barbara, USA
| | | |
Collapse
|
10
|
Commercial Bone Grafts Claimed as an Alternative to Autografts: Current Trends for Clinical Applications in Orthopaedics. MATERIALS 2021; 14:ma14123290. [PMID: 34198691 PMCID: PMC8232314 DOI: 10.3390/ma14123290] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 02/08/2023]
Abstract
In the last twenty years, due to an increasing medical and market demand for orthopaedic implants, several grafting options have been developed. However, when alternative bone augmentation materials mimicking autografts are searched on the market, commercially available products may be grouped into three main categories: cellular bone matrices, growth factor enhanced bone grafts, and peptide enhanced xeno-hybrid bone grafts. Firstly, to obtain data for this review, the search engines Google and Bing were employed to acquire information from reports or website portfolios of important competitors in the global bone graft market. Secondly, bibliographic databases such as Medline/PubMed, Web of Science, and Scopus were also employed to analyse data from preclinical/clinical studies performed to evaluate the safety and efficacy of each product released on the market. Here, we discuss several products in terms of osteogenic/osteoinductive/osteoconductive properties, safety, efficacy, and side effects, as well as regulatory issues and costs. Although both positive and negative results were reported in clinical applications for each class of products, to date, peptide enhanced xeno-hybrid bone grafts may represent the best choice in terms of risk/benefit ratio. Nevertheless, more prospective and controlled studies are needed before approval for routine clinical use.
Collapse
|
11
|
Diaz RR, Savardekar AR, Brougham JR, Terrell D, Sin A. Investigating the efficacy of allograft cellular bone matrix for spinal fusion: a systematic review of the literature. Neurosurg Focus 2021; 50:E11. [PMID: 34062505 DOI: 10.3171/2021.3.focus2179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of allograft cellular bone matrices (ACBMs) in spinal fusion has expanded rapidly over the last decade. Despite little objective data on its effectiveness, ACBM use has replaced the use of traditional autograft techniques, namely iliac crest bone graft (ICBG), in many centers. METHODS In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review was conducted of the PubMed, Cochrane Library, Scopus, and Web of Science databases of English-language articles over the time period from January 2001 to December 2020 to objectively assess the effectiveness of ACBMs, with an emphasis on the level of industry involvement in the current body of literature. RESULTS Limited animal studies (n = 5) demonstrate the efficacy of ACBMs in spinal fusion, with either equivalent or increased rates of fusion compared to autograft. Clinical human studies utilizing ACBMs as bone graft expanders or bone graft substitutes (n = 5 for the cervical spine and n = 8 for the lumbar spine) demonstrate the safety of ACBMs in spinal fusion, but fail to provide conclusive level I, II, or III evidence for its efficacy. Additionally, human studies are plagued with several limiting factors, such as small sample size, lack of prospective design, lack of randomization, absence of standardized assessment of fusion, and presence of industry support/relevant conflict of interest. CONCLUSIONS There exist very few objective, unbiased human clinical studies demonstrating ACBM effectiveness or superiority in spinal fusion. Impartial, well-designed prospective studies are needed to offer evidence-based best practices to patients in this domain.
Collapse
|
12
|
Härtl R, Arts JJC, Bae HW. Editors' Introduction: Biologics and Regenerative Medicine in Intervertebral Disc Regeneration and Spinal Fusion. Int J Spine Surg 2021; 15:8-9. [PMID: 34376492 DOI: 10.14444/8051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Roger Härtl
- Weill Cornell Center for Comprehensive Spine Care, New York, New York
| | - Jacobus J C Arts
- Department of Orthopaedic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Orthopaedic Biomechanics, Faculty of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Hyun W Bae
- The Spine Institute Center for Spinal Restoration, Santa Monica, California
| |
Collapse
|
13
|
Philipp LR, Leibold A, Mahtabfar A, Montenegro TS, Gonzalez GA, Harrop JS. Achieving Value in Spine Surgery: 10 Major Cost Contributors. Global Spine J 2021; 11:14S-22S. [PMID: 33890804 PMCID: PMC8076814 DOI: 10.1177/2192568220971288] [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: 11/25/2022] Open
Abstract
STUDY DESIGN Narrative Review. OBJECTIVES The increasing cost of healthcare overall and for spine surgery, coupled with the growing burden of spine-related disease and rising demand have necessitated a shift in practice standards with a new emphasis on value-based care. Despite multiple attempts to reconcile the discrepancy between national recommendations for appropriate use and the patterns of use employed in clinical practice, resources continue to be overused-often in the absence of any demonstrable clinical benefit. The following discussion illustrates 10 areas for further research and quality improvement. METHODS We present a narrative review of the literature regarding 10 features in spine surgery which are characterized by substantial disproportionate costs and minimal-if any-clear benefit. Discussion items were generated from a service-wide poll; topics mentioned with great frequency or emphasis were considered. Items are not listed in hierarchical order, nor is the list comprehensive. RESULTS We describe the cost and clinical data for the following 10 items: Over-referral, Over-imaging & Overdiagnosis; Advanced Imaging for Low Back Pain; Advanced imaging for C-Spine Clearance; Advanced Imaging for Other Spinal Trauma; Neuromonitoring for Cervical Spine; Neuromonitoring for Lumbar Spine/Single-Level Surgery; Bracing & Spinal Orthotics; Biologics; Robotic Assistance; Unnecessary perioperative testing. CONCLUSIONS In the pursuit of value in spine surgery we must define what quality is, and what costs we are willing to pay for each theoretical unit of quality. We illustrate 10 areas for future research and quality improvement initiatives, which are at present overpriced and underbeneficial.
Collapse
Affiliation(s)
- Lucas R. Philipp
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA,Lucas R. Philipp, Thomas Jefferson University, 909 Walnut St., 3 rd Floor, Department of Neurosurgery, Philadelphia, PA 19107, USA.
| | - Adam Leibold
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Aria Mahtabfar
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thiago S. Montenegro
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Glenn A. Gonzalez
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
14
|
Santos FRD, Minto BW, Silva SWGD, Coelho LDP, Rossignoli PP, Costa Junior JS, Taba Junior M, Dias LGGG. Caprine demineralized bone matrix (DBMc) in the repair of non-critical bone defects in rabbit tibias. A new bone xenograft. Acta Cir Bras 2020; 35:e202000801. [PMID: 32901678 PMCID: PMC7478467 DOI: 10.1590/s0102-865020200080000001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 07/14/2020] [Indexed: 11/22/2022] Open
Abstract
Purpose To evaluate the use of demineralized bone matrix of caprine origin in experimental bone defects of the tibia in New Zealand rabbits. Methods Fragments of the tibia diaphysis were collected aseptically from clinically healthy goats. The bones were sectioned into 1 cm fragments and stored at -20°C for subsequent hydrochloric acid (HCL) demineralization. A 70 mg portion of DBMc was used to fill the experimental bone defects. Twenty-four female adult New Zealand rabbits were divided into 2 groups: the MG (matrix group, left tibia) and CG (control group, right tibia). Additionally, they were separated into 4 groups with 6 animals, according to the period of analysis (15, 30, 60 and 90 days postoperatively). Using microCT, volumetric parameters were evaluated: bone volume, relationship between bone volume and total volume, bone surface area, relationship between bone surface area and total volume, number of trabeculae, trabecular thickness and trabecular separation. Results There was a statistically significant difference (P<0.05) between groups considering bone volume (BV) and bone:total volume (BV/TV), on 15, 30 and 90 days postoperatively. Control group showed a statistically significant superiority (P < 0.05) considering the mean of the variables bone surface (BS), number of trabeculae (Tb.N) and between bone surface and total volume (BS/TV) at 15 and 90 days. Conclusions Caprine demineralized bone matrix was safe and tolerable. No signs of material rejection were seen macroscopically. It is an alternative for the treatment of bone defects when autologous graft is not available or in insufficient quantities.
Collapse
|