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Smith KA, Russo GS, Vaccaro AR, Arnold PM. Scientific, Clinical, Regulatory, and Economic Aspects of Choosing Bone Graft/Biological Options in Spine Surgery. Neurosurgery 2020; 84:827-835. [PMID: 30032187 DOI: 10.1093/neuros/nyy322] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/17/2018] [Indexed: 01/07/2023] Open
Abstract
Spinal arthrodesis is a major element of the spinal surgeon's practice. To attain successful fusion rates, attention must be paid to spinal segment immobilization and proper selection of bone graft. Autogenous bone graft (ie, ICBG), the "gold standard," with or without graft extenders and enhancers provides the foundation for most spinal fusions. ABG is the only graft option containing all 3 factors of new bone growth: osteoconductivity, osteoinductivity, and osteogenicity. While many bone graft alternatives function well as bone graft extenders, only growth factors proteins (ie, rhBMP-2 or OP-2) function as bone graft enhancers and substitutes. The search for optimal hybrid interbody cages, bone graft substitutes, autogenous or allogenic stem cells, and nanostructure scaffolds for release of growth factors continues.
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Affiliation(s)
- Kyle A Smith
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Glenn S Russo
- Department of Orthopedics, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexander R Vaccaro
- Department of Orthopedics, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
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Vukicevic S, Grgurevic L, Erjavec I, Pecin M, Bordukalo-Niksic T, Stokovic N, Lipar M, Capak H, Maticic D, Windhager R, Sampath TK, Gupta M. Autologous blood coagulum is a physiological carrier for BMP6 to induce new bone formation and promote posterolateral lumbar spine fusion in rabbits. J Tissue Eng Regen Med 2019; 14:147-159. [PMID: 31671243 PMCID: PMC7027565 DOI: 10.1002/term.2981] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 09/27/2019] [Accepted: 10/17/2019] [Indexed: 12/22/2022]
Abstract
In the present study, we describe autologous blood coagulum (ABC) as a physiological carrier for BMP6 to induce new bone formation. Recombinant human BMP6 (rhBMP6), dispersed within ABC and formed as an autologous bone graft substitute (ABGS), was evaluated either with or without allograft bone particles (ALLO) in rat subcutaneous implants and in a posterolateral lumbar fusion (PLF) model in rabbits. ABGS induced endochondral bone differentiation in rat subcutaneous implants. Coating ALLO by ABC significantly decreased the formation of multinucleated foreign body giant cells (FBGCs) in implants, as compared with ALLO alone. However, addition of rhBMP6 to ABC/ALLO induced a robust endochondral bone formation with little or no FBGCs in the implant. In rabbit PLF model, ABGS induced new bone formation uniformly within the implant resulting in a complete fusion when placed between two lumbar transverse processes in the posterolateral gutter with an optimum dose of 100‐μg rhBMP6 per ml of ABC. ABGS containing ALLO also resulted in a fusion where the ALLO was replaced by the newly formed bone via creeping substitution. Our findings demonstrate for the first time that rhBMP6, with ABC as a carrier, induced a robust bone formation with a complete spinal fusion in a rabbit PLF model. RhBMP6 was effective at low doses with ABC serving as a physiological substratum providing a permissive environment by protecting against foreign body reaction elicited by ALLO.
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Affiliation(s)
- Slobodan Vukicevic
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Lovorka Grgurevic
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Igor Erjavec
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Marko Pecin
- Clinics for Surgery, Orthopedics and Ophthalmology, School of Veterinary Medicine, University of Zagreb, Zagreb, Croatia
| | - Tatjana Bordukalo-Niksic
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Nikola Stokovic
- Laboratory for Mineralized Tissues, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Marija Lipar
- Clinics for Surgery, Orthopedics and Ophthalmology, School of Veterinary Medicine, University of Zagreb, Zagreb, Croatia
| | - Hrvoje Capak
- Department of Radiology, School of Veterinary Medicine, University of Zagreb, Zagreb, Croatia
| | - Drazen Maticic
- Clinics for Surgery, Orthopedics and Ophthalmology, School of Veterinary Medicine, University of Zagreb, Zagreb, Croatia
| | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St. Louis, MO
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The Holy Grail of Orthopedic Surgery: Mesenchymal Stem Cells-Their Current Uses and Potential Applications. Stem Cells Int 2017; 2017:2638305. [PMID: 28698718 PMCID: PMC5494105 DOI: 10.1155/2017/2638305] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 04/16/2017] [Indexed: 02/07/2023] Open
Abstract
Only select tissues and organs are able to spontaneously regenerate after disease or trauma, and this regenerative capacity diminishes over time. Human stem cell research explores therapeutic regenerative approaches to treat various conditions. Mesenchymal stem cells (MSCs) are derived from adult stem cells; they are multipotent and exert anti-inflammatory and immunomodulatory effects. They can differentiate into multiple cell types of the mesenchyme, for example, endothelial cells, osteoblasts, chondrocytes, fibroblasts, tenocytes, vascular smooth muscle cells, and sarcomere muscular cells. MSCs are easily obtained and can be cultivated and expanded in vitro; thus, they represent a promising and encouraging treatment approach in orthopedic surgery. Here, we review the application of MSCs to various orthopedic conditions, namely, orthopedic trauma; muscle injury; articular cartilage defects and osteoarthritis; meniscal injuries; bone disease; nerve, tendon, and ligament injuries; spinal cord injuries; intervertebral disc problems; pediatrics; and rotator cuff repair. The use of MSCs in orthopedics may transition the practice in the field from predominately surgical replacement and reconstruction to bioregeneration and prevention. However, additional research is necessary to explore the safety and effectiveness of MSC treatment in orthopedics, as well as applications in other medical specialties.
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6
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Low J, Ross JS, Ritchie JD, Gross CP, Lehman R, Lin H, Fu R, Stewart LA, Krumholz HM. Comparison of two independent systematic reviews of trials of recombinant human bone morphogenetic protein-2 (rhBMP-2): the Yale Open Data Access Medtronic Project. Syst Rev 2017; 6:28. [PMID: 28196521 PMCID: PMC5310069 DOI: 10.1186/s13643-017-0422-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 01/25/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND It is uncertain whether the replication of systematic reviews, particularly those with the same objectives and resources, would employ similar methods and/or arrive at identical findings. We compared the results and conclusions of two concurrent systematic reviews undertaken by two independent research teams provided with the same objectives, resources, and individual participant-level data. METHODS Two centers in the USA and UK were each provided with participant-level data on 17 multi-site clinical trials of recombinant human bone morphogenetic protein-2 (rhBMP-2). The teams were blinded to each other's methods and findings until after publication. We conducted a retrospective structured comparison of the results of the two systematic reviews. The main outcome measures included (1) trial inclusion criteria; (2) statistical methods; (3) summary efficacy and risk estimates; and (4) conclusions. RESULTS The two research teams' meta-analyses inclusion criteria were broadly similar but differed slightly in trial inclusion and research methodology. They obtained similar results in summary estimates of most clinical outcomes and adverse events. Center A incorporated all trials into summary estimates of efficacy and harms, while Center B concentrated on analyses stratified by surgical approach. Center A found a statistically significant, but small, benefit whereas Center B reported no advantage. In the analysis of harms, neither showed an increased cancer risk at 48 months, although Center B reported a significant increase at 24 months. Conclusions reflected these differences in summary estimates of benefit balanced with small but potentially important risk of harm. CONCLUSIONS Two independent groups given the same research objectives, data, resources, funding, and time produced broad general agreement but differed in several areas. These differences, the importance of which is debatable, indicate the value of the availability of data to allow for more than a single approach and a single interpretation of the data. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42012002040 and CRD42012001907 .
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Affiliation(s)
- Jeffrey Low
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church Street, Suite 200, New Haven, CT, 06510, USA.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208093, New Haven, CT, 06510, USA.,Robert Wood Johnson Foundation Clinical Scholars Program, P.O. Box 208088, New Haven, CT, 06510, USA.,Department of Health Policy and Management, Yale School of Public Health, P.O. Box 208034, New Haven, CT, 06520, USA
| | - Jessica D Ritchie
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church Street, Suite 200, New Haven, CT, 06510, USA
| | - Cary P Gross
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208093, New Haven, CT, 06510, USA.,Robert Wood Johnson Foundation Clinical Scholars Program, P.O. Box 208088, New Haven, CT, 06510, USA
| | - Richard Lehman
- Department of Primary Care Health Sciences, Oxford University, 33 St Ebbes Street, Oxford, OX1 1PU, UK
| | - Haiqun Lin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church Street, Suite 200, New Haven, CT, 06510, USA.,Department of Biostatistics, Yale School of Public Health, P.O. Box 208034, New Haven, CT, 06520, USA
| | - Rongwei Fu
- Department of Public Health and Preventive Medicine, Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR, 97239-3098, USA
| | - Lesley A Stewart
- Centre for Reviews and Dissemination, University of York, Heslington, York, YO10 5DD, UK
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church Street, Suite 200, New Haven, CT, 06510, USA. .,Robert Wood Johnson Foundation Clinical Scholars Program, P.O. Box 208088, New Haven, CT, 06510, USA. .,Department of Health Policy and Management, Yale School of Public Health, P.O. Box 208034, New Haven, CT, 06520, USA. .,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208093, New Haven, CT, 06510, USA.
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