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Segina D, Ryaby J. Osteogenesis Stimulator Devices Reduce Surgical Intervention, Opioid Utilization, and Overall Costs in Patients with Fracture Nonunions. Orthop Rev (Pavia) 2023; 15:88398. [PMID: 38025826 PMCID: PMC10667263 DOI: 10.52965/001c.88398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Background Approximately 10% of fractures result in delayed union or nonunion. These cases result in pain and disability as well as increased utilization of healthcare resources such as pain medication, physical therapy, and subsequent surgery. Osteogenesis stimulator devices are a safe and low-cost, non-invasive option to aid healing in nonunion cases. Objective Study objectives aimed to evaluate real-world data of osteogenesis stimulator device usage in a variety of healthcare utilization endpoints including surgical intervention for nonunion, pain medication use, and overall healthcare costs. Data were stratified into three groups: the Stim Device group and the No Stim and Surgical control groups. Methods A retrospective analysis of a large claims-based database was conducted. The database was queried for adult patients having a diagnosis of nonunion, with evidence of a prior fracture in the previous 180 days (n = 11,010). The osteogenesis stimulator group (Stim Device group, n = 1,628) was defined as those patients having at least one claim for an osteogenesis stimulator in the period 90 to 180 days following fracture and up to 60 days following the nonunion diagnosis. The control group (No Stim group, n = 9,382) had a nonunion diagnosis with evidence of a fracture in the prior 180 days but did not receive a device. A total of 1,751 patients from the No Stim group were sub-grouped into surgical/operative controls (No Stim - Surgical group). Results Stim Device patients showed lower rates of surgical intervention for their bone nonunion compared to the No Stim patients (214/1,628, 13.1% vs. 1,751/9,382, 18.7%, p < 0.001). Stim Device patients had lower rates of opioid utilization post-index compared to No Stim patients (948/1,628, 58.2% vs. 6,359/9,382, 67.8%, p < 0.001). Overall healthcare costs were significantly reduced in the Stim Device group ($21,654) compared with No Stim ($29,101; p < 0.001) and Surgical ($35,914; p < 0.001) control groups. Conclusion The results show that bone growth stimulator devices have a positive individual and societal impact on treating patients with fracture nonunions.
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Di Martino A, Villari E, Poluzzi R, Brunello M, Rossomando V, D’Agostino C, Ruta F, Faldini C. Role of biophysical stimulation in multimodal management of vertebral compression fractures. Comput Struct Biotechnol J 2023; 21:5650-5661. [PMID: 38047233 PMCID: PMC10692617 DOI: 10.1016/j.csbj.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/10/2023] [Accepted: 11/10/2023] [Indexed: 12/05/2023] Open
Abstract
Raised life expectancy and aging of the general population are associated with an increased concern for fragility fractures due to factors such as osteoporosis, reduced bone density, and an higher risk of falls. Among these, the most frequent are vertebral compression fractures (VCF), which can be clinically occult. Once the diagnosis is made, generally thorough antero-posterior and lateral views of the affected spine at the radiographs, a comprehensive workup to assess the presence of a metabolic bone disease or secondary causes of osteoporosis and bone frailty is required. Treatment uses a multimodal management consisting of a combination of brace, pain management, bone metabolism evaluation, osteoporosis medication and has recently incorporated biophysical stimulation, a noninvasive technique that uses induced electric stimulation to improve bone recovery through the direct and indirect upregulation of bone morphogenic proteins, stimulating bone formation and remodeling. It contributes to the effectiveness of the therapy, promoting accelerated healing, supporting the reduction of bed rest and pain medications, improving patients' quality of life, and reducing the risk to undergo surgery in patients affected by VCFs. Therefore, the aim of this review is to outline the fundamental concepts of multimodal treatment for VCF, as well as the present function and significance of biophysical stimulation in the treatment of VCF patients.
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Affiliation(s)
- Alberto Di Martino
- 1st Orthopaedic and Traumatologic Department, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Eleonora Villari
- 1st Orthopaedic and Traumatologic Department, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Riccardo Poluzzi
- 1st Orthopaedic and Traumatologic Department, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Matteo Brunello
- 1st Orthopaedic and Traumatologic Department, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Valentino Rossomando
- 1st Orthopaedic and Traumatologic Department, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Claudio D’Agostino
- 1st Orthopaedic and Traumatologic Department, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Federico Ruta
- 1st Orthopaedic and Traumatologic Department, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | - Cesare Faldini
- 1st Orthopaedic and Traumatologic Department, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
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Matur AV, Plummer ZJ, Mejia-Munne JC, Tabbosha M, Virojanapa JN, Nasser R, Cheng JS. Noninvasive electrical stimulation as an adjunct to fusion procedures: a systematic review and meta-analysis. J Neurosurg Spine 2022; 37:137-148. [PMID: 35090134 DOI: 10.3171/2021.11.spine211098] [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: 08/18/2021] [Accepted: 11/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Noninvasive electrical stimulation represents a distinct group of devices used to augment fusion rates. However, data regarding outcomes of noninvasive electrical stimulation have come from a small number of studies. The goal of this systematic review and meta-analysis was to determine outcomes of noninvasive electrical stimulation used as an adjunct to fusion procedures to improve rates of successful fusion. METHODS PubMed, Embase, and the Cochrane Clinical Trials database were searched according to search strategy and PRISMA guidelines. Random-effects meta-analyses of fusion rates with the three main modalities of noninvasive electrical stimulation, capacitively coupled stimulation (CCS), pulsed electromagnetic fields (PEMFs), and combined magnetic fields (CMFs), were conducted using R version 4.1.0 (The R Foundation for Statistical Computing). Both retrospective studies and clinical trials were included. Animal studies were excluded. Risk-of-bias analysis was performed with the Risk of Bias 2 (RoB 2) and Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tools. RESULTS Searches of PubMed, Embase, and the Cochrane Clinical Trials database identified 8 articles with 1216 participants meeting criteria from 213 initial results. There was a high overall risk of bias identified for the majority of randomized studies. No meta-analysis could be performed for CCS as only 1 study was identified. Meta-analysis of 6 studies of fusion rates in PEMF did not find any difference between treatment and control groups (OR 1.89, 95% CI 0.36-9.80, p = 0.449). Meta-analysis of 2 studies of CMF found no difference in fusion rates between control and treatment groups (OR 0.90, 95% CI 0.07-11.93, p = 0.939). Subgroup analysis of PEMF was limited given the small number of studies and patients, although significantly increased fusion rates were seen in some subgroups. CONCLUSIONS This meta-analysis of clinical outcomes and fusion rates in noninvasive electrical stimulation compared to no stimulation did not identify any increases in fusion rates for any modality. A high degree of heterogeneity between studies was noted. Although subgroup analysis identified significant differences in fusion rates in certain groups, these findings were based on a small number of studies and further research is needed. This analysis does not support routine use of these devices to augment fusion rates, although the data are limited by a high risk of bias and a small number of available studies.
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Affiliation(s)
- Abhijith V Matur
- 1Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati; and
| | - Zachary J Plummer
- 1Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati; and
| | - Juan C Mejia-Munne
- 1Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati; and
| | - Monir Tabbosha
- 2Department of Neurosurgery, The Christ Hospital, Cincinnati, Ohio
| | - Justin N Virojanapa
- 1Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati; and
| | - Rani Nasser
- 1Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati; and
| | - Joseph S Cheng
- 1Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati; and
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Virk S, Vaishnav AS, Sheha E, Urakawa H, Sato K, Othman Y, Chaudhary C, Lee R, Cong GT, Chaudhary S, Qureshi SA. Combining Expandable Interbody Cage Technology With a Minimally Invasive Technique to Harvest Iliac Crest Autograft Bone to Optimize Fusion Outcomes in Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery. Clin Spine Surg 2021; 34:E522-E530. [PMID: 34224423 DOI: 10.1097/bsd.0000000000001228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 06/01/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective cohort review. OBJECTIVE The objective of this study was to determine the rate of fusion associated with an expandable cage and iliac crest bone graft in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) surgery. SUMMARY OF BACKGROUND DATA MI-TLIF is a commonly performed procedure, but challenges inherent in MI-TLIF technique can make achieving an interbody fusion difficult. METHODS A retrospective review was performed on consecutive patients treated with an MI-TLIF for degenerative lumbar pathology. Patients that completed patient-reported outcome measures and 1-year computed tomography (CT)-scans for fusion analysis were included. Fusion morphology was analyzed by evaluating CT scans for location of bridging trabecular bone in relation to the cage. Patients with bridging bone were considered fused. Preoperative and postoperative health-related quality of life scores were compared. A Kolmogrov-Smirnoff test was used to determine normality of health-related outcome scores. A Friedman 2-way analysis of variance by ranks with pairwise comparisons to determine statistical significance of differences between the date of a follow-up examination and preoperative examination was done. RESULTS Of 75 patients evaluated 23 patients were excluded due to loss to follow-up, adjacent segment degeneration, inability to obtain a CT scan, or reoperation for nonfusion related symptoms. Of 61 disk spaces that were included, 55 had bridging bone through the intervertebral cage, resulting in an overall fusion rate of 90.2%. There was a higher rate of fusion at L5-S1 as compared to L4-L5. There was mean improvement in patient-reported outcome measures for Oswestry Disability Index, Short Form-12 Physical Component Score, Visual Analog Scale Back/Leg pain, and Patient-Reported Outcome Measurement Information System Physical Function. There were no complications associated with iliac crest bone graft harvesting. CONCLUSION Combining an expandable cage with iliac crest autograft bone harvested through a minimally invasive technique can allow for improved fusion rates without graft-site complications in MI-TLIF surgery.
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Affiliation(s)
| | | | - Evan Sheha
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
| | | | | | | | | | | | | | | | - Sheeraz A Qureshi
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
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Jin YZ, Zheng GB, Cho M, Lee JH. Effect of Whitlockite as a new bone substitute for bone formation in spinal fusion and ectopic ossification animal model. Biomater Res 2021; 25:34. [PMID: 34674765 PMCID: PMC8529756 DOI: 10.1186/s40824-021-00237-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/05/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Bone substrates like hydroxyapatite and tricalcium phosphate have been widely used for promoting spinal fusion and reducing the complications caused by autograft. Whitlockite has been reported to promote better bone formation in rat calvaria models compare with them, but no study investigated its effect on spinal fusion yet. Also, the higher osteoinductivity of whitlockite raised concern of ectopic ossification, which was a complication of spinal fusion surgery that should be avoided. METHODS In this study, we compared the osteoinductivity of whitlockite, hydroxyapatite, and tricalcium phosphate porous particles with SD rat spine posterolateral fusion model and investigated whether whitlockite could induce ectopic ossification with SD rat abdominal pouch model. RESULTS The micro-CT result from the posterolateral fusion model showed whitlockite had slightly but significantly higher percent bone volume than tricalcium phosphate, though none of the materials formed successful fusion with surrounding bone tissue. The histology results showed the bone formed on the cortical surface of the transverse process but did not form a bridge between the processes. The result from the abdominal pouch model showed whitlockite did not induce ectopic bone formation. CONCLUSION Whitlockite had a potential of being a better bone substrate hydroxyapatite and tricalcium phosphate in spinal fusion with low risk of inducing ectopic ossification.
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Affiliation(s)
- Yuan-Zhe Jin
- Department of Orthopedic Surgery, College of Medicine, Seoul National University, Seoul, 03080, South Korea.,The First Hospital of Jilin University, Changchun City, 130021, China
| | - Guang-Bin Zheng
- Department of Orthopaedics, Taizhou Hospial of Zhejiang Province, Linhai, Zhejiang, 317000, China
| | - Minjoon Cho
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Boramae-ro 5-gil 20, Dongjak-gu, Seoul, 07061, South Korea
| | - Jae Hyup Lee
- Department of Orthopedic Surgery, College of Medicine, Seoul National University, Seoul, 03080, South Korea. .,Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Boramae-ro 5-gil 20, Dongjak-gu, Seoul, 07061, South Korea.
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Pulsed Electromagnetic Field Stimulation Is a Practical Adjunctive Therapy for Fusion in Spine Surgery. Clin Spine Surg 2020; 33:255-257. [PMID: 31580260 DOI: 10.1097/bsd.0000000000000880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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