Bone Morphogenetic Protein-2 and Bone Marrow Aspirate With Allograft as Alternatives to Autograft in Instrumented Revision Posterolateral Lumbar Spinal Fusion A Minimum Two-Year Follow-up Study
ABSTRACT Retrospective cohort study.
Compare the efficacy of rhBMP-2 and bone marrow aspirate with allograft (BMAA) as alternatives to autograft in instrumented revision posterolateral lumbar fusion (PLF).
The use of autogenous bone graft is the current gold standard in revision PLF; however, this practice is associated with significant donor-site morbidity. Revision PLF pose the additional challenges of a less than ideal fusion environment and a limited quantity of autogenous bone graft. rhBMP-2 and BMAA have been shown to be acceptable bone graft substitutes in several primary orthopedic procedures. The role of these bone graft substitutes in instrumented revision PLF has yet to be determined.
Sixty-two patients (125 levels) who underwent instrumented revision PLF with a minimum 2-year follow-up were included. Group 1 contained 24 patients (13 single- [group 1A] and 11 multilevel [group 1B]) who underwent instrumented revision PLF using rhBMP-2 on an absorbable collagen sponge. Group 2 included 18 patients (7 single- [group 2A] and 11 multilevel [group 2B]) with procedures using BMAA. Group 3 consisted of 20 patients (10 single- [group 3A] and 10 multilevel [group 3B]) with procedures using autograft. Demographic, surgical, and clinical data were collected from medical records. Time to solid fusion mass formation, fusion rate, complications, and clinical outcomes were evaluated. The progression of the fusion mass was evaluated by reviewing radiographs. A diagnosis of nonunion was based on exploration during an additional revision surgery or evidence of nonunion on dynamic radiographs or computerized tomography. Clinical outcomes were assessed using a visual analog scale (VAS) before surgery and at 6-week, 6-, 12-, and 24-month follow-ups.
Overall fusion rate was 93.5% (58/62). All single-level revision PLF achieved solid fusion. Groups 1B and 3B achieved 100% fusion, (11/11) and (10/10), respectively;whereas group 2B had a fusion rate of 63.6% (7/11). Group 1 also developed a solid fusion mass earlier than the other groups. There was a significant decrease between preoperative and 2-year postoperative VAS scores in all groups, but no significant difference among groups. Three patients in group 2 required an additional revision surgery.
rhBMP-2 may be an appropriate alternative to autogenous bone graft in both single- and multilevel revision PLF, whereas BMAA may be appropriate as a substitute in single-level revision PLF. The use of BMAA in single-level revisions may be a more cost-effective option than rhBMP-2.
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ABSTRACT: Spondylodesis in the operative management of lumbar spine diseases has been the subject of numerous studies over the past several decades. The posterolateral fusion (PLF) with pedicle screw fixation is a commonly used procedure. The purpose of the presented study was whether the addition of BMC to allograft bone increases fusion rate after instrumented posterior lumbar fusion. The study was prospective, randomized, controlled and blinded. Eighty patients with degenerative disease of the lumbar spine underwent instrumented lumbar or lumbosacral PLF (22 males, 58 females , BMI less 35 for a good visualisation of the PL fusion on the x-rays). In forty cases, the PLF was done with spongious allograft chips alone (Group I, age 62,7 in average, range 47-77, level of fusion 1-2). In another forty cases, spongious allograft chips were mixed with BMC (Group II, age 58,5 in average, range 42-80, level of fusion 1-3).) included the mesenchymal stem cell (MSCs). Patients were scheduled for anteroposterior and lateral radiographs at 12 and 24 months after the surgery and for CT scanning at 24 months after the surgery. Fusion status and the degree of mineralization of the fusion mass were evaluated separately by two radiologists blinded to patient group affiliation. The bony mass was judged as fused if there was uninterrupted bridging of well-mineralized bone between the transverse processes or sacrum with trabeculation indicating bone maturation at least at one side of the spines. In Group I at 12 months, the bone graft mass was assessed in X-rays as fused in no case (0 %) and at 24 months in 4 cases (10 %). In Group II, 6 cases (15 %) achieved fusion at 12 months and 14 cases (35 %) at 24 months. The statistically significant difference between both groups was proven for complete fusion at 12 months (p = 0.041) and at 24 months (p = 0.011), too. CT scans showed that 16 cases (40 %) in Group I and 32 cases (80 %) in Group II had evidence of at least unilateral continuous bridging bone between neighboring vertebrae at 24 months (p < 0.05). We have confirmed the hypothesis that the autologous BMC together with the allograft is a better alternative for the PLF than the allograft alone. The use of autologous MSCs in form of the BMC in combination with allograft is an effective option how to enhance the PLF healing. Level of Evidence: Therapeutic Level I.The spine journal: official journal of the North American Spine Society 12/2013; 14(7). DOI:10.1016/j.spinee.2013.12.014 · 2.90 Impact Factor
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ABSTRACT: Osteonecrosis of the femoral head is an entity which occurs mainly in young and active patients aged between 20 and 50. The success of hip joint preserving treatments ranges from 15% to 50% depending on the stage and amount of osteonecrotic lesion. Total hip replacement is indicated in late post-collapse hips but it has unsatisfactory survival because of the wear and osteolysis in young and active patients. Osteochondral allografts have been reported in the treatment of large articular lesions with defects in underlying bone in knee, talus and shoulder. By combining osteoconductive properties of osteochondral allograft with osteogenic abilities of bone marrow-derived mesenchymal cells it has a potential to be an alternative to an autologous graft. The adjunct of hinged joint distraction should minimize stresses in subchondral bone to promote creeping substitution and prevent femoral head collapse. Unlike current treatment modalities, it would provide both structural support and allow bony and articular substitution.Medical Hypotheses 07/2014; DOI:10.1016/j.mehy.2014.07.004 · 1.15 Impact Factor
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ABSTRACT: Aim: To enumerate and characterize multipotential stromal cells (MSCs) in a cellular bone allograft and compare with fresh age-matched iliac crest bone and bone marrow (BM) aspirate. Materials & methods: MSC characterization used functional assays, confocal/scanning electron microscopy and whole-genome microarrays. Resident MSCs were enumerated by flow cytometry following enzymatic extraction. Results: Allograft material contained live osteocytes and proliferative bone-lining cells defined as MSCs by phenotypic and functional capacities. Without cultivation/expansion, the allograft displayed an 'osteoinductive' molecular signature and the presence of CD45(-)CD271(+)CD73(+)CD90(+)CD105(+) MSCs; with a purity over 100-fold that of iliac crest bone. In comparison with BM, MSC numbers enzymatically released from one gram of cellular allograft were equivalent to approximately 45 ml of BM aspirate. Conclusion: Cellular allograft bone represents a unique nonimmune material rich in MSCs and osteocytes. This osteoinductive graft represents an attractive alternative to autograft bone or composite/synthetic grafts in orthopedics and broader regenerative medicine settings.Regenerative Medicine 03/2014; DOI:10.2217/rme.14.17 · 3.87 Impact Factor