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Plantz MA, Gerlach EB, Hsu WK. Synthetic Bone Graft Materials in Spine Fusion: Current Evidence and Future Trends. Int J Spine Surg 2021; 15:104-112. [PMID: 34376499 DOI: 10.14444/8058] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Historically, iliac crest bone autograft has been considered the gold standard bone graft substitute for spinal fusion. However, the significant morbidity associated with harvesting procedures has influenced decision-making and practice patterns. To minimize these side effects, many clinicians have pursued the use of bone graft extenders to minimize the amount of autograft required for fusion in certain applications. Synthetic materials, including a variety of ceramic compounds, are a class that has been studied extensively as bone graft extenders. These have been used in combination with a wide array of other biomaterials and investigated in a variety of different spine fusion procedures. This review will summarize the current evidence of different synthetic materials in various spinal fusion procedures and discuss the future of novel synthetics.
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Affiliation(s)
- Mark A Plantz
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Erik B Gerlach
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Wellington K Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Liang W, Wu X, Dong Y, Shao R, Chen X, Zhou P, Xu F. In vivo behavior of bioactive glass-based composites in animal models for bone regeneration. Biomater Sci 2021; 9:1924-1944. [PMID: 33506819 DOI: 10.1039/d0bm01663b] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
This review presents the recent advances and the current state-of-the-art of bioactive glass-based composite biomaterials intended for bone regeneration. Composite materials comprise two (or more) constituents at the nanometre scale, in which typically, one constituent is organic and functions as the matrix phase and the other constituent is inorganic and behaves as the reinforcing phase. Such materials, thereby, more closely resemble natural bio-nanocomposites such as bone. Various glass compositions in combination with a wide range of natural and synthetic polymers have been evaluated in vivo under experimental conditions ranging from unloaded critical-sized defects to mechanically-loaded, weight-bearing sites with highly favourable outcomes. Additional possibilities include controlled release of anti-osteoporotic drugs, ions, antibiotics, pro-angiogenic substances and pro-osteogenic substances. Histological and morphological evaluations suggest the formation of new, highly vascularised bone that displays signs of remodelling over time. With the possibility to tailor the mechanical and chemical properties through careful selection of individual components, as well as the overall geometry (from mesoporous particles and micro-/nanospheres to 3D scaffolds and coatings) through innovative manufacturing processes, such biomaterials present exciting new avenues for bone repair and regeneration.
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Affiliation(s)
- Wenqing Liang
- Department of Orthopaedics, Zhoushan Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University, Zhoushan 316000, Zhejiang Province, P. R. China.
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Kampleitner C, Changi K, Felfel RM, Scotchford CA, Sottile V, Kluger R, Hoffmann O, Grant DM, Epstein MM. Preclinical biological and physicochemical evaluation of two-photon engineered 3D biomimetic copolymer scaffolds for bone healing. Biomater Sci 2020; 8:1683-1694. [PMID: 31984995 DOI: 10.1039/c9bm01827a] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A major challenge in orthopedics is the repair of large non-union bone fractures. A promising therapy for this indication is the use of biodegradable bioinspired biomaterials that stabilize the fracture site, relieve pain and initiate bone formation and healing. This study uses a multidisciplinary evaluation strategy to assess immunogenicity, allergenicity, bone responses and physicochemical properties of a novel biomaterial scaffold. Two-photon stereolithography generated personalized custom-built scaffolds with a repeating 3D structure of Schwarz Primitive minimal surface unit cell with a specific pore size of ∼400 μm from three different methacrylated poly(d,l-lactide-co-ε-caprolactone) copolymers with lactide to caprolactone monomer ratios of 16 : 4, 18 : 2 and 9 : 1. Using in vitro and in vivo assays for bone responses, immunological reactions and degradation dynamics, we found that copolymer composition influenced the scaffold physicochemical and biological properties. The scaffolds with the fastest degradation rate correlated with adverse cellular effects and mechanical stiffness correlated with in vitro osteoblast mineralization. The physicochemical properties also correlated with in vivo bone healing and immune responses. Overall these observations provide compelling support for these scaffolds for bone repair and illustrate the effectiveness of a promising multidisciplinary strategy with great potential for the preclinical evaluation of biomaterials.
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Affiliation(s)
- Carina Kampleitner
- Department of Pharmacology and Toxicology, University of Vienna, Vienna, Austria
| | - Katayoon Changi
- Laboratory of Experimental Allergy, Division of Immunology, Allergy and Infectious Diseases, Medical University of Vienna, Department of Dermatology, Vienna, Austria.
| | - Reda M Felfel
- Advanced Materials Research Group, Faculty of Engineering, University of Nottingham, UK
| | - Colin A Scotchford
- Advanced Materials Research Group, Faculty of Engineering, University of Nottingham, UK
| | | | - Rainer Kluger
- Wolfson STEM Centre, School of Medicine, University of Nottingham, UK
| | - Oskar Hoffmann
- Department of Pharmacology and Toxicology, University of Vienna, Vienna, Austria
| | - David M Grant
- Advanced Materials Research Group, Faculty of Engineering, University of Nottingham, UK
| | - Michelle M Epstein
- Laboratory of Experimental Allergy, Division of Immunology, Allergy and Infectious Diseases, Medical University of Vienna, Department of Dermatology, Vienna, Austria.
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Efficacy of a Standalone Microporous Ceramic Versus Autograft in Instrumented Posterolateral Spinal Fusion: A Multicenter, Randomized, Intrapatient Controlled, Noninferiority Trial. Spine (Phila Pa 1976) 2020; 45:944-951. [PMID: 32080013 PMCID: PMC7337108 DOI: 10.1097/brs.0000000000003440] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN in the rest of the article written as patient- and observer-blinded, multicenter, randomized, intrapatient controlled, noninferiority trial. OBJECTIVE The aim of this study was to determine noninferiority of a biphasic calcium-phosphate (AttraX® Putty) as a bone graft substitute for autograft in instrumented posterolateral fusion (PLF). SUMMARY OF BACKGROUND DATA Spinal fusion with autologous bone graft is a frequently performed surgical treatment. Several drawbacks of autografting have driven the development of numerous alternatives including synthetic ceramics. However, clinical evidence for the standalone use of these materials is limited. METHODS This study included 100 nontraumatic adults who underwent a primary, single- or multilevel, thoracolumbar, instrumented PLF. After instrumentation and preparation for grafting, the randomized allocation side of AttraX® Putty was disclosed. Autograft was applied to the contralateral side of the fusion trajectory, so each patient served as his/her own control. For the primary efficacy outcome, PLF was assessed at 1-year follow-up on computed tomography scans. Each segment and side was scored as fused, doubtful fusion, or nonunion. After correction for multilevel fusions, resulting in a single score per side, the fusion performance of AttraX Putty was tested with a noninferiority margin of 15% using a 90% confidence interval (CI). RESULTS There were 49 males and 51 females with a mean age of 55.4 ± 12.0 (range 27-79) years. Two-third of the patients underwent a single-level fusion and 62% an additional interbody fusion procedure. The primary analysis was based on 87 patients, including 146 instrumented segments. The fusion rate of AttraX Putty was 55% versus 52% at the autograft side, with an overall fusion rate of 71%. The 90% CI around the difference in fusion performance excluded the noninferiority margin (difference = 2.3%, 90% CI = -9.1% to +13.7%). CONCLUSION The results of this noninferiority trial support the use of AttraX Putty as a standalone bone graft substitute for autograft in instrumented thoracolumbar PLF. LEVEL OF EVIDENCE 1.
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Abstract
STUDY DESIGN This study was a multi-endpoint analysis of bone graft substitutes implanted as a standalone graft in a clinically relevant Ovine model of instrumented posterolateral spinal fusion (PLF). OBJECTIVE The objective of this study was to obtain high-quality evidence on the efficacy of commercial bone graft substitutes compared with autograft in instrumented PLF using a state-of-the-art model with a complete range of assessment techniques. SUMMARY OF BACKGROUND DATA Preclinical and clinical data on the quality of spinal fusions obtained with bone graft substitutes are often limited. Calcium phosphates with submicron topography have shown promising results in PLF, as these are able to induce bone formation in tissues distant from the host bone, which facilitates bony union. METHODS Nine female, skeletally mature sheep (4-5 y) underwent posterior pedicle screw/rods instrumented PLF at L2-L3 and L4-L5 using the following bone graft materials as a standalone graft per spinal segment: (1) biphasic calcium phosphate with submicron topography (BCP<µm), (2) 45S5 Bioglass (BG), and (3) collagen-β-tricalcium phosphate with a 45S5 Bioglass adjunct (TCP/BG). Autograft bone (AB) was used as a positive control treatment. Twelve weeks after implantation, the spinal segments were evaluated by fusion assessment (manual palpation, x-ray, micro-computed tomography, and histology), fusion mass volume quantification (micro-computed tomography), range of motion (ROM) testing, histologic evaluation, and histomorphometry. RESULTS Fusion assessment revealed equivalence between AB and BCP<µm by all fusion assessment methods, whereas BG and TCP/BG led to significantly inferior results. Fusion mass volume was highest for BCP<µm, followed by AB, BG, and TCP/BG. ROM testing determined equivalence for spinal levels treated with AB and BCP<µm, while BG and TCP/BG exhibited higher ROM. Histologic evaluation revealed substantial bone formation in the intertransverse regions for AB and BCP<µm, whereas BG and TCP/BG grafts contained fibrous tissue and minimal bone formation. Histologic observations were supported by the histomorphometry data. CONCLUSIONS This study reveals clear differences in efficacy between commercially available bone graft substitutes, emphasizing the importance of clinically relevant animal models with multiendpoint analyses for the evaluation of bone graft materials. The results corroborate the efficacy of calcium phosphate with submicron topography, as this was the only material that showed equivalent performance to autograft in achieving spinal fusion.
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Jones JR, Gibson IR. Ceramics, Glasses, and Glass-Ceramics. Biomater Sci 2020. [DOI: 10.1016/b978-0-12-816137-1.00022-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Yang F, Chen B, Hashimoto T, Zhang Y, Thompson G, Robinson I. Investigation of Three-Dimensional Structure and Pigment Surrounding Environment of a TiO₂ Containing Waterborne Paint. MATERIALS 2019; 12:ma12030464. [PMID: 30717389 PMCID: PMC6384949 DOI: 10.3390/ma12030464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 01/24/2019] [Accepted: 01/31/2019] [Indexed: 02/04/2023]
Abstract
Serial block-face scanning electron microscopy (SBFSEM) has been used to investigate the three-dimensional (3D) structure of a cured waterborne paint containing TiO2 pigment particles, and the surrounding environment of the TiO2 pigment particles in the cured paint film was also discussed. The 3D spatial distribution of the particles in the paint film and their degree of dispersion were clearly revealed. More than 55% of the measured TiO2 particles have volumes between 1.0 × 106 nm3 and 1.0 × 107 nm3. From the obtained 3D images, we proposed that there are three different types of voids in the measured cured waterborne paint film: voids that exist in the cured paint themselves, voids produced by particle shedding, and voids produced by quasi-liquid phase evaporation during measurement. Among these, the latter two types of voids are artefacts caused during SBFSEM measurement which provide evidence to support that the pigment particles in the cured paint/coating films are surrounding by quasi-liquid environment rather than dry solid environment. The error caused by particle shedding to the statistical calculation of the TiO2 particles was corrected in our analysis. The resulting 3D structure of the paint, especially the different voids are important for further systematic research, and are critical for understanding the real environment of the pigment particles in the cured paint films.
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Affiliation(s)
- Fei Yang
- School of Materials Science and Engineering, Tongji University, Shanghai 201804, China.
| | - Bo Chen
- School of Materials Science and Engineering, Tongji University, Shanghai 201804, China.
- London Centre for Nanotechnology, University College London, London WC1H 0AH, UK.
- Key Laboratory of Performance Evolution and Control for Engineering Structures of the Ministry of Education, Tongji University, Shanghai 200092, China.
| | - Teruo Hashimoto
- School of Materials, The University of Manchester, Manchester M13 9PL, UK.
| | - Yongming Zhang
- School of Materials Science and Engineering, Tongji University, Shanghai 201804, China.
| | - George Thompson
- School of Materials, The University of Manchester, Manchester M13 9PL, UK.
| | - Ian Robinson
- School of Materials Science and Engineering, Tongji University, Shanghai 201804, China.
- London Centre for Nanotechnology, University College London, London WC1H 0AH, UK.
- Division of Condensed Matter Physics and Materials Science, Brookhaven National Laboratory, Upton, NY 11973, USA.
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Karadjian M, Essers C, Tsitlakidis S, Reible B, Moghaddam A, Boccaccini AR, Westhauser F. Biological Properties of Calcium Phosphate Bioactive Glass Composite Bone Substitutes: Current Experimental Evidence. Int J Mol Sci 2019; 20:ijms20020305. [PMID: 30646516 PMCID: PMC6359412 DOI: 10.3390/ijms20020305] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 01/08/2019] [Accepted: 01/09/2019] [Indexed: 12/19/2022] Open
Abstract
Standard treatment for bone defects is the biological reconstruction using autologous bone—a therapeutical approach that suffers from limitations such as the restricted amount of bone available for harvesting and the necessity for an additional intervention that is potentially followed by donor-site complications. Therefore, synthetic bone substitutes have been developed in order to reduce or even replace the usage of autologous bone as grafting material. This structured review focuses on the question whether calcium phosphates (CaPs) and bioactive glasses (BGs), both established bone substitute materials, show improved properties when combined in CaP/BG composites. It therefore summarizes the most recent experimental data in order to provide a better understanding of the biological properties in general and the osteogenic properties in particular of CaP/BG composite bone substitute materials. As a result, BGs seem to be beneficial for the osteogenic differentiation of precursor cell populations in-vitro when added to CaPs. Furthermore, the presence of BG supports integration of CaP/BG composites into bone in-vivo and enhances bone formation under certain circumstances.
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Affiliation(s)
- Maria Karadjian
- Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118 Heidelberg, Germany.
| | - Christopher Essers
- Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118 Heidelberg, Germany.
| | - Stefanos Tsitlakidis
- Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118 Heidelberg, Germany.
| | - Bruno Reible
- Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118 Heidelberg, Germany.
| | - Arash Moghaddam
- Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118 Heidelberg, Germany.
- ATORG-Aschaffenburg Trauma and Orthopedics Research Group, Center for Trauma Surgery, Orthopedics, and Sports Medicine, Klinikum Aschaffenburg-Alzenau, Am Hasenkopf 1, 63739 Aschaffenburg, Germany.
| | - Aldo R Boccaccini
- Institute of Biomaterials, University of Erlangen-Nuremberg, Cauerstr. 6, 91058 Erlangen, Germany.
| | - Fabian Westhauser
- Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118 Heidelberg, Germany.
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Yang F, Liu X, Zhao Y, Zhang Y, Wang P, Robinson I, Chen B. Investigation of Three-Dimensional Microstructure of Tricalcium Silicate (C₃S) by Electron Microscopy. MATERIALS 2018; 11:ma11071110. [PMID: 29966230 PMCID: PMC6073500 DOI: 10.3390/ma11071110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 06/18/2018] [Accepted: 06/27/2018] [Indexed: 11/16/2022]
Abstract
A serial block-face scanning electron microscopy (SBFSEM) system, composed of a scanning electron microscope (SEM) and an ultra-microtome installed within the SEM vacuum chamber, has been used to characterize the three-dimensional (3D) microstructure of tricalcium silicate (C3S) grains embedded in epoxy resin. A selection of C3S grains were segmented and rendered with 3D-image processing software, which allowed the C3S grains to be clearly visualized and enabled statistically quantitative analysis. The results show that about 5% of the C3S grains have volumes larger than 1 μm3 and the average volume of the grains is 25 μm3. Pores can also be clearly seen in the biggest C3S grain, the volume of which is 3.6 × 104 μm3, and the mean volume and total volume of all the pores within this grain are 4.8 μm3 and 3.0 × 103 μm3, respectively. The reported work provides a new approach for the characterization of the 3D spatial structure of raw C3S materials, and the resulting 3D structure of the raw C3S is important for further systematic research on the relationships between the spatial microstructure and the hydration kinetics of C3S and other cement minerals.
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Affiliation(s)
- Fei Yang
- School of Materials Science and Engineering, Tongji University, Shanghai 201804, China.
| | - Xianping Liu
- School of Materials Science and Engineering, Tongji University, Shanghai 201804, China.
- Key Laboratory of Advanced Civil Engineering Materials (Tongji University), Ministry of Education, Shanghai 201804, China.
| | - Yongjuan Zhao
- School of Materials Science and Engineering, Tongji University, Shanghai 201804, China.
| | - Yongming Zhang
- School of Materials Science and Engineering, Tongji University, Shanghai 201804, China.
| | - Peiming Wang
- School of Materials Science and Engineering, Tongji University, Shanghai 201804, China.
- Key Laboratory of Advanced Civil Engineering Materials (Tongji University), Ministry of Education, Shanghai 201804, China.
| | - Ian Robinson
- School of Materials Science and Engineering, Tongji University, Shanghai 201804, China.
- London Centre for Nanotechnology, University College London, London WC1H 0AH, UK.
- Division of Condensed Matter Physics and Materials Science, Brookhaven National Laboratory, Upton, NY 11973, USA.
| | - Bo Chen
- School of Materials Science and Engineering, Tongji University, Shanghai 201804, China.
- London Centre for Nanotechnology, University College London, London WC1H 0AH, UK.
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Kowalczewski CJ, Saul JM. Biomaterials for the Delivery of Growth Factors and Other Therapeutic Agents in Tissue Engineering Approaches to Bone Regeneration. Front Pharmacol 2018; 9:513. [PMID: 29896102 PMCID: PMC5986909 DOI: 10.3389/fphar.2018.00513] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/27/2018] [Indexed: 12/14/2022] Open
Abstract
Bone fracture followed by delayed or non-union typically requires bone graft intervention. Autologous bone grafts remain the clinical "gold standard". Recently, synthetic bone grafts such as Medtronic's Infuse Bone Graft have opened the possibility to pharmacological and tissue engineering strategies to bone repair following fracture. This clinically-available strategy uses an absorbable collagen sponge as a carrier material for recombinant human bone morphogenetic protein 2 (rhBMP-2) and a similar strategy has been employed by Stryker with BMP-7, also known as osteogenic protein-1 (OP-1). A key advantage to this approach is its "off-the-shelf" nature, but there are clear drawbacks to these products such as edema, inflammation, and ectopic bone growth. While there are clinical challenges associated with a lack of controlled release of rhBMP-2 and OP-1, these are among the first clinical examples to wed understanding of biological principles with biochemical production of proteins and pharmacological principles to promote tissue regeneration (known as regenerative pharmacology). After considering the clinical challenges with such synthetic bone grafts, this review considers the various biomaterial carriers under investigation to promote bone regeneration. This is followed by a survey of the literature where various pharmacological approaches and molecular targets are considered as future strategies to promote more rapid and mature bone regeneration. From the review, it should be clear that pharmacological understanding is a key aspect to developing these strategies.
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Affiliation(s)
| | - Justin M Saul
- Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH, United States
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Lu J, Yu H, Chen C. Biological properties of calcium phosphate biomaterials for bone repair: a review. RSC Adv 2018; 8:2015-2033. [PMID: 35542623 PMCID: PMC9077253 DOI: 10.1039/c7ra11278e] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 12/17/2017] [Indexed: 11/21/2022] Open
Abstract
This article reviews the recent advances and various factors affecting the improvement of the biological properties of calcium phosphate for bone repair.
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Affiliation(s)
- Jingyi Lu
- Shenzhen Research Institute of Shandong University
- Shenzhen 518057
- P. R. China
- Key Laboratory of High-Efficiency and Clean Mechanical Manufacture (Shandong University)
- Ministry of Education
| | - Huijun Yu
- Shenzhen Research Institute of Shandong University
- Shenzhen 518057
- P. R. China
- Key Laboratory of High-Efficiency and Clean Mechanical Manufacture (Shandong University)
- Ministry of Education
| | - Chuanzhong Chen
- Shenzhen Research Institute of Shandong University
- Shenzhen 518057
- P. R. China
- Key Laboratory for Liquid-Solid Structural Evolution and Processing of Materials (Ministry of Education)
- School of Materials Science and Engineering
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