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Kitzen J, Bakker WM, Jacobs E, Kuijper MT, Öner FC. Surgeon reported treatment choices for AO type B and C thoracolumbar fractures without neurological deficits: An expert survey. Injury 2024; 55:111389. [PMID: 38341996 DOI: 10.1016/j.injury.2024.111389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/27/2023] [Accepted: 01/26/2024] [Indexed: 02/13/2024]
Abstract
INTRODUCTION Less invasive spine surgery (LISS) has become well-established for thoracolumbar burst fractures without neurological deficits. However, notable controversy persists regarding the adequacy of LISS for more unstable AO type B and C injuries, as it does not allow for formal open fusion. MATERIALS AND METHODS In this cross-sectional survey experienced spine surgeons of the Dutch Spine Society were invited to participate (56 participants). They were asked to indicate the most appropriate treatment for AO type B1, B2 (L1: A1 and L1: A3), B3 and C (L1: A4) injuries at level Th12-L1. Taking into account: age, AO N0-N1, or polytrauma. Specific agreement between participants was obtained applying Variation Ratio (VR). RESULTS A significant level of overall agreement was observed for AO type-B1 injuries with 73.8% of participants opting for percutaneous short-segment fixation (VR 0.775). For AO type-B3 injuries, 79.4% of participants favored percutaneous long-segment fixation (VR 0.794). for AO type-B2 injuries, there was less overall agreement (VR 0.571-0.657). Nonetheless, when considering all AO type-B injuries combined, percutaneous fixation emerged as the most preferred treatment option with substantial agreement (VR 0.871-0.923). Conversely, for AO type-C injuries, there was less agreement among the participants (VI 0.411), 26.5% of them chose additional open spinal fusion. CONCLUSION For all AO type-B injuries there was substantial agreement to treat these fractures with percutaneous techniques. For AO type-C injuries, the survey results do not support a consensus. Nevertheless, the responses raise important questions about the necessity of spinal fusion for such injuries.
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Affiliation(s)
- J Kitzen
- Department of Orthopedic Surgery, Maasstad Medical Centre, P.O. Box 9100, Rotterdam 3007 AC, the Netherlands.
| | - W M Bakker
- Department of Orthopedic Surgery, Maasstad Medical Centre, P.O. Box 9100, Rotterdam 3007 AC, the Netherlands
| | - E Jacobs
- Department of Orthopedic Surgery, Maastricht University Medical Centre, P.O. Box 5800, Maastricht 6202 AZ, the Netherlands
| | - M T Kuijper
- Department of Clinical Epidemiology, Maasstad Medical Centre, P.O. Box 9100, Rotterdam 3007 AC, the Netherlands
| | - F C Öner
- Department Orthopedic Surgery, University Medical Centre Utrecht, P.O. Box 88500, Utrecht 3508 GA, the Netherlands
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2
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Stadhouder A, van Rossenberg LX, Kik C, Muijs SPJ, Öner FC, Houwert RM. Natural Experiments as a Study Method in Spinal Trauma Surgery: A Systematic Review. Global Spine J 2023:21925682231220889. [PMID: 38073538 DOI: 10.1177/21925682231220889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES To determine if the natural experiment design is a useful research methodology concept in spinal trauma care, and to determine if this methodology can be a viable alternative when randomized controlled trials are either infeasible or unethical. METHODS A Medline, Embase and Cochrane database search was performed between 2004 and 2023 for studies comparing different treatment modalities of spinal trauma. All observational studies with a natural experiment design comparing different treatment modalities of spinal trauma were included. Data extraction and quality assessment with the MINORS criteria was performed. RESULTS Four studies with a natural experiment design regarding patients with traumatic spinal fractures were included. All studies were retrospective, one study collected follow-up data prospectively. Three studies compared different operative treatment modalities, whereas one study compared different antibiotic treatment strategies. Two studies compared preferred treatment modalities between expertise centers, one study between departments (neuro- and orthopedic surgery) and one amongst surgeons. For the included retrospective studies, MINORS scores (maximum score 18) were high ranging from 12-17 and with a mean (SD) of 14.6 (1.63). CONCLUSIONS Since 2004 only four studies using a natural experiment design have been conducted in spinal trauma. In the included studies, comparability of patient groups was high emphasizing the potential of natural experiments in spinal trauma research. Natural experiments design should be considered more frequently in future research in spinal trauma as they may help to address difficult clinical problems when RCT's are infeasible or unethical.
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Affiliation(s)
- Agnita Stadhouder
- Department of Orthopaedics and Sports Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Luke Xander van Rossenberg
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- Department of Trauma Surgery, Diakonessenhuis, Utrecht, Netherlands
| | - Charlotte Kik
- Department of Neurosurgery, Erasmus MC, Rotterdam, Netherlands
| | - S P J Muijs
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, Netherlands
| | - F C Öner
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, Netherlands
| | - R Marijn Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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3
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Ochtman AEA, Bisschop A, Bleys RLAW, Öner FC, van Gaalen SM. Surgical techniques in restoration lumbar lordosis: a biomechanical human cadaveric study. Spine Deform 2023; 11:35-40. [PMID: 35951242 PMCID: PMC9768003 DOI: 10.1007/s43390-022-00549-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/25/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Degenerative changes of the lumbar spine lead in general to decrease of lumbar lordosis (LL). This change affects the overall balance of the spine, and when surgery is deemed, necessary restoration of the LL is considered. How this restoration can be achieved is a matter of controversy. The main purpose of this cadaveric study was to investigate the different steps of common posterior surgical techniques to understand the contribution of each successive step in restoring LL. METHODS Ten fresh-frozen human lumbar spine specimens were used to perform a sequential correction and instrumentation with a pedicle screw construct. RESULTS The mean LL angle measured at L3-L4 in intact condition was 12.9°; after screw insertion and compression, this increased to 13.8° (+ 7%, p = 0.04), after bilateral facetectomy to 16.3° (+ 20%, p = 0.005), after discectomy and insertion of interbody cage to 18.0º (+ 9%, p = 0.012), after resection of the lamina and the processes spinosus to 19.8° (+ 10%, p = 0.017), and after resection of the anterior longitudinal ligament to 25.4° (+ 22%, p = 0.005). CONCLUSIONS Each step contributed statistically significant to restoration of segmental lordosis with bilateral facetectomy contributing the most in terms of percentage. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- A. E. A. Ochtman
- grid.7692.a0000000090126352Department of Orthopedics, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, The Netherlands
| | - A. Bisschop
- grid.16872.3a0000 0004 0435 165XDepartment of Orthopedics, VU University Medical Center, Amsterdam, The Netherlands
| | - R. L. A. W. Bleys
- grid.7692.a0000000090126352Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F. C. Öner
- grid.7692.a0000000090126352Department of Orthopedics, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, The Netherlands
| | - S. M. van Gaalen
- Acibadem International Medical Center, Arlandaweg 100, 1043 HP Amsterdam, The Netherlands
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4
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Kersten RFMR, Öner FC, Arts MP, Mitroiu M, Roes KCB, de Gast A, van Gaalen SM. The SNAP Trial: 2-Year Results of a Double-Blind Multicenter Randomized Controlled Trial of a Silicon Nitride Versus a PEEK Cage in Patients After Lumbar Fusion Surgery. Global Spine J 2022; 12:1687-1695. [PMID: 33406905 PMCID: PMC9609539 DOI: 10.1177/2192568220985472] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Randomized controlled trial. OBJECTIVES Lumbar interbody fusion with cages is performed to provide vertebral stability, restore alignment, and maintain disc and foraminal height. Polyetheretherketone (PEEK) is commonly used. Silicon nitride (Si3N4) is an alternative material with good osteointegrative properties. This study was designed to assess if Si3N4 cages perform similar to PEEK. METHODS A non-inferiority double-blind multicenter RCT was designed. Patients presenting with chronic low-back pain with or without leg pain were included. Single- or double-level instrumented transforaminal lumbar interbody fusion (TLIF) using an oblique PEEK or Si3N4 cage was performed. The primary outcome was the Roland-Morris Disability Questionnaire (RMDQ). The non-inferiority margin for the RMDQ was 2.6 points on a scale of 24. Secondary outcomes included the Oswestry Disability Questionnaire (ODI), Visual Analogue Scales (VAS), SF-36 Physical Function, patient and surgeon Likert scores, radiographic evaluations for subsidence, segmental motion, and fusion. Follow-up was planned at 3, 6, 12, and 24-months. RESULTS Ninety-two patients were randomized (i.e. 48 to PEEK and 44 to Si3N4). Both groups showed good clinical improvements on the RMDQ scores of up to 5-8 points during follow-up. No statistically significant differences were observed in clinical and radiographic outcomes. Mean operative time and blood loss were statistically significantly higher for the Si3N4 cohort. Although not statistically significant, there was a higher incidence of complications and revisions associated with the Si3N4 cage. CONCLUSIONS There was insufficient evidence to conclude that Si3N4 was non-inferior to PEEK.
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Affiliation(s)
- R. F. M. R. Kersten
- Department of Orthopedics, Clinical
Orthopedic Research Center–midden Nederland (CORC-mN), Diakonessenhuis
Utrecht/Zeist, The Netherlands,Department of Orthopedics, University Medical Center
Utrecht, Utrecht University, The Netherlands,R. F. M. R. Kersten, Department of
Orthopedics, University Medical Center Utrecht, Heidelberglaan 100, 3584CX,
Utrecht, the Netherlands.
| | - F. C. Öner
- Department of Orthopedics, University Medical Center
Utrecht, Utrecht University, The Netherlands
| | - M. P. Arts
- Department of Neurosurgery, Haaglanden Medical Center, the Hague, The Netherlands
| | - M. Mitroiu
- Department of Biostatistics and Research
Support, Clinical Trial Methodology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, The
Netherlands
| | - K. C. B. Roes
- Department of Health Evidence, Section
Biostatistics, Radboud University Medical Center, Radboud University, The
Netherlands
| | - A. de Gast
- Department of Orthopedics, Clinical
Orthopedic Research Center–midden Nederland (CORC-mN), Diakonessenhuis
Utrecht/Zeist, The Netherlands
| | - S. M. van Gaalen
- Department of Orthopedics, Clinical
Orthopedic Research Center–midden Nederland (CORC-mN), Diakonessenhuis
Utrecht/Zeist, The Netherlands,Spinecenter.Amsterdam, Acibadem
International Medical Center, Amsterdam, the Netherlands
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5
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Xiao L, Hu B, Ding B, Zhao Q, Liu C, Öner FC, Xu H. N(6)-methyladenosine RNA methyltransferase like 3 inhibits extracellular matrix synthesis of endplate chondrocytes by downregulating sex-determining region Y-Box transcription factor 9 expression under tension. Osteoarthritis Cartilage 2022; 30:613-625. [PMID: 35007741 DOI: 10.1016/j.joca.2022.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Tension stimulation is an important inducer of endplate cartilage degeneration, but the specific regulatory mechanism remains unclear. This study was the first to reveal the mechanism by which methyltransferase-like 3 (METTL3)-mediated N(6)-methyladenosine (m6A) modification affected the extracellular matrix anabolism by tension-induced endplate chondrocytes. METHOD We examined the differences in METTL3 expression and m6A methylation levels in human endplate chondrocytes and human cartilage endplate tissues under in vitro tension. The effect on endplate cartilage degeneration was evaluated by manipulating m6A methylation mediated by METTL3 in vivo and in vitro. The effect of METTL3-mediated m6A methylation on the stability of sex-determining region Y-box transcription factor 9 (SOX9) gene expression was determined experimentally. RESULTS METTL3 expression and m6A methylation levels were significantly increased in degenerative human endplate cartilage tissue. Similarly, tension stimulation inhibited the ability of human endplate chondrocytes to synthesize extracellular matrix, which was accompanied by an increase in METTL3-mediated m6A methylation. The ability of endplate chondrocytes to resist tension was significantly enhanced by inhibiting METTL3 expression and subsequently downregulating m6A methylation in vitro and in vivo, thereby reducing intervertebral disc degeneration. Furthermore, METTL3 mediated SOX9 RNA methylation and disrupted SOX9 mRNA stability, thereby inhibiting the gene expression of the downstream collagen type II alpha 1 chain. CONCLUSION Tension stimulation downregulated SOX9 expression through METTL3-mediated m6A methylation, thereby inhibiting the synthesis of extracellular matrix in endplate chondrocytes.
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Affiliation(s)
- L Xiao
- Department of Spine Surgery, Yijishan Hospital of Wannan Medical College, No. 2 Zheshan West Road, Wuhu, Anhui, 241001, China
| | - B Hu
- Spine Research Center of Wannan Medical College, No.22 Wenchang West Road, Wuhu, Anhui, 241001, China
| | - B Ding
- Spine Research Center of Wannan Medical College, No.22 Wenchang West Road, Wuhu, Anhui, 241001, China
| | - Q Zhao
- Department of Spine Surgery, Yijishan Hospital of Wannan Medical College, No. 2 Zheshan West Road, Wuhu, Anhui, 241001, China
| | - C Liu
- Key Laboratory of Non-Coding RNA Transformation Research of Anhui Higher Education Institution, No. 2 Zheshan West Road, Wuhu, Anhui, 241001, China
| | - F C Öner
- Department of Orthopedics, University Medical Center Utrecht, Heidelberglaan, 1003508, Netherlands.
| | - H Xu
- Spine Research Center of Wannan Medical College, No.22 Wenchang West Road, Wuhu, Anhui, 241001, China.
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6
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Ochtman AEA, Kruyt MC, Jacobs WCH, Kersten RFMR, le Huec JC, Öner FC, van Gaalen SM. Surgical Restoration of Sagittal Alignment of the Spine: Correlation with Improved Patient-Reported Outcomes: A Systematic Review and Meta-Analysis. JBJS Rev 2021; 8:e1900100. [PMID: 32796194 DOI: 10.2106/jbjs.rvw.19.00100] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The sagittal-plane curvatures of the human spine are the consequence of evolution from quadrupedalism to bipedalism and are needed to maintain the center of mass of the body within the base of support in the bipedal position. Lumbar degenerative disorders can lead to a decrease in lumbar lordosis and thereby affect overall alignment of the spine. However, there is not yet enough direct evidence that surgical restoration of spinal malalignment would lead to a better clinical outcome. Therefore, the aim of this study was to assess the correlation between patient-reported outcomes and actual obtained spinal sagittal alignment in adult patients with lumbar degenerative disorders who underwent surgical treatment. METHODS A comprehensive literature search was conducted through databases (PubMed, Cochrane, Web of Science, and Embase). The last search was in November 2018. Risk of bias was assessed with the Newcastle-Ottawa quality assessment scale. A meta-regression analysis was performed. RESULTS Of 2,024 unique articles in the original search, 34 articles with 973 patients were included. All studies were either retrospective or prospective cohort studies; no randomized controlled trials were available. A total of 54 relations between preoperative-to-postoperative improvement in patient-reported outcome measures (PROMs) and radiographic spinopelvic parameters were found, of which 20 were eligible for meta-regression analysis. Of these, 2 correlations were significant: pelvic tilt (PT) versus Oswestry Disability Index (ODI) (p = 0.009) and PT versus visual analog scale (VAS) pain (p = 0.008). CONCLUSIONS On the basis of the current literature, lower PT was significantly correlated with improved ODI and VAS pain in patients with sagittal malalignment caused by lumbar degenerative disorders that were treated with surgical correction of the sagittal balance. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- A E A Ochtman
- Department of Orthopedics, Clinical Orthopedic Research Center midden-Nederland (CORC-mN), Utrecht, the Netherlands
| | - M C Kruyt
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - W C H Jacobs
- The Health Scientist, The Hague, the Netherlands
| | - R F M R Kersten
- Department of Orthopedics, Clinical Orthopedic Research Center midden-Nederland (CORC-mN), Utrecht, the Netherlands
| | - J C le Huec
- Orthospine Unit, Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France
| | - F C Öner
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - S M van Gaalen
- Acibadem International Medical Center, Amsterdam, the Netherlands
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7
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Sanli I, Spoor A, Muijs SPJ, Öner FC. Less Invasive Surgery is Feasible in the Management of Traumatic Thoracolumbar Fractures in Isolated and Polytrauma Injury. Int J Spine Surg 2020; 13:561-567. [PMID: 31970052 DOI: 10.14444/6078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Less invasive stabilization systems (LISSs) have gained popularity. However, limited quality of life (QOL) and clinical outcome data exist for trauma patients treated with LISSs. The objective of this study is to describe QOL and outcome for posterior percutaneous pedicle screw fixation in the management of traumatic thoracolumbar fractures. Methods Between January 2006 and December 2011, data from all patients treated with a posterior percutaneous pedicle screw fixation technique for thoracolumbar fractures were collected and analyzed. Sixty-nine patients met the inclusion criteria. Additional vertebral reduction and cement augmentation was used in 25 patients, when there was more than 50% of vertebral body comminution. Results Mean follow up of 19 months (range = 6-49 months). Fifty-one percent of the study population consisted of polytrauma patients, with 22% having injury severity score ≥ 15. In 6 cases (8.7%) there were perioperative complications. Response rate for the follow-up health survey was 78%, with a satisfactory overall median EuroQuol score of 0.811 (Q1-Q3 95% confidence interval = 0.709-0.897). Conclusions Posterior percutaneous pedicle screw fixation proves to be effective in the management of traumatic thoracolumbar fractures, with a good overall functional outcome. Percutaneous techniques that reduce perioperative morbidity are an alternative approach well suited for damage control orthopaedics, as long as there are no neurological deficits. Especially in polytrauma patients with spine fractures, the spinal column can be stabilized in an emergency setting, while limiting the risks of "a second hit" at the patients' already frail condition. Level of Evidence 3.
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Affiliation(s)
- I Sanli
- Department of Orthopaedic Surgery, Maastricht University Medical Centre+, the Netherlands
| | - A Spoor
- Department of Orthopaedic Surgery, Elisabeth Hospital Tilburg, the Netherlands
| | - S P J Muijs
- Department of Orthopaedic Surgery, Utrecht University Medical Centre, the Netherlands
| | - F C Öner
- Department of Orthopaedic Surgery, Utrecht University Medical Centre, the Netherlands
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8
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Croes M, Kruyt MC, Boot W, Pouran B, Braham MV, Pakpahan SA, Weinans H, Vogely HC, Fluit AC, Dhert WJ, Alblas J, Öner FC. The role of bacterial stimuli in inflammation-driven bone formation. Eur Cell Mater 2019; 37:402-419. [PMID: 31094449 DOI: 10.22203/ecm.v037a24] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Immune cells and their soluble factors regulate skeletal cells during normal bone regeneration and pathological bone formation. Bacterial infections can trigger immune responses that activate pro-osteogenic pathways, but these are usually overshadowed by osteolysis and concerns of systemic inflammation. The aim of this study was to determine whether the transient local inflammatory reaction to non-viable bacterial immune agonists could lead to favourable new bone formation. In a series of rabbit studies, as proof-of-concept, how tibial intramedullary injection of viable or killed bacterial species affected bone remodelling and new bone formation was determined. Application of killed bacteria led to considerable new bone formation after 4 weeks, without the prolonged systemic inflammation and exaggerated bone lysis seen with active infection. The osteo-immunomodulatory effects of various species of killed bacteria and the dose response relationship were subsequently screened in ectopically-implanted ceramic scaffolds. Histomorphometry after 8 weeks showed that a relatively low dose of killed bacteria enhanced ectopic bone induction. Moreover, lipoteichoic acid - the bacterial cell-wall derived toll-like-receptor (TLR)-2 activator - was identified as an osteo-stimulatory factor. Collectively, the data indicated that bacterial stimuli could be harnessed to stimulate osteogenesis, which occurs through a synergy with osteoinductive signals. This finding holds promise for the use of non-viable bacteria, bacterial antigens, or their simplified analogues as immuno-modulatory bone regenerating tools in bone biomaterials.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - J Alblas
- Department of Orthopaedics University Medical Centre Utrecht, Rm G05.228, P.O. Box 85500, Utrecht 3508 GA, the Netherlands. j.alblas @umcutrecht.nl
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9
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Duits AAA, Vendeuvre T, Germaneau A, Rigoard P, Brèque C, de Gast A, Öner FC, van Gaalen SM. Fracture reduction with novel auto-adjust poly-axial pedicle screws: a cadaveric pilot study. Comput Methods Biomech Biomed Engin 2019. [DOI: 10.1080/10255842.2020.1714987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- A. A. A. Duits
- Clinical Orthopedic Research Center - mN, Diakonessenhuis Zeist, Zeist, the Netherlands
- Department of Orthopaedic Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - T. Vendeuvre
- Institut Pprime UPR 3346, CNRS – Université de Poitiers – ENSMA, Poitiers, France
- Spine & Neuromodulation Functional Unit, Poitiers University Hospital, Poitiers, France
| | - A. Germaneau
- Institut Pprime UPR 3346, CNRS – Université de Poitiers – ENSMA, Poitiers, France
| | - P. Rigoard
- Institut Pprime UPR 3346, CNRS – Université de Poitiers – ENSMA, Poitiers, France
- Spine & Neuromodulation Functional Unit, Poitiers University Hospital, Poitiers, France
| | - C. Brèque
- Institut Pprime UPR 3346, CNRS – Université de Poitiers – ENSMA, Poitiers, France
- ABS Lab Université de Poitiers, Poitiers, France
| | - A. de Gast
- Clinical Orthopedic Research Center - mN, Diakonessenhuis Zeist, Zeist, the Netherlands
- Department of Orthopaedic Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - F. C. Öner
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - S. M. van Gaalen
- International Spine Center Amsterdam (ISCA), Amsterdam, The Netherlands
- Department of Orthopaedic Surgery, Acibadem, Amsterdam, The Netherlands
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10
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Croes M, Kruyt MC, Groen WM, van Dorenmalen KMA, Dhert WJA, Öner FC, Alblas J. Interleukin 17 enhances bone morphogenetic protein-2-induced ectopic bone formation. Sci Rep 2018; 8:7269. [PMID: 29740080 PMCID: PMC5940874 DOI: 10.1038/s41598-018-25564-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/24/2018] [Indexed: 02/06/2023] Open
Abstract
Interleukin 17 (IL-17) stimulates the osteogenic differentiation of progenitor cells in vitro through a synergy with bone morphogenetic protein (BMP)-2. This study investigates whether the diverse responses mediated by IL-17 in vivo also lead to enhanced BMP-2-induced bone formation. Since IL-17 is known to induce osteoclastogenesis, we studied the interactions between IL-17 and BMP-2 in ceramic scaffolds either or not carrying a coating with the bisphosphonate zoledronic acid (ZOL). Histological evaluation revealed that IL-17 alone did not induce any osteoclasts at day 10. On the other hand, BMP-2 clearly stimulated early tissue ingrowth and osteoclastogenesis. Both of these processes were blocked in presence of ZOL. IL-17 signaling restored early vascularized connective tissue formation and osteoclastogenesis induced by BMP-2 in ZOL-coated scaffolds. After 12 weeks, the bone volume induced by co-delivery of BMP-2 and IL-17 was doubled as compared to that induced by BMP-2 alone. We conclude that IL-17 has osteo-stimulatory effects through a synergy with bone-inductive BMP-2. Although local and single application of IL-17 does not mediate osteoclast formation, it could promote other processes involved in bone formation such as connective tissue ingrowth. The use of IL-17 may contribute to the development of improved bone graft substitutes.
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Affiliation(s)
- M Croes
- Department of Orthopaedics, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M C Kruyt
- Department of Orthopaedics, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - W M Groen
- Department of Orthopaedics, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - K M A van Dorenmalen
- Department of Orthopaedics, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - W J A Dhert
- Department of Orthopaedics, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Faculty of Veterinary Medicine, Utrecht University, Yalelaan 1, 3508 TD, Utrecht, The Netherlands
| | - F C Öner
- Department of Orthopaedics, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - J Alblas
- Department of Orthopaedics, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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11
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Loozen LD, Vandersteen A, Kragten AH, Öner FC, Dhert WJ, Kruyt MC, Alblas J. Bone formation by heterodimers through non-viral gene delivery of BMP-2/6 and BMP-2/7. Eur Cell Mater 2018; 35:195-208. [PMID: 29589649 DOI: 10.22203/ecm.v035a14] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Non-viral gene delivery is a safe technique to release sustained physiologic dosages of bone morphogenetic protein (BMP). Co-delivery of multiple BMPs can result in the formation of more potent BMP heterodimers. In this study, non-viral co-delivery of BMP-2/6 and BMP-2/7, as a mean to produce heterodimers, was assessed. Goat MSCs were non-virally transfected with plasmid DNA encoding BMP isoforms (pBMP) known to be relevant for osteogenesis: BMP-2, -6 or -7. As a result, BMP-2, -6 and -7 were produced and detectable for up to 14 d and their combined delivery (pBMP-2 with pBMP-6 or pBMP-7) was used to create BMP-2/6 and BM-2/7 heterodimers. Formation and secretion of the heterodimer proteins was validated by sandwich enzyme-linked immunosorbent assay (ELISA). Produced BMPs and heterodimers were biologically active, as confirmed by differentiation of reporter cells and MSCs. To assess bone formation, transfected MSCs were seeded on to ceramic scaffolds and implanted subcutaneously into nude mice. Bone formation was significantly enhanced in the pBMP-2/6 condition and a trend for more bone formation was observed in the pBMP-2/7 and pBMP-6 homodimer condition. No bone was found in the pBMP-2, pBMP-7 or control condition. In conclusion, simultaneous delivery of pBMP-2 with pBMP-6 or -7 resulted in the production of heterodimers that were beneficial for bone formation as compared to BMP homodimers. Combination of BMP sequences could reduce the need for high BMP protein dosages and might enhance prolonged availability of the growth factors.
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Affiliation(s)
| | | | | | | | | | | | - J Alblas
- Department of Orthopaedics, University Medical Centre Utrecht, Room G05.228, Heidelberglaan 100, 3584 CX Utrecht, the
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12
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Croes M, Kruyt MC, Loozen L, Kragten AH, Yuan H, Dhert WJ, Öner FC, Alblas J, Alblas J. Local induction of inflammation affects bone formation. Eur Cell Mater 2017; 33:211-226. [PMID: 28266689 DOI: 10.22203/ecm.v033a16] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
To explore the influence of inflammatory processes on bone formation, we applied a new in vivo screening model. Confined biological pockets were first created in rabbits as a response to implanted bone cement discs. These biomembrane pockets were subsequently used to study the effects of inflammatory stimuli on ectopic bone formation within biphasic calcium phosphate (BCP) constructs loaded with TNF-α, lipopolysaccharide (LPS) or lipoteichoic acid (LTA), all with or without bone morphogenetic protein (BMP)-2. Analysis of bone formation after 12 weeks demonstrated that the inflammatory mediators were not bone-inductive in combination with the BCP alone, but inhibited or enhanced BMP-induced bone formation. LPS was associated with a strong inhibition of bone formation by BMP-2, while LTA and TNF-α showed a positive interaction with BMP-2. Since the biomembrane pockets did not interfere with bone formation and prevented the leakage of pro-inflammatory compounds to the surrounding tissue, the biomembrane model can be used for in vivo approaches to study local inflammation in conjunction with new bone formation. Using this model, it was shown that the modulation of the inflammatory response could be beneficial or detrimental to the subsequent bone formation process. The co-delivery of inflammatory factors and bone-related growth factors should be further explored as a strategy to enhance the bone-forming efficacy of bone substitutes.
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Affiliation(s)
| | | | | | | | | | | | | | - J Alblas
- Department of Orthopaedics, University Medical Centre Utrecht, Rm G05.228, P.O. Box 85500, Utrecht 3508 GA, The
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13
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Schutgens EM, Tryfonidou MA, Smit TH, Öner FC, Krouwels A, Ito K, Creemers LB, Creemers LB. Biomaterials for intervertebral disc regeneration: past performance and possible future strategies. Eur Cell Mater 2015; 30:210-31. [PMID: 27227695 DOI: 10.22203/ecm.v030a15] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Intervertebral disc (IVD) degeneration is associated with most cases of cervical and lumbar spine pathologies, amongst which chronic low back pain has become the number one cause of loss of quality-adjusted life years. In search of alternatives to the current less than optimal and usually highly invasive treatments, regenerative strategies are being devised, none of which has reached clinical practice as yet. Strategies include the use of stem cells, gene therapy, growth factors and biomaterial carriers. Biomaterial carriers are an important component in musculoskeletal regenerative medicine techniques. Several biomaterials, both from natural and synthetic origin, have been used for regeneration of the IVD in vitro and in vivo. Aspects such as ease of use, mechanical properties, regenerative capacity, and their applicability as carriers for regenerative and anti-degenerative factors determine their suitability for IVD regeneration. The current review provides an overview of the biomaterials used with respect to these properties, including their drawbacks. In addition, as biomaterial application until now appears to have been based on a mix of mere availability and intuition, a more rational design is proposed for future use of biomaterials for IVD regeneration. Ideally, high-throughput screening is used to identify optimally effective materials, or alternatively medium content comparative studies should be carried out to determine an appropriate reference material for future studies on novel materials.
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Affiliation(s)
- E M Schutgens
- Dept Orthopaedics G05 228, Heidelberglaan 100, 3584 CX Utrecht, The
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14
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Poldervaart MT, van der Stok J, de Haas MFP, 't Hart MC, Öner FC, Dhert WJ, Weinans H, Alblas J. Growth factor-induced osteogenesis in a novel radiolucent bone chamber. Eur Cell Mater 2015; 29:35-41; discussion 41. [PMID: 25552427 DOI: 10.22203/ecm.v029a03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Treatment of large bone defects is currently performed using mainly autograft or allograft bone. There are important drawbacks to bone grafting, such as limited availability, donor site morbidity in the case of autograft and inferior performance of allografts. Therefore, there is a great need for a suitable bone graft substitute. In order to evaluate efficiently newly developed biomaterials and factors intended for orthopaedic surgery, the bone chamber is a very suitable model. To allow longitudinal investigation of bone growth with μCT, a new bone chamber made of radiolucent polyether ether ketone (PEEK) was developed and studied for its feasibility. Therefore, PEEK bone chambers were placed on rat tibiae, and filled with vehicle (Matrigel without growth factors, negative controls), with bone morphogenetic protein 2 (BMP-2, positive controls), or a mix of growth factors combining BMP-2, vascular endothelial growth factor and the chemokine stromal cell-derived factor 1α, all laden on gelatin microspheres for controlled release (combined growth factors). Growth factor presence led to a significant increase in bone formation after 8 weeks, which subsided after 12 weeks, underlining the importance of longitudinal analysis. We conclude that the PEEK-bone chamber is a suitable translational animal model to assess orthotopic bone formation in a longitudinal manner.
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Affiliation(s)
- M T Poldervaart
- Department of Orthopaedics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The
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15
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van der Heijden L, van de Sande MAJ, van der Geest ICM, Schreuder HWB, van Royen BJ, Jutte PC, Bramer JAM, Öner FC, van Noort-Suijdendorp AP, Kroon HM, Dijkstra PDS. Giant cell tumors of the sacrum--a nationwide study on midterm results in 26 patients after intralesional excision. Eur Spine J 2014; 23:1949-62. [PMID: 24614982 DOI: 10.1007/s00586-014-3263-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 02/20/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Evaluation of recurrences, complications and function at mid-term follow-up after curettage for sacral giant cell tumor (GCT). METHODS We retrospectively studied all 26 patients treated for sacral GCT in the Netherlands (from 1990 to 2010). Median follow-up was 98 (6-229) months. All patients underwent intralesional excision, 21 with local adjuvants, 5 radiotherapy, 3 IFN-α, 1 bisphosphonates. Functional outcome was assessed using Musculoskeletal Tumor Society (MSTS) score. Statistics were performed with Kaplan-Meier, Cox regression, log rank and Mann-Whitney U. RESULTS Recurrence rate was 14/26 after median 13 (3-139) months and was highest after isolated curettage (4/5). Soft tissue masses >10 cm increased recurrence risk (HR = 3.3, 95 % CI = 0.81-13, p = 0.09). Complications were reported in 12/26 patients. MSTS was superior in patients without complications (27 vs. 21; p = 0.024). CONCLUSION Recurrence rate for sacral GCT was highest after isolated curettage, indicating that (local) adjuvant treatment is desired to obtain immediate local control. Complications were common and impaired function.
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Affiliation(s)
- L van der Heijden
- Department of Orthopedic Surgery, Leiden University Medical Center (LUMC), Postzone J11-70, PO Box 9600, 2300 RC, Leiden, The Netherlands,
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Spoor AB, Öner FC. Minimally invasive spine surgery in chronic low back pain patients. J Neurosurg Sci 2013; 57:203-218. [PMID: 23877267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Low back pain (LBP) is a common disorder with a lifetime prevalence of 85%. The pathophysiology of LBP can be various depending on the underlying problem. Only in about 10% of the patients specific underlying disease processes can be identified. Patients with scoliosis, spondylolisthesis, herniated discs, adjacent disc disease, disc degeneration, failed back surgery syndrome or pseudoartrosis all have symptoms of LBP in different ways. Chronic low back pain patients are advised to stay active, however, there is no strong evidence that exercise therapy is significantly different than other nonsurgical therapies. Not every patient with symptoms of LBP is an appropriate candidate for surgery. Even with thorough systematic reviews, no proof can be found for the benefit of surgery in patients with low back pain, without serious neurologic deficit. And subjects like psychologic and socio-demographic factors also seem to be influencing a patients perception of back pain, expectations of treatment, and outcomes of treatment. Open lumbar fusion procedures are typically lengthy procedures and require a long exposure, which may result in ischemic necrosis of the paraspinal musculature, atrophy, and prolonged back pain. Minimally invasive spine surgery needed to take care of a decrease in muscle injuries due to retraction and avoidance of disruption of the osseotendineous complex of the paraspinal muscles, especially the multifidus attachment to the spinous process and superior articular process. Therefore, effort has been made to develop percutaneous fusion, as well as fixation methods, which avoid the negative effects of open surgery. Several minimally invasive fusion strategies have been described, like anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF) and two lateral approaches (XLIF and DLIF), all with pro's and con's compared to open surgery and each other. The effect of MIS of all type is that patients have less blood loss, faster postoperative ambulation, lower use of opioids, and shorter in hospital stay, which is nearly always significantly better than an open procedure. And most of the studies show a significant improvement of VAS leg-and back pain, Oswestry Disability Index and a high fusion rate, but most of the times not significantly different than the open counterpart. When it comes to cost-effectiveness there is a trend in favor of MIS, but to when we want to differentiate MIS from open surgery, comorbidities and complications significantly affect general and disease-specific outcome measures. In our opinion, the actual better outcome of minimal invasive surgery comes down to obtain a good cost-effectiveness study, provided that minimally invasive surgery has an equal or better clinical and radiologic outcome, given that socio-economic, demographic and psychological influencers are equal for both types of surgery. There are no studies done on the subject MIS and low back pain solely. Deriving answers from the difference in VAS back pain in MIS studies reveal a 100% improvement of back pain after surgery. But that does not imply that this procedure, which is still in its childhood, will be the solution to all low back pain patients.
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Affiliation(s)
- A B Spoor
- Department of Orthopedic Surgery, St Elisabeth Hospital , Tilburg, The Netherlands -
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