Successful Fusion Rate Research Articles

Comparison of platelet quality and the effect of platelet collection in single donor platelet collected by 2 brands of apheresis machines

Posterolateral fusion (PLF) with autogenous iliac bone graft is one of the most common surgical procedures for lumbar spinal disease. However, its limited success demands new biologically competent graft enhancers or substitutes. Although the use of direct current (DC) electrical stimulation has been shown to increase rate of successful spinal fusions, little is known about the effect of the type of current in DC stimulation.To evaluate the effects of various DC stimulators on the strength and success rate of posterolateral fusion facilitated by using a nitinol mesh container, in rats.This was an experimental animal study.A conductive, tubular nitinol mesh container was used to carry small pieces of bone grafts. The nitinol mesh container received electrical stimulation via a lead that connected the container to different types of DC stimulators. Sixty male Sprague-Dawley rats were divided into three groups (N=20 in each): a control group that underwent PLF with a nitinol container filled with autograft, a constant DC group that received a nitinol container and constant DC (100 μA), and a pulsed DC group that received a nitinol container and pulsed DC (100 μA, 100 Hz, 200 μs). The rats underwent PLF between L4 and L5, and transverse processes were grafted with bilateral iliac grafts. A stimulator was implanted subcutaneously. The rats were sacrificed 8 weeks postsurgery, and lumbar spines were removed. Spinal fusion was evaluated by microcomputed tomography, manual testing, biomechanical testing, histologic examination, and molecular analysis.All animals in the DC stimulation groups displayed solid fusion, whereas only 70% of control animals showed solid fusion. Radiographic images, biomechanical testing, histologic examination, and molecular analysis revealed improved fusion in the order control group<constant DC group<pulsed DC group. The volume of new bone mass was significantly higher in the pulsed DC group (p<.05). Fusion was more solid in the pulsed DC group than in control group (p<.05). The pulsed DC group displayed the lowest inflammatory responses.Pulsed DC electrical stimulation is efficacious in improving both strength and fusion rate in a rat spinal fusion model. In addition, tubular nitinol mesh, made of conductive suture, appears useful for holding small pieces of bone grafts and maintaining a good environment for bone fusion.Pulsed DC electrical stimulation may be potentially useful to increase the fusion rate after spinal fusion in humans. Future research is required to evaluate the safety and efficacy of tubular nitinol mesh and pulsed DC electrical stimulation in humans.

Clinical application of intraosseous internal fixation in ankle-foot arthrodesis

Objective To investigate the short-to medium-term therapeutic effects of a new internal fixation device, intraosseous internal fixation (IO-FIX), in the foot-ankle arthrodesis. Methods From August 2016 to December 2018, 32 patients (40 feet) underwent foot-ankle arthrodesis with IO-FIX at De-partment of Orthopaedic Surgery, The Ninth People’s Hospital of Shanghai.They were 6 males and 26 fe-males, aged from 23 to 83 years (61.7±15.1 years).There were 28 cases (36 feet) of hallux valgus, 2 cases (2 feet) of ankle arthritis, one case (1 foot) of ankle rheumatoid arthritis and one case (1 foot) of naviculocuneiform arthrosis.The therapeutic effects were assessed in terms of imaging evaluation, American Orthopaedic Foot and Ankle Society (AOFAS) score, fusion rate and full weight-bearing time. Results The follow-up ranged from 3.0 to 31.3 months (mean, 12.6 months).The total fusion rate was 95.0%(38/40); the total AOFAS score increased significantly from preoperative 41.9±9.5 to postoperative 86.9±4.7 (P< 0.05).The 28 patients (36 feet) with hallux valgus achieved a successful fusion rate of 97.2%(35/36) and full weight-bearing at 8 weeks after operation.Their fusion time ranged from 45 to 64 days (57.1 days).Their metatarsophalangeal angle was decreased significantly from 52.1°±13.5° preoperatively to 13.4°±4.9° postoperatively and their 1-2 intermetatarsal angle significantly from 14.5°±2.4° to 8.9°±2.4° (P<0.05). Their AOFAS ankle-hindfoot score was improved significantly from 41.8±9.9 to 87.0±4.8 (P<0.05). All the 3 cases of ankle arthrodesis achieved good bone union and full weight-bearing within 12 weeks and their AOFAS ankle-hindfoot score was improved significantly from preoperative 43.4±3.5 to 86.3±3.5 at the final follow-up. Conclusion In foot-ankle joint arthrodesis, due to advantages of stable fixation, zero profile, limited soft tissue irritation, reinforced bone bridge and easy reproducibility, IO-FIX can lead to satisfactory short-to mid-term therapeutic effects. Key words: Foot; Arthrodesis; Internal fixators

Scientific, Clinical, Regulatory, and Economic Aspects of Choosing Bone Graft/Biological Options in Spine Surgery

Spinal arthrodesis is a major element of the spinal surgeon's practice. To attain successful fusion rates, attention must be paid to spinal segment immobilization and proper selection of bone graft. Autogenous bone graft (ie, ICBG), the "gold standard," with or without graft extenders and enhancers provides the foundation for most spinal fusions. ABG is the only graft option containing all 3 factors of new bone growth: osteoconductivity, osteoinductivity, and osteogenicity. While many bone graft alternatives function well as bone graft extenders, only growth factors proteins (ie, rhBMP-2 or OP-2) function as bone graft enhancers and substitutes. The search for optimal hybrid interbody cages, bone graft substitutes, autogenous or allogenic stem cells, and nanostructure scaffolds for release of growth factors continues.

Evaluation of an increased strut porosity silicate-substituted calcium phosphate, SiCaP\xa0EP, as a synthetic bone graft substitute in spinal fusion surgery: a prospective, open-label study

PurposeSilicate-substituted calcium phosphate-enhanced porosity (SiCaP EP, Inductigraft™, Altapore) is a synthetic bone graft material with enhanced strut porosity of 31–47%. SiCaP EP remains to be fully clinically evaluated in patients undergoing instrumented posterolateral fusion (PLF) surgery. We conducted a prospective, open-label, non-randomised, multicentre clinical study to evaluate efficacy of SiCaP EP as bone grafting material in PLF surgery with instrumentation for treatment of spinal disorders.MethodsPatients with degenerative disc disease, spondylolisthesis or spinal stenosis underwent PLF surgery with SiCaP EP. The primary endpoint was evaluated in the per protocol population (N = 102) as solid fusion at postoperative month 12 assessed using computed tomography scans, with motion assessed using flexion–extension radiographs. Clinical outcomes included the Oswestry Disability Index, 36-item short-form health survey for quality-of-life, visual analog scale for pain scores and neurological assessments. Adverse events were recorded.ResultsSuccessful fusion was achieved in 59/89 (66.3%) patients at month 6, 88/102 patients (86.3%) at month 12 (primary endpoint) and 87/96 (90.6%) patients at month 24. Disability and pain reduced following surgery. Quality-of-life improved and neurological function was maintained postoperatively. Forty-three (33.3%) of the 129 patients who underwent surgery experienced adverse events; back pain was most frequent (n = 10); nine and 14 patients experienced serious adverse events judged related to device and procedure, respectively.ConclusionsEnhanced strut porosity SiCaP EP provided high (month 12: 86.3%) spinal fusion success rates in PLF surgery. Fusion success was associated with improved clinical outcomes in patients within 12 months, relative to baseline.ClinicalTrials.gov identifierNCT01452022Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Distal fibula osteotomies improve tibiotalar joint compression: A biomechanical study in a cadaveric model

BackgroundSuccessful tibiotalar joint fusion relies on adequate compression. Compression following joint preparation may be affected by the extent to which the fibula holds the joint out to anatomical length. The purpose of this study was to evaluate the effect of various distal fibula osteotomies on tibiotalar joint compression. MethodsEight adult cadaveric lower extremity specimens with an intact ankle joint and syndesmotic complex were evaluated. The ankle joint cartilage was denuded to subchondral bone. The fibula was surgically modified with three progressing procedures including an oblique fibula osteotomy, 1 cm resection, and distal fibula resection. A transducer was utilized to measure tibiotalar joint force, contact area, and peak pressure values while compressive forces of 30 N, 50 N, and 100 N were applied to the proximal tibia/fibula. FindingsDistal fibula resection significantly increased tibiotalar joint force, contact area, and peak pressure the most of all fibula conditions tested compared to intact fibula control (p < .05). Tibiotalar joint force and peak pressures were significantly increased with a distal fibula oblique osteotomy, 1 cm resection, and complete resection under both 30 and 50 N applied compressive force (p < .05). InterpretationComplete distal fibular resection results in higher tibiotalar joint force, contact area, and peak pressure which may improve clinical rates of successful ankle fusion.

Effect of the type of electrical stimulation on spinal fusion in a rat posterolateral spinal fusion model

BACKGROUND CONTEXTPosterolateral fusion (PLF) with autogenous iliac bone graft is one of the most common surgical procedures for lumbar spinal disease. However, its limited success demands new biologically competent graft enhancers or substitutes. Although the use of direct current (DC) electrical stimulation has been shown to increase rate of successful spinal fusions, little is known about the effect of the type of current in DC stimulation. PURPOSETo evaluate the effects of various DC stimulators on the strength and success rate of posterolateral fusion facilitated by using a nitinol mesh container, in rats. STUDY DESIGNThis was an experimental animal study. METHODSA conductive, tubular nitinol mesh container was used to carry small pieces of bone grafts. The nitinol mesh container received electrical stimulation via a lead that connected the container to different types of DC stimulators. Sixty male Sprague-Dawley rats were divided into three groups (N=20 in each): a control group that underwent PLF with a nitinol container filled with autograft, a constant DC group that received a nitinol container and constant DC (100 μA), and a pulsed DC group that received a nitinol container and pulsed DC (100 μA, 100 Hz, 200 μs). The rats underwent PLF between L4 and L5, and transverse processes were grafted with bilateral iliac grafts. A stimulator was implanted subcutaneously. The rats were sacrificed 8 weeks postsurgery, and lumbar spines were removed. Spinal fusion was evaluated by microcomputed tomography, manual testing, biomechanical testing, histologic examination, and molecular analysis. RESULTSAll animals in the DC stimulation groups displayed solid fusion, whereas only 70% of control animals showed solid fusion. Radiographic images, biomechanical testing, histologic examination, and molecular analysis revealed improved fusion in the order control group<constant DC group<pulsed DC group. The volume of new bone mass was significantly higher in the pulsed DC group (p<.05). Fusion was more solid in the pulsed DC group than in control group (p<.05). The pulsed DC group displayed the lowest inflammatory responses. CONCLUSIONSPulsed DC electrical stimulation is efficacious in improving both strength and fusion rate in a rat spinal fusion model. In addition, tubular nitinol mesh, made of conductive suture, appears useful for holding small pieces of bone grafts and maintaining a good environment for bone fusion. CLINICAL RELEVANCEPulsed DC electrical stimulation may be potentially useful to increase the fusion rate after spinal fusion in humans. Future research is required to evaluate the safety and efficacy of tubular nitinol mesh and pulsed DC electrical stimulation in humans.

Intraoperative relaxed muscle positioning technique results in a tertiary Center for Thyroid Orbitopathy Related Strabismus

BackgroundPrevious techniques resulted with low rates of successful fusion after the surgeries and high necessity of additional surgeries in the treatment of thyroid orbitopathy related strabismus. In this study, reviewing the results of our patients who had surgical correction with relaxed muscle positioning technique due to thyroid orbitopathy related strabismus to evaluate the effectiveness of the surgery was aimed.MethodsThe medical records of 8 patients who had surgical correction with intraoperative relaxed muscle positioning (IRMP) technique were studied retrospectively. The extent of strabismus was determined with prism cover test both at near and distance. The extent of recession was determined by marking the natural place of the released tendon during the primary position. The muscle then sutured to the globe at this precise point.ResultsSeven eyes (87.5%) of 8 patients had orthophoria after the surgery and they reported no diplopia in primary and reading gaze. The mean age of the patients was 51 ± 8.8 years. The mean follow-up time was 32.7 ± 18.5 months. Three patients had inferior rectus recession (IRR), 3 had bilateral medial rectus recession (MRR), 1 had only right MRR and 1 had combined MRR with IRR during the surgical correction of the strabismus. The mean amount of recession for IR was 7.5 ± 1.34 mm and it was 6.75 ± 0.95 mm for the MR muscles. The mean prism diopter before the surgery was 37.8 ± 23.3 and it was 0 after surgery except only one of the patients who had > 60 prism diopter (PD) left esotropia (ET) before surgery and had 30 PD left ET after surgery (3.3 ± 9.4).ConclusionIRMP technique is a unique option for the surgical correction of thyroid orbitopathy related strabismus. By showing a dramatic increase in the quality of life of the patients, our surgical results are promising despite limited number of patients.

Engineered periosteum-bone biomimetic bone graft enhances posterolateral spine fusion in a rabbit model

BACKGROUND CONTEXTBone marrow derived mesenchymal stem cells (BMSCs) and periosteum-derived cells (PDCs) have shown great viability in terms of osteogenic potential and have been considered the major cellular source for skeletal tissue engineering. Using a PDCs-impregnated cell sheet to surround a BMSCs-impregnated tricalcium phosphate (TCP) scaffold might create a periosteum-bone biomimetic bone graft substitute to enhance spine fusion. PURPOSEThe purpose of this study was to determine the feasibility of using this newly tissue-engineered biomimetic bone graft for posterolateral spine fusion. STUDY DESIGN/SETTINGThis study design was based on an animal model using adult male New Zealand White rabbits. METHODSNew Zealand White rabbits underwent operation and were divided into three groups based on the experimental material implanted in the bilateral L4–L5 intertransverse space. Group 1 was BMSCs-free TCP wrapped in a PDCs-free cell sheet. Group 2 was BMSCs-loaded-TCP wrapped in a PDCs-free cell sheet. Group 3 was BMSCs-loaded-TCP wrapped in a PDCs-loaded cell sheet. After 12 weeks, six rabbits from each group were euthanized for computed tomography scanning, manual palpation, biomechanical testing, and histology. Each group had 12 radiographic fusion areas for analysis because the right and left intertransverse fusion areas were collected separately. RESULTSRadiographic union of 12 fusion areas for groups 1, 2, and 3 was 0, 3, and 9, respectively. Group 3 had significantly higher fusion success than groups 1 and 2 (p<.001). Solid fusion of six fusion segments in each group by manual palpation was 0, 1, and 5, accordingly. Group 3 had a higher successful solid fusion rate than groups 1 and 2 (p=.005). The average maximal torques at failure were 727±136 N mm, 627±91 N mm, and 882±195 N mm for groups 1, 2, and 3, accordingly. The maximal torque was significantly higher in group 3 than in group 2 (p=.028). Histological evaluation verified that new bone regeneration were greater in the group 3 samples. CONCLUSIONSThe results indicated the potential of using a PDCs-impregnated cell sheet to surround the BMSCs-impregnated TCP scaffold for creating a periosteum-bone biomimetic bone graft substitute to enhance bone regeneration and posterolateral fusion success.

The Role of the RN Circulator in a Navigated Posterior Spinal Fusion: 1.3 www.aornjournal.org/content/cme.

The RN circulator plays a vital role in preparing for a minimally invasive spinal fusion with navigation by confirming that the necessary equipment and stakeholders are available and ensuring that the amount of equipment and the number of people in the room do not compromise patient safety or the sterility of the surgical field. Patients who undergo minimally invasive spinal fusion experience less blood loss, shorter hospital stays, and reduced costs than those who undergo open spinal fusion procedures. The overall successful fusion rates and improvement in patient quality of life are equivalent between the two approaches. Using navigation during minimally invasive and open spinal fusion procedures decreases radiation exposure to the patient and surgical team and helps ensure a more accurate placement of pedicle screws compared with nonnavigated minimally invasive or open spinal fusions.

Effect of osteoporosis on the clinical and radiological outcomes following one-level posterior lumbar interbody fusion

BackgroundCage subsidence or pedicle screw loosening following lumbar fusion surgery is frequently reported in osteoporotic patients. However, few studies have analyzed clinical as well as radiological outcomes after such surgeries as a function of bone mineral density. We aimed to evaluate the impact of osteoporosis on the clinical and radiological outcomes of patients who underwent one-level posterior lumbar interbody fusion (PLIF). MethodsFifty-five non-osteoporotic (T-score ≥ −1.0) and 31 osteoporotic (T-score ≤ −2.5) patients who underwent one-level PLIF were followed up for >2 years. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and EuroQol 5-Dimension (EQ-5D) parameters were assessed. Fusion success was identified with dynamic plain radiographs and computed tomography. Pedicle screw loosening and cage subsidence were evaluated. The clinical and radiological parameters were compared between osteoporotic and non-osteoporotic patients. Subgroup analysis was performed on cage subsidence or screw loosening. ResultsAlthough VAS score for back pain was higher in osteoporotic patients than in non-osteoporotic patients at 6 months postoperatively (3.3 vs. 2.2, P = 0.062), this difference disappeared at 1 year postoperatively (2.9 vs. 2.5, P = 0.606). However, no differences were noted between the groups in ODI and EQ-5D grades. Cage subsidence (65.4% vs. 17.6%, P < 0.001) and screw loosening rates (32.3% vs. 12.7%, P = 0.029) were significantly higher in osteoporotic patients than in non-osteoporotic patients, but fusion rate did not differ between the groups. Although clinical outcomes did not differ between those who had cage subsidence or screw loosening and those who did not, fusion rate was lower in those who showed screw loosening than those who did not (71.4% vs. 93.9%, P = 0.038). ConclusionsHigher cage subsidence and pedicle screw loosening rates in osteoporotic patients did not significantly affect the clinical outcomes, but screw loosening, which occurred more frequently in older patients, significantly reduced the fusion success rate. Thus, PLIF procedure may be a good surgical treatment option to achieve good clinical outcomes, even in osteoporotic patients despite higher rates of cage subsidence and pedicle screw loosening. However, surgeons should monitor screw loosening because of its significant association with non-union.

Distal Fibula Osteotomies Improve Tibiotalar Joint Compression

Category: Basic Sciences/Biologics Introduction/Purpose: Compression is a vital component of achieving a successful ankle arthrodesis. Various modifications of the fibula are used in hopes of achieving higher clinical rates of successful fusion in ankle arthrodesis procedures. We hypothesized that distal fibula osteotomies would improve tibiotalar joint compression under various loading conditions. The purpose of this study was to evaluate the effect of various distal fibula osteotomies on tibiotalar joint compression. Methods: Eight paired adult cadaveric lower extremity specimens with an intact ankle joint and syndesmosis were prepared by exposing and fixating together the proximal tibia and fibula. A jig was constructed to secure the specimen in a vertical position while allowing free axial loading. An anterior surgical approach to the ankle was performed and the joint cartilage denuded. A pressure transducer was used to record baseline ankle pressure distribution. The proximal specimen was loaded with 30, 50, and 100 N static weight and ankle pressure measurements repeated for each load. The fibula was surgically modified with the three procedures: (1) oblique fibular osteotomy 3 cm proximal to the ankle joint; (2) 1 cm long distal fibula resection; (3) complete distal fibula excision. Increasing loads of 30, 50, and 100 N following each surgical procedure were applied and the ankle pressure measurements repeated. Results: Distal fibula resection increased tibiotalar joint force, peak pressure, and contact area compared to intact fibula control for 30, 50, and 100 N loads applied (p&lt;0.05). Compared to intact fibula control, an oblique osteotomy performed and 30 N applied force resulted in a mean ankle joint force increase of 7.5 N (p = 0.007). A 1 cm excisional fibula osteotomy under a 30 N load significantly increased the ankle joint force by 6.6 N (p = 0.015). Complete distal fibula resection under 30 N load significantly increased the ankle joint force compared to control by 13.9 N (p &lt; 0.001). Similar trends were seen for 50 N and 100 N loads with significance reached (*) as represented in Figure 1 (error bar = standard error). Conclusion: A distal fibula oblique osteotomy, 1 cm excisional osteotomy, or complete distal fibula excision may increase the amount of force transmitted to the ankle joint under loading. Our findings suggest complete distal fibular resection results in the highest ankle joint force, contact area, and peak pressure of the surgical options tested. Leaving the fibula intact may decrease tibiotalar compression during ankle arthrodesis. Clinical testing would be important to ultimately test the effects on rates of successful fusion.

Identifying Factors Predictive of Atlantoaxial Fusion Failure in Pediatric Patients: Lessons Learned From a Retrospective Pediatric Craniocervical Society Study.

Multicenter retrospective cohort study with multivariate analysis. To determine factors predictive of posterior atlantoaxial fusion failure in pediatric patients. Fusion rates for pediatric posterior atlantoaxial arthrodesis have been reported to be high in single-center studies; however, factors predictive of surgical non-union have not been identified by a multicenter study. Clinical and surgical details for all patients who underwent posterior atlantoaxial fusion at seven pediatric spine centers from 1995 to 2014 were retrospectively recorded. The primary outcome was surgical failure, defined as either instrumentation failure or fusion failure seen on either plain x-ray or computed tomography scan. Multiple logistic regression analysis was undertaken to identify clinical and technical factors predictive of surgical failure. One hundred thirty-one patients met the inclusion criteria and were included in the analysis. Successful fusion was seen in 117 (89%) of the patients. Of the 14 (11%) patients with failed fusion, the cause was instrumentation failure in 3 patients (2%) and graft failure in 11 (8%). Multivariate analysis identified Down syndrome as the single factor predictive of fusion failure (odds ratio 14.6, 95% confidence interval [3.7-64.0]). This retrospective analysis of a multicenter cohort demonstrates that although posterior pediatric atlantoaxial fusion success rates are generally high, Down syndrome is a risk factor that significantly predicts the possibility of surgical failure. 3.

A pharmacological study of Arabidopsis cell fusion between the persistent synergid and endosperm.

Cell fusion is a pivotal process in fertilization and multinucleate cell formation. A plant cell is ubiquitously surrounded by a hard cell wall, and very few cell fusions have been observed except for gamete fusions. We recently reported that the fertilized central cell (the endosperm) absorbs the persistent synergid, a highly differentiated cell necessary for pollen tube attraction. The synergid-endosperm fusion (SE fusion) appears to eliminate the persistent synergid from fertilized ovule in Arabidopsis thaliana Here, we analyzed the effects of various inhibitors on SE fusion in an in vitro culture system. Different from other cell fusions, neither disruption of actin polymerization nor protein secretion impaired SE fusion. However, transcriptional and translational inhibitors decreased the SE fusion success rate and also inhibited endosperm division. Failures of SE fusion and endosperm nuclear proliferation were also induced by roscovitine, an inhibitor of cyclin-dependent kinases (CDK). These data indicate unique aspects of SE fusion such as independence of filamentous actin support and the importance of CDK-mediated mitotic control.

A Novel Technique for Cervical Laminoplasty Fusion: Simultaneously Enhancing Stabilization and Decompression in Various Cervical Myelopathies: A Technical Note and Outcomes.

Cervical laminectomy has 2 major disadvantages: postlaminectomy adhesion of dural membrane and lack of a fusion bed. The objective of this study was to determine whether simultaneous cervical laminoplasty with fusion (CLPF) might overcome these unwanted outcomes. Patients who underwent CLPF for treating cervical myelopathy with instability who were followed up for at least 12 months were enrolled. Preoperative and postoperative Neck Disability Index (NDI) and Japanese Orthopedic Association (JOA) scores before and after surgery, recovery rates (RRs), C2-C7 lordosis, and fusion success rates were evaluated. The study cohort comprised 50 patients (35males and 15 females; mean age, 60.5 ± 14.0 years) who underwent CLPF. The average duration of clinical follow-up was 24.6 ± 16.1 months. Mean preoperative and postoperative NDI scores were 27.0 ± 10.6 and 17.6 ± 7.2, respectively (P= 0.004). Mean preoperative and postoperative JOA scores were 10.4 ± 4.2 and 13.6 ± 3.0, respectively (P= 0.001). The mean JOA RR was 49.8 ± 42.2%. No significant changes in C2-7 lordosis were noted after surgery (preoperative, 7.0 ± 8.0°; postoperative, 7.3 ± 6.3°; P= 0.789). The fusion success rate was 96% (48 of 50 patients). Fusion mass areas at C5 level were significantly different between the opening side and the hinge side (opening side, 15.8 ± 13.1 mm2; hinge side, 50.8 ± 27.2 mm2; P < 0.001). There was no postoperative restenosis or epidural fibrosis. CLPF might be useful for canal decompression and a good fusion bed while avoiding postoperative epidural fibrosis.

Polyetheretherketone (PEEK) Rods for Lumbar Fusion: A Systematic Review and Meta-Analysis.

The purpose of this systematic review is to evaluate the safety and effectiveness of polyetheretherketone (PEEK) rod systems in patients receiving lumbar interbody fusion treatment. Meta-analyses of relevant clinical data were also conducted when possible. Relevant studies were identified by searching the PubMed, EMBASE, and Cochrane Library databases. Clinical studies evaluating the safety and/or effectiveness of the PEEK rod spinal stabilization system in patients receiving lumbar spinal fusion procedure were included. Studies regarding dynamic stabilization and hybrid stabilization (fixed and dynamic; eg, topping-off technique) were not included in this analysis. The analyses included patients who had a lumbar fusion procedure with PEEK rods or titanium rods as a control reference (only for controlled studies). Fusion success, functional and pain improvement, and safety data were evaluated, if reported. The search yielded 5 studies (1 prospective and 4 retrospectives) that included 177 participants (156 received PEEK rods, and 21 received titanium rods). Meta-analysis of interbody fusion success rate in PEEK rod patients yields the estimate of 95.6% (confidence interval: 91.6% to 98.4%). Functional outcomes in PEEK rod patients demonstrated clinically significant improvement when comparing postoperative to preoperative scores, with an average improvement of 67.4% ± 8.5%. Similarly, pain improvement was clinically significant with an average visual analog scores-back pain and visual analog scores-leg pain improvement percentages of 68.9% ± 8.6% and 76.6% ± 1.5%, respectively. Rod fracture was not reported in any of the studies. The rates of screw fracture and loosening were 3/114 (2.6%) and 1/50 (2.0%), respectively. In the controlled study, no statistically significant difference was reported in the fusion success rate, function improvement, pain improvement, or device-related events between subjects treated with PEEK rods and the subjects treated with titanium rods. Experience with PEEK rod systems has shown satisfactory clinical outcomes. Therefore, these results support the use of PEEK rod systems as supplemental fixation during lumbar fusion procedures.

Modified posterior lumbar interbody fusion augmented with bone cement in the treatment of senile degenerative lumbar spondylolisthesis: study protocol for a self-controlled trial

Background and objectives: Posterior lumbar interbody fusion is the main repair method for senile degenerative lumbar spondylolisthesis. For elderly patients with osteoporosis, single screw rod system fixation regularly results in dislocation. The incidence of implant loosening is high, and therefore, effective internal fixation is not achieved. Thus, this study will use the modified posterior lumbar interbody fusion procedure combined with bone cement augmentation for the treatment of senile degenerative lumbar spondylolisthesis so as to increase the stability of the vertebral body, make the fixator firm, and to maximize the recovery of postoperative motor function. Design: This is a prospective, single-center, self-controlled trial. Methods: 113 patients with senile degenerative lumbar spondylolisthesis, aged 65–70 years, irrespective of sex, will be recruited from the Department of Orthopedics of Affiliated Hospital of Qinghai University of China. The patients will be treated with modified posterior lumbar interbody fusion combined with bone cement augmentation. Follow-up will be performed at 3 and 12 months. Outcome measures: The primary outcome measure is recovery of motor function as indicated by the postoperative Oswestry Disability Index score at 12 months. The secondary outcome measures are the change in the rate of excellent and good Oswestry Disability Index scores (comparing preoperative scores with the 4-month postoperative scores), Visual Analogue Scale scores, intervertebral space height, foraminal height, the preoperative and 4 and 14 months postoperative slip distance and slip angle, incidence of adverse reactions, success rate of vertebral fusion, and incidence of secondary slip 4 and 14 months postoperatively. Discussion: This trial aims to observe the efficacy of modified posterior lumbar interbody fusion combined with bone cement augmentation in the treatment of senile degenerative lumbar spondylolisthesis and to validate whether the procedure is safe and reliable. Ethics and dissemination: This trial has been approved by the Medical Ethics Committee of Affiliated Hospital of Qinghai University of China (approval number: QHY023G). The study protocol will be proformed in accordance with the Declaration of Helsinki, formulated by the World Medical Association. Written informed consent will be obtained from all participants. This trial was designed in October 2017. The recruitment of subjects and data collection will begin in June 2018. The recruitment will be finished in December 2018. Outcome measures will be analyzed in January 2020. This trial will be completed in February 2020. The results of the trial will be reported in a scientific conference or disseminated in a peer-reviewed journal. Trial registration: This trial had been registered in the Chinese Clinical Trial Registry (registration number: ChiCTR1800015335). Protocol version (1.0).

Electrical Stimulation and Bone Healing: A Review of Current Technology and Clinical Applications.

Pseudarthrosis is an exceedingly common, costly, and morbid complication in the treatment of long bone fractures and after spinal fusion surgery. Electrical bone growth stimulation (EBGS) presents a unique approach to accelerate healing and promote fusion success rates. Over the past three decades, increased experience and widespread use of EBGS devices has led to significant improvements in stimulation paradigms and clinical outcomes. In this paper, we comprehensively review the literature and examine the history, scientific evidence, available technology, and clinical applications for EBGS. We summarize indications, limitations, and provide an overview of cost-effectiveness and future directions of EBGS technology. Various models of electrical stimulation have been proposed and marketed as adjuncts for spinal fusions and long bone fractures. Clinical studies show variable safety and efficacy of EBGS under different conditions and clinical scenarios. While the results of clinical trials do not support indiscriminate EBGS utilization for any bone injury, the evidence does suggest that EBGS is desirable and cost efficient for certain orthopedic indications, especially when used in combination with standard, first-line treatments. This review should serve as a reference to inform practicing clinicians of available treatment options, facilitate evidence-based decision making, and provide a platform for further research.

Effect of Smoking Status on Successful Arthrodesis, Clinical Outcome, and Complications After Anterior Lumbar Interbody Fusion (ALIF).

Anterior lumbar interbody fusion (ALIF) is a surgical technique indicated for the treatment of several lumbar pathologies. Smoking has been suggested as a possible cause of reduced fusion rates after ALIF, although the literature regarding the impact of smoking status on lumbar spine surgery is not well established. This study aims to assess the impact of perioperative smoking status on the rates of perioperative complications, fusion, and adverse clinical outcomes in patients undergoing ALIF surgery. A retrospective analysis was performed on a prospectively maintained database of 137 patients, all of whom underwent ALIF surgery by the same primary spine surgeon. Smoking status was defined by the presence of active smoking in the 2 weeks before the procedure. Outcome measures included fusion rates, surgical complications, Short-Form 12, and Oswestry Disability Index. Patients were separated into nonsmokers (n=114) and smokers (n= 23). Univariate analysis demonstrated that the percentage of patients with successful fusion differed significantly between the groups (69.6% vs. 85.1%, P= 0.006). Pseudarthrosis rates were shown to be significantly associated with perioperative smoking. Results for other postoperative complications and clinical outcomes were similar for both groups. On multivariate analysis, the rate of failed fusion was significantly greater for smokers than nonsmokers (odds ratio 37.10, P= 0.002). The rate of successful fusion after ALIF surgery was found to be significantly lower for smokers compared with nonsmokers. No significant association was found between smoking status and other perioperative complications or adverse clinical outcomes.

Bone Growth Stimulation: A Critical Analysis Review.

➢ Bone growth stimulators are increasingly used in the treatment of delayed union and nonunion after fracture, ankle fusion, and spinal fusion.➢ Substantial basic science and animal studies and clinical evidence exist for the use of bone growth stimulation.➢ Current Level-I evidence supports the use of capacitive coupling and inductive coupling stimulation for adjunctive use in spinal fusion to increase the successful fusion rate.➢ Substantial Level-I evidence is lacking for the treatment of acute high-risk fractures or delayed union and nonunion after fractures with bone growth stimulation.➢ Weak Level-I evidence supports low-intensity pulsed ultrasonic (LIPUS) stimulation for the adjunctive treatment of fresh high-risk fractures and both inductive coupling and capacitive coupling stimulation for the adjunctive treatment of delayed union or nonunion after fractures.➢ The Level-I evidence of the recently published TRUST (Trial to Evaluate Ultrasound in the Treatment of Tibial Fractures) trial indicates that LIPUS does not improve functional recovery or accelerate radiographic healing after intramedullary nailing of acute tibial shaft fractures. That study questions the clinical efficacy of adjunctive LIPUS for acute long-bone fractures and disproves its use for adjunctive treatment in acute tibial shaft fractures treated with intramedullary nailing.

Anterior cervical fusion with interbody cage containing beta-tricalcium phosphate: Clinical and radiological results

AimBeta tricalcium phosphate (beta-TCP) is an osteoconductive, resorbable material. Its clinical effectiveness has been proved in many indications. This study was clinical and radiographic study report obtained in patients undergoing anterior cervical discectomy and fusion ACDF in which PEEK cages were filled beta-TCP in an injectable form. Material and methodsBetween January 2010 and June 2011, 16 consecutive patients underwent ACDF using PEEK cages with beta-TCP. The cohort compromised 10 men and 6 women with a mean age of 45.2 years. The surgery was performed when the patient had myelopathy or radiculopathy with progressive neurological deficit, or failure of conservative treatment (a minimum of 3 months). The patients were evaluated by Odom criteria preoperatively and postoperative 3rd, 6th, 12th and 24th months. Preop and postop pain was evaluated with visual analogue scala (VAS). Disc height and fusion success rates were evaluated. ResultsPreoperative average VAS score was 7.9 (7–10) for neck pain and 8 (7–10) for arm pain. At the final follow-up, these scores became 1.5 and 1.4 for neck and arm pain, respectively. The average improvement rate was 81% for neck pain and 82.5% for arm pain. Postop ODOM's criteria main rate was 3.4. Bone fusion was achieved in 14 segments (70%) at 3rd month, 19 segments (95%) at 12th month follow-up assessment. ConclusionClinical and radiological results revealed that B-TCP is a good alternative synthetic fusion material for cervical interbody fusion.Level of evidence: Level IV, therapeutic study.