171. Bone on the back table: effects of autograft handling on spinal fusion
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Iliac crest
Cancellous bone
Different techniques were proposed for reconstruction after distal radial resection for bone tumors. When not dealing with heavy workers or complex revision cases, a motility preserving procedure can be used. From 1999 to 2007 we performed a reconstruction with an ostearticular allograft in 18 patients. Age of the patients ranged from 13 to 56 years. Histotypes were: giant cell tumor in 16 patients, Ewing sarcoma in 1, osteosarcoma in 1. Neadjuvant chemotherapy was used in Ewing and osteosarcoma patients. Length of resection ranged from 5 to 13 cm. An accurate host-graft capsulorraphy was performed to reestablish joint stability; no adjunctive distal radioulnar stabilization procedures were used. In one case the procedure was performed after a failed previous graft-arthrodesis; in this case also a proximal row carpectomy was performed. Non-union of the allograft occurred in 2 cases. In one case autologous cancellous bone grafting from the iliac crest was performed. In the second case the patient due to mild symptoms has till now refused further surgery. No septic complications occurred. One patient presented a fracture of the allograft; a revision procedure was performed with a new allograft but also the second graft failed and an arthrodesis was performed. This was the only complete failure of our series. Follow-up ranged from 20 to 103 months. No recurrences (local or distant) were observed. The patients were evaluated with radiographic and clinical examination. Functional evaluation was performed using ISOLS-MSTS score and a wrist-specific functional score (PRWE). The oncological and functional results in our series highlight that a functional wrist can be restored with an osteoarticular allograft after distal radial resection for bone tumors. Deterioration of the results could occur in the long-term and thus further monitoring with a longer follow-up is needed.
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Purpose of the study: Although the iliac autograft is the gold standard for single-level intervertebral fusion, complications and morbidity related to autologous graft harvesting from the iliac crest remain a point of concern. Bone morphogenic protein (BMP) has proven advantages for fusion of the intersomatic and posterolateral graft. This study compared the efficacy and tolerance of OP-1 compared with an autologous graft in patients with symptomatic spondylolisthesis. This study reports the preliminary results of a prospective randomised controlled trial comparing OP-1 with an iliac autologous graft for instrumented single-level posterolateral fusion for arthrodesis of grade 1 spondylolisthesis. Material and methods: Lamino-arthrectomy associated with a posteriolateral instrumented arthrodesis with an iliac autologous graft or a mixture of OP-1 and local autologous graft material was performed in 27 patients with spondylolisthesis leading to lumboradiculalgia or neurogenic claudication. The final outcome was time to fusion at one year on the scanner and plain x-rays. The Oswestry score and pain at the harvesting site as well as side effects were also noted. Results: The cohort included 27 patients. Three were excluded from the analysis, leaving 24 patients assessed at one year. The demographic data were comparable for the two groups regarding mean age (64 years versus 69 years for the OP-1 group). At one year, ten radiographically certain fusions were noted in the control group and eight in the OP-1 group. Two nonunions and one doubtful fusion were noted in the control group compared with three doubtful fusions in the OP-1 group. The mean Oswestry score was comparable in the two groups. The mean score in the control group improved from 49.5 to 28.5 compared with 45.9 to 29.7 in the OP-1 group. There was no secondary effect attributable to use of OP-1. There were no cases of systemic toxicity, nor heterotopic calcification or restenosis for the 11 patients in the OP-1 group. Conclusion: A fusion rate of 73% without secondary effects attributable to OP-1 was observed in this preliminary study. This study allows the conclusion that this technique is reliable, safe and, in terms of fusion, a valid alternative to autologous iliac crest graft. The main advantage resulting from the use of OP-1 is to avoid the morbidity linked with harvesting the iliac graft.
Iliac crest
Pseudarthrosis
Claudication
Investigational device exemption
Oswestry Disability Index
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Study Design. Controlled animal study. Objective. To assess the cellular contribution of autograft to spinal fusion and determine the effects of intraoperative storage conditions on fusion. Summary of Background Data. Autograft is considered the gold standard graft material in spinal fusion, purportedly due to its osteogenic properties. Autograft consists of adherent and non-adherent cellular components within a cancellous bone scaffold. However, neither the contribution of each component to bone healing is well understood nor are the effects of intraoperative storage of autograft. Materials and Methods. Posterolateral spinal fusion was performed in 48 rabbits. Autograft groups evaluated included: (1) Viable, (2) partially devitalized, (3) devitalized, (4) dried, and (5) hydrated iliac crest. Partially devitalized and devitalized grafts were rinsed with saline, removing nonadherent cells. Devitalized graft was, in addition, freeze/thawed, lysing adherent cells. For 90 minutes before implantation, air dried iliac crest was left on the back table whereas the hydrated iliac crest was immersed in saline. At 8 weeks, fusion was assessed through manual palpation, radiography, and microcomputed tomography. In addition, the cellular viability of cancellous bone was assayed over 4 hours. Results. Spinal fusion rates by manual palpation were not statistically different between viable (58%) and partially devitalized (86%) autografts ( P = 0.19). Both rates were significantly higher than devitalized and dried autograft (both 0%, P < 0.001). In vitro bone cell viability was reduced by 37% after 1 hour and by 63% after 4 hours when the bone was left dry ( P < 0.001). Bone cell viability and fusion performance (88%, P < 0.001 vs . dried autograft) were maintained when the graft was stored in saline. Conclusions. The cellular component of autograft is important for spinal fusion. Adherent graft cells seem to be the more important cellular component in the rabbit model. Autograft left dry on the back table showed a rapid decline in cell viability and fusion but was maintained with storage in saline.
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Pagetoid
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Autograft – Since before modern surgical techniques were described, ancient Greeks new of the possibilities for bone to grow after fracture. Studying open fractures, often post mortem, they new of the importance of both the “amount and integrity of bone architecture” that was necessary for two ends of a bone to heal. More recently, modern spinal surgical techniques, many pioneered by surgeons such as John Moe MD, use the same knowledge that for the intentional arthrodesis of two or more bony spinal levels there requires a certain amount and quality of bone – both capturing osteoinductive and osteoconductive properties. Autograft can be harvested in many ways for spinal arthrodesis and can be taken from iliac crest, tibia or fibula, and from local vertebral sources. Often requiring a separate skin and/or fascial incision, morbidities such as pain, neurovascular injury, infection, blood loss, haematoma, seroma, and fracture can plague the technique. Limited quantities, especially in children, can also be an issue with autograft. Cancellous or cortico-cancellous structural grafts can be milled and used for posterolateral fusion, interbody fusion, and can be mixed with other graft substitutes/expanders. Morbidity profile aside, autograft still remains the gold standard for spinal arthrodesis with regards “ideal properties” of bone grafts. Allograft – Currently, allograft is the most common substitute for autograft bone in spinal fusion. Allograft is primarily osteoconductive, with minimal osteoinductive potential. Avoidance of donor site morbidity, quantity issues, and surgical time saving are all features of allograft. Increased costs and potential for infection are negative issues. Preparation can vary and fresh unprocessed grafts are no longer used. Freeze drying (lyophilization) involves drying of the grafts before freezing at sub zero temperatures, and the technique reduces immunogenicity, though upon rehydration, structural strength is lost by around 50%. Low dose radiation ( Incorporation of allograft is similar to that of autograft, though the process takes more time. Allograft cancellous particles provide a larger surface area and therefore incorporate faster. Studies suggest that mulched allograft femoral heads provides as good a fusion rate in posterior spinal surgeries for children with scoliosis as does the use of autograft. Combination of osteoinductive agents (BMP etc) with allograft is now possible and will likely enhance its further use. Structural fibular allografts in cervical interbody fusion and femoral ring allografts in lumbar interbody fusion have been well described and have very high rates of fusion.
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We treated eleven skeletally mature patients who had a high-grade lumbosacral spondylolisthesis by a single-stage operation that involved posterior spinal decompression, posterolateral arthrodesis with autogenous iliac-crest graft, and anterior arthrodesis with a fibular graft inserted from the posterior approach. We did not attempt to correct the deformity. Preoperatively, all but one patient had severe pain in the back and lower limb; the exceptional patient had severe pain only in the low back. All but one patient had sensory deficits and objective motor impairment before the operation, and five had cauda equina syndrome. Six patients had had a previous operation that had failed. The duration of follow-up ranged from two to twelve years. A solid fusion was obtained in all patients, and all had major or complete neurological recovery. The results did not deteriorate with time.
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Cauda Equina Syndrome
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Discectomy
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Diskectomy
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The aim of this retrospective analysis of spinal fusion, was to document the clinical, functional, and radiological outcomes with a local bone graft plus the highly osteoconductive hydroxyapatite, bio-derived Orthoss®, with or without bone marrow aspirate.Forty seven patients submitted to spinal posterolateral fusion were operated for four major indications: scoliosis in young patients (11), degenerative spine (18), lumbosacral transitional anomalies in young adults (14), and spine trauma (four). Sixteen patients had more than four levels fused. In addition to spinal decompression and instrumented fusion, autologous bone grafts from the excised lamina were augmented with Orthoss® granules in a 1:1 ratio. In addition iliac crest bone marrow aspirate was used in 70 % of the patients. The results were assessed clinically in terms of pain, and return to school or professional activities were checked at three, six, and 12 months following surgery with a mean follow-up of 20 months. In scoliotic patients, correction of the major angle was evaluated from one to four years after surgery.Pain persistence was reported only in four cases, after three months after surgery. A functional recovery was noted in almost all patients groups within these three months. Progressive bone formation with evidence of bone fusion masses were already observed at six months. No fusion failure was observed.Local bone enhanced by an osteoconductive long-term stable scaffold, used with and without bone marrow aspirate, led to successful fusion in all patients by six months while functional recovery was reported already within three to six months.
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Bone marrow aspirate
Pseudarthrosis
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An iliac crest autograft is the gold standard for bone grafting in posterior atlantoaxial arthrodesis but can be associated with significant donor-site morbidity. Conversely, an allograft has historically performed suboptimally for atlantoaxial arthrodesis as an onlay graft. The authors have modified a bone grafting technique to allow placement of a bicortical iliac crest allograft in an interpositional manner, and they evaluated it as an alternative to an autograft in posterior atlantoaxial arthrodesis.The records of 89 consecutive patients in whom C1-2 arthrodesis was performed between 2001 and 2005 were reviewed.Forty-seven patients underwent 48 atlantoaxial arthrodeses with an allograft (mean follow-up 16.1 months, range 0-49 months), and 42 patients underwent autograft bone grafting (mean follow-up 17.6 months, range 0-61.0 months). The operative time was 50 minutes shorter in the allograft (mean 184 minutes, range 106-328 minutes) than in the autograft procedure (mean 234 minutes, range 154-358 minutes), and the estimated blood loss was 50% lower in the allograft group than in the autograft group (mean 103 ml [range 30-200 ml] vs mean 206 ml [range 50-400 ml], respectively). Bone incorporation was initially slower in the allograft than in the autograft group but equalized by 12 months postprocedure. The respective fusion rates after 24 months were 96.7 and 88.9% for autografts and allografts. Complications at the donor site occurred in 16.7% of the autograft patients, including 1 pelvic fracture, 1 retained sponge, 1 infection, 2 hernias requiring repair, 2 hematomas, and persistent pain.The authors describe a technique for interpositional bone grafting between C-1 and C-2 that allows for the use of an allograft with excellent fusion results. This technique reduced the operative time and blood loss and eliminated donor-site morbidity.
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Corpectomy
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