Autograft: The Gold Standard Steven R. Garfin, MD Distinguished Professor and Chair Department of Orthopaedic Surgery UC San Diego
Disclosures • Magnifi Group • AO Spine • Medtronic • Benvenue Medical • NuVasive, Inc. • EBI • SI Bone, Inc. • Globus Medical • Spinal Kinetics • Intrinsic Therapeutics • Vertiflex • Johnson & Johnson, DePuy Spine
Requirements for Successful Fusion • Osteogenic Cells – Osteoblasts and osteogenic progenitor cells • Osteoconductive Matrix – Bony matrix and matrix proteins • Osteoinductive Signals – Native BMPs and TGF-β
• Autograft – esp ICBG has higher amounts of mesenchymal stem cells than local bone, bone marrow aspirate, and “Osteocel” (viable cellular bone allograft)
Time Tested • 1911 - Hibbs: local bone autograft in spinal arthrodesis for Pott’s disease - Albee: tibial autograft for scoliosis • Autograft fusion rates >90% in lumbar spine (Dimar et al., Spine J, 2009) • Autograft fusion rates >95% in cervical spine (Suchomel et al., Eur Spine J, 2004) • No concern for disease transmission or tissue compatibility (Campana et al. J Mater Sci Mater Med, 2014) • Low cost (OR time for iliac crest, no extra time for local bone)
• Single-level instrumented PL fusion with ICBG Multicenter, retrospective, 194 pts • Fusion evaluated with CT scan at 6, 12, 24 months • Fusion at 24 months = 89% • Statistically significant improvements in SF-36 and Oswestry • ~80% of pts achieved minimum clinically important difference for SF-36
Donor Site Pain is Over-Estimated • Multiple studies have demonstrated over-estimation of pain – The incidence of donor site pain after bone graft harvesting from posterior iliac crest may be over estimated: a study on spine fracture patients. Delawi et al. Spine 2007 – Posterior iliac crest pain after posterolateral fusion with or without iliac crest harvest. Howard et al. Spine 2011 – Natural history of posterior iliac crest bone graft donation for spinal surgery: a prospective analysis of morbidity. Robertson et al. Spine 2001
Pirris, et al. JNeurosurg Spine 2014 • 25 patients underwent iliac crest autografting with allograft reconstruction of donor site during L-spine fusion – Autograft harvest from same skin incision but different fascial incision – Pt blinded as to what side graft was taken from • Asked at various post op intervals (1-22 mo) which side the iliac crest autograft was taken from • Results – 64% (16) could NOT correctly identify which iliac crest had been taken – 7/9 pts who correctly identified side only did so by guessing – 2 patients who confidently identified side had no pain at rest and minimal pain with activity
Spine 2016 • Prospective evaluation of 47 pts undergoing ACDF with anterior tri- cortical ICBG vs control group of allograft • Followed pts for 1 yr • Outcomes measured: SF-12 and VAS pain (arm, neck and donor site) at 1wk, 2wks, 6wks, 3mo, 6mo and 1year and complications • Results – At 2 weeks, ICBG group used more narcotics – At 1 year – no difference in SF-12 and VAS scores compared to allograft control • 2 patients experienced continued donor site pain 2 pts had minor donor site wound infection tx c PO abx
No statistical difference btw ICBG and allograft groups
Spine 2006 • Retrospective chart review, 76 cases (50F, 26M) • Varying diagnoses (spinal stenosis 47, degen spondy 12, isthmic spondy 12, degen scoliosis 5) • 1 level fusion: 51 (67%) • 2 level fusion: 16 (21%) • 3 level fusion: 5 (7%) • 4 level fusion: 4 (5%)
• Similar fusion rates in single level fusions with local vs ICBG • Less complications in the local group • Less blood loss in local group • Similar fusion rates, but smaller fusion mass on x-ray with local autograft
Oswestry Disability Index • 36% improvement in local • 34% improvement in ICBG • 87.5% of all pts reported ‘excellent’ outcome” – Return to work without pain – Pain-free exercise Blood Loss • 80cc less in local group
JBJS Am, 2012
• Compared 108 ICBG pts c 246 no ICBG (local bone +) in pts with degen spondy • No differences in demographics, comorbidities or pre-op clinical scores • ICBG group had higher number of patients having multilevel fusions and fusions at L5-S1 (inherently lower fusion rate) • No differences in post-op complications (infections or reoperations) – 1 patient in ICBG had hematoma
At 1 and 2 yrs, no statistical difference in SF-36, Oswestry or Bothersomeness Indices
Autograft vs The Rest • Autograft vs Calcium sulfate pellets (Lu et al, 2013) – Autograft: 88% fusion at 35 mo – CaS pellets: 67% at 35mo • ICBG to femoral ring allograft (Wimmer et al, CORR 1999) – ICBG 97% – Allograft 92% • ICBG vs structural allograft (Putzier et al, 2009) – ICBG: 87% – Allograft: 80% • ICBG always (at least a little) better
• Based on the literature – FDA uses autograft as the comparative for all bone graft substitutes
Conclusions • ICBG vs local autograft – similar fusion rates • Overestimation of morbidity of procedure • Most patients can’t tell -- if you take the crest graft via single incision technique • Overall -- Bone is (the most) reliable
Thank Thank You You
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