Autograft: The Gold Standard Steven R. Garfin, MD Distinguished - - PowerPoint PPT Presentation

Autograft: The Gold Standard

Steven R. Garfin, MD Distinguished Professor and Chair Department of Orthopaedic Surgery UC San Diego

Disclosures

• AO Spine
• Benvenue Medical
• EBI
• Globus Medical
• Intrinsic Therapeutics
• Johnson & Johnson,

DePuy Spine

• Magnifi Group
• Medtronic
• NuVasive, Inc.
• SI Bone, Inc.
• Spinal Kinetics
• Vertiflex

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

• 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 Pirris, et al. JNeurosurg Spine 2014

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

• 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%)

Spine 2006

• 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’
• utcome”

– 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