Abstract
This prospective longitudinal randomized clinical and radiological study compared the evolution of instrumented posterolateral lumbar and lumbosacral fusion using either coralline hydroxyapatite (CH), or iliac bone graft (IBG) or both in three comparable groups, A, B and C, which included 19, 18 and 20 patients, respectively, who suffered from symptomatic degenerative lumbar spinal stenosis and underwent decompression and fusion. The patients were divided randomly according to the graft used and the side that it was applied. The spines of group A received autologous IBG bilaterally; group B, IBG on the left side and hydroxyapatite mixed with local bone and bone marrow on the right side; group C, hydroxyapatite mixed with local bone and bone marrow bilaterally. The age of the patients in the groups A, B and C was 61±11 years, 64±8 years and 58±8 years, respectively. The SF-36, Oswestry Disability Index (ODI), and Roland-Morris (R-M) surveys were used for subjective evaluation of the result of the surgery and the Visual Analogue Scale (VAS) for pain severity. Plain roentgenograms including anteroposterior, lateral and oblique views, and lateral plus frontal bending views of the instrumented spine and CT scan were used to evaluate the evolution of the posterolateral fusion in all groups and sides. Two independent senior orthopaedic radiologists were asked to evaluate first the evolution of the dorsolateral bony fusion 3–48 months postoperatively with the Christiansen’s radiologic method, and secondly the hydroxyapatite resorption course in the spines of groups B and C. The diagnosis of solid spinal fusion was definitively confirmed with the addition of the bending views, CT scans and self-assessment scores. The intraobserver and interobserver agreement (r) for radiological fusion was 0.71 and 0.69, respectively, and 0.83 and 0.76 for evaluation of CH resorption. T12−S1 lordosis and segmental angulation did not change postoperatively. There was no radiological evidence for non-union on the plain roentgenograms and CT scans. Radiological fusion was achieved 1 year postoperatively and was observed in all groups and vertebral segments. Six months postoperatively there was an obvious resorption of hydroxyapatite granules at the intertransverse intersegmental spaces in the right side of the spines of group B and both sides of group C. The resorption of hydroxyapatite was completed 1 year postoperatively. Bone bridging started in the third month postoperatively in all instrumented spines and all levels posteriorly as well as between the transverse processes in the spines of the group A and on the left side of the spines of group B where IBG was applied. SF-36, ODI, and R-M score improved postoperatively in a similar way in all groups. There was one pedicle screw breakage at the lowermost instrumented level in group A and two in group C without radiologically visible pseudarthrosis, which were considered as having non-union. Operative time and blood loss were less in the patients of group C, while donor site complaints were observed in the patients of the groups A and B only. This study showed that autologous IBG remains the “gold standard” for achieving solid posterior instrumented lumbar fusion, to which each new graft should be compared. The incorporation of coralline hydroxyapatite mixed with local bone and bone marrow needs adequate bleeding bone surface. Subsequently, hydroxyapatite was proven in this series to not be appropriate for intertransverse posterolateral fusion, because the host bone in this area is little. However, the use of hydroxyapatite over the decorticated laminae that represents a wide host area was followed by solid dorsal fusion within the expected time.
Similar content being viewed by others
References
Abott LC (1944) The use of iliac bone in the treatment of ununited fractures. In: Instructional Course Lectures. The American Academy of Orthopaedic Surgeons, Park Ridge, pp 13–22
An HS, Simpson JM, Glover JM, Stephany J (1995) Comparison between allograft plus demineralized bone matrix versus autograft in anterior cervical fusion: a prospective multicenter study. Spine 20:2211–2216
Arrington ED, Smith WJ, Cambers HG, et al (1996) Complications of iliac crest bone graft harvesting. Clin Orthop 329:300–309
Banwart JA, Asher MA, Hassanein RS(1995) Iliac crest bone graft harvest donor site morbidity. A statistical evaluation. Spine 20:1055–1060
Baramki GH, Steffen T, Lander P, Chang M, Marchesi D (2000) The efficacy of interconnected porous hydroxyapatite in achieving posterolateral lumbar fusion in sheep. Spine 25:1053–1060
Bernardt M, Swartz DE, Clothiaux PL, Crowell RR, White AA (1992) Posterolateral lumbar and lumbosacral fusion with and without pedicle screw internal fixation. Clin Orthop 284:109–115
Boachie-Adjei O, Dendrinos GK, Ogilvie JW, Bradford DS (1991) Management of adult spinal deformity with combined anterior-posterior arthrodesis and Luque-Galveston instrumentation. J Spinal Disord 4:131–141
Boden SD, Schimandle JH, Hutton WC (1995) An experimental lumbar intertransverse process spinal fusion model. Radiographic, histologic and biomechanical healing characteristics. Spine 20:412–420
Boden SD, Schimandle JH, Hutton WC et al (1997) In vivo evaluation of a resorbable osteoinductive composite as a graft substitute for lumbar spinal fusion. J Spinal Disord 10:1–11
Brantigan JW, McAfee PC, Cunningham BW, Wang H, Orbegoso CM (1994) Interbody lumbar fusion using a carbon fiber cage implant versus allograft bone: an investigational study in the Spanish goat. Spine 19:1436–1444
Bucholz MP, Carlton A, Holmes RE (1994) Interporous hydroxyapatite as a bone graft substitute in tibial plateau fractures. Clin Orthop 240:53–62
Burchardt H (1983) The biology of bone graft repair. Clin Orthop 174:28–42
Burwell RG (1985) The function of bone marrow in the incorporation of bone graft. Clin Orthop 200:125–141
Cavagna R, Daculsi G, Bouler JM (1999) Macroporous calcium phosphate ceramic: a prospective study of 106 cases in lumbar spinal fusion. J Long Term Eff Med Implants 9:403–412
Christensen BF, Laursen M, Gelineck J, Eiskj R, PS Thomsen K, Bunger EC (2001) Interobserver and intraobserver agreement of radiograph interpretation with and without pedicle screw implants. Spine 26:538–544
Connolly JF, Guse R, Lippiello L et al (1989) Development of an osteogenic bone marrow preparation. J Bone Joint Surg 71:684–691
Delecrin J, Aguado E, Nguyen JM, Royer J, Passuti N (1997) Influence of local enviroment on incorporation of ceramic for lumbar fusion. Comparison of laminar and Intertransverse fusion in a canine model. Spine 22:1683–1689
Delecrin J, Deschamps C, Romih M, Heymann D, Passuti N (2001) Influence of bone enviroment on ceramic osteointegration in spinal fusion: comparison of bone—poor and bone rich sites. Eur Spine J 10 (Suppl 2): S110–S113
Delecrin J, Takahashi S, Gouin F, Passuti N (2000) A synthetic porous ceramic as a bone substitute in the surgical management of scoliosis: a prospective randomized study. Spine 25:563–569
Dvorac J, Panjabi MM, Chang DG, Theiler R, Crob D (1991) Functional radiographiv diagnosis of the lumbar spine. Flexion–extension and lateral bending. Spine 16:562
Dvorac J, Panjabi MM, Novotny JE, Chang DG, Crob D (1991) Clinical validation of functional flexion–extension roentgenograms of the lumbar spine. Spine 16:943
Enneking WF, Early JL, Burchardt H et al (1980) Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects. J Bone Joint Surg 62:1039–1058
Enneking WF, Mindell ER (1991) Observations on massive retrieved human allografts. J Bone Joint Surg Am 73:1123–1142
Friedlaender GE, Goldberg VM (eds) (1991) Bone and cartilage allografts: biology and clinical application. American Academy of Orthopaedic Surgeons, Park Ridge
Frobin W, Brinckmann P, Leivesth G, Biggemann M, Reikeras O (1996) Precision measurement of segmental motion from flexion–extension radiographs of the lumbar spine. Clin Biomech 11:457–465
Glaser J, Stanley M, Sayre H, Woody J, Found E, Spratt K (2003) A 10-year follow-up evaluation of lumbar spine fusion with pedicle screw fixation. Spine 28:1390–1395
Guigui P, Plais PY, Flautre B et al (1994) Experimental model of posterolateral spinal arthrodesis in sheep part 2 application of the model: evaluation of vertebral fusion obtained with coral (Porites) or with a biphasic ceramic (Triosite). Spine 19:2798–2803
Khan SN, Tomin E, Lane JM (2000) Clinical applications of bone graft substitutes. Orthop Clin North Am 31:389–398
Korovessis P, Papazisis Z, Petsinis G (2000) Unilateral psoas abscess following posterior transpedicular stabilization of the lumbar spine. Eur Spine J 9:588–590
Korovessis P, Koureas G, Repanti M. (2002) Histological findings in revision surgery of instrumented spine fusion with the use of coralline hydroxyapatite: advances in spinal fusion-molecular science, biomechanics and clinical management. Marcel Dekker, New York
Lord CF, Gebhardt MC, Tomford WW, Mankin HJ(1988) Infection in bone allografts: incidence, nature and treatment J Bone Joint Surg Am 70:369–376
Mashoof AA, Siddiqui SA, Otero M, Tucci JJ. (2002) Supplementation of autogenous bone graft with coralline hydroxyapatite in posterior spine fusion for idiopathic adolescent scoliosis. Orthopaedics 25:1073–1076
Marchesi DG, Thalgott JS, Aebi M (1998) Application and results of the AO internal fixation system in non traumatic indications. Spine 23:159–167
Martin RB, Chapman MW, Homes RE et al (1989) Effects of bone ingrowth on the strength and non-invasive assessment of a coralline hydroxyapatite material. Biomaterials 10:481–488
Morone MA, Boden SD (1998) Experimental posterolateral lumbar spinal fusion with a demineralized bone matrix gel. Spine 23:159–167
Muschler GF, Negami S, Hyodo A, Gaisser D, Easley K, Kambic H (1996) Evaluation of collagen ceramic composite graft material in a spinal fusion model. Clin Orthop 328:250–260
Ragni P, Lindholm S (1978) Interaction of allogeneic demineralized bone matrix and porous hydroxyapatite bioceramics in lumbar interbody fusion in rabbits Clin Orthop 272:292–299
Rahimi F, Maurer BT, Enzweiler MG (1997) Coralline hydroxyapatite: a bone graft alternative in foot and ankle surgery. J Foot Ankle Surg 36:192–203
Simon SR (ed) (1994) Orthopaedic basic science, 2nd edn. American Academy of Orthopaedic Surgeons, Rosemont, pp 284–293
Simmons JW, Andersson GB, Russell GS, Hadjipavlou AG (1998) Aprospective study of 342 patients using transpedicular fixation instrumentation for lumbosacral spine arthrodesis. J Spinal Disord 11:367–374
Stricker SJ, Sher JS (1997) Freeze dried cortical allograft in posteror spinal arthrodesis. Use with segmental instrumentation for idiopathic adolescent scoliosis. Orthopaedics 20:1039–1043
Thalgott SJ, Giuffre MJ, Fritts K, Timlin M, Klezl Z (2001) Instrumented posterolateral lumbar fusion using coralline hydroxyapatite with or without demineralized bone matrix, as an adjunct to autologous bone. Spine J 2:131–137
Truumees E, Herkowitz HN(1999) Alternatives to autologous bone harvest in spine surgery. Orthop J 12:77–88
Turner JA, ErSek M, Herron L, et al (1992) Patients outcomes after lumbar spinal fusions. JAMA 268:907–911
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Korovessis, P., Koureas, G., Zacharatos, S. et al. Correlative radiological, self-assessment and clinical analysis of evolution in instrumented dorsal and lateral fusion for degenerative lumbar spine disease. Autograft versus coralline hydroxyapatite. Eur Spine J 14, 630–638 (2005). https://doi.org/10.1007/s00586-004-0855-5
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00586-004-0855-5