Timothy Ganey

TEM analysis of the nanostructure of normal and osteoporotic human trabecular bone

Transmission electron microscopy (TEM) was used to investigate the crystal-collagen interactions in normal and osteoporotic human trabecular bone at the nanostructural level. More specifically, two-dimensional TEM observations were used to infer the three-dimensional information on the shape, the size, the orientation, and the alignment of apatite crystals in collagen fibrils in normal and osteoporotic bone. We found that crystals were of platelet shape with irregular edges and that there was no substantial difference in crystal length or crystal thickness between normal and osteoporotic trabecular bone. The crystal arrangement in cross-sectioned fibrils did not neatly conform to the parallel arrangement of crystals seen in longitudinally-sectioned fibrils. Instead, the crystal arrangement in both normal and osteoporotic trabecular bone took on more of a random, undulated arrangement, with certain localized areas demonstrating circular oriented patterns. The TEM imaging was done using bright fields only. Thus, the results presented are within the limitations of this approach.

The effect of compressive force applied to the intervertebral disc in vivo. A study of proteoglycans and collagen

Study Design. Coil springs were stretched and attached to produce a compressive force across the lumbar intervertebral discs of dogs for up to 27 weeks. Objective. To test the hypothesis that a high compressive force applied over a period of time affects the production of proteoglycans and collagen by the intervertebral disc cells. Summary of Background Data. It is a commonly held belief that high forces applied to the intervertebral disc, and to joints in general, play a role in causing degeneration. Methods. Pairs of stainless steel coil springs were stretched and attached to produce a compressive force across the lumbar intervertebral discs (L1‐L2 and L3‐L4) of 16 dogs. Dogs were killed between 13 and 27 weeks after the springs were attached. The discs (L1‐L2 and L3‐L4) were excised and assessed using immunohistochemical analyses and enzyme‐linked immunosorbent assay; T13‐L1 and L4‐L5 were used as controls. Results. The main result relates to a group effect in the six dogs, assessed using enzyme‐linked immunosorbent assay, that were generally at the highest values of force for the greatest number of weeks. For the nucleus, but not the anulus, Spearman rank correlations revealed a strong correlation between increases in force and force‐weeks (force multiplied by number of weeks) and increases in collagen type I accompanied by decreases in proteoglycans, chondroitin sulfate, and collagen type II for both experimental discs (L1‐L2 and L3‐L4), as compared with corresponding values in the controls (T13‐L1 and L4‐L5). In other words, as either the force or the force‐weeks increased, the effect on the nucleus became greater. Conclusion. A high compressive force applied to the disc over a period of time initiates changes in proteoglycans and collagen.

A pulsing electric field (PEF) increases human chondrocyte proliferation through a transduction pathway involving nitric oxide signaling

A potential treatment modality for joint pain due to cartilage degradation is electromagnetic fields (EMF) that can be delivered, noninvasively, to chondrocytes buried within cartilage. A pulsed EMF in clinical use for recalcitrant bone fracture healing has been modified to be delivered as a pulsed electric field (PEF) through capacitive coupling. It was the objective of this study to determine whether the PEF signal could have a direct effect on chondrocytes in vitro. This study shows that a 30‐min PEF treatment can increase DNA content of chondrocyte monolayer by approximately 150% at 72 h poststimulus. Studies intended to explore the biological mechanism showed this PEF signal increased nitric oxide measured in culture medium and cGMP measured in cell extract within the 30‐min exposure period. Increasing calcium in the culture media or adding the calcium ionophore A23187, without PEF treatment, also significantly increased short‐term nitric oxide production. The inhibitor W7, which blocks calcium/calmodulin, prevented the PEF‐stimulated increase in both nitric oxide and cGMP. The inhibitor L‐NAME, which blocks nitric oxide synthase, prevented the PEF‐stimulated increase in nitric oxide, cGMP, and DNA content. An inhibitor of guanylate cyclase (LY83583) blocked the PEF‐stimulated increase in cGMP and DNA content. A nitric oxide donor, when present for only 30 min, increased DNA content 72 h later. Taken together, these results suggest the transduction pathway for PEF‐stimulated chondrocyte proliferation involves nitric oxide and the production of nitric oxide may be the result of a cascade that involves calcium, calmodulin, and cGMP production.

Ex vivo loading of trussed implants for spine fusion induces heterogeneous strains consistent with homeostatic bone mechanobiology

A truss structure was recently introduced as an interbody fusion cage. As a truss system, some of the connected elements may be in a state of compression and others in tension. This study aimed to quantify both the mean and variance of strut strains in such an implant when loaded in a simulated fusion condition with vertebral body or contoured plastic loading platens ex vivo. Cages were each instrumented with 78 fiducial spheres, loaded between platens (vertebral body or contoured plastic), imaged using high resolution micro-CT, and analyzed for deformation and strain of each of the 221 struts. With repeated loading of a cage by vertebral platens, the distribution (variance, indicated by SD) of strut strains widened from 50N control (4±114με, mean±SD) to 1000N (-23±273με) and 2000N (-48±414με), and between 1000N and 2000N. With similar loading of multiple cages, the strain distribution at 2000N (23±389με) increased from 50N control. With repeated loading by contoured plastic platens, induced strains at 2000N had a distribution similar to that induced by vertebral platens (84±426με). In all studies, cages exhibited increases in strut strain amplitude when loaded from 50N to 1000N or 2000N. Correspondingly, at 2000N, 59-64% of struts exhibited strain amplitudes consistent with mechanobiologically-regulated bone homeostasis. At 2000N, vertically-oriented struts exhibited deformation of -2.87±2.04μm and strain of -199±133με, indicating overall cage compression. Thus, using an ex vivo 3-D experimental biomechanical analysis method, a truss implant can have strains induced by physiological loading that are heterogeneous and of amplitudes consistent with mechanobiological bone homeostasis.

Osteoconductive carriers for integrated bone repair

Successful bone repair is judged in achieving restitution of space and mechanical integrity, and in regaining function. When the biology or anatomy are insufficient to attain a full repair, therapeutic use of graft material has been used to omit compliance features such as strain tolerance, reduced stiffness, and attenuated strength, and instead promote primary or membranous-type bone formation within the physical approximation of a graft material. The challenge of most conductive materials is that they emerge from a static platform and in placement force the living system to adapt to placement, dimension, different properties, and eventually are only successful in degradation and replacement, or in integration. The synergy and interdependency between adhesion, ECM, and proteolysis are important concepts that must be understood to engineer scaffolds capable of holding up to standards which are more than cell decoration. Moreover, the reactive specificity to loading, degradation, therapeutic delivery during absorption remains a key aim of both academic and industrial designs. Achieving conductivity comes with challenges of best fit integration, delivery, and in integrated modeling. The more liquid is the delivery, the more modular the components, and adaptive the matrix to meeting the intended application, the more likely that the conductivity will not be excluded by the morphology of the injury site. Considerations for osteoconductive materials for bone repair and replacement have developed conceptually and advanced parallel with a better understanding of not only bone biology but of materials science. First models of material replacements utilized a reductionist-constructionist logic; define the constituents of the material in terms of its morphology and chemical composition, and then engineer material with similar content and properties as a means of accommodating a replacement. Unfortunately for biologic systems, empiric formulation is insufficient to promote adequate integration in a timely fashion. Future matrices will need to translate their biological surfaces as more than a scaffold to be decorated with cells. Conductivity will be improved by formulations that enhance function, further extended from understanding what composition best suits cell attachment, and be adopted by conveniences of delivery that meet those criteria.

Multiple osteochondroma of the hand: initial and long-term follow-up study

BackgroundThe purpose is to determine the location and type of osteochondromas in patients with multiple osteochondroma of the hand as well as the presence of shortening and angulation. Second, it aims to establish longitudinal data on the change in tumors.MethodsRetrospective review of patients with multiple osteochondroma affecting the hand evaluating the location and type of tumors as well as the presence of shortening and angulation is done. We examined radiographs from final follow-up and analyzed them based on patient age at presentation (group I = ages 2–6; II = ages 7–10; III = ages 11–19), to determine changes over time and any differences in the number of tumors, location, and shortening and angulation.ResultsThe most affected bones were the index and small finger metacarpals with an increase seen around the metacarpophalangeal (MCP) joints. The most shortening and angulation were seen on the ulnar side. Group II had the most tumors and the most bones with angulation. Twenty-three hands had longitudinal follow-up with an overall increase of 2.7 tumors per hand with a range of loss of 8 to gain of 16. There was an increase in the number of bones with angulation and shortening. Group I showed the largest increase in tumors, shortening, and angulation.ConclusionsThe ulnar side and bones around the MCP joints are affected most commonly. The largest change was seen as the patients went from young childhood into adolescence, which may be due to rapid growth during this time. This is the largest study of these patients with the longest longitudinal data.

Transforaminal Lumbar Interbody Fusion With Viable Allograft: 75 Consecutive Cases at 12-Month Follow-up

Abstract Background When conservative treatments fail to alleviate the discomfort of abnormal motion, spinal fusion has been shown to provide symptomatic treatment for spinal instability, stenosis, spondylolisthesis, and symptomatic degenerative disc disease. The trend and rates of fusion over the past few years have been dramatic in the United States. Accompanying that higher incidence has been the shifting from traditional open surgery to minimally invasive techniques to reduce scar tissue formation, extent of muscle stripping, and muscle retraction which all have been shown to adversely affect outcomes. Other reasons supporting the widespread transition to minimally invasive surgical (MIS) techniques include decreased postoperative pain, decreased intraoperative blood loss, shorter postoperative hospital stay, faster return to normal activity, and reduced reoperation rates. Spinal fusion procedures rely on a bony fusion substrate in addition to fixation hardware. While available grafting options include autogenous, allogeneic, and synthetic materials, recent interest in viable allograft material with living cells has drawn attention and attraction for incorporating a biologic basis for regenerative consideration. A recent viable allograft, complete with cellular and designated bone carrier (VIA Graft, Vivex Biomedical, Marietta, Georgia) has been developed. This study represents a retrospective review of a single-practice, single-surgeon evaluation of the product in 75 consecutive patients for fusion by computed tomography (CT) and radiographic evaluation at 12 months in conjunction with a MIS approach. Viable allograft was used to fill the peri-implant space, and central implant lumen was filled with a cancellous bone sponge soaked in perivertebral bone marrow. Posterolateral supplementation was attained with beta-tricalcium phosphate as a bulking agent. Methods A retrospective review identified patients treated for both primary and revision surgery who received VIA Graft cellular bone matrix material in minimally invasive interbody fusion (MIS-TLIF) with a minimum of 12-month follow up. The patient diagnoses included radiculopathy in all instances and varied collateral indications such as foraminal collapse, recurrent disc herniation, and spondylolisthesis to which pain and morbidity had been unresolved by conservative treatment. Adverse events including infection, revisions, and evidence of immune response were evaluated and patient comorbidities defined for the entire population of patients. Patient fusion status was assessed using thin slice CT by 2 independent radiologists separate from the surgeon. There were 75 consecutive adult patients with degenerative conditions of the lumbar spine who underwent MIS-TLIF surgery of which 40 (53%) were male and 35 (47%) were female. Mean age, height, and weight were 58 years, 170.18 cm (67 in), and 88.45 kg (195 lbs), respectively. The mean body mass index was 30. There were 16 patients (21%) who smoked and 12 (16%) with a history of diabetes. Independent blinded review of fusion was obtained by a board certified musculoskeletal radiologist and an experienced board certified orthopaedic surgeon to assess patient fusion status. Spinal segments were deemed fused if 12-month CT scans demonstrated evidence of bridging bone at the fusion site without observed motion on flexion-extension radiographs. Findings such as osteolysis around the implant or pedicle screws, extensive endplate cystic changes, or linear defects parallel to the endplates through intradiscal new bone formation were interpreted as signs of pseudarthrosis. Interobserver and intraobserver error and κ assessments were analyzed to assure agreement in the CT outcomes assessment where interpretation of κ were as follows: <0.00 = poor agreement, 0.00–0.20 = slight agreement, 0.21–0.40 = fair agreement, 0.41–0.60 = moderate agreement, 0.61–0.80 = substantial agreement, and 0.81–1.00 = almost perfect agreement. Differences were resolved by consensus amongst the observers. Results In total, 96% of the 75 patients with a total of 85 levels (96.5% of levels treated) achieved a fusion at 12 months. There were no perioperative or latent complications and no transfusions in all 75 patients. Conclusions In this population, 96% of the patients treated achieved the surgical objective in 96.5% of the levels treated. Level of Evidence IV. Clinical Relevance The high rate of fusion, the lack of secondary morbidity with autologous bone harvest, and the clinical success account for the benefits of viable allograft matrix for MIS-TLIF use.

Strains in trussed spine interbody fusion implants are modulated by load and design

Titanium cages with 3-D printed trussed open-space architectures may provide an opportunity to deliver targeted mechanical behavior in spine interbody fusion devices. The ability to control mechanical strain, at levels known to stimulate an osteogenic response, to the fusion site could lead to development of optimized therapeutic implants that improve clinical outcomes. In this study, cages of varying design (1.00 mm or 0.75 mm diameter struts) were mechanically characterized and compared for multiple compressive load magnitudes in order to determine what impact certain design variables had on localized strain. Each cage was instrumented with small fiducial sphere markers (88 total) at each strut vertex of the truss structure, which comprised of 260 individual struts. Cages were subjected to a 50 N control, 1000 N, or 2000 N compressive load between contoured loading platens in a simulated vertebral fusion condition, during which the cages were imaged using high-resolution micro-CT. The cage was analyzed as a mechanical truss structure, with each strut defined as the connection of two vertex fiducials. The deformation and strain of each strut was determined from 50 N control to 1000 N or 2000 N load by tracking the change in distance between each fiducial marker. As in a truss system, the number of struts in tension (positive strain) and compression (negative strain) were roughly equal, with increased loads resulting in a widened distribution (SD) compared with that at 50 N tare load indicating increased strain magnitudes. Strain distribution increased from 1000 N (+156 ± 415 με) to 2000 N (+180 ± 605 με) in 1.00 mm cages, which was similar to 0.75 mm cages (+132 ± 622 με) at 1000 N load. Strain amplitudes increased 42%, from 346με at 1000 N to 492με at 2000 N, for 1.00 mm cages. At 1000 N, strain amplitude in 0.75 mm cages (481με) was higher by 39% than that in 1.00 mm cages. These amplitudes corresponded to the mechanobiological range of bone homeostasis+formation, with 63 ± 2% (p < .05 vs other groups), 72 ± 3%, and 73 ± 1% of struts within that range for 1.00 mm at 1000 N, 1.00 mm at 2000 N, and 0.75 mm at 1000 N, respectively. The effective compressive modulus for both cage designs was also dependent on strut diameter, with modulus decreasing from 12.1 ± 2.3 GPa (1.25 mm) to 9.2 ± 7.5 GPa (1.00 mm) and 3.8 ± 0.6 GPa (0.75 mm). This study extended past micro-scale mechanical characterization of trussed cages to compare the effects of design on cage mechanical behavior at moderate (1000 N) and strenuous (2000 N) load levels. The findings suggest that future cage designs may be modulated to target desired mechanical strain regimes at physiological loads.