Issue link: https://beckershealthcare.uberflip.com/i/571000
56 Executive Briefing: Surface Technology for Spine Devices: Key Trends & Concepts By Laura Dydra Q: In your opinion, what is the role of "surface technology" for interbody spinal fusion implants? Adam Bruggeman, MD, Texas Spine Care, San Antonio: Surface technology is the new frontier for today's spine surgeons. For decades we have thought of interbodies as spacers designed to hold two bones in anatomic space from each other, but not designed to participate in the fusion. Surface technology changes the paradigm of interbody devices by creating a device that is actually a participant in the fusion as opposed to being a bystander or inhibitor of fusion. David DeWitt, MD, NeuroSpine Center of Wisconsin, Appleton: Anything implanted in the body triggers a reaction. This reaction starts when the body's cell receptors, called integrins, interact with the surface of the implant. This takes place at the nano-structure level and triggers an internal cellular response. Technology has now advanced to the point that we are able to study the cellular responses to different implant nano-structure surfaces. The creation of spinal implants that utilize surface nano-technology to harness the body's cellular response to promote fusion will optimize the surgeon's ability to provide patients with the desired outcome. Q: How do devices that incorporate this type of technology function differently from others, for instance, like those made of PEEK? Kade Huntsman, MD, Salt Lake Orthopaedic Clinic, Salt Lake City: There is very good basic science indicating PEEK is hydrophobic, causes local cell death and the creation of a fibrous tissue layer around the implant which inhibits fusion. A specialized surface using titanium will signal the local cells to become osteoblasts, stimulate them to be highly functional and use the local hosts biology for fusion. It does not make sense to use implants that inhibit our goal of fusion, when implants that will help us are available. Dan Bradley, MD, Texas Back Institute, Plano: Bone is known to have a natural affinity for titanium and has a natural attachment. We've seen this for decades in the dental industry. There is quite a bit of science and literature and experience with surface technology and titanium there. However, as we really study PEEK, it's hardly used in any other spine or orthopedic implant than for fusion. We know it's hydrophobic and has a fibrous layer that repels bone and diminishes fusion aspects. Some of the more recent research suggests PEEK inhibits bone growth locally. Q: When did the cellular reaction to implant surfaces first become important to you? Raphael R. Roybal, MD, Chatham Orthopaedic Associates, Savannah, Ga.: Once I found out about it, basically. This is a technology that has actually been around for a while, but the spine community has taken a while to catch up. In general orthopedics there has always been references to bony ingrowth and titanium coated stems used for hip ingrowth or tooth implants, and that's a hostile environment. It's been a well-known technology for years that we have ignored in the spine world until now. AB: The cellular reaction became important to me as the latest YODA studies were being published regarding BMP and its use in spine surgery. The last eight to 10 years have seen tremendous focus on biologics as opposed to the implants themselves. Implant surface technology provided an alternative pathway to fusion that didn't involve the expensive biologics that were being placed on the market, many without significant scientific research. The research surrounding cellular biology and implant surfaces is impressive and overwhelming when compared to the research seen in the biologic industry with regards to spinal fusion. Q: Describe how this cellular reaction impacts spinal fusion surgery and outcomes. DD: In my practice, harnessing this cellular response has given me greater confidence that I will get a fusion every time. I don't utilize adjunctive therapies such as internal or external bone stimulators. I don't use any braces. I have used a variety of different bone grafts and synthetics that all work with these nano-scaled titanium implants. My graft choice is based on lowering cost and decreasing morbidity. I am more aggressive about letting patients return to activity and in some cases have let patients perform activity as tolerated immediately postop without compromising their outcome. AB: The outcomes data is still being accumulated, but my personal experience is earlier return to function when compared to previous techniques I used with biologics and PEEK cages. Hopefully surgeons currently using surface technology implants will be publishing data soon to allow for more discussion revolving around the effectiveness of this technology specific to spinal fusion and outcomes. What is interesting to me is the way that the bone seems to be reacting to these implants on early CT scans. I am seeing trabecular bone that appears to be condens- ing around the stress lines of the endplates, particularly Sponsored by: Executive Roundtable: Surface Technology