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16 Executive Briefing for bone ingrowth and conduction. Clinical studies have found that fusion rates are significantly higher in patients treated with a porous Plasmapore implant when compared to patients treated with a smooth titanium implant. 7 JK: While I do not have extensive experience with porous surfac- es outside of Plasmapore XP technology, my follow-up CT scans of Arcadius® XP L, a stand-alone Plasmapore XP treated ALIF device, reveal a remarkable, near-immediate bony ingrowth into the sur- face. One of my ALIF patients returned to sedentary work six days after her procedure and was discharged from medical care with a solid fusion three months later without restrictions. Designed with over 30 years of experience in TPS coatings on titanium, Aesculap's Plasmapore XP surface on PEEK has the ide- al porosity for bone ingrowth. This surface treatment has been tested side by side with and mimics Plasmapore, which has been studied in over 1,000 orthopedic and spine patients. 2 4. The Move Away from Titanium Although interbody fusion began with autograft, researchers be- gan looking for a fatigue-resistant alternative, which led to the development of titanium alloy and stainless steel cages. Early issues with subsidence and visualization eventually led to the development of PEEK-OPTIMA® by Invibio® in 1999. This bioma- terial quickly gained traction as a standard of care in interbody fusion due to its superior imaging properties and a modulus of elasticity that mimics bone. 8 BS: Bone as an organ/tissue relies heavily on mechanical signals and stimulation to maintain and repair itself through a balance of anabolic (formation) and catabolic (resorption) processes. Im- plants placed in bone must be able to share and transmit this mechanical information in order maintain the right balance be- tween these processes. The inherent material properties (mod- ulus of elasticity) and design (shape, architecture) dictate the overall strength/stiffness of an implant. Titanium implants with inadequate design and strength/stiffness properties can lead to implant subsidence. Plasmapore XP titanium-PEEK implants match the material properties of bone and tilt the balance of response toward formation as opposed to resorption. JK: I have never used titanium implants. However, it is well known that imaging on the interspace is negligible. To the greatest possible extent, the use of radiolucent PEEK-OP- TIMA prevents artifact formation. This enables surgeons to assess the structures around the implant, even postoperatively. Recent studies show that chance of subsidence is up to six times less with PEEK-OPTIMA devices when compared to solid titanium in- terbodies. 9 Despite these biomechanical advantages, PEEK-OP- TIMA has been shown to exhibit a fibrous tissue response and does not have the ideal biocompatible properties of titanium. 10 For this reason, many companies have found innovative ways to treat the surface of the PEEK-OPTIMA interbody with titanium without disrupting the modulus of elasticity. 5. Breaking Down Nanotechnology The business end of the response to an implant takes place at a micro- (10-6 m) and nanoscale (10-9 m) level. Cellular compo- nents involved in the bone-forming process (MSCs, osteoblasts, osteoclasts) must be able to adhere, grow and differentiate in or- der to build new bone that integrates with the implant surface. These events are driven by the specific surface receptor-based interaction of cells with cell adhesive proteins that bind to the implant surface and signal bone-forming responses. The micro- and nanoscale topography and composition of the implant serve as the template for adhesive protein conformation and cell shape that direct the resulting cell response. The TPS Plasmapore sur- face enhancing process creates both microscale porosity and na- noscale topography optimal for osseointegration. 2, 10 n 1 Volkmann R, Bretschneider C, Eingartner C, Weller S. Revision arthroplasty – femoral as- pect: the concept to solve high grade defects. International Orthopaedics. 2003;27(1 Sup- pl):S24-S28. 2 Data on file, Aesculap AG. 3 Cunningham BW, Hallab NJ, Hu N, Mcafee PC. Epidural application of spinal instrumentation particulate wear debris: a comprehensive evaluation of neurotoxicity using an in vivo animal model. Journal of Neurosurgery. Spine. 2013;19(3):336-350. 4 Kienle A, Graf N, Wilke H-J. Does impaction of titanium-coated interbody fusion cages into the disc space cause wear debris or delamination? The Spine Journal. 2016;16(2):235-242. 5 Vasconcellos L, Leite D, Oliveira F, Carvalho Y, Cairo C. Evaluation of bone ingrowth into porous titanium implant: histomorphometric analysis in rabbits. Brazilian Oral Research. 2010;24(4), 399-405. 6 Klawitter JJ, Bagwell JG, Weinstein AM, Sauer BW. An evaluation of bone growth into porous high density polyethylene. J Biomed Mater Res. 1976;10(2):311-23. 7 Takeuchi M, Yasuda M, Niwa A, et al. Plasmapore-Coated Titanium Cervical Cages Induce More Rapid and Complete Bone Fusion After Anterior Cervical Discectomy and Fusion as Compared to Noncoated Titanium Cages. World Neurosurgery. 2014;82(3-4):519-522. 8 Invibio® Biomaterial Solutions. PEEK-OPTIMA® Natural Typical Material Properties. www.in- vibio.com (10/2013). 9 Chen Y, Wang X, Lu X, Yang L, Yang H, Yuan W, Chen D. Comparison of titanium and poly- etheretherketone (PEEK) cages in the surgical treatment of multi-level cervical spondylotic myelopathy: a prospective, randomized, control study with over 7-year follow-up. European Spine Journal. 7. 22(2013):1539–1546. 10 Cheng BC. Biomechanical pullout strength and histology of Plasmapore®XP Coated Im- plants: Ovine multi time point survival study. Aesculap Implant Systems. Whitepaper. 2013. (ART 129). Serial CT Scans at six and 12 weeks show steady bone ingrowth into the surface of the device. Optimized Plasmapore XP surface thickness means implant contours can be clearly seen in X-rays with low artifact formation in CT and MRI scans. Aesculap Implant Systems, LLC, a B. Braun company, is part of a 175-year-old global organization focused on meeting the needs of the changing healthcare environment. Through close collaboration with its customers, Aesculap Implant Systems develops advanced spine and orthopaedic implant technologies to treat complex disorders of the spine, hip and knee. Aesculap Implant Systems strives to deliver products and services that improve the quality of patients' lives. For more information, call 800-234-9179 or visit aesculapimplantsystems.com/spine.