Becker's Spine Review

46 Executive Briefing Titan Spine has revolutionized interbody fusions through the utilization of specialized surface technologies that have been proven to prompt the body to heal itself and grow bone naturally. Whereas standard interbody fusion implants act only as spacers, Titan Spine is focused on the design and manufacture of devices that participate in the fusion process through nanotechnology. The company recently launched its next-generation nanoLOCK® surface technology, the only nano-cleared technology for the spine. Titan Spine, located in Mequon, Wisconsin and Laichingen, Germany, markets a full line of Endoskel- eton® interbody fusion devices, which are backed by an industry-first warranty. #StandWithTheFuture at www.titanspine.com. body fusion device that effectively stimulates a patient's body to start growing bone and fuse as quickly as possible? Titan Spine's Endoskeleton® interbody devices featuring its nanoLOCK® surface technology takes advantage of a concept called biomimicry that leverages nature's expertise in solving complex challenges. nanoLOCK® is created through a propri- etary subtractive manufacturing process to generate osteoclas- tic pits and nano-scaled textures within them to best mimic the architecture of natural bone at the micro and nano levels that are integral to natural and rapid bone remodeling and produc- tion. By mimicking native bone, nanoLOCK® promotes the rapid osteogenic differentiation of attachment-dependent stem cells while skipping the time-consuming resorptive phase of bone remodeling. "There are many ways to improve your positioning in a val- ue-based care model, but most will require significant infrastruc- ture changes and cost money," says Dr. Bruggeman. "Switching to the utilization of Titan Spine implants is the easiest, and likely most cost effective, manner in which to immediately make a suc- cessful transition into the new paradigm of value-based care." There has been substantial published research into how Titan Spine's surface technology can impact rapid bone growth. For example: • Osteogenesis: The Titan Spine surface was found to be sufficient to create an osteogenic environment without the addition of exogenous growth factors, which the au- thors concluded may induce better and faster bone for- mation during interbody fusion. 2 • Angiogenesis: It was shown that the Titan Spine surface stimulated an angiogenic-osteogenic environment with factors important in bone formation and remodeling. The researchers stated that this angio-osteogenic environ- ment may enhance bone formation, implant stability, and fusion. 3 • Inflammation: The Titan Spine nanoLOCK® surface was found to upregulate anti-inflammatory factors and down regulate inflammatory factors, while PEEK demonstrated the opposite effect. The authors stated that the fibrous tissue interface seen with PEEK implants may be due to increased inflammatory cytokines and decreased cell vi- ability. 4 • Nano-architecture: It was shown that nanoLOCK® gener- ated a significantly higher amount of the osteogenic and angiogenic factors necessary for bone growth and fusion compared to the other titanium surfaces tested, including the Titan original surface. The researchers concluded that osteoblast lineage cells are sensitive to specific micro/ nano-structures, even when overall macro roughness is comparable, and suggest that nano surface character- istics such as skewness and kurtosis are important vari- ables. 5 All of this in-vitro research appears to translate to faster patient healing. Optum Health data show that surgeons who use Titan Spine's surface technology for their patients reduce the average length of stay during index hospitalization from three days to two days as compared to competitive implants. They also show that Titan Spine patients are able to begin physical therapy more than twice as fast as its competitors and are able to attend a statistically greater amount of physical therapy. "In my patients, I see the earliest changes occurring in the im- mediate postoperative period," said Dr. Bruggeman. "Physical therapists have commented on how quickly the Titan patients recover and their speed of progressing through the discharge criteria. Many floor nurses have commented on lower pain scores and less requirement for pain medications compared to other patients." Titan's in-vitro findings also appear to translate to lower overall treatment costs. The same Optum Health study showed treat- ment with Titan Spine's surface technology demonstrated a re- duced total cost of medical claims through 24 months post-op of over $11,000 versus its competitors by lowering the cost of medical claims during index hospitalization and the two-year post-op period. "By allowing patients to be more active at earlier time points, patients are using less narcotics and requiring fewer readmis- sions," said Dr. Bruggeman. "The faster and more robust fusion results are leading to fewer, if any, revisions on Titan patients, thus driving cost out of the healthcare system." For surgeons looking to excel in this new high-stakes, high-re- ward pay-for-performance era, Titan Spine's nanoLOCK® is uniquely qualified to help spinal fusion patients heal faster and meet the triple aim objectives of improving the quality of healthcare at a reduced cost. When faced with the heat of being placed under the microscope, surgeons can now find solace un- der the same microscope at the nano level. n 1 h t t p s : / / w w w. c m s . g o v / R e s e a r c h - S t a t i s t i c s - D a t a - a n d - S y s t e m s / S t a t i s - tics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf 2 Olivares-Navarrete, R., Gittens, R.A., Schneider, J.M., Hyzy, S.L., Haithcock, D.A., Ullrich, P.F., Schwartz, Z., Boyan, B.D. (2012). Osteoblasts exhibit a more differenti- ated phenotype and increased bone morphogenetic production on titanium alloy substrates than poly-ether-ether-ketone. The Spine Journal, 12, 265-272. 3 Olivares-Navarrete, R., Hyzy, S.L., Gittens, R.A., Schneider, J.M., Haithcock, D.A., Ullrich, P.F., Slosar, P. J., Schwartz, Z., Boyan, B.D. (2013). Rough titanium alloys reg- ulate osteoblast production of angiogenic factors. The Spine Journal, 13, 1563- 1570. 4 Olivares-Navarrete, R., Hyzy, S.L., Slosar, P.J., Schneider, J.M., Schwartz, Z., and Boyan, B.D. (2015). Implant materials generate different peri-implant inflammatory factors: PEEK promotes fibrosis and micro-textured titanium promotes osteogenic factors. Spine, Volume 40, Issue 6, 399–404. 5 Olivares-Navarrete, R., Hyzy S.L., Gittens, R.A., Berg, M.E., Schneider, J.M., Hotch- kiss, K., Schwartz, Z., Boyan, B. D. Osteoblast lineage cells can discriminate mi- croscale topographic features on titanium-aluminum-vanadium surfaces. Ann Biomed Eng. 2014 Dec; 42 (12): 2551-61.

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