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BACKGROUND CONTEXT Although frequently used for anterior lumbar interbody fusion (ALIF), concerns regarding the use of recombinant human bone morphogenetic protein 2 (BMP-2) include off-label use, elevated cost and adverse outcomes such as osteolysis. The growing evolution of porous implant technology in promoting osseous integration via ingrowth provides an opportunity for a paradigm shift by relying less on biologic-assisted through-growth and leveraging implant on-growth and in-growth in similar fashion to porous metallic implants used in other orthopedic settings such as hip arthroplasty. PURPOSE This study compared perioperative clinical and radiographic outcomes between patients undergoing ALIF with the assistance of BMP-2 in a nonporous, traditional window interbody cage vs those with no biologic using a minimal-window porous titanium interbody cage. STUDY DESIGN/SETTING Retrospective clinical. PATIENT SAMPLE This study retrospectively examined 75 consecutive patients who underwent 1- or 2-level ALIF between 2014 and 2020 with the use of BMP-2 in a nonporous PEEK cage vs a porous titanium interbody cage and no biologic. All patients had surgery with the senior surgeon and were followed for a minimum follow-up of 6-months postoperatively. OUTCOME MEASURES Patient demographics, comorbidities, postoperative complications, and preoperative, immediate and final postoperative patient-reported outcomes (PROs) were assessed. Rates of reoperation were recorded, and arthrodesis was evaluated using Bridwell radiographic criteria and CT when available. Pre- and postoperative radiographic parameters were evaluated for differences in spinopelvic alignment and correction. METHODS Statistical methods included student's t-test and chi-square for continuous and categorical variables, respectively. Continuous variables were reported as means and standard deviations, and categorical variables as proportions. The threshold for statistical significance was set to p RESULTS Forty-three (13 female, 30 male) and 32 (19 female, 13 male) patients were assessed in the BMP-2 and titanium cage cohorts, respectively. On PRO assessment, baseline VAS leg among BMP-2 patients (6.87, SD: 1.96 vs 5.16, SD: 2.41; p = .023) while the titanium cage group reported worse VAS back scores (6.23, SD: 2.39 vs 7.82, SD: 1.40; p = .023). However, there were no significant differences recorded in postoperative PRO surveys between groups. Correction of spinopelvic alignment was equally maintained between groups at final follow-up when compared to immediate postoperative radiographs. Similarly, disc spaces were equivalently upheld across cohorts, with the exception of greater degeneration among BMP-2 patients at the L4-L5 anterior (-1.78, SD: 3.00 vs -0.07, SD: 2.63; p = .039) and foraminal (-2.34, SD: 3.11 vs -0.07, SD: 2.06; p = .006) disc spaces. Interbody subsidence was similar at the superior (1.13, SD: 0.84 vs 1.28, SD: 0.88; p = .458) and inferior endplates (0.55, SD: 0.79 vs 0.91, SD: 1.27; p = .154), and radiographic evidence of fusion was observed at equivalent rates (90% vs 90.9%, p = .776). There were no differences in the rates of secondary surgeries for adjacent segment disease (ASD) (4.6% vs 0%, p = .222) or index-level revisions (9.1% vs 18.8%, p = .219). CONCLUSIONS Porous titanium interbody cages for ALIF may be equivalent to BMP-2 in nonporous PEEK in achieving arthrodesis, alignment durability and reoperation rates. Although long-term follow-up is necessary, the use of porous titanium implants without external biologics is an intriguing paradigm change which may produce similar outcomes at lower costs. FDA DEVICE/DRUG STATUS Alphatec Identiti Cage (Approved for this indication), Recombinant Human Bone Morphogenetic Protein-2 (Approved for this indication) |
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