Bone Healing Strategies for Lumbar Interbody Fusion

Bone Grafts

Bone grafts, including autogenous iliac crest bone grafting, are frequently utilized in spinal fusion procedures to promote bone healing. ICBG is the preferred bone grafting method for spinal fusion due to its ability to promote new bone growth and non-immunogenic properties.

However, harvesting bone from the iliac crest can result in pain and complications. The negative effects of harvesting bone from the iliac crest for spinal fusion highlight the importance of exploring alternative techniques.

Bone Biomaterials

Bone biomaterials refer to either synthetic or naturally occurring materials utilized to facilitate bone repair in instances of bone defects. An ideal bone biomaterial for repairing bone defects should possess characteristics such as biocompatibility, moldability, absorbability, radiographic identifiability, sterilizability, and accessibility.

Numerous biomaterials, such as polyesters, collagen scaffolds, hydroxyapatite, and β-tricalcium phosphate, have been employed for spinal fusion. Combining bone biomaterial with osteogenic cells and/or growth factors is more effective in achieving favorable spinal fusion outcomes.

Bone biomaterials aid in spinal fusion by serving as a scaffold for cell migration, proliferation, and osteogenic differentiation. They also function as a carrier for osteogenic proteins.

Osteoinductive Protein‑Based Osteobiologics

It has been reported in literature that the use of demineralized rabbit bone can induce the formation of new bone. The discovery of demineralized rabbit bone’s ability to induce new bone formation led to the production of recombinant human BMP-2 (rhBMP2), which has been extensively used as an osteoinductive growth factor in spinal fusion procedures.

RhBMP2 has been demonstrated to have better fusion results than the conventional ICBG harvesting technique, resulting in FDA approval for anterior lumbar fusion in 2002. Its applications have expanded to various on and off-label uses.

However, there are conflicting reports on the potential of high doses of rhBMP2 to cause tumorigenesis or life-threatening complications. Therefore, further research with different doses and long-term follow-up is needed to clarify these concerns.

Improvement Of Interbody Cages And Surgical Techniques

Various materials, including titanium, PEEK, carbon fiber, bioabsorbable, and composite implants, are used as interbody options for spinal fusion. These have its unique set of benefits and drawbacks.

There is a growing body of clinical evidence, but there are varying opinions on the optimal shape for interbody cages for spinal fusion. This includes considerations such as the construction material, shape, biomechanical properties, and whether to use expandable or fixed height cages.

Advantages And Disadvantages Of Peek, Titanium, And Composite Cages

The interbody implants that are commonly used in spinal fusion procedures include titanium, PEEK, and composite implants that incorporate both materials.

Titanium cages have the potential for osseointegration and biocompatibility, but they also have increased stiffness and radiopacity. PEEK is radiolucent and has a stiffness similar to cortical bone, but lacks osteoconductivity and may impact cage stability and fusion rates.

Spinal implant companies have developed proprietary processing techniques to address the limitations of interbody implants, such as surface modifications and composite implants, including PEEK with titanium coating.

Recent research has shown that composite implants, such as PEEK with titanium coating, have significant potential for bone ongrowth. In addition, a novel PEEK interbody cage with impactionless insertion technology has been shown to improve lumbar bony fusion and provide relief from back pain and ASD.

Expandable Versus Fixed Height Cages

An important design consideration is whether to use expandable or fixed interbody implants. Fixed interbody implants usually have a larger bone graft window, whereas expandable interbody implants provide improved bony endplate contact and disc height restoration.

Recent research has demonstrated that using expandable interbody implants can result in a greater improvement in disc height and foraminal height than fixed implants. 3D-printed dynamically semi-crystalline liquid crystal elastomer (LCE) for an expandable endplate-conforming interbody fusion cage may have improved mechanical properties compared to other expandable interbody implants.

However, studies have yielded inconsistent findings on the efficacy of expandable interbody implants compared to fixed implants. More extensive and long-term studies are needed to assess the clinical efficacy of different types of interbody fusion cages.

Improvement Of Surgical Techniques

There is ongoing progress in surgical techniques to enhance the effectiveness of spinal fusion procedures and improve patient outcomes. The use of cortical bone trajectory (CBT) screw insertion through a caudomedial starting point is a surgical technique that offers benefits such as reducing the need for dissection of the superior facet joints and muscles.

As a result, it has been found to have lower rates of early cephalad adjacent segment degeneration (ASD) after posterior lumbar interbody fusion (PLIF) compared to the traditional trajectory screw fixation (TT-PLIF). However, it is necessary to conduct further studies with a larger patient population and a longer follow-up period to make accurate comparisons of novel surgical techniques and fusion cages.

Conducting future studies with a larger patient population and a longer follow-up period can offer greater insights into the strategies for enhancing fusion rates, alleviating back pain and neurological symptoms, and mitigating the risk of ASD.

Development Of More Effective Osteobiologic Products And Bone‑forming Stimulators

Spinal fusion outcomes are dependent on both the surgical procedure and the use of effective bone grafting or osteogenic products. Despite the advancements made in the development of osteoinductive proteins and osteoconductive biomaterials, there is currently no agreement on the specific type or quantity of osteogenic products required for successful spinal fusion.

Discovering Novel Osteogenic Proteins

Literature has reported that AB204, an activin A/BMP2 chimera, had better bony fusion than rhBMP2 alone at a low dose in a rat model of posterolateral spinal fusion. However, additional studies are necessary to explore other osteogenic proteins for spinal fusion.

Developing Novel Biomaterials And Controlled Release Techniques

Different types of biomaterials, such as collagen, ceramics, and synthetic polymers, have been employed for delivering proteins to promote bone healing or fusion. However, these biomaterials differ in their ability to undergo resorption and remodeling.

Using delivery materials with low affinity for rhBMP2 can result in a burst release, which may cause supraphysiological doses and associated complications. To solve these problems, it is necessary to develop nanomaterials that can limit the movement of proteins, contain them in particular areas, and gradually release them over time.

Defining The Role Of Mesenchymal Stem Cells In Spinal Fusion

Recent research has indicated that MSC-based therapies have the potential to be effective for spinal fusion in both animal models and human clinical trials. However, there is still a need for further investigation to gain a better understanding of the mechanisms of action and the long-term efficacy of these therapies.

Mesenchymal stem cells (MSCs) have been demonstrated to be safe and effective for intervertebral disc repair and spinal fusion, although, in some studies, they did not show better results compared to current treatments.

Electrical Stimulation

Both preclinical and clinical studies suggest that electrical stimulation technologies, particularly direct current stimulation (DCS), have the potential to increase the rate of spinal fusion.

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Based on 115 reviews
Dr. Karlkare and his staff were excellent. Dr. Karkare explained everything clearly and took his time getting to know my Dad.
Anna Acker
22:46 07 Sep 23
Dr Vedant Vaksha had done emergency surgery in 2020 after a traumatic injury.His office at Complete Orthopedics handled the continued care thereafter.Dr V and his staff had been Professional and friendly throughout the process, taking the time to explain all the questions on how to proceed and what to expect.Whenever I needed to speak with Dr V or the office they were a phone call away, without waiting or calling several numbers like in so many other medical offices.The office was accommodating to scheduling to my needs at all times. Dr Vedant Vaksha earned the following5 out of 5 stars, highly recommended.
John Kuey
20:58 05 Sep 23
Dr. Vaksha helped me recover from an injury. I am very thankful that he took the time to explain the best treatment for my injury. Also thankful for the wonderful office staff!
Joseph Castelli
22:30 02 Aug 23
The office is wonderful!… Dr Paresh was very helpful and attentive and made my sister in laws recovery so much better.. Thank you for everything
Jazz Lorenzo
17:48 14 Jul 23
The ladies are very welcoming, the service is great, the doctor is very professional and caring and the building is super clean. I really like to come here, the atmosphere is very friendly... Come and you will love it too.
Joan Carasco
14:41 30 Jun 23
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

Please take a look at my profile page and don't hesitate to come in and talk.