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.2020 Nov 26:7:526020.
doi: 10.3389/fsurg.2020.526020. eCollection 2020.

Complete Osseointegration of a Retrieved 3-D Printed Porous Titanium Cervical Cage

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Complete Osseointegration of a Retrieved 3-D Printed Porous Titanium Cervical Cage

Wimar van den Brink et al. Front Surg..

Abstract

Introduction: Porous 3D-printed titanium has only recently been introduced for spinal applications. Evidence around its use is currently limited to animal studies and only few human case series. This study describes the histological findings of a retrieved EIT cervical cage, explanted 2 years after insertion.Materials and Methods: The patient underwent a double level C4/C5 & C5/C6 anterior cervical decompression using EIT cervical cages without an anterior plate. Two years later the C6/7 level degenerated and began to cause myelopathic symptoms. In order to address the kyphotic imbalance of the cervical spine and fix the C6/7 level, the surgeon decided to remove the C5/6 cervical cage and bridge the fusion from C4 to C7 inclusive. The retrieved cage was histologically evaluated for bone ingrowth and signs of inflammation.Results: MRI demonstrated spinal canal stenosis at C6/C7. Plain radiographs confirmed well-integrated cervical cages at 2 years postoperative. The peroperative surgical need to use a chisel to remove the implant at C5/C6 reconfirmed the solid fusion of the segment. Macroscopically white tissue, indicative of bone, was present at both superior and inferior surfaces of the explanted specimen. Histological evaluation revealed complete osseointegration of the 5 mm high EIT Cellular Titanium® cervical cage, displaying mature lamellar bone in combination with bone marrow throughout the cage. Furthermore, a pattern of trabecular bone apposition (without fibrous tissue interface) and physiological remodeling activity was observed directly on the cellular titanium scaffold.Conclusion: This histological retrieval study of a radiologically fused cervical EIT cage clearly demonstrates complete osseointegration within a 2-year time frame. The scaffold exhibits a bone in growth pattern and maturation of bone tissue similar of what has been demonstrated in animal studies evaluating similar porous titanium implants. The complete osseointegration throughout the cage indicates physiological loading conditions even in the central part of the cage. This pattern suggests the absence, or at least the minimization, of stress-shielding in this type of porous titanium cage.

Keywords: 3d printed titanium implant; bone ingrowth spinal cage; cervical spine fusion; osseointegration; porous titanium alloy.

Copyright © 2020 van den Brink and Lamerigts.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
X-ray double level EIT CIF cage C4C5 and C5C6 2 years postop. Arrow indicates symptomatic level.
Figure 2
Figure 2
MRI double level EIT CIF cage 2 years postop Arrow indicates spinal stenosis C6/C7.
Figure 3
Figure 3
(A) EIT cervical cage.(B) Retrieved cervical cage specimen. The red line indicates the intersection line from which the histological sections were cut.
Figure 4
Figure 4
HE stained specimen, 20x magnification: This overview shows direct mature bone apposition onto the titanium struts (black spots), also present in the middle of the cage, indicating that the mechanical stimulation is transferred through the total cage.
Figure 5
Figure 5
(A–C) HE stained specimen: Higher magnification from the cage middle and surface area. The lamellar bone has a mature, vivid appearance without any fibrous tissue intervening between the titanium and the bone. Healthy bone marrow can be observed throughout the scaffold.(D–F) HE stained specimen: Higher magnification from the posterior 1/3th of the cage. Dense collagen fibers are directed in a cranial to caudal trajectory, attaching to the titanium struts.
Figure 6
Figure 6
Masson Goldner Trichrome stained specimen, 20x magnification: In this staining the lamellar bone is colored light blue and young woven bone and osteoid has a red appearance.
Figure 7
Figure 7
(A–C) Higher magnification of the cage central part; the bone (light blue) is remodeling, demonstrating adaptive reactivity. The red lining is osteoid, indicating active bone apposition by osteoblasts. No signs of inflammation are present. The whitisch bullous tissue is healthy bone marrow.
See this image and copyright information in PMC

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