Biomaterials & Augmentation

Vertebroplasty and kyphoplasty for osteoporotic compression fractures, including biomaterial selection and fusion augmentation strategies.

Overview

Biologic augmentation in orthopaedic surgery demonstrates mixed results, with preclinical and clinical studies indicating improved structural healing and functional scores in rotator cuff repair [1]. While a lack of standardized protocols leads to outcome heterogeneity [1], specific applications show promise. In revision rotator cuff tear repair, bioinductive collagen patches provide clinical and functional improvement, with over 70% of repairs remaining intact at one-year follow-up [9]. Conversely, in acute patellar tendon repair, augmentation does not improve functional outcomes compared with isolated repair but is associated with a lower rate of surgical failure and significantly lower patellar height [8]. Notably, this augmentation does not increase the risk of complications [8].

Beyond soft tissue, next-generation scaffolds in tissue engineering are expected to decrease the invasiveness of grafting techniques for bone, osteochondral defects, and tendon-to-bone interfaces [4]. In spinal applications, cement augmentation for symptomatic osteoporotic vertebral fractures yields positive outcomes compared with medical treatment or sham, though conclusions must be drawn cautiously due to industry sponsorship bias [23]. Novel osteopromotive growth factors and ceramics function best as bone graft extenders in posterolateral lumbar fusions, where hydroxyapatite/tricalcium phosphate ceramics perform comparably to autogenous bone grafts but with fewer complications [51]. The paucity of long-term data regarding bioabsorbable interbody spacers requires careful weighing against potential benefits [14], while 3D-printed prosthetics in total en bloc spondylectomy have yielded favorable clinical outcomes [7].

Anatomy & Pathophysiology

Osseous

Screw Design: In healthy vertebrae, conical and dual-core/dual-thread screw designs improve pullout strength compared to other designs, with a combination of these features achieving optimal stability [24]. Boron-coated titanium alloy pedicle screws demonstrate stronger biomechanical properties than currently used titanium screws in a rabbit spine model [22]. Fixation Configuration: For osteoporotic vertebrae, intermediate bilateral screws combined with cement-augmented screws offer the best biomechanical performance [26]. However, cement-augmented pedicle screw instrumentation (CAPSI) increases range of motion and disc stresses in osteoporotic lumbar models compared to non-augmented instrumentation and is more likely to increase the potential risk of adjacent segment degeneration compared to cement-augmented pedicle screws (CPS) [37]. The stabilising effect of cement augmentation of pedicle screws might not be as beneficial as expected from biomechanical pull-out tests in the treatment of osteoporotic vertebral fractures [68]. Cage Selection: Selecting a lumbar vertebral ring apophysis cage that exceeds the width of the pedicle by at least 5 mm demonstrates remarkable biomechanical performance and is expected to reduce complications such as cage subsidence and internal fixation system failure [52]. Conversely, the stress of the endplate-cage interface decreases as the stiffness of a cervical interbody fusion cage is reduced, indicating that subsidence is less likely to occur in cages with lower stiffness [41]. Material Modelling: The mechanical bone properties of vertebral cancellous bone can be modelled with high accuracy based on quantitative computed tomography within the investigated bone density range [35]. Cyclic loading based on physiological conditions during walking allows the simulation of postoperative conditions and clinical failure mechanisms in vitro for non-augmented and augmented pedicle screws in human vertebrae with reduced bone density [66]. Diabetic Pathology: Continuous subcutaneous insulin infusion (CSII) was investigated for its effects on the microstructure, mechanical properties, and bone mineral composition of the lumbar spine in type 2 diabetic rats, as the effect of CSII on the lumbar spine was previously unknown prior to this study [57]. Emerging Devices: Tektona® requires further biomechanical tests and clinical studies to prove its capabilities for height and volume restoration in osteoporotic vertebral compression fractures [42]. A height-adjustable nano-hydroxyapatite/polyamide-66 vertebral body (HAVB) had similar biomechanical efficacy in spinal stability reconstruction as compared with TMC and AVB [60].

Ligamentous

Interspinous Spacers: Early data support the short-term efficacy of interspinous process spacers in treating claudication related to spinal stenosis, though sufficient medium- and long-term data regarding the durability and device migration of interspinous process spacers are lacking [27]. Dynamic Stabilization: A novel pedicle screw-based posterior dynamic stabilization device protected the adjacent level of fusion segments but led to much greater range of motion, disc stresses, and facet joint contact forces at the adjacent level of instrumented segments [63]. Muscle Pathology: Paraspinal muscle health is related to fibrogenic, adipogenic, and myogenic gene expression in patients with lumbar spine pathology [67].

Disc & Joint

Total Disc Replacement: No mechanical failures were observed in viscoelastic discs or articulating total disc replacements after 30-million-cycle intervals, simulating approximately 80 years of lumbar-bending motions [33].

Research Models

A novel rat model of interbody fusion based on anterior lumbar corpectomy and fusion (ALCF) could provide a new choice for fundamental research using animal models of spinal fusion [64].

Classification

Biologic Augmentation: Current research on biologic augmentation in rotator cuff repair presents mixed results regarding structural healing and functional scores [1]. A lack of standardized protocols in biologic augmentation for rotator cuff repair leads to heterogeneity in outcomes [1]. Biological augmentation and tissue engineering strategies in meniscus surgery appear to have significant potential to enhance options for repair and replacement [3].

Scaffold Engineering: Next generation scaffolds in orthopaedic tissue engineering are expected to decrease the invasiveness of current grafting techniques for reconstruction of bone and osteochondral defects [4]. Next generation scaffolds in orthopaedic tissue engineering are expected to decrease the invasiveness of current grafting techniques for reconstruction of tendon-to-bone interfaces [4]. Biocompatible poly-L-lactic acid (PLLA) scaffolds can be efficiently loaded with human bone marrow-derived mesenchymal stem cells to support chondrogenic differentiation and extracellular matrix deposition [11]. Loading biocompatible PLLA scaffolds with mesenchymal stem cells improves the mechanics of the scaffold [11]. A composite of platelet-rich plasma and collagen-mineral scaffold showed a positive effect on spinal fusion in a rat model [15].

Implant Materials & Design: Surgeons must understand differences in chemical composition, structural strength, and resorption rates of available osteoconductive bone graft substitutes to select appropriate materials for specific clinical situations [5]. Highlighting biologic and material-related advantages and inadequacies of current and potential implant materials may guide further research and development for spinal implants [6]. The incorporation of 3D-printed prosthetics in total en bloc spondylectomy procedures yielded favorable clinical outcomes [7]. Advanced technologies like 3D-printing and hybrid materials are expected to enable the design of mechanically competent patient-specific bone grafts [20]. A finite element study of three novel cervical porous fusion cages provided valuable insights for the development of next-generation orthopaedic medical devices [25]. Nano boron nitride enhanced bone cement composites demonstrate improved mechanical, thermal, and drug release properties [55].

Graft Benchmarks: Autograft remains the benchmark for bone graft materials as it is the only graft containing all three characteristics: osteogenic, osteoinductive, and osteoconductive [58]. The cellular component of two commercially available cellular bone matrices yielded no additional benefits in terms of spinal fusion [59].

Other Considerations: Technologic advances in implant materials, design, amputee care, and imaging continue to drive improvements in patient care and outcomes [2].

Clinical Presentation

Current evidence regarding biologic augmentation in orthopaedic surgery presents mixed results, particularly for structural healing and functional scores in rotator cuff repair [1]. A lack of standardized protocols contributes to significant heterogeneity in outcomes across these procedures [1]. While next-generation scaffolds in tissue engineering are expected to decrease the invasiveness of grafting techniques for bone, osteochondral defects, and tendon-to-bone interfaces [4], and show potential for enhancing meniscus repair options [3], the clinical application remains nuanced. Technologic advances in implant materials, design, and imaging continue to drive improvements in patient care [2].

In the context of acute patellar tendon repair, biological augmentation is associated with a lower rate of surgical failure but does not improve functional outcomes compared with isolated repair [8]. This intervention is also linked to significantly lower patellar height, though it does not increase the risk of complications [8]. These findings are based on follow-up periods of at least two years [8]. Conversely, for revision rotator cuff tear repair, biologic augmentation with a bioinductive collagen patch provides clinical and functional improvement, with over 70% of repairs remaining intact at one-year follow-up [9].

Material selection requires a precise understanding of chemical composition, structural strength, and resorption rates for osteoconductive bone graft substitutes [5]. Allografts demonstrate a better clinical track record with superior outcomes and fewer adverse events compared with xenograft or synthetic materials [17]. Specifically, acellular dermal matrix allografts can augment rotator cuff tendon healing, particularly in tears greater than 3 cm in length [17]. In spinal applications, titanium coating on polyetheretherketone oblique cages appears to have no negative effects on short-term outcome or safety [18], while 3D-printed prosthetics in total en bloc spondylectomy have yielded favorable clinical outcomes [7]. However, significant bone resorption occurs within one year after implantation of the Wallis device in more than 50% of patients [13].

Biologic approaches to tissue healing range from experimental preclinical techniques to those currently in use [10]. Biocompatible poly-L-lactic acid (PLLA) scaffolds can be efficiently loaded with mesenchymal stem cells (MSCs), which support chondrogenic differentiation, extracellular matrix deposition, and improved scaffold mechanics [11]. In rabbit models, both alginate-embedded allogenic MSCs and autologous chondrocytes resulted in superior tissue regeneration compared with untreated defects [12]. For degenerative disc disease, supplementation with a commercially available allogeneic nucleus pulposus product ameliorated back pain and functional impairment at 12 months [19]. A novel nanocrystalline hydroxyapatite paste (OSTIM®) has shown good tissue incorporation in human cancellous bone [16].

Variability in clinical benefit for platelet-rich plasma (PRP) is observed, with differences between preparations suggesting distinct results for treated tissue [29]. These variations may explain the large variability in reported clinical benefits of PRP in the literature [29]. In Dupuytren's contracture, early recurrence is most common in individuals with Dupuytren's diathesis [31]. In this specific setting, the use of full-thickness skin grafts may be helpful [31]. Highlighting the advantages and inadequacies of current and potential implant materials may guide further research and development for spinal implants [6].

Investigations

Plain radiography: Current research on biologic augmentation in rotator cuff repair presents mixed results regarding structural healing and functional scores [1]. A lack of standardized protocols in biologic augmentation research leads to heterogeneity in outcomes [1]. Improvements in radiographic and clinical findings were observed one year postoperatively in both cellular bone allograft containing multipotent adult progenitor cells and recombinant human bone morphogenetic protein-2 treatment groups for anterior lumbar interbody fusion [62]. Balloon assisted endplate reduction with tricalcium phosphate cement in combination with short-segment instrumentation might reduce recurrence of deformity even after removal of instrumentation for thoracic or lumbar burst fractures [75]. Significant bone resorption occurs within 1 year after implantation of the Wallis device in more than 50% of patients [13].

MRI: Platelet-rich plasma did not accelerate tendon-to-bone integration in anatomic ACL reconstruction, as indicated by no difference in signal intensity of the fibrous interzone on magnetic resonance imaging among four groups [73]. Magnetic resonance imaging indicates that the donor site after autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [45]. The Trufit Plug synthetic bone-graft substitute offers a bone-sparing alternative for patients who have failed to improve with core decompression and wish to avoid metal implants, although plugs remain visible on MRI [49]. Metal suppression magnetic resonance imaging techniques provide a comprehensive overview of different metal artifacts in orthopaedic MRI and factors affecting their magnitude [54].

Other Considerations: Technologic advances in implant materials, design, amputee care, and imaging continue to drive improvements in patient care and outcomes [2]. Biological augmentation and tissue engineering strategies show significant potential to enhance options for meniscus repair and replacement [3]. Next generation scaffolds in orthopaedic tissue engineering are expected to decrease the invasiveness of current grafting techniques for bone, osteochondral defects, and tendon-to-bone interfaces [4]. Surgeons must understand differences in chemical composition, structural strength, and resorption rates of osteoconductive bone graft substitutes to select appropriate materials for specific clinical situations [5]. Highlighting biologic and material-related advantages and inadequacies of current and potential implant materials may guide further research and development [6]. The incorporation of 3D-printed prosthetics in total en bloc spondylectomy procedures yielded favorable clinical outcomes [7]. A composite of platelet-rich plasma and collagen-mineral scaffold showed a positive effect on spinal fusion in a rat model [15]. The nanocrystalline hydroxyapatite paste OSTIM® showed good tissue incorporation in human cancellous bone [16]. The Trabecular Metal Monoblock Acetabular Cup System showed excellent early clinical and radiographic behavior [28]. No neoplastic complications were detected at any autologous adipose tissue-derived stem cell implantation sites in 100 joints in 91 patients treated with platelet-rich plasma [65]. Treatment of 3D-printed bone scaffolds with CRFP improves their biomechanical properties [76]. Bone tissue engineering is a promising area due to the rise in bone-related injuries, though improvements are needed in processing techniques to make scaffolds mechanically stronger without weakening biological characteristics [77].

Treatment

Current research on biologic augmentation in rotator cuff repair presents mixed results, with preclinical and clinical studies showing improved structural healing and functional scores, though a lack of standardized protocols leads to heterogeneity in outcomes [1]. Technologic advances in implant materials, design, amputee care, and imaging continue to drive improvements in patient care and outcomes [2]. Biologic approaches to tissue-healing and regeneration range from experimental techniques in preclinical testing to techniques currently in use, providing a basis for future studies in tissue engineering [10]. There appears to be significant potential for biological augmentation and tissue engineering strategies in meniscus surgery to enhance options for repair and replacement [3]. Next generation scaffolds in orthopaedic tissue engineering are expected to have positive impacts by decreasing the invasiveness of current grafting techniques used for reconstruction of bone, osteochondral defects, and tendon-to-bone interfaces [4].

Implant Selection: Surgeons must understand the differences in chemical composition, structural strength, and resorption rates of available osteoconductive bone graft substitutes to select the appropriate material for specific clinical situations [5]. Highlighting the biologic- and material-related advantages and inadequacies of current and potential implant materials may guide further research and development for spinal implants [6]. The incorporation of 3D-printed prosthetics in total en bloc spondylectomy (TES) procedures yielded favorable clinical outcomes [7]. Advanced technologies like 3D-printing and hybrid materials are expected to enable the design of mechanically competent patient-specific bone grafts [20]. Biocompatible poly-L-lactic acid (PLLA) scaffolds can be efficiently loaded with mesenchymal stem cells (MSCs), supporting chondrogenic differentiation and extracellular matrix (ECM) deposition that improves the mechanics of the scaffold [11]. Both alginate-embedded allogenic mesenchymal stem cells and autologous chondrocytes resulted in superior tissue regeneration compared with untreated defects in a rabbit model of focal articular cartilage defects [12]. Loading porous Ti6Al4V scaffolds to incorporate cells is a promising treatment strategy for improving osseointegration through dual-cell delivery titanium alloy scaffolds [69].

Surgical Approach / Technique: Moderate-to-excellent healing was seen both radiographically and biomechanically by four months in groups treated with strut-autografting, with and without osteogenic protein-1, whereas untreated defects did not heal [21]. An unconventional long-segment fibula graft with pelvis-vertebral support was an effective reconstruction method for complicated spinal tuberculosis, and limited debridement combined with anti-tuberculosis drug therapy is safer than thorough debridement surgery for lesions that cannot be entirely debrided [70]. Femoral marrow cavity bone harvesting used for arthroscopic refilling of misplaced or enlarged bone tunnels in revision ACL surgery is feasible and results in significantly reduced pain levels during post-operative recovery [47].

Adjuncts: A composite of platelet-rich plasma and collagen-mineral scaffold showed a positive effect on spinal fusion in a rat model and could be potentially used as a bone graft in humans [15]. The use of cellular bone allograft (CBA) as an adjunct graft material in lumbar spinal fusion showed high rates of successful arthrodesis and significant improvements in pain and disability scores at 24 months [53]. If the treating surgeon is of the opinion that there is a need to reduce epidural scar, the use of Adcon-L appears worthwhile [56]. Supplementation of degenerated disc tissue with a commercially available allogeneic nucleus pulposus (NP) product ameliorated back pain and functional impairment in patients with lumbar discogenic pain at 12 months [19]. The presence of multiple factors within a cell-free stem cell-derived extract formulation, along with the ability to promote cell proliferation and induce stem cell migration, may reduce inflammation and pain and augment tissue repair [40].

Pain Management: Polymethylmethacrylate augmentation in adult degenerative scoliosis with osteoporosis is associated with less oral pain medicine taken, but at the cost of more medical spending [32]. Surgeon-directed postoperative local injection with an analgesic mixture can contribute significantly to postoperative analgesia in posterior fusion surgery for adolescent idiopathic scoliosis [38]. Evidence supports that cannabinoid receptor agonists should be further investigated as a potential alternative approach for postoperative analgesia following spinal fusion and other orthopaedic procedures requiring bone-healing [43].

Revision: Titanium interference screws presented significantly higher fixation strengths than bioabsorbable expansion bolts for patellar tendon bone graft fixation, but all groups demonstrated ultimate loads to failure which exceeded the minimum request for initial stability [61]. Adult non-cultivated bone marrow stem cells do not seem to accelerate graft-to-bone healing in ACL reconstruction [72].

Other Considerations: The paucity of definitive, long-term data regarding bioabsorbable interbody spacers must be carefully weighed against their potential benefits [14]. Boron-coated titanium alloy pedicle screws demonstrated stronger biomechanical properties in a rabbit spine model and could be a better alternative to currently used titanium screws [22]. In healthy vertebrae, both conical and dual-core/dual-thread screw designs improve pullout strength, with a combination achieving optimal stability [24]. Among configurations for short-segment fixation combined with expandable polyetheretherketone vertebral body replacement in osteoporotic vertebrae, intermediate bilateral screws combined with cement-augmented screws offer the best biomechanical performance [26]. Requirements for bone cement in a kyphoplasty setting were excellently fulfilled regarding properties and clinical application safety [46]. Current research on interbody cage design in anterior cervical discectomy and fusion focuses on the promotion of osseointegration through bioactivation of surface materials, as well as streamlining anterior fixation with integrated screws and zero profile designs [48]. The combination of vancomycin-loaded calcium sulfate and vancomycin-loaded PMMA in the treatment of chronic osteomyelitis may achieve immediate structural stabilization and higher concentration of antibiotic at the local site of infection [71].

Complications

Infection (PJI): Pooling of Level 1 evidence and registry data does not support a reduction in infection risk in primary total joint arthroplasty with antibiotic-impregnated polymethyl methacrylate cement [79]. Revision surgery, particularly in the setting of prior infection, increases the risk of future surgical site infection after shoulder arthroplasty [96]. Allogeneic red blood cell transfusion increases the risk of surgical site infection after shoulder arthroplasty in a dose-dependent manner [96]. TiNbN-coated orthopedic implants do not increase the risk of periprosthetic joint infections while ameliorating tribological and surface properties [91].

Patellar / Extensor-mechanism: Biological augmentation after acute patellar tendon repair is associated with a lower rate of surgical failure but does not improve functional outcomes at a minimum of two years' follow-up [8]. This augmentation is also associated with significantly lower patellar height without an increased risk of complications [8]. Major primary complications and a high incidence of radiographic signs of degenerative changes occur after bipolar radial head arthroplasty, though mainly good clinical results are achieved [90].

Polyethylene wear: Mechanical failure of the porous-coated anatomic prosthesis in total knee arthroplasty was due to severe polyethylene wear [89].

Thromboembolism: Thromboembolic complications after simple arthroscopy surgery are life-threatening and devastating despite their low incidence [78]. Life-threatening disseminated intravascular coagulation was caused by a combination of dilutional coagulopathy, intraoperative blood salvage, and the use of absorbable gelatin sponges soaked in topical thrombin [85].

Other Considerations: Biologic augmentation in rotator cuff repair presents mixed results with heterogeneity in outcomes due to a lack of standardized protocols [1]. Significant bone resorption occurs within 1 year after implantation of the Wallis interspinous stabilization device in more than 50% of patients [13]. The paucity of definitive, long-term data regarding bioabsorbable interbody spacers must be weighed against their potential benefits [14]. Early data support the short-term efficacy of interspinous process spacers in treating claudication related to spinal stenosis, but sufficient medium- and long-term data are lacking regarding durability and device migration [27]. The Trabecular Metal Monoblock Acetabular Cup System showed excellent early clinical and radiographic behavior [28]. Safety concerns and conflicts of interest in original trials complicate the routine use of BMP-2 in spine surgery despite its effectiveness for achieving high fusion rates [82]. The type of graft substitute used in minimally invasive scoliosis surgery for adolescent idiopathic scoliosis did not affect facet fusion rate or clinical outcomes [88]. Complication rates for bone-block augmentation procedures treating anterior shoulder instability remained relatively high at 20.8% and did not decrease with increased surgical exposure [97]. Major surgical complications occurred in 11.6% of patients receiving high-dose rhBMP-2 for adults [99]. Major medical complications occurred in 11.6% of patients receiving high-dose rhBMP-2 for adults [99].

Recovery

Light activity (weeks): Evidence does not specify a discrete week range for light activity or driving in the provided literature. However, PMMA augmentation for insufficiency fractures of the tibial plateau allows for early mobilization in selected old osteoporotic patients [80]. Similarly, pre-solidified chitosan implants elicit early wound-repair responses including neutrophil and stromal cell chemotaxis, suggesting potential for early biological engagement [30].

Full activity (months): Moderate-to-excellent healing was observed radiographically and biomechanically by four months in groups treated with strut-autografting, with or without osteogenic protein-1 [21]. In revision rotator cuff repairs augmented with a bioinductive collagen patch, over 70% of repairs remained intact at 1-year follow-up [9]. At a minimum of two years' follow-up, biological augmentation was associated with a lower rate of surgical failure and significantly lower patellar height compared with isolated repair [8].

Complete recovery / outcome plateau (months): The literature indicates that while biological augmentation reduces failure rates, it does not improve functional outcomes after acute patellar tendon repair [8]. Conversely, biologic augmentation with a bioinductive collagen patch provides clinical and functional improvement in patients undergoing revision rotator cuff tear repair [9]. Biological augmentation in rotator cuff repair shows mixed results, with studies indicating improved structural healing and functional scores, though a lack of standardized protocols leads to heterogeneity in outcomes [1].

Rehabilitation protocol: The effectiveness of orthobiologic agents is currently being studied, and while they have the potential to improve local biology and expedite healing, it is difficult to interpret the current literature to determine their efficacy and clinical usefulness due to heterogeneity in preparations and lack of consensus [36]. Surgeons must understand the differences in chemical composition, structural strength, and resorption rates of available osteoconductive bone graft substitutes to select the appropriate material for specific clinical situations [5]. Technologic advances in implant materials, design, amputee care, and imaging continue to drive improvements in patient care and outcomes [2].

Functional milestones: Acellular dermal matrix allografts can augment rotator cuff tendon healing, especially in tears greater than 3 cm in length [17]. Allografts have a better clinical track record with better outcomes and fewer adverse events compared with xenograft or synthetic materials [17]. Both autologous and allogenic chondrocytes delivered via a biodegradable mesh resulted in superior tissue regeneration compared with untreated defects in a rabbit model [12]. Use of autologous and allogenic chondrocytes delivered via a biodegradable mesh enhanced healing of avascular meniscal lesions [44].

Other Considerations: Next generation scaffolds in orthopaedic tissue engineering are expected to have positive impacts by decreasing the invasiveness of current grafting techniques used for reconstruction of bone, osteochondral defects, and tendon-to-bone interfaces [4]. Biological augmentation and tissue engineering strategies in meniscus surgery appear to have significant potential to enhance options for repair and replacement [3]. Biologic adjuvants improve fracture healing by providing osteoconduction, osteoinduction, and/or osteogenic cells [34]. Pre-solidified chitosan implants are tunable by molecular mass and could be beneficial for augmented marrow stimulation therapy if the recruited stromal cells can progress to bone and cartilage repair [30]. The tendon-to-bone repair process was facilitated by the use of rhBMP-2 delivered by β-tricalcium phosphate at 4 weeks in rabbit models [74]. Untreated defects did not heal in the strut-autografting study [21]. Biologic approaches to tissue-healing and regeneration range from experimental techniques in preclinical testing to techniques currently in use, providing a basis for future studies in tissue engineering [10].

Key Evidence

• [L5] Current research on biologic augmentation presents mixed results; while preclinical and clinical studies show improved structural healing and functional scores, a lack of standardized protocols leads to heterogeneity in outcomes. (10.1016/j.xrrt.2026.100705)
• [L4] There appears to be significant potential for biological augmentation and tissue engineering strategies in meniscus surgery to enhance options for repair and replacement. (10.1016/j.arthro.2014.11.044)
• [L4] Positive impacts of the use of next generation scaffolds in orthopaedic tissue engineering can be expected in terms of decreasing the invasiveness of current grafting techniques used for reconstruction of bone and osteochondral defects, and tendon-to-bone interfaces in near future. (10.1007/s00167-014-3453-z)
• [L5] Surgeons must understand the differences in chemical composition, structural strength, and resorption rates of available osteoconductive bone graft substitutes to select the appropriate material for specific clinical situations. (10.5435/00124635-200709000-00003)
• [L5] Highlighting the biologic- and material-related advantages and inadequacies of current and potential implant materials may guide further research and development. (10.5435/jaaos-d-17-00645)
• [L4] The incorporation of 3D-printed prosthetics in TES procedures yielded favorable clinical outcomes. (10.1186/s12891-024-08069-7)
• [L3] At a minimum of two years' follow-up, biological augmentation did not improve functional outcomes compared with isolated repair but was associated with a lower rate of surgical failure and significantly lower patellar height, without an increased risk of complications. (10.1016/j.jisako.2025.101045)
• [L4] Biologic augmentation with a bioinductive collagen patch provides clinical and functional improvement in patients undergoing revision rotator cuff tear repair, with over 70% of the revision repairs remaining intact at 1-year follow-up. (10.1016/j.jse.2025.07.031)
• [L5] The symposium discussed biologic approaches to tissue-healing and regeneration, ranging from experimental techniques in preclinical testing to techniques currently in use, providing a basis for future studies in tissue engineering. (10.2106/jbjs.k.01505)
• [L5] Biocompatible PLLA scaffolds have been developed that can be efficiently loaded with MSCs, supporting chondrogenic differentiation and ECM deposition that improves the mechanics of the scaffold. (10.1007/s00167-012-2148-6)
• [L5] Both treatments resulted in superior tissue regeneration compared with untreated defects. (10.1177/0363546511420819)
• [L3] Significant bone resorption occurs within 1 year after implantation of the Wallis device in more than 50% of patients. (10.1186/s12891-015-0561-y)
• [L5] The paucity of definitive, long-term data must be carefully weighed against the potential benefits of these implants. (10.5435/00124635-200705000-00005)
• [L5] In the future, this composite could be potentially used as a bone graft in humans. (10.1186/s13018-019-1076-2)
• [L4] The studied nanocrystalline hydroxyapatite paste showed good tissue incorporation. (10.1186/1471-2474-7-50)
• [L1] The titanium coating appears to have no negative effects on outcome or safety in the short term. (10.1302/0301-620x.99b10.bjj-2016-1292.r2)
• [L4] Supplementation of degenerated disc tissue with a commercially available allogeneic NP product ameliorated back pain and functional impairment in patients with lumbar discogenic pain at 12 months. (10.1186/s12891-025-08701-0)
• [L5] Advanced technologies like 3D-printing and hybrid materials are expected to enable the design of mechanically competent patient-specific bone grafts. (10.1302/2058-5241.3.170056)
• [L5] Moderate-to-excellent healing was seen both radiographically and biomechanically by four months in the groups treated with grafting, with and without osteogenic protein-1, whereas untreated defects did not heal. (10.2106/00004623-200107000-00006)
• [L5] With stronger biomechanical properties, they could be a better alternative to currently used titanium screws. (10.1186/s12891-024-07864-6)
• [L5] Cement augmentation for the treatment of symptomatic osteoporotic vertebral fractures seems to have positive outcomes compared with optimal medical treatment or sham, although conclusions should be drawn cautiously due to a high likelihood of bias with most studies being sponsored by industry. (10.1302/2058-5241.2.160057)
• [L5] In healthy vertebrae, both conical and dual-core/dual-thread designs improve pullout strength, with a combination achieving optimal stability. (10.1371/journal.pone.0229328)
• [L5] This study provides valuable insights for the development of next-generation orthopaedic medical devices. (10.1186/s12891-023-06999-2)
• [L5] Among configurations, intermediate bilateral screws combined with cement-augmented screws offer the best biomechanical performance. (10.1186/s12891-025-09065-1)
• [L5] Early data from biomechanical and clinical studies support the short-term efficacy of interspinous process spacers in treating claudication related to spinal stenosis, but sufficient medium- and long-term data are lacking regarding durability and device migration. (10.5435/00124635-200704000-00003)
• [L4] The implant showed excellent early clinical and radiographic behavior. (10.1016/j.arth.2008.09.027)
• [L5] The observed differences suggest different results for treated tissue and could explain the large variability in the clinical benefit of PRP reported in the literature. (10.1016/j.arthro.2014.02.020)
• [L5] Pre-solidified chitosan implants are tunable by molecular mass, and could be beneficial for augmented marrow stimulation therapy if the recruited stromal cells can progress to bone and cartilage repair. (10.1186/1471-2474-14-27)
• [L5] Early recurrence of disease is most common in individuals with Dupuytren's diathesis, and the use of full-thickness skin grafts may be helpful in this setting. (10.5435/00124635-199801000-00003)
• [L3] Less oral pain medicines taken are the potential benefits of Polymethylmethacrylate augmentation, but that is at the cost of more medical spending. (10.1186/1471-2474-12-286)
• [L5] No mechanical failures were observed, even after each 30-million-cycle interval, which simulates approximately 80 years of lumbar-bending motions. (10.2106/jbjs.25.00594)
• [L5] The mechanical bone properties of vertebral cancellous bone could be modelled with high accuracy in the investigated bone density range. (10.1186/s12891-021-04571-4)
• [L5] Biomechanical analysis showed that both CPS and CAPSI increase ROM and disc stresses in osteoporotic lumbar models, but CAPSI is more likely to increase the potential risk of adjacent segment degeneration compared to CPS. (10.1186/s13018-020-01650-5)
• [L3] This technique can contribute significantly to postoperative analgesia. (10.1186/s12891-022-05158-3)
• [L5] The presence of multiple factors within one formulation, along with the ability to promote cell proliferation and induce stem cell migration, may reduce inflammation and pain and augment tissue repair. (10.3390/ijms21249364)
• [L5] We also observed that the stress of the endplate-cage interface decreased as the reduction of the cage's stiffness, indicating that subsidence is less likely to occur in the cage with lower stiffness. (10.1186/s12891-021-04244-2)
• [L5] Further biomechanical tests and clinical studies have to proof Tektona®'s capabilities. (10.1186/s12891-020-03899-7)
• [L5] This supports that cannabinoid receptor agonists should be further investigated as a potential alternative approach for postoperative analgesia following spinal fusion and other orthopaedic procedures requiring bone-healing. (10.2106/jbjs.20.00573)
• [L5] Use of autologous and allogenic chondrocytes delivered via a biodegradable mesh enhanced healing of avascular meniscal lesions. (10.1177/0363546506290666)
• [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
• [L4] Requirements for bone cement in a kyphoplasty setting were excellently fulfilled. (10.1186/s13018-019-1200-3)
• [L3] The clinical relevance is shown by the feasibility of this technique and the significantly reduced pain levels during post-operative recovery. (10.1007/s00167-013-2736-0)
• [L2] Current research is focusing on the promotion of osseointegration through bioactivation of surface materials, as well as streamlining anterior fixation with the introduction of integrated screws and zero profile designs. (10.1186/s12891-015-0546-x)
• [L4] Although the plugs were still visible on MRI, the technique offers a bone-sparing alternative for patients who have failed to improve with core decompression and wish to avoid metal implants. (10.1111/j.1758-5740.2012.00181.x)
• [L5] Well-designed clinical studies are needed to establish safe and effective guidelines for various modalities to enhance new bone formation during distraction osteogenesis in children. (10.5435/00124635-201102000-00005)
• [L5] Novel osteopromotive growth factor preparations and ceramics function best as bone graft extenders or bioactive carriers in posterolateral lumbar fusions, with hydroxyapatite/tricalcium phosphate ceramics performing as well as autogenous bone grafts but with fewer complications. (10.5435/00124635-200503000-00006)
• [L5] Selecting a cage that exceeds the width of the pedicle by at least 5 mm (ensuring complete coverage of the vertebral ring) demonstrates remarkable biomechanical performance and is expected to reduce complications such as cage subsidence and internal fixation system failure. (10.1186/s12891-023-06792-1)
• [L2] The use of CBA as an adjunct graft material showed high rates of successful lumbar arthrodesis and significant improvements in pain and disability scores. (10.1186/s12891-023-06996-5)
• [L5] This review provides a comprehensive overview of different metal artifacts in orthopaedic MRI and factors affecting their magnitude, discussing commonly applied techniques and recent technological advances to facilitate better-informed diagnostic decisions. (10.5435/jaaos-d-24-01057)
• [L5] The comprehensive performance evolution evaluation of h-BN/PMMA composites provides a reference for the innovative application of modified bone cement, demonstrating improved mechanical, thermal, and drug release properties. (10.1186/s13018-025-05626-1)
• [L5] If the treating surgeon is of the opinion that there is a need to reduce epidural scar, the use of this product appears worthwhile. (10.5435/00124635-200011000-00001)
• [L5] The study aimed to investigate the effects of CSII on the microstructure, mechanical properties, and bone mineral composition of the lumbar spine in type 2 diabetic rats, noting that while CSII improved femur structure in previous studies, its effect on the lumbar spine was previously unknown. (10.1186/s12891-022-05452-0)
• [L5] The cellular component of 2 commercially available CBMs yielded no additional benefits in terms of spinal fusion. (10.2106/jbjs.20.00330)
• [L5] HAVB had similar biomechanical efficacy in spinal stability reconstruction as compared with TMC and AVB. (10.1186/s13018-019-1432-2)
• [L5] Titanium interference screws presented significantly higher fixation strengths than bioabsorbable implants, but all groups demonstrated ultimate loads to failure which exceeded the minimum request for initial stability. (10.1007/s00167-003-0463-7)
• [L3] Improvements in radiographic and clinical findings were observed in both treatment groups one-year postoperatively. (10.1186/s13018-017-0618-8)
• [L5] While it protected the adjacent level of fusion segments, it led to much greater ROM, disc stresses, and facet joint contact forces increasing at the adjacent level of instrumented segments. (10.1186/s12891-015-0538-x)
• [L5] It could provide a new choice for fundamental research using animal models of spinal fusion. (10.1186/s12891-021-04822-4)
• [L4] Using both MRI tracking and telephone follow ups in 100 joints in 91 patients treated, no neoplastic complications were detected at any ADSC implantation sites. (10.1186/1471-2474-14-337)
• [L5] The cyclic loading based on physiological conditions during walking has allowed the postoperative conditions and clinical failure mechanisms to be simulated in vitro and clarified. (10.1186/s12891-020-3158-z)
• [L4] These findings provide insight into molecular pathways associated with muscle health in the presence of lumbar spine pathology. (10.1186/s12891-022-05572-7)
• [L5] The stabilising effect of cement augmentation of pedicle screws might not be as beneficial as expected from biomechanical pull-out tests. (10.1302/0301-620x.98b8.37413)
• [L5] Overall, the strategy of loading porous Ti6Al4V scaffolds to incorporate cells is a promising treatment for improving osseointegration. (10.1186/s12891-021-04617-7)
• [Case_report] An unconventional long-segment fibula graft with pelvis-vertebral support was an effective reconstruction method, and limited debridement combined with anti-tuberculosis drug therapy is safer than thorough debridement surgery for lesions that cannot be entirely debrided. (10.1186/s12891-023-06935-4)
• [L3] The immediate structural stabilization and higher concentration of antibiotic at the local site of infection may be achieved through the combination of biodegradable and non-biodegradable devices. (10.1186/s12891-016-1352-9)
• [L2] Adult non-cultivated bone marrow stem cells do not seem to accelerate graft-to-bone healing in ACL reconstruction. (10.1007/s00167-012-2279-9)
• [L2] The study found no difference among the four groups when comparing the signal intensity of the fibrous interzone on magnetic resonance imaging, indicating that PRP did not accelerate tendon-to-bone integration in this setting. (10.1007/s00167-009-0762-8)
• [L5] The tendon-to-bone repair process was facilitated by the use of rhBMP-2 delivered by β-TCP at 4 weeks. (10.1016/j.jse.2017.11.025)
• [L4] BAER with TCP in combination with short-segment instrumentation might reduce recurrence of deformity even after removal of the instrumentation. (10.1186/s12891-017-1770-3)
• [L5] This work will lead to creating 3D structures that can be used in the replacement of not only bone segments, but entire bones. (10.1186/s13018-017-0700-2)
• [L4] Bone tissue engineering is a promising area due to the rise in bone-related injuries, though there is still room for improvements in processing techniques, especially those that make scaffolds mechanically stronger without weakening their biological characteristics. (10.3390/ijms25073836)
• [L4] Despite the low incidence of thromboembolic complications after simple arthroscopy surgery, its life-threatening and devastating property make clinicians rethink the necessity of thromboprophylaxis and importance of preoperative relative risk factors screening. (10.1186/s12891-017-1919-0)
• [L2] Pooling of available Level 1 evidence and registry data does not support a reduction in infection risk in primary total joint arthroplasty. (10.1016/j.arth.2025.10.073)
• [L4] Closed reduction and PMMA augmentation proved beneficial for insufficiency fractures of the tibial plateau in selected old osteoporotic patients, offering feasible stabilization with a low complication rate and allowing early mobilization. (10.1007/s00167-009-1003-x)
• [L5] While BMP-2 is effective for achieving high fusion rates and equal clinical outcomes compared to autograft, safety concerns and conflicts of interest in original trials complicate its routine use. (10.5435/jaaos-20-09-547)
• [Case_report] The authors believe the life-threatening disseminated intravascular coagulation was caused by a combination of dilutional coagulopathy, intraoperative blood salvage, and the use of absorbable gelatin sponges soaked in topical thrombin. (10.2106/00004623-199709000-00014)
• [L3] The type of graft substitute did not affect facet fusion rate or clinical outcomes. (10.1186/s12891-023-06134-1)
• [L3] The design of the implant and clinical factors contributed to the mechanical failure of the polyethylene. (10.2106/00004623-199403000-00019)
• [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. (10.1016/j.jse.2010.05.022)
• [L5] Although the onset of a PJI is more complex than in an in vitro scenario, these findings suggest that TiNbN-coated orthopedic implants do not increase PJIs risk while ameliorating tribological and surface properties could represent a valid choice to limit possible complications such as metal hypersensitivity. (10.1186/s13018-020-01613-w)
• [L3] Revision surgery, particularly in the setting of prior infection, increased risk of future infection, and allogeneic red blood cell transfusion increases SSI risk after shoulder arthroplasty in a dose-dependent manner. (10.1016/j.jse.2017.04.006)
• [L4] Complication rates remained relatively high (20.8%) for these procedures and did not decrease as anticipated with increased surgical exposure to these techniques. (10.2106/jbjs.15.01478)
• [L4] Major surgical complications occurred in 11.6% of patients, and 11.6% experienced major medical complications. (10.2106/jbjs.l.01730)

See Also

• Pain Management
• Surgical Complications

References

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