BMP
Building A Better Back With Genetic Engineering!
Thomas C. Schuler M.D., an internationally known expert in spinal surgery and president of the Virginia Spine Institute, is ecstatic about this medical breakthrough. “We are now able to solve many patients disabling back pain faster with less pain, and obtain more successful results thanks to this advance!”
What is the breakthrough? It is BMP or Bone Morphogenetic Protein. BMP is a naturally occurring protein within our bodies, which stimulates bone to form. This protein is essential for broken bones to heal. BMP triggers primitive cells in the bloodstream to become bone cells. The spinal surgeon places the BMP on a sponge at the surgical site and this will cause the adjacent bones to fuse together. DNA illustrationBone Morphogenetic Protein was first identified in the 1960’s. Since then, genes that make it have been identified, isolated and implanted in tissue cultures. This enables large quantities of the protein to be manufactured with no risk of communicable diseases. The FDA cleared the product for nationwide use in July of 2002. This is the first genetically engineered product to become available in the US for a general orthopedic and spinal surgical use.
The traditional way to treat chronic back pain was for a spinal surgeon to remove the painful disk from the back and then fuse the two adjacent vertebrae (or backbones) together by taking bone from the patient’s own pelvis, a very painful procedure. BMP eliminates the need for the painful graft harvest procedure, while also improving the fusion success rate. The traditional gold standard for bone graft material for spinal fusion was the harvesting of pelvis bone, which carried a fusion success rate of 88%. The new gold standard is BMP, which carries a fusion rate of greater than 95%.
“This is a landmark breakthrough in medicine and spinal care”, says Dr. Schuler. “ We can more predictably obtain a fusion of the spine, with less pain, faster surgery, shorter hospitalization and greater patient satisfaction!”
Introducing INFUSE™ Bone Graft with LT-CAGE™ Lumbar Tapered Fusion Device
Industry leader Medtronic Sofamor Danek has altered-permanently- the landscape of spinal fusion technology. Studied under extensive clinical trials, INFUSE™ Bone Graft and the LT-CAGE™ Device consistently achieved rates of fusion and recovery equivalent to autograft. And because it contains the only bone morphogenetic protein approved for spinal fusion, INFUSE™ Bone Graft/LT-CAGE™ Device requires no autograft. With one surgery site instead of two, patients need less healing and suffer less.
BMP
Recombinant human bone morphogenetic protein (rhBMP) has long been recognized for its remarkable potential as a bone graft substitute. In fact, BMPs are the only known proteins capable of inducing new bone formation. And the first commercially available BMP ever to exhibit clinically proven osteoinductivity is the INFUSE™ Bone Graft.
- Among the most rigorously tested fusion products on the market today, including consistent greater than 95% efficacy in three pre-clinical models.
- Stimulates new bone growth as effectively as autograft in large-scale human studies.
- Proven rhBMP-2 concentration and carrier combination.
- In pre-clinical studies, the rate of bridging bone through the cages was superior.
From revelation to reality:
Marshall Urist's initial discovery of BMPs in 1965 set off an intense drive to develop a viable treatment employing the proteins. INFUSE™ Bone Graft was initially cloned and manufactured by the Genetics Institute in Cambridge, Massachusetts.
Osteoconductivity. The decisive factor:
Bone void fillers are far less osteoconductive than INFUSE™ Bone Graft/LT-CAGE™ Device. In fact, most are believed to be merely osteoconductive. That is, they merely assist the body's own mechanism for bone growth and have no ability to induce de novo bone formation. Osteoconductive materials are limited to bone void filling applications that are less challenging. And typically, those materials require mixing with harvested autograft bone.
In contrast INFUSE™ Bone Graft/LT-CAGE™ Device has been shown to grow new bone in nonbony sites, all by itself. By virtue of its undisputed osteoinductive capabilities, INFUSE™ Bone Graft/LT-CAGE™ Device is widely heralded as a pivotal introduction to the field of spinal fusion technology.
Demineralized bone matrix (DBM), another graft material available from allograft tissue banks, is also osteoinductive-but only because it contains extremely minute amounts of BMP. The inductive potential of INFUSE™ Bone Graft-that is, its concentration of BMP-is 1 million times that of the leading allograft DBM currently identified as "osteoinductive."
In fact, the grafting protein in INFUSE™ Bone Graft is pure BMP.
- For small defects, osteoconductive materials provide a scaffold around which the body must grow its own new bone.
- For larger defects, osteoconductive materials are generally considered minimally effective.
BMPs in the Bone Formation Process
The osteoinductive activity of BMPs has exciting implications in lumbar spinal fusion procedures. BMPs initiate a complex multistage cascade of events in promoting in vivo bone formation. BMPs have been shown in both in vivo and in vitro studies to induce chemotaxis (stimulation of cell migration in response to a chemical signal), and cell proliferation. A significant amount of the research on BMPs has been performed to elucidate the effects of individual BMPs at a cellular level.
One of the first steps in bone formation is the migration of mesenchymal stem cells, osteoprogenitor cells, and osteoblasts to the area. These cells respond to chemical signals that are normally released in response to bone injury. rhBMP-2 can contribute to this influx of cells since it has been shown in vitro to have chemotactic properties for stromal osteoblasts and mature osteoblasts.
As the cells migrate into the area, they begin to proliferate. This proliferation can be enhanced by mitogenic factors present at the site of injury or graft site.
Creation of INFUSE™ Bone Graft
The discovery of the natural osteoinductive factors in bone extracts was only the start of a long journey. The identification of the individual proteins responsible for the osteoinductive nature of bone extracts was a painstaking task. By using a series of extraction and purification steps, scientists were able to identify individual proteins that induce in vivo bone formation. The process was complicated by the fact that a time-consuming in vivo rat ectopic assay was necessary at each purification step to identify which fractions contained the components responsible for the osteoinductive activity. One of the osteoinductive proteins that were eventually identified was designated BMP-2. Once BMP-2 protein was identified and subsequently characterized, the next step was to identify the gene that encodes the human BMP-2 protein. The identification of the gene that codes for BMP-2 makes the production of a recombinant version of the protein possible.
Following its identification and isolation, the BMP-2 gene was inserted into the chromosome of a special type of mammalian production cell. This process is called recombination. These cells will then produce rhBMP-2, because the information provided in the BMP-2 gene is transcribed into the m-RNA and the m-RNA translated into proteins by the genetic and metabolic machinery of the mammalian production cell. The production cells are allowed to grow and multiply. The BMP-2 gene that was spliced into the production cell DNA is copied each time a production cell divides. Each new production cell is able to produce rhBMP-2 (the protein in INFUSE™ Bone Graft).
Testing INFUSE™ Bone Graft with the LT-CAGE™ Device
Capping years of promising performance in preclinical studies, INFUSE™ Bone Graft and the LT-CAGE™ Device were tested in the most rigorous manner possible, in a prospective randomized large-scale clinical trial using an open surgical approach. Involving 279 patients and 16 investigative sites, the trial achieved its initial goal-proving that INFUSE™ Bone Graft and the LT-CAGE™ Device were just as effective as autogenous bone graft.
Other advantages surfaced as well. The INFUSE™ Bone Graft/LT-CAGE™ Device group lost significantly less blood than autograft recipients. Operating times were shorter. And most notably, though statistically equivalent, rates of fusion were 94.5% in the INFUSE™ Bone Graft/LT-CAGE™ Device group and 88.7% in the autograft group at 24 months.
The Study
- Multicentered, prospective, randomized, 2-year trial.
- Patient breakdown: 136 autograft/LT-CAGE™ Device, 143 INFUSE™ Bone Graft/LT-CAGE™ Device
- Subjects had single-level, symptomatic degenerative disc disease.
The Findings
- INFUSE™ Bone Graft/LT-CAGE™ Device was found safe.
- INFUSE™ Bone Graft/LT-CAGE™ Device patients showed a slightly higher though statistically equivalent average fusion rate than autograft control group.
- From CT reconstructions, INFUSE™ Bone Graft/LT-CAGE™ Device patients exhibited new bone growth.
- Operating times and blood loss were reduced for INFUSE™ Bone Graft/LT-CAGE™
- Device open patients as compared to control patients.
- INFUSE™ Bone Graft/LT-CAGE™ Device eliminated pain and complications relating to bone harvest.
- All new bone growth was within the margins of the disc space.
In preclinical studies, INFUSE™ Bone Graft/LT-CAGE™ Device proved safe and effective in lower species before higher order testing commenced.
Threaded Cages with Absorbable Collagen Sponge
The ultimate goal of interbody spine fusion is to achieve bony fusion across a disc space that has been distracted open to its normal height from a diseased compressed state. At this time, there are no BMP carriers that can sustain compressive loads associated with disc distraction and also degrade or remodel as fusion occurs. Therefore, in the development of INFUSE™ Bone Graft/LT-CAGE™ Device for interbody spinal fusion applications, research was conducted with the use of interbody constructs such as metallic cages. The interbody constructs posses internal spaces normally packed with autologous bone graft to achieve a fusion across the intervertebral space. The bone grafting material placed inside such interbody devices is not subjected to any significant loads or forces, eliminating the requirement that the carrier for BMP be load bearing under compressive forces.
The carrier for INFUSE™ Bone Graft used in the interbody fusion studies was Type I bovine absorbable collagen sponge (ACS). This cohesive sponge is hydrated with INFUSE™ Bone Graft solution at the time of surgery. The INFUSE™ Bone Graft binds to the collagen sponge, which is then rolled and placed into the interbody device cavity.
Am I A Candidate?
INFUSE™ Bone Graft/LT-CAGE™ Device is a revolutionary technology, which can be used to eliminate the need for an autogenous bone graft to be harvested from the patient's hip. INFUSE™ Bone Graft is to be used in an Anterior Lumbar Interbody Fusion (ALIF) surgical procedure in combination with an LT-CAGE™ Lumbar Tapered Device. If you are anticipating spine surgery, ask your doctor if you are a potential candidate for INFUSE™ Bone Graft/LT-CAGE™ Device.
