Efficacy of a Standalone Microporous Ceramic Versus Autograft in Instrumented Posterolateral Spinal Fusion A Multicenter, Randomized, Intrapatient Controlled, Noninferiority Trial

Study Design: in the rest of the article written as patient- and observer-blinded, multicenter, randomized, intrapatient controlled, noninferiority trial. Objective: The aim of this study was to determine noninferiority of a biphasic calcium-phosphate (AttraX (R) Putty) as a bone graft substitute for autograft in instrumented posterolateral fusion (PLF). Summary of Background Data: Spinal fusion with autologous bone graft is a frequently performed surgical treatment. Several drawbacks of autografting have driven the development of numerous alternatives including synthetic ceramics. However, clinical evidence for the standalone use of these materials is limited. Methods: This study included 100 nontraumatic adults who underwent a primary, single- or multilevel, thoracolumbar, instrumented PLF. After instrumentation and preparation for grafting, the randomized allocation side of AttraX (R) Putty was disclosed. Autograft was applied to the contralateral side of the fusion trajectory, so each patient served as his/her own control. For the primary efficacy outcome, PLF was assessed at 1-year follow-up on computed tomography scans. Each segment and side was scored as fused, doubtful fusion, or nonunion. After correction for multilevel fusions, resulting in a single score per side, the fusion performance of AttraX (R) Putty was tested with a noninferiority margin of 15% using a 90% confidence interval (CI). Results: There were 49 males and 51 females with a mean age of 55.4 +/- 12.0 (range 27-79) years. Two-third of the patients underwent a single-level fusion and 62% an additional interbody fusion procedure. The primary analysis was based on 87 patients, including 146 instrumented segments. The fusion rate of AttraX (R) Putty was 55%versus52% at the autograft side, with an overall fusion rate of 71%. The 90% CI around the difference in fusion performance excluded the noninferiority margin (difference = 2.3%, 90% CI = -9.1% to +13.7%). Conclusion: The results of this noninferiority trial support the use of AttraX (R) Putty as a standalone bone graft substitute for autograft in instrumented thoracolumbar PLF.