Shayna Korol -

David DeWitt, MD, is a board-certified orthopedic spine surgeon at the NeuroSpine Center of Wisconsin in Appleton. Dr. DeWitt recently spoke with Becker's Spine Review about spinal implants, barriers to adopting nanosurface technology and how to overcome them to transform spine care.

Question: How do you see implant selection, in particular the implant's surface technology, impacting patient care?

Dr. David DeWitt: The implant surface controls the biology within the disc space. In particular, the body can sense whether an implant is a "friend" or "foe" based on the architecture of the implant at the nanoscale and the material of the implant. If the textures at that scale are constructed in an appropriate way that mimics natural bone, the patient's cells can interface with it in such a way to drive osteogenesis. Suboptimal nanoarchitecture does not drive as robust of an osteogenic response. And in the case of PEEK, the body actually tries to wall it off in a fibrous capsule since it causes inflammation. In my practice, the utilization of implant nanosurface technology, such as Titan Spine's nanoLOCK, has allowed me to dramatically reduce postsurgical restrictions and the prescription of opioid medication.

Manufacturers have begun to flood the market with cages claiming some sort of surface technology. A few years ago, we saw a lot of devices made of titanium-coated PEEK. However, they have been shown to be susceptible to flaking during insertion that can, in the worst case, lead to osteolysis.

More recently, 3D printed titanium implants have been released that are touted to mimic bone's natural porous structure, but porosity in and of itself does not drive bone growth. It is the nanoarchitecture on the walls of the pores that signals for bone growth or not. It is impossible to print a meaningful nanoscaled surface with today's 3D printing technology. So, it is important to understand that porosity and nanotechnology are not the same thing. Nanotechnology is the way of the future, and it's about getting more out of the implant. NanoLOCK is essentially a biologic in addition to being a spacer.

Q: Where do you see the biggest opportunities for continued growth and development in implant materials and nanotechnology for spine surgery in the future?

DD: I think the greatest opportunity for continued growth is to explore ways that nanosurface technology can affect patient recovery following surgery — and specifically how it can help address the opioid epidemic our country is facing. With spine surgery, simply achieving a fusion is not the end goal. It's really about catering to the patient and getting the fusion with less narcotic use and less loss of productivity. We have started to look at how nanoLOCK can help reduce the amount of opioid medication that is required during recovery. The early results are very encouraging, which I think is because of the suppression of inflammatory factors that has been shown to occur in vitro.

Other opportunities for growth include looking outside of spine to see where there are other orthopedic applications that can benefit from a nanoLOCK surface.

Q: What are some challenges to adoption of nanotechnology as the standard of care?

DD: It's hard to get spine surgeons to understand something you can’t see or touch and to appreciate just how small of a scale nanotechnology really is. But as we are becoming more educated on the nanotechnology story and how it is critical to the body’s response, everything is starting to swing that way.

What holds back these technologies are competing companies that don't have nanotechnology but claim that they do. This confuses the market, which makes it difficult to decide what is backed by science or what is simply a marketing ploy.

Q: How can those challenges be resolved?

DD: Education is crucial. Surgeons should, first and foremost, look to scientific evidence when making decisions on how best to care for their patients. There is a large amount of in vitro work that supports nanotechnology, and nanoLOCK specifically, in its ability to signal bone growth that starts at the cellular level, which is now starting to be tied to improved clinical outcomes. And as we get more and more clinical data, the technology becomes more and more clinically relevant.

If the results are dramatically better, the question becomes "Why am I not using it?" not "Why should I use it?"

More articles on surface technology:

New orthopedic implant surface technology fights infection: 3 insights

DePuy Synthes to promote Fibergraft for spine fusion: 4 insights

Does spine implant coating effect spinal fusion outcomes? — 5 study findings