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BACKGROUND CONTEXT Bone graft extenders are being used more in spine surgery as a substitute for iliac crest bone graft, but potential conflict of interest could impact how the fusion rates are reported. PURPOSE To evaluate if the reported fusion rates are significantly greater in studies where there are potential conflicts of interest versus studies where there are no conflicts of interest. STUDY DESIGN/SETTING Meta-analysis PATIENT SAMPLE Comparison between studies where there were no reported conflicts of interest versus studies where there were reported conflicts of interest. OUTCOME MEASURES Reported fusion rates in the studies. METHODS PubMed was searched for studies evaluating fusion rates when bone graft extenders including demineralized bone matrix and hydroxyapatite and tricalcium sulfate are used as bone graft extenders with laminectomy bone. Studies were screened for one- or two-level fusions and for degenerative spinal conditions. RESULTS A total of 1,928 studies were evaluated with 86 studies included in the study. The fusion rates varied from 4% to 100%. There were 24 studies where there was a potential conflict of interest and 62 studies where there was no conflict of interest. There were 1,308 total patients in the studies where there was a potential conflict of interest and 3,696 patients in studies without conflict of interest. The fusion rates of all the studies combined was 84.63%. The fusion rates of those studies where there was a conflict of interest was 80.93% versus 86.06% when there was no conflict of interest, this was not statistically significant (p>0.07). The fusion rates with CT was 79.79% vs 87.94% when there was no CT. The fusion rates when there was an independent reviewer was 82.61% vs 85.63% when there was no independent reviewer. CONCLUSIONS There is a great variability in the reported fusion rates of bone graft extenders. The reported fusion rates were actually lower in the studies where there was a potential conflict of interest. This is counter to what would be expected. The use of CT scans and an independent reviewer seem to account for the lower reported fusion rates. The use of CT scans and independent reviewers may be a means of negating the potential conflicts of interest in fusion studies. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

H.L. Mencken wrote that ‘‘When somebody says it’s not about money. It’s about the money.’’ Once again, the issue is about the money. Five years ago, I founded the Association for Medical Ethics (AME), calling for full disclosure of all money paid to researchers by manufacturers. Over those past 5 years, I have often heard ‘‘It’s the principle, not the money,’’ from defensive clinical researchers and industry folks. Would any reasonable person believe what I write when my article is about a product whose manufacturer is paying me? Well, if it is a little money say for implant expenses for testing you will probably have more confidence than if it is millions of dollarsdwith large sum comes large doubts. In those cases, you will probably reserve judgment on using the product and first perform the necessary due diligence to confirm the findings independently. This scenario may be a big problem for industries with marginal products who have a low expectation that initial company data will stand up to independent surveillance and analysis. Conversely, companies with substantial confidence in product performance have little to fear if surgeons choose conservative ‘‘wait and see’’ attitudes and do not jump right in there using the new product. Most prudent doctors will ‘‘wait and see’’ when they detect the influence of something other than independent unbiased literature from a historically trusted source in medicine. ‘‘Wait and see’’ can be very bad for launching new products because as industry folks say, ‘‘what ruins all those good papers is follow-up.’’ Unless practice patterns have already been changed to adopt the product in the absence of independent data, if complications and bad results surface in articles with generalized use, the battle to launch a new product with efficacy or safety problems is lost. It should not be surprising then that the solution for some company executives to prevent hindering profit making is to sweep these problems (complications) under the rug