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Hydroxyapatite possesses desirable properties as a scaffold in tissue engineering: it is
biocompatible at a site of implantation, and it is degradable to non-toxic products. Moreover, its
porosity enables infiltration of cells, nutrients and waste products. The outcome of hydroxyapatite
implantation highly depends on the extent of the host immune response. Authors emphasise major
roles of the chemical, morphological and physical properties of the surface of biomaterial used. A
number of techniques have been applied to transform the theoretical osteoconductive features of
HAp into spinal fusion systems—from integration of HAp with autograft to synthetic intervertebral
implants. The most popular uses of HAp in spine surgery include implants (ACDF), bone grafts in
posterolateral lumbar fusion and transpedicular screws coating. In the past, autologous bone graft
has been used as an intervertebral cage in ACDF. Due to the morbidity related to autograft harvesting
from the iliac bone, a synthetic cage with osteoconductive material such as hydroxyapatite seems to
be a good alternative. Regarding posterolateral lumbar fusion, it requires the graft to induce new bone
growth and reinforce fusion between the vertebrae. Hydroxyapatite formulations have shown good
results in that field. Moreover, the HAp coating has proven to be an efficient method of increasing
screw fixation strength. It can decrease the risk of complications such as screw loosening after pedicle
screw fixation in osteoporotic patients. The purpose of this literature review is to describe in vivo
reaction to HAp implants and to summarise its current application in spine surgery.