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Yang S, Zhou B, Mo J, He R, Mei K, Zeng Z, Yang G, Chen Y, Luo M, Tang S, Xiao Z. Risk factors affecting spinal fusion: A meta-analysis of 39 cohort studies. PLoS One 2024; 19:e0304473. [PMID: 38848350 PMCID: PMC11161075 DOI: 10.1371/journal.pone.0304473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/13/2024] [Indexed: 06/09/2024] Open
Abstract
PURPOSE We performed a meta-analysis to identify risk factors affecting spinal fusion. METHODS We systematically searched PubMed, Embase, and the Cochrane Library from inception to January 6, 2023, for articles that report risk factors affecting spinal fusion. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using fixed-effects models for each factor for which the interstudy heterogeneity I2 was < 50%, while random-effects models were used when the interstudy heterogeneity I2 was ≥ 50%. Using sample size, Egger's P value, and heterogeneity across studies as criteria, we categorized the quality of evidence from observational studies as high-quality (Class I), moderate-quality (Class II or III), or low-quality (Class IV). Furthermore, the trim-and-fill procedure and leave-one-out protocol were conducted to investigate potential sources of heterogeneity and verify result stability. RESULTS Of the 1,257 citations screened, 39 unique cohort studies comprising 7,145 patients were included in the data synthesis. High-quality (Class I) evidence showed that patients with a smoking habit (OR, 1.57; 95% CI, 1.11 to 2.21) and without the use of bone morphogenetic protein-2 (BMP-2) (OR, 4.42; 95% CI, 3.33 to 5.86) were at higher risk for fusion failure. Moderate-quality (Class II or III) evidence showed that fusion failure was significantly associated with vitamin D deficiency (OR, 2.46; 95% CI, 1.24 to 4.90), diabetes (OR, 3.42; 95% CI, 1.59 to 7.36), allograft (OR, 1.82; 95% CI, 1.11 to 2.96), conventional pedicle screw (CPS) fixation (OR, 4.77; 95% CI, 2.23 to 10.20) and posterolateral fusion (OR, 3.63; 95% CI, 1.25 to 10.49). CONCLUSIONS Conspicuous risk factors affecting spinal fusion include three patient-related risk factors (smoking, vitamin D deficiency, and diabetes) and four surgery-related risk factors (without the use of BMP-2, allograft, CPS fixation, and posterolateral fusion). These findings may help clinicians strengthen awareness for early intervention in patients at high risk of developing fusion failure.
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Affiliation(s)
- Shudong Yang
- Department of Orthopedic Trauma, Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Beijun Zhou
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Jiaxuan Mo
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Ruidi He
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Kunbo Mei
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Zhi Zeng
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Gaigai Yang
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Yuwei Chen
- Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Mingjiang Luo
- Department of Spine Surgery, Lishui Hospital of Wenzhou Medical University, Lishui People’s Hospital, Lishui, Zhejiang, China
| | - Siliang Tang
- Department of Spine Surgery, Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang City, Hunan Province, China
| | - Zhihong Xiao
- Department of Spine Surgery, Lishui Hospital of Wenzhou Medical University, Lishui People’s Hospital, Lishui, Zhejiang, China
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Wang T, Wang J, Hu X, Hao K, Xiang G, Wu Z, Ma Z, Li T, Chen Y, Zhao X, Zhang Y, Ma T, Ren J, Lei W, Feng Y. Diabetes-related Screw Loosening: The Distinction of Surgical Sites and the Relationship among Diabetes, Implant Stabilization and Clinical Outcomes. Orthop Surg 2023; 15:3136-3145. [PMID: 37853938 PMCID: PMC10694010 DOI: 10.1111/os.13915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 09/05/2023] [Accepted: 09/12/2023] [Indexed: 10/20/2023] Open
Abstract
OBJECTIVES Diabetes mellitus (DM) is correlated with poor clinical outcomes in spinal surgery. However, the effect of it on screw stabilization has not been investigated. The aim of this study was to evaluate the screw loosening rate and postoperative outcomes in diabetic patients and to identify potential risk factors associated with loosening. METHODS This was a retrospective study. Two hundred and forty-three patients who received cervical or lumbar internal fixation between 2015 and 2019 were enrolled. Screw loosening was assessed on radiography, and clinical outcomes were evaluated by the improvement of visual analogue scale (VAS), Oswestry disability index (ODI) or Japanese Orthopaedic Association (JOA) scores. The relationship of DM, screw loosening and clinical outcomes were analyzed with chi-square tests and regression analyses. RESULTS One hundred and twenty-two patients (50.2%) with diabetes were included in this study. Diabetes led to the increase of the rate of screw loosening in the lumbar spine, while the loosening rate did not vary significantly in the cervical spine. The occurrence of screw loosening in the lumbar spine was more likely to be associated with clinical outcomes for motor performance including walking and sitting. However, no significant effect on JOA and VAS scores in the cervical spine of screw loosening was found. Moreover, the history of DM affected the outcomes of the patients who underwent spinal surgery. CONCLUSION DM had an adverse effect on screw stabilization. The impaired improvement of clinical outcomes in diabetics after spinal surgery was related to screw loosening. In addition to the direct effects on operative wounds and neural function, the impact on the screws due to DM was also worth noting.
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Affiliation(s)
- Tianji Wang
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Jing Wang
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Xiaofan Hu
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Kaili Hao
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Geng Xiang
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Zixiang Wu
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Zhensheng Ma
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Tianqing Li
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Yu Chen
- Department of Critical Care MedicineXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Xiong Zhao
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Yang Zhang
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Tiancheng Ma
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Jingjuan Ren
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Wei Lei
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
| | - Yafei Feng
- Department of OrthopedicsXijing Hospital, The Fourth Military Medical UniversityXi'anChina
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Zhao G, He S, Chen E, Ma T, Wu K, Wu J, Li W, Song C. Biomechanical effects of osteoporosis severity on the occurrence of proximal junctional kyphosis following long-segment posterior thoracolumbar fusion. Clin Biomech (Bristol, Avon) 2023; 110:106132. [PMID: 37924756 DOI: 10.1016/j.clinbiomech.2023.106132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/17/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Proximal junctional kyphosis is a common long-term complication in adult spinal deformity surgery that involves long-segment posterior spinal fusion. However, the underlying biomechanical mechanisms of the impact of osteoporosis on proximal junctional kyphosis remain unclear. The present study was to evaluate adjacent segment degeneration and spine mechanical instability in osteoporotic patients who underwent long-segment posterior thoracolumbar fusion. METHODS Finite element models of the thoracolumbar spine T1-L5 with posterior long-segment T8-L5 fusion under different degrees of osteoporosis were constructed to analyze intervertebral disc stress characterization, vertebrae mechanical transfer, and pedicle screw system loads during various motions. FINDINGS Compared with normal bone mass, the maximum von Mises stresses of T7 and T8 were increased by 20.32%, 22.38%, 44.69%, 4.49% and 29.48%, 17.84%, 40.95%, 3.20% during flexion, extension, lateral bending, and axial rotation in the mild osteoporosis model, and by 21.21%, 18.32%, 88.28%, 2.94% and 37.76%, 15.09%, 61.47%, -0.04% in severe osteoporosis model. The peak stresses among T6/T7, T7/T8, and T8/T9 discs were 14.77 MPa, 11.55 MPa, and 2.39 MPa under lateral bending conditions for the severe osteoporosis model, respectively. As the severity of osteoporosis increased, stress levels on SCR8 and SCR9 intensified during various movements. INTERPRETATION Osteoporosis had an adverse effect on proximal junctional kyphosis. The stress levels in cortical bone, intervertebral discs and screws were increased with bone mass loss, which can easily lead to intervertebral disc degeneration, bone destruction as well as screw pullout. These factors have significantly affected or accelerated the occurrence of proximal junctional kyphosis.
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Affiliation(s)
- Gaiping Zhao
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, PR China.
| | - Shenglan He
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, PR China
| | - Eryun Chen
- School of Energy and Power Engineering, University of Shanghai for Science and Technology, Shanghai 200093, PR China
| | - Tong Ma
- Department of Bone and Joint Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, China
| | - Kunneng Wu
- Shanghai Institute of Medical Device Testing, Shanghai 201318, China
| | - Jie Wu
- Key Laboratory of Hydrodynamics, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Weiqi Li
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, PR China
| | - Chengli Song
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, PR China
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Eastlack RK, Nunley PD, Poelstra KA, Vaccaro AR, Stone M, Miller LE, Legay P, Clin J, Agarwal A. Finite element analysis comparing a PEEK posterior fixation device versus pedicle screws for lumbar fusion. J Orthop Surg Res 2023; 18:855. [PMID: 37950318 PMCID: PMC10636999 DOI: 10.1186/s13018-023-04349-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Pedicle screw loosening and breakage are common causes of revision surgery after lumbar fusion. Thus, there remains a continued need for supplemental fixation options that offer immediate stability without the associated failure modes. This finite element analysis compared the biomechanical properties of a novel cortico-pedicular posterior fixation (CPPF) device with those of a conventional pedicle screw system (PSS). METHODS The CPPF device is a polyetheretherketone strap providing circumferential cortical fixation for lumbar fusion procedures via an arcuate tunnel. Using a validated finite element model, we compared the stability and load transfer characteristics of CPPF to intact conditions under a 415 N follower load and PSS conditions under a 222 N preload. Depending on the instrumented levels, two different interbody devices were used: a lateral lumbar interbody device at L4-5 or an anterior lumbar interbody device at L5-S1. Primary outcomes included range of motion of the functional spinal units and anterior load transfer, defined as the total load through the disk and interbody device after functional motion and follower load application. RESULTS Across all combinations of interbody devices and lumbar levels evaluated, CPPF consistently demonstrated significant reductions in flexion (ranging from 90 to 98%), extension (ranging from 88 to 94%), lateral bending (ranging from 75 to 80%), and torsion (ranging from 77 to 86%) compared to the intact spine. Stability provided by the CPPF device was comparable to PSS in all simulations (range of motion within 0.5 degrees for flexion-extension, 0.6 degrees for lateral bending, and 0.5 degrees for torsion). The total anterior load transfer was higher with CPPF versus PSS, with differences across all tested conditions ranging from 128 to 258 N during flexion, 89-323 N during extension, 135-377 N during lateral bending, 95-258 N during torsion, and 82-250 N during standing. CONCLUSION Under the modeled conditions, cortico-pedicular fixation for supplementing anterior or lateral interbody devices between L4 and S1 resulted in comparable stability based on range of motion measures and less anterior column stress shielding based on total anterior load transfer measures compared to PSS. Clinical studies are needed to confirm these finite element analysis findings.
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Affiliation(s)
- Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego, CA, USA
| | | | - Kornelis A Poelstra
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marcus Stone
- Spine Institute of Louisiana, Shreveport, LA, USA
| | - Larry E Miller
- Miller Scientific, 3101 Browns Mill Road, Ste 6, #311, Johnson City, TN, 37604, USA.
| | | | | | - Aakash Agarwal
- Departments of Bioengineering and Orthopaedic Surgery, University of Toledo, Toledo, OH, USA
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Patel RV, Yearley AG, Isaac H, Chalif EJ, Chalif JI, Zaidi HA. Advances and Evolving Challenges in Spinal Deformity Surgery. J Clin Med 2023; 12:6386. [PMID: 37835030 PMCID: PMC10573859 DOI: 10.3390/jcm12196386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Surgical intervention is a critical tool to address adult spinal deformity (ASD). Given the evolution of spinal surgical techniques, we sought to characterize developments in ASD correction and barriers impacting clinical outcomes. METHODS We conducted a literature review utilizing PubMed, Embase, Web of Science, and Google Scholar to examine advances in ASD surgical correction and ongoing challenges from patient and clinician perspectives. ASD procedures were examined across pre-, intra-, and post-operative phases. RESULTS Several factors influence the effectiveness of ASD correction. Standardized radiographic parameters and three-dimensional modeling have been used to guide operative planning. Complex minimally invasive procedures, targeted corrections, and staged procedures can tailor surgical approaches while minimizing operative time. Further, improvements in osteotomy technique, intraoperative navigation, and enhanced hardware have increased patient safety. However, challenges remain. Variability in patient selection and deformity undercorrection have resulted in heterogenous clinical responses. Surgical complications, including blood loss, infection, hardware failure, proximal junction kyphosis/failure, and pseudarthroses, pose barriers. Although minimally invasive approaches are being utilized more often, clinical validation is needed. CONCLUSIONS The growing prevalence of ASD requires surgical solutions that can lead to sustained symptom resolution. Leveraging computational and imaging advances will be necessary as we seek to provide comprehensive treatment plans for patients.
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Affiliation(s)
- Ruchit V. Patel
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Alexander G. Yearley
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Hannah Isaac
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
| | - Eric J. Chalif
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Joshua I. Chalif
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Hasan A. Zaidi
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (R.V.P.); (A.G.Y.); (E.J.C.); (J.I.C.)
- Harvard Medical School, Boston, MA 02115, USA
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Aghajanloo M, Abdoli A, Poorolajal J, Abdolmaleki S. Comparison of clinical outcome of lumbar spinal stenosis surgery in patients with and without osteoporosis: a prospective cohort study. J Orthop Surg Res 2023; 18:443. [PMID: 37344883 DOI: 10.1186/s13018-023-03935-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/16/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Osteoporosis is one of the most important risk factors for failure of the spine instrumentation. Management of patients with osteoporosis who requires spinal surgery because of the difficulty in instrument placement and the potential complications is still a challenge. This study was designed to evaluate the clinical outcome of lumbar spinal canal stenosis after instrumentation in patients with and without osteoporosis. METHODS This prospective cohort study was performed from June 2018 to December 2020, in Be'sat Hospital, Hamadan, Iran. The sample consisted of patients over 50 years old referred to Be'sat Hospital with a diagnosis of lumbar spinal canal stenosis who underwent instrumental surgery (n = 107). Based on bone densitometry, the sample was divided into two groups with osteoporosis (n = 34) and without osteoporosis (n = 73). To collect data, we used a three-part researcher-made questionnaire (demographic information, medical records information, and paraclinical parameters). Statistical analyzes were performed by the Fisher Exact, chi-square, independent t-test, Multiple ANCOVA, Mann-Whitney and the Rank Wilcoxson tests using Stata version 17 software. RESULTS The mean age (SD) of patients in the two groups with and without osteoporosis was 67.9 (7.0) and 59.1 (5.1) years, respectively (p = 0.001). The results indicated that a significant difference was observed between the two groups in sex (p = 0.032), educational status (p = 0.001), marital status (p = 0.023), employment status (p = 0.004), menopausal status (p = 0.018), taking corticosteroids (p = 0.028), and body mass index (p = 0.015). Also, there was a significant difference between two groups in the loosening of instrument (p = 0.039), the postoperative pain intensity (p = 0.007), fusion (p = 0.047), and neurogenic claudication (p = 0.003). Based on multiple ANCOVA test, there was not a significant difference between two groups in the clinical and paraclinical charatecristics (p > 0.05). The mean (SD) of T-Score in the osteoporosis group was 3.06 (0.37). CONCLUSION This study provides evidence that there is no significant difference in the clinical outcomes of lumbar spine instrumentation due to spinal canal stenosis in patients with and without osteoporosis. Because of the high cost of specific instrumentation developed for patients with osteoporosis and their unavailability, it seems that the use of conventional instrumentation along with complete treatment of osteoporosis can help improve the clinical outcome of surgery in these patients.
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Affiliation(s)
- Mashhood Aghajanloo
- Department of Neurosurgery, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Ali Abdoli
- Department of Neurosurgery, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Jalal Poorolajal
- Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Sajjad Abdolmaleki
- Department of Neurosurgery, Hamadan University of Medical Sciences, Hamadan, Iran.
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Nunley PD, Eastlack RK, Miller LE, Poelstra KA, Cox JB, Shedden PM, Stone M. Metal-Free Cortico-Pedicular Device for Supplemental Fixation in Lumbar Interbody Fusion. World Neurosurg 2023; 174:4-10. [PMID: 36871655 DOI: 10.1016/j.wneu.2023.02.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE Pedicle screw fixation is a commonly utilized adjunct for lumbar interbody fusion, yet risks include screw malposition, pullout, loosening, neurovascular injury, and stress transfers leading to adjacent segment degeneration. This report describes the preclinical and initial clinical results of a minimally invasive, metal-free cortico-pedicular fixation device used for supplemental posterior fixation in lumbar interbody fusion. METHODS Safety of arcuate tunnel creation was evaluated in cadaveric lumbar (L1-S1) specimens. A finite element analysis study evaluated clinical stability of the device to pedicular screw-rod fixation at L4-L5. Preliminary clinical results were assessed by analysis of Manufacturer and User Facility Device Experience database complications, and 6-month outcomes in 13 patients treated with the device. RESULTS Among 35 curved drill holes in 5 lumbar specimens, no breaches of the anterior cortex were identified. The mean minimum distance from the anterior surface of the hole to the spinal canal ranged from 5.1 mm at L1-L2 to 9.8 mm at L5-S1. In the finite element analysis study, the polyetheretherketone strap provided comparable clinical stability and reduced anterior stress shielding compared to the conventional screw-rod construct. The Manufacturer and User Facility Device Experience database identified 1 device fracture with no clinical sequelae among 227 procedures. Initial clinical experience showed a 53% decrease in pain severity (P = 0.009), a 50% decrease in Oswestry Disability Index (P < 0.001), and no device-related complications. CONCLUSIONS Cortico-pedicular fixation is a safe and reproducible procedure that may address limitations of pedicle screw fixation. Longer term clinical data in large clinical studies are recommended to confirm these promising early results.
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Affiliation(s)
| | - Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego, CA, United States
| | | | - Kornelis A Poelstra
- The Robotic Spine Institute of Las Vegas at Nevada Spine Clinic, Las Vegas, NV, United States
| | - J Bridger Cox
- Neuroscience Specialists, Oklahoma City, OK, United States
| | - Peter M Shedden
- Greater Houston Neurosurgery Center, The Woodlands, TX, United States
| | - Marcus Stone
- Spine Institute of Louisiana, Shreveport, LA, United States
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Li YD, Hsieh MK, Chen WP, Lee DM, Tsai TT, Lai PL, Tai CL. Biomechanical evaluation of pedicle screw stability after 360-degree turnback from full insertion: effects of screw shape, pilot hole profile and bone density. Front Bioeng Biotechnol 2023; 11:1151627. [PMID: 37214307 PMCID: PMC10196264 DOI: 10.3389/fbioe.2023.1151627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/26/2023] [Indexed: 05/24/2023] Open
Abstract
Intraoperative pedicle screw depth adjustment after initial insertion, including both forward and backward adjustments, is sometimes necessary to facilitate rod application and ensure that the screw is in the correct position, which is determined by intraoperative fluoroscopy. Adjusting the screw with forward turns has no negative influence on the screw fixation stability; however, screw turnback may weaken the fixation stability. The aim of this study is to evaluate the biomechanical properties of screw turnback and demonstrate the reduction in the fixation stability after the screw is turned 360° from its full insertion position. Commercially available synthetic closed-cell polyurethane foams with three different densities simulating various degrees of bone density were utilized as substitutes for human bone. Two different screw shapes (cylindrical and conical) together with two different pilot hole profiles (cylindrical and conical) were tested. Following specimen preparation, screw pullout tests were conducted using a material test machine. The mean maximal pullout strength between full insertion and 360-degree turnback from full insertion in each setting was statistically analyzed. The mean maximal pullout strength after 360-degree turnback from full insertion was generally lower than that at full insertion. The reduced mean maximal pullout strength after turnback increased with decreasing bone density. Conical screws had significantly lower pullout strength after 360-degree turnback than cylindrical screws. The mean maximal pullout strength was reduced by up to approximately 27% after 360-degree turnback when using a conical screw in a low bone density specimen. Additionally, specimens treated with a conical pilot hole presented a less reduction in pullout strength after screw turnback as compared to those with a cylindrical pilot hole. The strength of our study was that we systematically investigated the effects of various bone densities and screw shapes on screw stability after turnback, which has rarely been reported in the literature. Our study suggests that pedicle screw turnback after full insertion should be reduced in spinal surgeries, particularly procedures that use conical screws in osteoporotic bone. Pedicle screw secured with a conical pilot hole might be beneficial for screw adjustment.
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Affiliation(s)
- Yun-Da Li
- Department of Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Orthopaedic Surgery, New Taipei Municipal TuCheng Hospital, Built and Operated by Chang Gung Medical Foundation, New TaipeiCity, Taiwan
| | - Ming-Kai Hsieh
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Weng-Pin Chen
- Department of Mechanical Engineering, National Taipei University of Technology, Taipei, Taiwan
| | - De-Mei Lee
- Department of Mechanical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ching-Lung Tai
- Department of Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
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Schömig F, Becker L, Schönnagel L, Völker A, Disch AC, Schnake KJ, Pumberger M. Avoiding Spinal Implant Failures in Osteoporotic Patients: A Narrative Review. Global Spine J 2023; 13:52S-58S. [PMID: 37084355 PMCID: PMC10177307 DOI: 10.1177/21925682231159066] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVES With an aging population, the prevalence of osteoporosis is continuously rising. As osseous integrity is crucial for bony fusion and implant stability, previous studies have shown osteoporosis to be associated with an increased risk for implant failure and higher reoperation rates after spine surgery. Thus, our review's purpose was to provide an update of evidence-based solutions in the surgical treatment of osteoporosis patients. METHODS We summarize the existing literature regarding changes associated with decreased bone mineral density (BMD) and resulting biomechanical implications for the spine as well as multidisciplinary treatment strategies to avoid implant failures in osteoporotic patients. RESULTS Osteoporosis is caused by an uncoupling of the bone remodeling cycle based on an unbalancing of bone resorption and formation and resulting reduced BMD. The reduction in trabecular structure, increased porosity of cancellous bone and decreased cross-linking between trabeculae cause a higher risk of complications after spinal implant-based surgeries. Thus, patients with osteoporosis require special planning considerations, including adequate preoperative evaluation and optimization. Surgical strategies aim towards maximizing screw pull-out strength, toggle resistance, as well as primary and secondary construct stability. CONCLUSIONS As osteoporosis plays a crucial role in the fate of patients undergoing spine surgery, surgeons need to be aware of the specific implications of low BMD. While there still is no consensus on the best course of treatment, multidisciplinary preoperative assessment and adherence to specific surgical principles help reduce the rate of implant-related complications.
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Affiliation(s)
- Friederike Schömig
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Luis Becker
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lukas Schönnagel
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Völker
- Department of Orthopaedic, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Alexander C Disch
- University Comprehensive Spine Center, University Center for Orthopedics, Traumatology and Plastic Surgery, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Klaus John Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St Marien gGmbH, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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10
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Huang W, Wang W, Xu X, Wang L, Wang J, Yu X. Radiological outcomes of PEEK rods in patients with lumbar degenerative diseases: A minimum 5-year follow-up. Front Surg 2023; 10:1146893. [PMID: 37051573 PMCID: PMC10083248 DOI: 10.3389/fsurg.2023.1146893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/08/2023] [Indexed: 03/28/2023] Open
Abstract
PurposeTo determine the long-term radiological outcomes of PEEK rods in patients with lumbar degenerative diseases.MethodsRadiological outcomes of cohort cases with lumbar degenerative diseases following PEEK rods were retrospectively studied. Disc height index (DHI) and range of motion (ROM) were measured by x-rays. The CT scans and reconstruction were used to determine screw breakage, rods fracture, screw loosening and intervertebral bony fusion status. The MRI scans were used to evaluate the changes of intervertebral discs at the non-fusion segments and adjacent segments in terms of Pfirrmann Classification.ResultsA total of 40 patients completed the mean of 74.8 ± 9.6 months follow-up, with 32 patients undergoing hybrid surgery and 8 patients undergoing non-fusion surgery. The mean DHI changed from preoperative 0.34 to 0.36 at the final follow-up and the ROM declined from 8.8° preoperatively to 3.2° at the final visit, however, both had no statistical differences. Of the 40 levels underwent non-fusion procedure, 9 levels showed disc rehydration with 7 patients from Grade 4 to Grade 3 and 2 patients from Grade 3 to Grade 2. The other 30 cases did not show distinctive change. No screw loosening or rods breakage were detected during the follow-up periods.ConclusionPEEK rods have obvious protective effects on degenerated intervertebral disc of non-fusion segments and the incidence of complications related to internal fixation is low. PEEK rods pedicle screw system is safe and effective in the treatment of lumbar degenerative diseases.
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11
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Wu J, Shi L, Liu D, Wu Z, Gao P, Liu W, Li X, Guo Z. Evaluating Screw Stability After Pedicle Screw Fixation With PEEK Rods. Global Spine J 2023; 13:393-399. [PMID: 33657872 PMCID: PMC9972285 DOI: 10.1177/2192568221996692] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
STUDY DESIGN Animal experiment. OBJECTIVE To evaluate whether the use of polyetheretherketone (PEEK) rods for posterior spinal fixation can improve screw stability. METHODS Sheep models of anterior-posterior cervical fusion were used in this study. Six sheep were randomly assigned to the PEEK rod group and titanium alloy group. A total of 8 screws and 2 fixing rods were implanted in each sheep. At 24 weeks postoperatively, a computed tomography (CT) evaluation, pull-out test, micro-CT evaluation and histological evaluation were conducted to evaluate screw stability in the harvested surgical segments. RESULT According to the CT evaluation, there were no signs of screw loosening in either group. The pull-out force and energy of the PEEK rod group were significantly higher than those of the titanium alloy rod group. Denser and thicker trabecular bone around the screw was observed in the PEEK rod group according to the micro-CT reconstructed images, and quantitative analysis of the micro-CT data confirmed this finding. In the histological evaluation, more abundant and denser bone trabeculae were also observed in the PEEK rod group. However, there was no significant difference in the bone-screw interface between the 2 groups. CONCLUSION Posterior spinal fixation with PEEK rods can increase screw stability by promoting bone growth around the screw but cannot promote bone integration at the bone-screw interface in an animal model study. This finding presents a new idea for clinical practices to reduce screw loosening rate.
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Affiliation(s)
- Jie Wu
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, Shanxi, China,Department of Orthopaedics, the 8th Medical Center of Chinese PLA General
Hospital, Beijing, China
| | - Lei Shi
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, Shanxi, China
| | - Daohong Liu
- Department of Orthopaedics, the 8th Medical Center of Chinese PLA General
Hospital, Beijing, China
| | - Zhigang Wu
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, Shanxi, China
| | - Peng Gao
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, Shanxi, China
| | - Wenwen Liu
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, Shanxi, China
| | - Xiaokang Li
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, Shanxi, China,Zheng Guo and Xiaokang Li, Department of
Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, Shanxi
710032, China. Emails: ;
| | - Zheng Guo
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, Shanxi, China,Zheng Guo and Xiaokang Li, Department of
Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi’an, Shanxi
710032, China. Emails: ;
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12
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Pei B, Xu Y, Zhao Y, Wu X, Lu D, Wang H, Wu S. Biomechanical comparative analysis of conventional pedicle screws and cortical bone trajectory fixation in the lumbar spine: An in vitro and finite element study. Front Bioeng Biotechnol 2023; 11:1060059. [PMID: 36741751 PMCID: PMC9892841 DOI: 10.3389/fbioe.2023.1060059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/09/2023] [Indexed: 01/21/2023] Open
Abstract
Numerous screw fixation systems have evolved in clinical practice as a result of advances in screw insertion technology. Currently, pedicle screw (PS) fixation technology is recognized as the gold standard of posterior lumbar fusion, but it can also have some negative complications, such as screw loosening, pullout, and breakage. To address these concerns, cortical bone trajectory (CBT) has been proposed and gradually developed. However, it is still unclear whether cortical bone trajectory can achieve similar mechanical stability to pedicle screw and whether the combination of pedicle screw + cortical bone trajectory fixation can provide a suitable mechanical environment in the intervertebral space. The present study aimed to investigate the biomechanical responses of the lumbar spine with pedicle screw and cortical bone trajectory fixation. Accordingly, finite element analysis (FEA) and in vitro specimen biomechanical experiment (IVE) were performed to analyze the stiffness, range of motion (ROM), and stress distribution of the lumbar spine with various combinations of pedicle screw and cortical bone trajectory screws under single-segment and dual-segment fixation. The results show that dual-segment fixation and hybrid screw placement can provide greater stiffness, which is beneficial for maintaining the biomechanical stability of the spine. Meanwhile, each segment's range of motion is reduced after fusion, and the loss of adjacent segments' range of motion is more obvious with longer fusion segments, thereby leading to adjacent-segment disease (ASD). Long-segment internal fixation can equalize total spinal stresses. Additionally, cortical bone trajectory screws perform better in terms of the rotation resistance of fusion segments, while pedicle screw screws perform better in terms of flexion-extension resistance, as well as lateral bending. Moreover, the maximum screw stress of L4 cortical bone trajectory/L5 pedicle screw is the highest, followed by L45 cortical bone trajectory. This biomechanical analysis can accordingly provide inspiration for the choice of intervertebral fusion strategy.
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Affiliation(s)
- Baoqing Pei
- Beijing key laboratory for design and evaluation technology of advanced implantable & interventional medical devices, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yangyang Xu
- Beijing key laboratory for design and evaluation technology of advanced implantable & interventional medical devices, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yafei Zhao
- Aerospace center hospital, Beijing, China
| | - Xueqing Wu
- Beijing key laboratory for design and evaluation technology of advanced implantable & interventional medical devices, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China,*Correspondence: Xueqing Wu, ; Shuqin Wu,
| | - Da Lu
- Beijing key laboratory for design and evaluation technology of advanced implantable & interventional medical devices, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Haiyan Wang
- School of Basic Medicine, Inner Mongolia Medical University, Hohhot, China
| | - Shuqin Wu
- School of Big Data and Information, Shanxi College of Technology, Shanxi, China,*Correspondence: Xueqing Wu, ; Shuqin Wu,
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13
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Peng JC, Guo HZ, Zhan CG, Huang HS, Ma YH, Zhang SC, Xu YR, Mo GY, Tang YC. Comparison of pedicle screw fixation with or without cement augmentation for treating single-segment isthmic spondylolisthesis in the osteoporotic spine. Sci Rep 2023; 13:827. [PMID: 36646752 PMCID: PMC9842729 DOI: 10.1038/s41598-023-27539-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 01/04/2023] [Indexed: 01/18/2023] Open
Abstract
The present study examined the necessity of cement-augmented pedicle screw fixation in osteoporotic patients with single-segment isthmic spondylolisthesis.Fifty-nine cases were reviewed retrospectively. Thirty-three cases were in the polymethylmethacrylate-augmented pedicle screw (PMMA-PS) group, and the other 26 cases were in the conventional pedicle screw (CPS) group. Evaluation data included operation time, intraoperative blood loss, hospitalization cost, hospitalization days, rates of fusion, screw loosening, bone cement leakage, visual analogue scale (VAS) scores, Oswestry disability index (ODI), lumbar lordosis (LL), pelvic tilt (PT) and sacral slope (SS).The operation time and blood loss in the CPS group decreased significantly compared to those in the PMMA-PS group. The average hospitalization cost of the PMMA-PS group was significantly higher than that of the CPS group. There was no significant difference in the average hospital stay between the 2 groups. The initial and last follow-up postoperative VAS and ODI scores improved significantly in the two groups. There were no significant differences in VAS and ODI between the 2 groups at each time point. The last postoperative spine-pelvic parameters were significantly improved compared with those preoperatively. In the PMMA-PS group, the fusion rate was 100%. The fusion rate was 96.15% in the CPS group. No significant difference was found between the two groups for the fusion rate. Nine patients in the PMMA-PS group had bone cement leakage. There was no screw loosening in the PMMA-PS group. There were 2 cases of screw loosening in the CPS group. There were no significant differences in screw loosening, postoperative adjacent segment fractures, postoperative infection or postoperative revision between the 2 groups. The use of PMMA-PS on a regular basis is not recommended in posterior lumbar interbody fusion for the treatment of single-segment isthmic spondylolisthesis with osteoporosis.
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Affiliation(s)
- Jian-Cheng Peng
- Longgang Orthopedics Hospital of Shenzhen, Shenzhen, 518100, China
| | - Hui-Zhi Guo
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Chen-Guang Zhan
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Hua-Sheng Huang
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yan-Huai Ma
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Shun-Cong Zhang
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yue-Rong Xu
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Guo-Ye Mo
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China.,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China
| | - Yong-Chao Tang
- The 1St Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, 12 Airport Road, Baiyun District, Guangzhou, 510405, Guangdong, China. .,Spine Surgery Department, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510407, China.
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14
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Witek L, Parente PEL, Torroni A, Greenberg M, Nayak VV, Hacquebord JH, Coelho PG. Evaluation of instrumentation and pedicle screw design for posterior lumbar fixation: A pre‐clinical
in vivo/ex vivo
ovine model. JOR Spine 2023. [DOI: 10.1002/jsp2.1245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Lukasz Witek
- Biomaterials Division New York University College of Dentistry New York New York USA
- Department of Biomedical Engineering New York University Tandon School of Engineering Brooklyn New York USA
| | | | - Andrea Torroni
- Hansjörg Wyss Department of Plastic Surgery New York University School of Medicine New York New York USA
| | - Michael Greenberg
- Biomaterials Division New York University College of Dentistry New York New York USA
| | - Vasudev Vivekanand Nayak
- Biomaterials Division New York University College of Dentistry New York New York USA
- Department of Mechanical and Aerospace Engineering New York University Tandon School of Engineering Brooklyn New York USA
| | - Jacques Henri Hacquebord
- Hansjörg Wyss Department of Plastic Surgery New York University School of Medicine New York New York USA
- Department of Orthopedic Surgery New York University School of Medicine New York New York USA
| | - Paulo G. Coelho
- Division of Plastic Surgery, Department of Surgery University of Miami Miller School of Medicine Miami Florida USA
- Department of Biochemistry and Molecular Biology University of Miami Miller School of Medicine Miami Florida USA
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15
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Ramakrishna VAS, Chamoli U, Mukhopadhyay SC, Diwan AD, Prusty BG. Measuring compressive loads on a 'smart' lumbar interbody fusion cage: Proof of concept. J Biomech 2023; 147:111440. [PMID: 36640615 DOI: 10.1016/j.jbiomech.2023.111440] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/08/2022] [Accepted: 01/06/2023] [Indexed: 01/11/2023]
Abstract
There are several complications associated with lumbar interbody fusion surgery however, pseudarthrosis (non-union) presents a multifaceted challenge in the postoperative management of the patient. Rates of pseudarthrosis range from 3 to 20 % in patients with healthy bone and 20 to 30 % in patients with osteoporosis. The current methods in post-operative follow-up - radiographs and CT, have high false positive rates and poor agreement between them. The aim of this study was to develop and test a proof-of-concept load-sensing interbody cage that may be used to monitor fusion progression. Piezoresistive pressure sensors were calibrated and embedded within a polyether ether ketone (PEEK) interbody cage. Silicone and poly (methyl methacrylate) (PMMA) were inserted in the graft regions to simulate early and solid fusion. The load-sensing cage was subjected to distributed and eccentric compressive loads up to 900 N between synthetic lumbar vertebral bodies. Under maximum load, the anterior sensors recorded a 56-58 % reduction in pressure in the full fusion state compared to early fusion. Lateral regions measured a 36-37 % stress reduction while the central location reduced by 45 %. The two graft states were distinguishable by sensor-recorded pressure at lower loads. The sensors more effectively detected left and right eccentric loads compared to anterior and posterior. Further, the load-sensing cage was able to detect changes in endplate stiffness. The proof-of-concept 'smart' cage could detect differences in fusion state, endplate stiffness, and loading conditions in this in vitro experimental setup.
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Affiliation(s)
- Vivek A S Ramakrishna
- School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney, Kensington, New South Wales, Australia; Spine Labs, St. George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia; School of Engineering, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, Australia.
| | - Uphar Chamoli
- Spine Labs, St. George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia; School of Biomedical Engineering, Faculty of Engineering and Information Technology, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Subhas C Mukhopadhyay
- School of Engineering, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, Australia
| | - Ashish D Diwan
- Spine Labs, St. George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Spine Service, Department of Orthopaedic Surgery St. George Hospital Campus, Kogarah, New South Wales, Australia
| | - B Gangadhara Prusty
- School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney, Kensington, New South Wales, Australia
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16
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Kao FC, Hsu YC, Chen TS, Tu YK, Liu PH. Incidence and risk factors of vertebral body collapse after posterior instrumented spinal fusion in elderly patients: An observational study. Medicine (Baltimore) 2022; 101:e31604. [PMID: 36343049 PMCID: PMC9646654 DOI: 10.1097/md.0000000000031604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This study investigates the incidence and risk factors of new vertebral body collapse (VC) after posterior instrumented spinal fusion in patients older than 70 years. This retrospective study analyzed the data of elderly patients who underwent posterior instrumented spinal fusion in the thoracolumbar spine between January 2013 and December 2017. The 2 subsamples comprised of patients who had experienced vertebral compression fracture (VCF) before the index spinal surgery (group 1, n = 324) and those who had not (group 2, n = 1040). We recorded and analyzed their baseline characteristics, their underlying comorbidities, and the details of their current instrumented spinal fusion. The incidences of new VC and screw loosening were recorded. In groups 1 and 2, the incidences of new VC were 31.8% and 22.7%, respectively, and those of new VC with screw loosening were 25.6% and 33%, respectively. The risk factor was upper screw level at the thoracolumbar junction (hazard ratio [HR] = 2.181, 95% confidence interval [CI]: 1.135-4.190) with previous VCF. The risk factors were age ≥ 80 years (HR = 1.782, 95% CI: 1.132-2.805), instrumented levels > 4 (HR = 1.774, 95% CI: 1.292-2.437), and peptic ulcer (HR = 20.219, 95% CI: 2.262-180.731) without previous VCF. Clinicians should closely monitor new VC after posterior instrumented spinal fusion in elderly patients with previous VCF with upper screw level at the thoracolumbar junction and in patients without previous VCF aged ≥ 80 years, with instrumented levels > 4 and peptic ulcer.
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Affiliation(s)
- Feng-Chen Kao
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of Orthopedics, E-Da Dachang Hospital, Kaohsiung, Taiwan
| | - Yao-Chun Hsu
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Division of Gastroenterology, E-Da Hospital, Kaohsiung, Taiwan
| | - Tzu-Shan Chen
- Department of Medical Research, E-Da Hospital, Kaohsiung, Taiwan
- Department of Medical Imaging and Radiological Sciences, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- * Correspondence: Yuan-Kun Tu, Department of Orthopedics, E-Da Hospital/I-Shou University; No. 1, E-Da Rd., Yan-Chao District, Kaohsiung 824, Taiwan (e-mail: )
| | - Pao-Hsin Liu
- Department of Biomedical Engineering, College of Medicine, I-Shou University, Kaohsiung, Taiwan
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17
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Liu ZX, Gao ZW, Chen C, Liu ZY, Cai XY, Ren YN, Sun X, Ma XL, Du CF, Yang Q. Effects of osteoporosis on the biomechanics of various supplemental fixations co-applied with oblique lumbar interbody fusion (OLIF): a finite element analysis. BMC Musculoskelet Disord 2022; 23:794. [PMID: 35986271 PMCID: PMC9392247 DOI: 10.1186/s12891-022-05645-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 07/12/2022] [Indexed: 11/25/2022] Open
Abstract
Background Oblique lumbar interbody fusion (OLIF) is an important surgical modality for the treatment of degenerative lumbar spine disease. Various supplemental fixations can be co-applied with OLIF, increasing OLIF stability and reducing complications. However, it is unclear whether osteoporosis affects the success of supplemental fixations; therefore, this study analyzed the effects of osteoporosis on various supplemental fixations co-applied with OLIF. Methods We developed and validated an L3-S1 finite element (FE) model; we assigned different material properties to each component and established models of the osteoporotic and normal bone lumbar spine. We explored the outcomes of OLIF combined with each of five supplemental fixations: standalone OLIF; OLIF with lateral plate fixation (OLIF + LPF); OLIF with translaminar facet joint fixation and unilateral pedicle screw fixation (OLIF + TFJF + UPSF); OLIF with unilateral pedicle screw fixation (OLIF + UPSF); and OLIF with bilateral pedicle screw fixation (OLIF + BPSF). Under the various working conditions, we calculated the ranges of motion (ROMs) of the normal bone and osteoporosis models, the maximum Mises stresses of the fixation instruments (MMSFIs), and the average Mises stresses on cancellous bone (AMSCBs). Results Compared with the normal bone OLIF model, no demonstrable change in any segmental ROM was apparent. The MMSFIs increased in all five osteoporotic OLIF models. In the OLIF + TFJF + UPSF model, the MMSFIs increased sharply in forward flexion and extension. The stress changes of the OLIF + UPSF, OLIF + BPSF, and OLIF + TFJF + UPSF models were similar; all stresses trended upward. The AMSCBs decreased in all five osteoporotic OLIF models during flexion, extension, lateral bending, and axial rotation. The average stress change of cancellous bone was most obvious under extension. The AMSCBs of the five OLIF models decreased by 14%, 23.44%, 21.97%, 40.56%, and 22.44% respectively. Conclusions For some supplemental fixations, the AMSCBs were all reduced and the MMSFIs were all increased in the osteoporotic model, compared with the OLIF model of normal bone. Therefore, the biomechanical performance of an osteoporotic model may be inferior to the biomechanical performance of a normal model for the same fixation method; in some instances, it may increase the risks of fracture and internal fixation failure.
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18
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De Kater EP, Weststeijn CF, Sakes A, Breedveld P. A Toggling Resistant In-Pedicle Expandable Anchor: A Preliminary Study. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:3313-3317. [PMID: 36086162 DOI: 10.1109/embc48229.2022.9871068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Loosening of pedicle screws after spinal fusion surgery can prevent the desired fusion between vertebrae and may be a reason for revision surgery. Especially in osteoporotic bone, toggling of pedicle screws is a common problem that compromises the fixation strength of these screws and can lead to loosening or axial pull-out of the screw. In this study, we explore the use of an in-pedicle expandable anchor that shapes to the pedicle to increase the toggling resistance of the anchor by increasing the contact area between the anchor and the dense cortical bone of the pedicle. A scaled-up, two-dimensional prototype was designed. The prototype consists of a bolt and ten stainless steel wedges that expand by tensioning the bolt. During the expansion, the wedges are required to compress the cancellous bone. Based on the first preliminary experiment, it was found that the expansion of the wedges resulted in successful compression of 5 PCF cancellous bone phantom (Sawbones). This preliminary study shows that an expandable in-pedicle anchor could be a feasible option to increase the toggling resistance of spinal bone anchors, especially in osteoporotic bone. Clinical Relevance- Toggling of pedicle screws is a major cause of screw loosening. In this preliminary study, the use of an in-pedicle expandable anchor to increase the toggling resistance of spinal bone anchors is explored.
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19
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Beyond the pedicle screw-a patent review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1553-1565. [PMID: 35380271 DOI: 10.1007/s00586-022-07193-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE This review provides an overview of the patent literature on posteriorly placed intrapedicular bone anchors. Conventional pedicle screws are the gold standard to create a fixation in the vertebra for spinal fusion surgery but may lack fixation strength, especially in osteoporotic bone. The ageing population demands new bone anchors that have an increased fixation strength, that can be placed safely, and, if necessary, can be removed without damaging the surrounding tissue. METHODS The patent search was conducted using a classification search in the Espacenet patent database. Only patents with a Cooperative Patent Classification of A61B17/70 or A61B17/7001 concerning spinal positioners and stabilizers were eligible for inclusion. The search query resulted in the identification of 731 patents. Based on preset inclusion criteria, a total of 56 unique patents on different anchoring methods were included, reviewed and categorized in this study. RESULTS Five unique fixation methods were identified; (1) anchors that use threading, (2) anchors that utilize a curved path through the vertebra, (3) anchors that (partly) expand, (4) anchors that use cement and (5) anchors that are designed to initiate bone ingrowth. Of the anchor designs included in this study, eight had a corresponding commercial product, six of which were evaluated in clinical trials. CONCLUSION This review provides insights into worldwide patented intrapedicular bone anchors that aim to increase the fixation strength compared to the conventional pedicle screw. The identified anchoring methods and their working principles can be used for clinical decision-making and as a source of inspiration when designing novel bone anchors.
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20
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Prediction of Sacral Screw Loosening after Lumbosacral Surgeries Involving Rigid Fixation of Sacral Bone Using Preoperative Computed Tomography Scans. BIOMED RESEARCH INTERNATIONAL 2022; 2022:7123139. [PMID: 35655477 PMCID: PMC9152424 DOI: 10.1155/2022/7123139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 04/04/2022] [Accepted: 04/30/2022] [Indexed: 11/21/2022]
Abstract
Objective To find a preoperative computed tomography-based method to predict the incidence of sacral screw loosening and assist surgical planning. Methods Surgically treated patients for degenerative lumbosacral disorders with rigid pedicle screw fixation of patients with L5-S1 vertebra in our center from January 2016 to January 2021 were retrospectively included in the current study. CT scan attenuation of the horizontal plane of the sacrum was measured with Hounsfield units (HU). Postoperative X-ray tests were used to diagnose screw loosening. The data was analyzed by independent sample t-tests, X2 analysis, Pearson correlation analysis, and ROC curve analysis. Results A total of 162 (114 male, 48 female, average age 63.7 ± 7.3 years) patients were included in the final analysis. Significant differences were found between the screw loosening group and nonloosening group concerning the HU value of the sacrum at the horizontal plane (P < 0.01). In ROC curve analysis, AUC was 0.674 (95% CI: 0.592-0.756). A cutoff of 200 HU provided 64.8% sensitivity and 62.4% specificity, and a cutoff of 150 HU provided 90.2% sensitivity. Conclusions Analyzing 162 patients with at least 12 months of follow-up, we propose cutoff CT attenuation values of 200 HU and 150 HU to take moderate and radical measures of screw augmentation to prevent screw loosening in the sacral bone.
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Bokov A, Kalinina S, Leontev A, Mlyavykh S. Circumferential Fusion Employing Transforaminal vs. Direct Lateral Lumbar Interbody Fusion—A Potential Impact on Implants Stability. Front Surg 2022; 9:827999. [PMID: 35651676 PMCID: PMC9150499 DOI: 10.3389/fsurg.2022.827999] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDifferent fusion techniques were introduced in clinical practice in patients with lumbar degenerative disc disease, however, no evidence has been provided on the advantages of one technique over another.The Objective of This StudyIs to assess the potential impact of circumferential fusion employing transforaminal lumbar interbody fusion (TLIF) vs. direct lateral interbody fusion (DLIF) on pedicle screw stability.Materials and MethodsThis is a single-center prospective evaluation of consecutive 138 patients with degenerative instability of lumbar spinal segments. Either conventional transforaminal lumbar interbody fusion (TLIF) with posterior fusion or direct lateral interbody fusion (DLIF) using cages of standard dimensions, were applied. The conventional open technique was used to supplement TLIF with pedicle screws while percutaneous screw placement was used in patients treated with DLIF. The duration of the follow-up accounted for 24 months. Signs of pedicle screws loosening (PSL) and bone union after fusion were assessed by the results of CT imaging. Fisher‘s exact test was used to assess the differences in the rate of CT loosening and revision surgery because of implant instability. Logistic regression was used to assess the association between potential factors and complication rate.ResultsThe rate of PSL detected by CT and relevant revision surgery in groups treated with TLIF and DLIF accounted for 25 (32.9%) vs. 2 (3.2%), respectively, for the former and 9 (12.0%) vs. 0 (0%) for the latter (p < 0.0001 and p = 0.0043) respectively. According to the results of logistic regression, a decrease in radiodensity values and a greater number of levels fused were associated with a rise in PSL rate. DLIF application in patients with radiodensity below 140 HU was associated with a considerable decrease in complication rate. Unipolar or bipolar pseudoarthrosis in patients operated on with TLIF was associated with a rise in PSL rate while patients treated with DLIF tolerate delayed interbody fusion formation. In patients treated with TLIF supplementary total or partial posterior fusion resulted in a decline in PSL rate.ConclusionEven though the supplementary posterior fusion may considerably reduce the rate of PSL in patients treated with TLIF, the application of DLIF provide greater stability resulting in a substantial decline in PSL rate and relevant revision surgery.
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Affiliation(s)
- Andrey Bokov
- Department of Oncology and Neurosurgery, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Svetlana Kalinina
- Department of Traumatology, Orthopedics and Neurosurgery, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Andrei Leontev
- Department of Oncology and Neurosurgery, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Sergey Mlyavykh
- Department of Traumatology, Orthopedics and Neurosurgery, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
- *Correspondence: Sergey Mlyavykh
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The Usefulness of Trabecular CT Attenuation Measurement at L4 Level to Predict Screw Loosening After Degenerative Lumbar Fusion Surgery: Consider Number of Fused Levels and Postoperative Sagittal Balance. Spine (Phila Pa 1976) 2022; 47:745-753. [PMID: 35102120 DOI: 10.1097/brs.0000000000004330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To evaluate the absolute value of L4 trabecular region-of-interest (t-ROI) computed tomography (CT) attenuation, which can predict pedicle screw loosening, and determine the changes in value according to number of fused levels and sagittal balance in patients undergoing lumbar fusion surgery. SUMMARY OF BACKGROUND DATA Although osteoporosis was not diagnosed in spinal dual x-ray absorptiometry preoperatively, we encountered several cases of screw loosening within 1 year of lumbar fusion surgery. METHODS We enrolled 478 patients and analyzed factors related to screw loosening. We evaluated the association between L4 t-ROI CT attenuation and screw loosening and determined the best cutoff value of t L4 t-ROI CT attenuation for predicting screw loosening. RESULTS The number of fused levels, postoperative C7-S1 sagittal vertical axis (SVA), and L4 t-ROI CT attenuation were independently correlated with screw loosening. According to number of fused level and postoperative C7-T1 SVA (≥36.9 mm or <36.9 mm), in patients with one-level fusion and C7-S1 SVA less than 36.9 mm, the optimal cutoff point of the L4 t-ROI CT attenuation predicting screw loosening was 106.5 Hounsfield unit (HU). L4 t-ROI attenuation did not change until two-level fusions. In patients with three-level fusions and C7-S1 SVA less than 36.9 mm, the optimal cutoff point of the L4 t-ROI CT attenuation predicting screw loosening was 159.0 HU. The optimal cutoff point of L4 t-ROI CT attenuation in patients with three-level fusions and C7-S1 SVA more than or equal to 36.9 mm was 191.0 HU. CONCLUSION L4 t-ROI CT attenuation value considering number of fused levels and sagittal balance is an accurate measurement method to predict screw loosening. Spine surgeons should be aware of the L4 t-ROI attenuation before surgery to improve the fusion rate and reduce instrument-related complications of lumbar spine surgery in osteoporotic patients. LEVEL OF EVIDENCE 3.
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Innovation of Surgical Techniques for Screw Fixation in Patients with Osteoporotic Spine. J Clin Med 2022; 11:jcm11092577. [PMID: 35566703 PMCID: PMC9101243 DOI: 10.3390/jcm11092577] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/30/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023] Open
Abstract
Osteoporosis is a common disease in elderly populations and is a major public health problem worldwide. It is not uncommon for spine surgeons to perform spinal instrumented fusion surgeries for osteoporotic patients. However, in patients with severe osteoporosis, instrumented fusion may result in screw loosening, implant failure or nonunion because of a poor bone quality and decreased pedicle screw stability as well as increased graft subsidence risk. In addition, revision surgeries to correct failed instrumentation are becoming increasingly common in patients with osteoporosis. Therefore, techniques to enhance the fixation of pedicle screws are required in spinal surgeries for osteoporotic patients. To date, various instrumentation methods, such as a supplemental hook, sublaminar taping and sacral alar iliac screws, and modified screwing techniques have been available for reinforcing pedicle screw fixation. In addition, several materials, including polymethylmethacrylate and hydroxyapatite stick/granules, for insertion into prepared screw holes, can be used to enhance screw fixation. Many biomechanical tests support the effectiveness of these augmentation methods. We herein review the current therapeutic strategies for screw fixation and augmentation methods in the surgical treatment of patients with an osteoporotic spine.
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Hydroxyapatite Use in Spine Surgery—Molecular and Clinical Aspect. MATERIALS 2022; 15:ma15082906. [PMID: 35454598 PMCID: PMC9030649 DOI: 10.3390/ma15082906] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 04/03/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022]
Abstract
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.
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Su YF, Tsai TH, Lieu AS, Lin CL, Chang CH, Tsai CY, Su HY. Bone-Mounted Robotic System in Minimally Invasive Spinal Surgery for Osteoporosis Patients: Clinical and Radiological Outcomes. Clin Interv Aging 2022; 17:589-599. [PMID: 35497053 PMCID: PMC9041149 DOI: 10.2147/cia.s359538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/11/2022] [Indexed: 01/02/2023] Open
Abstract
Purpose Severe complications, including screw loosening events and low fusion rates, in spinal fusion surgery using the traditional open method are problematic. This retrospective study aimed to evaluate the rate of screw loosening and the clinical outcomes of bone-mounted miniature robot-assisted pedicle screw placement in patients treated for degenerative spinal disease. Patients and Methods Data were collected from the medical records of 118 patients (mean age, 69 years). Differences in clinical outcomes, including the Oswestry disability index, visual analog scale score, screw loosening rate, cage fusion rate, and complications, were evaluated among different bone mineral densities. Results The screw loosening and cage fusion rates for all patients, normal bone mineral density, osteopenia, and osteoporosis groups were 12%, 8.6%, 13.1%, and 14%, respectively, and 85.3%, 93%, 82.5%, and 81.4%, respectively. There was a higher screw loosening rate and a lower cage fusion rate in the osteopenia and osteoporosis groups than in the normal bone density group. The accuracy of the screw placement was 97.3%. There were no statistically significant differences in the Oswestry disability index and visual analog scale scores, and no major complications for dural tear or vascular or visceral injury. Conclusion Our study demonstrated an acceptable screw loosening rate in patients with osteoporosis compared to that in patients with normal bone mineral density. The robotic system resulted in accurate screw placement in patients with osteoporosis.
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Affiliation(s)
- Yu-Feng Su
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tai-Hsin Tsai
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ann-Shung Lieu
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Lung Lin
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Hui Chang
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Yu Tsai
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Ph.D. Program in Environmental and Occupational Medicine, College of Medicine, Kaohsiung Medical University and National Health Research Institutes, Kaohsiung, Taiwan
- Post Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Correspondence: Cheng-Yu Tsai; Hui-Yuan Su, Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung, 80708, Taiwan, Tel +886-7-3215049, Fax +886-7-3215039, Email ;
| | - Hui-Yuan Su
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Lai O, Zhang X, Hu Y, Sun X, Zhu B, Dong W, Yuan Z. Long-segment fixation VS short-segment fixation combined with kyphoplasty for osteoporotic thoracolumbar burst fracture. BMC Musculoskelet Disord 2022; 23:160. [PMID: 35177064 PMCID: PMC8855549 DOI: 10.1186/s12891-022-05109-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 02/11/2022] [Indexed: 11/30/2022] Open
Abstract
Background To retrospectively compare clinical and radiological results of long-segment fixation (LF) and six-screw short-segment fixation combined with kyphoplasty (SSFK) for osteoporotic thoracolumbar burst fracture (OTBF). Methods Forty patients affected by OTBF with mean age of 61.85 years were included in this study. The mean follow-up period was 13.63 months. Twenty-four patients were treated by SSFK, and 16 patients were treated by LF. Clinical outcomes, radiological parameters and complications were assessed and compared. Results The mean operative time and blood loss were 89.71 ± 7.62 min and 143.75 ± 42.51 ml for SSFK group, respectively; 111.69 ± 12.25 min (P < 0.01) and 259.38 ± 49.05 ml (P < 0.01) for LF group, respectively. The two groups were similar in terms of preoperative radiological and clinical results. Compared with preoperative values, both groups achieved significant improvement in terms of VAS, ODI, Cobb angle and anterior vertebral body height (AVH) ratio at final follow-up. However, during the follow-up period, significant loss of Cobb angle and AVH ratio were observed for both groups. Five cases (20.83%) of asymptomatic cement leakage were observed in SSFK group. One case of implant failure and two cases of adjacent or non-adjacent vertebral fractures were observed in LF group. Conclusions Both SSFK and LF are safe and effective for treatment of OTBF. Comparatively, SSFK is less invasive and can preserve more motion segments, which may be a more valuable surgical option in some elderly patients. A high-quality randomized controlled study is required to confirm our finding in the future.
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Affiliation(s)
- Oujie Lai
- Department of Spine Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Xinliang Zhang
- Department of Spine Surgery, Xi'an Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Yong Hu
- Department of Spine Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, People's Republic of China.
| | - Xiaoyang Sun
- Department of Spine Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Binke Zhu
- Department of Spine Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Weixin Dong
- Department of Spine Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Zhenshan Yuan
- Department of Spine Surgery, Ningbo No.6 Hospital, Ningbo, Zhejiang, People's Republic of China
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Koepke LG, Weiser L, Stangenberg M, Dreimann M, Heuer A, Strahl A, Viezens L. Outcome after Posterior Vertebral Column Resection in Patients with Severe Osteoporotic Fractures—A Retrospective Analysis from Two Centers. Medicina (B Aires) 2022; 58:medicina58020277. [PMID: 35208600 PMCID: PMC8879154 DOI: 10.3390/medicina58020277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: In osteoporotic fractures of the spine with resulting kyphosis and threatening compression of neural structures, therapeutic decisions are difficult. The posterior vertebral column resection (pVCR) has been described by different authors as a surgical treatment in a single-stage posterior procedure. The aim of this study is to evaluate midterm outcomes of patients treated by pVCR due to severe osteoporotic fractures. Materials and Methods: Retrospective data analysis of all the patients treated for osteoporotic fractures by pVCR from 2012–2020 at two centers was performed. Demographic data, visual analog scale (VAS), Frankel scale (FS), Karnofsky performance status (KPS), radiological result and spinal fusion rates were evaluated. Results: A total of 17 patients were included. The mean age was 70 ± 10.2 y. The mean VAS decreased significantly from 7.7 ± 2.8 preoperatively to 3.0 ± 1.6 at last follow-up (p < 0.001) and the segmental kyphosis decreased from 29.4 ± 14.1° to 7.9 ± 8.0° (p < 0.001). The neurologic function on the FS did not worsen in any and improved in four of the patients. The median KPS remained stable over the whole observation period (70% vs. 70%). Spinal fusion was observed in nine out of nine patients who received CT follow-up >120 days after index surgery. Conclusions: This study showed that pVCR is a safe surgical technique with few surgical complications and no neurological deterioration considering the cohort. The patients’ segmental kyphosis and VAS improved significantly, while the KPS remained stable.
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Affiliation(s)
- Leon-Gordian Koepke
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (M.S.); (M.D.); (A.H.); (L.V.)
- Correspondence: ; Tel.: +49-17632605843
| | - Lukas Weiser
- Clinic for Trauma, Orthopedics and Plastic Surgery, University Medical Center Göttingen, Georg-August-Universität, 37075 Göttingen, Germany;
| | - Martin Stangenberg
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (M.S.); (M.D.); (A.H.); (L.V.)
| | - Marc Dreimann
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (M.S.); (M.D.); (A.H.); (L.V.)
| | - Annika Heuer
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (M.S.); (M.D.); (A.H.); (L.V.)
- Mildred Scheel Cancer Career Center HaTriCS4, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - André Strahl
- Division of Orthopedics, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Lennart Viezens
- Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (M.S.); (M.D.); (A.H.); (L.V.)
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Xi X, Zeng Z, Li F, Wang C, Ma B, Xie N, Tsai TY, Li G, Yu Y, Cheng L. Caudad Insertion of Pedicle Screws Facilitates Interbody Distraction During Spondylolisthetic Vertebrae Restoration: A Retrospective Study. Pain Ther 2021; 10:1537-1550. [PMID: 34524629 PMCID: PMC8586389 DOI: 10.1007/s40122-021-00315-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/27/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Based on the results of long-term clinical and radiological follow-up studies of decompression and fusion with internal fixation for degenerative lumbar spondylolisthesis (DLS), we recognized that the direction of the pedicle screw affects the stability of the fixation. However, few studies have analyzed the role of pedicle screw insertion trajectory in disc height recovery after fusion. We therefore analyzed patients' general information, clinical efficacy and sagittal, coronal and implant parameters to determine whether there is a correlation between the insertion trajectory of screws and the recovery of intervertebral space height, with the ultimate aim to provide a basis for improving the clinical efficacy and radiological outcomes of patients with DLS and to identify an optimal technique for spine surgeons that would benefit patients with spondylolisthesis. METHODS From May 2015 to October 2019, patients who underwent single-segment decompression and fusion with internal fixation for DLS at our department were screened for enrollment in the study. The clinical history, pre- and post-operative lumbar sagittal parameters, intervertebral height, rate of recovery from spondylolisthesis and pedicle screw angle of inpatients were recorded and followed up for at least 6 months. Clinical assessments included the Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS) for lower back and leg pain. Data on screw angle, fusion segment intervertebral space height and clinical outcome were the primary outputs. Pearson correlation and multivariate regression analyses were performed to investigate the relationship between the pedicle screw angle, the sagittal parameters of the fusion segment and clinical efficacy. RESULTS A total of 50 patients were initially enrolled, two patients were lost to follow-up after 6 months, 48 patients (17 men, 31 women) were eventually enrolled, and the follow-up rate was 96%. At least 6 months after the operation, vertebral spondylolisthesis improved to varying degrees [> 80% in 17 cases (35.4%) and > 20% in 43 cases (87.5%), respectively]. Changes in disc height (DH) were significantly associated with lower pedicle screw angle, while lumbar lordosis and segment lordosis remained the same. Multivariate regression analysis showed a significant negative correlation between the upper and lower pedicle screw angles and the change in DH (P < 0.05). At 2 weeks post-operation, the VAS score for low back pain and the ODI had improved significantly compared to pre-operation (P < 0.05). CONCLUSIONS These results suggest that the Caudad insertion trajectory technique of pedicle screws may be an ideal alternative for the treatment of DLS. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR): ChiCTR1800020368.
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Affiliation(s)
- Xin Xi
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China ,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China
| | - Zhili Zeng
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China ,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China
| | - Fuping Li
- Department of Spine Surgery, Shanghai Fourth People’s Hospital Affiliated to Tongji University School of Medicine, Shanghai, 200434 China
| | - Cong Wang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, 200030 China
| | - Bin Ma
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China ,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China
| | - Ning Xie
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China ,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, 200030 China
| | - Guoan Li
- Department of Orthopedic Surgery, Orthopaedic Bioengineering Research Center, Newton-Wellesley Hospital/Harvard Medical School, Wellesley, MA USA
| | - Yan Yu
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China. .,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China.
| | - Liming Cheng
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China ,Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration, Ministry of Education, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065 China
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Yagi M, Ogiri M, Holy CE, Bourcet A. Comparison of clinical effectiveness of fenestrated and conventional pedicle screws in patients undergoing spinal surgery: a systematic review and meta-analysis. Expert Rev Med Devices 2021; 18:995-1022. [PMID: 34503387 DOI: 10.1080/17434440.2021.1977123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pedicle screws are commonly used for spinal procedures for fusion stability, which is particularly important in osteoporotic patients, who are at an increased risk of requiring revision procedures. AREAS COVERED A systematic review and meta-analysis were conducted to compare clinical effectiveness of conventional pedicle screws (CPS) vs fenestrated pedicle screws (FPS) in patients undergoing spinal surgery. Primary outcomes included screw loosening, revision surgeries (involving an implant) and reoperations (not involving intervention on an implant) in patients treated with CPS vs FPS, sub-stratified by with and without osteoporosis. Secondary outcomes included changes in pain scores. Forty-eight studies with 8,302 patients were included, with 1,565 (19.18%) treated with FPS and 6,710 (80.82%) treated with CPS. FPS was associated with a lower risk of screw loosening (p = 0.001) vs CPS. In the general population, there was a non-significant trend of lower revision rate, but no difference in reoperation rate, between patients treated with FPS vs CPS. In osteoporotic patients, revision rates were significantly lower for FPS vs CPS (p = 0.009). EXPERT OPINION This review suggests that FPS are effective for surgical fixation and reduce rates of screw loosening, and in osteoporotic patients, revision surgeries, compared to CPS.
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Affiliation(s)
- Mitsuru Yagi
- Department of Orthopedic Surgery, Keio University School of Medicine, Japan
| | - Mami Ogiri
- Division of the Chief Medical Officer, Johnson & Johnson K.K. Medical Company, Chiyoda, Tokyo, Japan
| | - Chantal E Holy
- Medical Devices, Johnson and Johnson Limited, New Brunswick, NJ, USA
| | - Anh Bourcet
- Health Economics & Market Access, Johnson & Johnson Medical Asia Pacific, Singapore, Singapore
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Rosinski AA, Mittal A, Odeh K, Ungurean V, Leasure J, Telles C, Kondrashov D. Alternatives to Traditional Pedicle Screws for Posterior Fixation of the Degenerative Lumbar Spine. JBJS Rev 2021; 9:01874474-202107000-00016. [PMID: 34319968 DOI: 10.2106/jbjs.rvw.20.00177] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Traditional pedicle screws are currently the gold standard to achieve stable 3-column fixation of the degenerative lumbar spine. However, there are cases in which pedicle screw fixation may not be ideal. Due to their starting point lateral to the pars interarticularis, pedicle screws require a relatively wide dissection along with a medialized trajectory directed toward the centrally located neural elements and prevertebral vasculature. In addition, low bone mineral density remains a major risk factor for pedicle screw loosening, pullout, and pseudarthrosis. The purpose of this article is to review the indications, advantages, disadvantages, and complications associated with posterior fixation techniques of the degenerative lumbar spine beyond the traditional pedicle screws. METHODS Comprehensive literature searches of the PubMed, Scopus, and Web of Science databases were performed for 5 methods of posterior spinal fixation, including (1) cortical bone trajectory (CBT) screws, (2) transfacet screws, (3) translaminar screws, (4) spinous process plates, and (5) fusion mass screws and hooks. Articles that had been published between January 1, 1990, and January 1, 2020, were considered. Non-English-language articles and studies involving fixation of the cervical or thoracic spine were excluded from our review. RESULTS After reviewing over 1,700 articles pertaining to CBT and non-pedicular fixation techniques, a total of 284 articles met our inclusion criteria. CBT and transfacet screws require less-extensive exposure and paraspinal muscle dissection compared with traditional pedicle screws and may therefore reduce blood loss, postoperative pain, and length of hospital stay. In addition, several methods of non-pedicular fixation such as translaminar and fusion mass screws have trajectories that are directed away from or posterior to the spinal canal, potentially decreasing the risk of neurologic injury. CBT, transfacet, and fusion mass screws can also be used as salvage techniques when traditional pedicle screw constructs fail. CONCLUSIONS CBT and non-pedicular fixation may be preferred in certain lumbar degenerative cases, particularly among patients with osteoporosis. Limitations of non-pedicular techniques include their reliance on intact posterior elements and the lack of 3-column fixation of the spine. As a result, transfacet and translaminar screws are infrequently used as the primary method of fixation. CBT, transfacet, and translaminar screws are effective in augmenting interbody fixation and have been shown to significantly improve fusion rates and clinical outcomes compared with stand-alone anterior lumbar interbody fusion. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander A Rosinski
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | - Ashish Mittal
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | - Khalid Odeh
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
| | | | | | | | - Dimitriy Kondrashov
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, California
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Wang TY, Mehta VA, Sankey EW, Shaffrey CI, Abd-El-Barr MM, Than KD. The Impact of Instrumentation and Implant Surface Technology on Cervical and Thoracolumbar Fusion. Oper Neurosurg (Hagerstown) 2021; 21:S12-S22. [PMID: 34128071 DOI: 10.1093/ons/opaa321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/23/2020] [Indexed: 11/12/2022] Open
Abstract
Spinal fusion has undergone significant evolution and improvement over the past 50 yr. Historically, spine fusion was noninstrumented and arthrodesis was based entirely on autograft. Improved understanding of spinal anatomy and materials science ushered in a new era of spinal fusion equipped with screw-based technologies and various interbody devices. Osteobiologics is another important realm of spine fusion, and the evolution of various osteobiologics has perhaps undergone the most change within the past 20 yr. A new element to spinal instrumentation has recently gained traction-namely, surface technology. New data suggest that surface treatments play an increasingly well-recognized role in inducing osteogenesis and successful fusion. Until now, however, there has yet to be a unified resource summarizing the existing data and a lack of consensus exists on superior technology. Here, authors provide an in-depth review on surface technology and its impact on spinal arthrodesis.
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Affiliation(s)
- Timothy Y Wang
- Duke University Medical Center Department of Neurological Surgery, Durham, North Carolina, USA
| | - Vikram A Mehta
- Duke University Medical Center Department of Neurological Surgery, Durham, North Carolina, USA
| | - Eric W Sankey
- Duke University Medical Center Department of Neurological Surgery, Durham, North Carolina, USA
| | - Christopher I Shaffrey
- Duke University Medical Center Department of Neurological Surgery, Durham, North Carolina, USA
| | - Muhammad M Abd-El-Barr
- Duke University Medical Center Department of Neurological Surgery, Durham, North Carolina, USA
| | - Khoi D Than
- Duke University Medical Center Department of Neurological Surgery, Durham, North Carolina, USA
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Diebo BG, Sheikh B, Freilich M, Shah NV, Redfern JAI, Tarabichi S, Shepherd EM, Lafage R, Passias PG, Najjar S, Schwab FJ, Lafage V, Paulino CB. Osteoporosis and Spine Surgery: A Critical Analysis Review. JBJS Rev 2021; 8:e0160. [PMID: 33006455 DOI: 10.2106/jbjs.rvw.19.00160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite being part of the aging process, early and adequate management of osteoporosis mitigates adverse outcomes associated with low bone mineral density. Although the health-care burden of osteoporosis is on the rise, screening and management of osteoporosis are not yet an integral part of preoperative patient evaluation in spine surgery. Patients with osteoporosis should undergo multidisciplinary evaluation and management, including lifestyle modifications and initiation of multiple therapeutic modalities. Integrating osteoporosis in preoperative optimization and surgical planning for patients undergoing spine surgery has the potential to mitigate osteoporosis-related postoperative complications.
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Affiliation(s)
- Bassel G Diebo
- 1Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York 2Royal College of Surgeons in Ireland (RCSI)-Bahrain, Al Sayh, Bahrain 3Division of Spine Surgery, Methodist Hospitals, Merrillville, Indiana 4Spine Service, Hospital for Special Surgery, New York, NY 5Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 6Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Torroni A, Lima Parente PE, Witek L, Hacquebord JH, Coelho PG. Osseodensification drilling vs conventional manual instrumentation technique for posterior lumbar fixation: Ex-vivo mechanical and histomorphological analysis in an ovine model. J Orthop Res 2021; 39:1463-1469. [PMID: 32369220 DOI: 10.1002/jor.24707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/01/2020] [Accepted: 04/29/2020] [Indexed: 02/04/2023]
Abstract
Lumbar fusion is a procedure associated with several indications, but screw failure remains a major complication, with an incidence ranging 10% to 50%. Several solutions have been proposed, ranging from more efficient screw geometry to enhance bone quality, conversely, drilling instrumentation have not been thoroughly explored. The conventional instrumentation (regular [R]) techniques render the bony spicules excavated impractical, while additive techniques (osseodensification [OD]) compact them against the osteotomy walls and predispose them as nucleating surfaces/sites for new bone. This work presents a case-controlled split model for in vivo/ex vivo comparison of R vs OD osteotomy instrumentation in posterior lumbar fixation in an ovine model to determine feasibility and potential advantages of the OD drilling technique in terms of mechanical and histomorphology outcomes. Eight pedicle screws measuring 4.5 mm × 45 mm were installed in each lumbar spine of eight adult sheep (four per side). The left side underwent R instrumentation, while the right underwent OD drilling. The animals were killed at 6- and 12-week and the vertebrae removed. Pullout strength and non-decalcified histologic analysis were performed. Significant mechanical stability differences were observed between OD and R groups at 6- (387 N vs 292 N) and 12-week (312 N vs 212 N) time points. Morphometric analysis did not detect significant differences in bone area fraction occupancy between R and OD groups, while it is to note that OD showed increased presence of bone spiculae. Mechanical pullout testing demonstrated that OD drilling provided higher degrees of implant anchoring as a function of time, whereas a significant reduction was observed for the R group.
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Affiliation(s)
- Andrea Torroni
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, New York
| | | | - Lukasz Witek
- Department of Biomaterials, New York University College of Dentistry, New York, New York.,Department of Biomedical Engineering, New York University Tandon School of Engineering, Brooklyn, New York
| | - Jacques Henri Hacquebord
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York.,Department of Mechanical and Aerospace Engineering, New York University Tandon School of Engineering, Brooklyn, New York
| | - Paulo G Coelho
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, New York.,Department of Biomaterials, New York University College of Dentistry, New York, New York.,Department of Mechanical and Aerospace Engineering, New York University Tandon School of Engineering, Brooklyn, New York
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Viezens L, Sellenschloh K, Püschel K, Morlock MM, Lehmann W, Huber G, Weiser L. Impact of Screw Diameter on Pedicle Screw Fatigue Strength-A Biomechanical Evaluation. World Neurosurg 2021; 152:e369-e376. [PMID: 34087457 DOI: 10.1016/j.wneu.2021.05.108] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Loosening of pedicle screws is a frequently observed complication in spinal surgery. Because additional stabilization procedures such as cement augmentation or lengthening of the instrumentation involve relevant risks, optimal stability of the primarily implanted pedicle screw is of essential importance. The aim of the present study was to investigate the effect of increasing the screw diameter on pedicle screw stability. METHODS A total of 10 human cadaveric vertebral bodies (L4) were included in the present study. The bone mineral density was evaluated using quantitative computed tomography and the pedicle diameter using computed tomography. The vertebrae underwent instrumentation using 6.0-mm × 45-mm pedicle screws on 1 side and screws with the largest possible diameter (8-10-mm × 45-mm) on the other side. Fatigue testing was performed by applying a cyclic loading (craniocaudal sinusoidal 0.5 Hz) with increasing peak force (100 N + 0.1 N/cycle) until screw head displacement of 5.4 mm was reached. RESULTS The mean fatigue load was 334 N for the 6-mm diameter screws and was increased significantly to 454 N (+36%) for the largest possible diameter screws (P < 0.001). With an increase in the fatigue load by 52%, this effect was even more pronounced in vertebrae with reduced bone density (bone mineral density <120 mg/cm3; n = 7; P < 0.001). The stiffness of the construct was significantly greater in the largest diameter screw group compared with the standard screw group during the entire testing period (start, P < 0.001; middle, P < 0.001; end, P = 0.009). CONCLUSIONS Increasing the pedicle screw diameter from a standard 6-mm screw to the largest possible diameter (8-10 mm) led to a significantly greater fatigue load.
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Affiliation(s)
- Lennart Viezens
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany; Division of Spine Surgery, Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kay Sellenschloh
- Institute of Biomechanics, Hamburg University of Technology, Hamburg, Germany
| | - Klaus Püschel
- Institute of Forensic Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael M Morlock
- Institute of Biomechanics, Hamburg University of Technology, Hamburg, Germany
| | - Wolfgang Lehmann
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Gerd Huber
- Institute of Biomechanics, Hamburg University of Technology, Hamburg, Germany
| | - Lukas Weiser
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany.
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Weiser L, Huber G, Sellenschloh K, Püschel K, Morlock MM, Viezens L, Lehmann W. Rescue Augmentation: Increased Stability in Augmentation After Initial Loosening of Pedicle Screws. Global Spine J 2021; 11:679-685. [PMID: 32875910 PMCID: PMC8165920 DOI: 10.1177/2192568220919123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Biomechanical study. OBJECTIVES Failure of pedicle screws is a major problem in spinal surgery not only postoperatively, but also intraoperatively. The aim of this study was to evaluate whether cement augmentation may restore mounting of initially loosened pedicle screws. METHODS A total of 14 osteoporotic or osteopenic human cadaveric vertebral bodies (L2)-according to quantitative computed tomography (QCT)-were instrumented on both sides by conventional pedicle screws and cement augmented on 1 side. In vitro fatigue loading (cranial-caudal sinusoidal, 0.5 Hz) with increasing peak force (100 N + 0.1 N/cycles) was applied until a screw head displacement of 5.4 mm (∼20°) was reached. After loosening, the nonaugmented screw was rescue augmented, and fatigue testing was repeated. RESULTS The fatigue load reached 207.3 N for the nonaugmented screws and was significantly (P = .009) exceeded because of initial cement augmentation (300.6 N). The rescue augmentation after screw loosening showed a fatigue load of 370.1 N which was significantly higher (P < .001) compared with the nonaugmented screws. The impact of bone density on fatigue strength decreased from the nonaugmented to the augmented to the rescue-augmented screws and shows the greatest effect of cement augmentation on fatigue strength at low bone density. CONCLUSIONS Rescue augmentation leads to similar or higher fatigue strengths compared with those of the initially augmented screws. Therefore, the cement augmentation of initially loosened pedicle screws is a promising option to restore adequate screw stability.
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Affiliation(s)
- Lukas Weiser
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany,Lukas Weiser, Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Robert Koch Str 40, 37099 Göttingen, Germany.
| | - Gerd Huber
- Institute of Biomechanics, TUHH Hamburg University of Technology, Hamburg, Germany
| | - Kay Sellenschloh
- Institute of Biomechanics, TUHH Hamburg University of Technology, Hamburg, Germany
| | - Klaus Püschel
- Institute of Forensic Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael M. Morlock
- Institute of Biomechanics, TUHH Hamburg University of Technology, Hamburg, Germany
| | - Lennart Viezens
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Wolfgang Lehmann
- Department of Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
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Bokov A, Pavlova S, Bulkin A, Aleynik A, Mlyavykh S. Potential contribution of pedicle screw design to loosening rate in patients with degenerative diseases of the lumbar spine: An observational study. World J Orthop 2021; 12:310-319. [PMID: 34055588 PMCID: PMC8152435 DOI: 10.5312/wjo.v12.i5.310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/15/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The majority of published data report the results of biomechanical tests of various design pedicle screw performance. The clinical relevance and relative contribution of screw design to instrumentation stability have been insufficiently studied.
AIM To estimate the contribution of screw design to rate of pedicle screw loosening in patients with degenerative diseases of the lumbar spine.
METHODS This study is a prospective evaluation of 175 patients with degenerative diseases and instability of the lumbar spine segments. Participants underwent spinal instrumentation employing pedicle screws with posterior only or transforaminal interbody fusion. Follow-up was for 18 mo. Patients with signs of pedicle screw loosening on computed tomography were registered; logistic regression analysis was used to identify the factors that influenced the rate of loosening.
RESULTS Parameters included in the analysis were screw geometry, type of thread, external and internal screw diameter and helical pitch, bone density in Hounsfield units, number of levels fused, instrumentation without anterior support, laminectomy, and unilateral and bilateral total facet joint resection. The rate of screw loosening decreased with the increment in outer diameter, decrease in core diameter and helical pitch. The rate of screw loosening correlated positively with the number of fused levels and decreasing bone density. Bilateral facet joint removal significantly favored pedicle screw loosening. The influence of other factors was insignificant.
CONCLUSION Screw parameters had a significant impact on the loosening rate along with bone quality characteristics, the number of levels fused and the extensiveness of decompression. The significance of the influence of screw parameters was comparable to those of patient- and surgery-related factors. Pedicle screw loosening was influenced by helical pitch, inner and outer diameter, but screw geometry and thread type were insignificant factors.
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Affiliation(s)
- Andrey Bokov
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
| | - Svetlana Pavlova
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
| | - Anatoliy Bulkin
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
| | - Alexandr Aleynik
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
| | - Sergey Mlyavykh
- Department of Oncology and Neurosurgery, Federal State Budgetary Educational Institution of Higher Education “Privolzhsky Research Medical University” of the Ministry of Health of the Russian Federation, Nizhniy Novgorod 603000, Russia
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Utility of a Computer-assisted Rod Bending System to Avoid Pull-out and Loosening of Percutaneous Pedicle Screws. Clin Spine Surg 2021; 34:E166-E171. [PMID: 33060429 DOI: 10.1097/bsd.0000000000001099] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/24/2020] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective observational study of a cohort of consecutive patients. OBJECTIVE To compare the influence of (1) manual and (2) computer-assisted (CA) rod bending techniques on pedicle screw pull-out resulting in loosening during rod reduction and final tightening. SUMMARY OF BACKGROUND DATA Our recent study showed screw pull-out during rod reduction might be a risk factor for loosening of percutaneous pedicle screws (PPSs) postoperatively, resulting in worse postoperative back pain. We retrospectively analyzed data from 53 consecutive patients who underwent minimally invasive lumbar or thoracic spinal stabilization using intraoperative computed tomography image (CT)-guided navigation with conventional manual rod bending or CA rod bending and were followed up for 1 year. METHOD Screw pull-out length was measured on axial CT images obtained immediately after screw insertion and postoperatively. Loosening of screws and clinical outcome were evaluated radiographically, clinically, and by CT 1 year after surgery. The frequencies of screw pull-out and screw loosening between the 2 rod bending techniques were compared. Lumbar pain-related factors for both groups of patients were determined preoperatively and 1 year after surgery. RESULTS Overall, 360 pedicle screws were placed in the manual group and 124 pedicle screws were placed in the CA group. There was no significant difference in the mean age, sex, bone mineral density, mean stabilized length, or smoking habits of patients between the groups. The diameters, lengths, and trajectory angle (axial and sagittal) of the screws placed were not significantly different between the groups. Screw pull-out rate/length and loosening in the CA group was significantly lower than that in the manual group. Postoperative low back pain improved significantly in the CA group compared with that in the manual group. CONCLUSION CA bending is useful to avoid PPS pull-out during rod reduction and screw loosening postoperatively. CA bending is useful to avoid PPS pull-out during rod reduction and screw loosening postoperatively. This result might have been a factor leading to reduced postoperative back pain in the CA group, however, that future studies are need to investigate this association.
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Todeschi J, Ganau M, Zaed I, Bozzi MT, Mallereau CH, Gallinaro P, Cebula H, Ollivier I, Spatola G, Chaussemy D, Coca HA, Proust F, Chibbaro S. Managing Incomplete and Complete Thoracolumbar Burst Fractures (AO Spine A3 and A4). Results from a Prospective Single-Center Study Comparing Posterior Percutaneous Instrumentation plus Mini-Open Anterolateral Fusion versus Single-Stage Posterior Instrumented Fusion. World Neurosurg 2021; 150:e657-e667. [PMID: 33757885 DOI: 10.1016/j.wneu.2021.03.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/13/2021] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The treatment strategy for thoracolumbar burst fractures is still debated. The aim of this study is to evaluate clinical and radiologic outcomes of a 2-stage strategy with immediate posterior percutaneous instrumentation and delayed anterolateral fusion (group A) versus a single-stage open posterior instrumented fusion (group B). METHODS Demographics and clinical and surgical data of patients operated for AO Spine A3 and A4 fractures were prospectively collected. Vertebral height and deformity were evaluated before and after surgery. Visual analog scale score for back pain, Oswestry Disability Index, and 12-Item Short Form Health Survey results for quality-of-life assessment were collected during follow-up. RESULTS Among the 110 patients enrolled, 66 were allocated to group A and 44 to group B; the most common fractured level was T12 (34%). Postoperative complications were higher in group B, especially the wound infection rate (18% vs. 3%), and pseudomeningocele (14% vs. 0%). The 2-stage approach allowed an average long-term gain of 15.8° at the local kyphosis of fractured vertebra and 5.8° at the regional level (Cobb angle), versus 15.4° and 5.5° in group B. At 2 years follow-up, both groups showed significant functional improvements; however, the visual analog scale and Oswestry Disability Index metrics seemed more favorable for group A patients (P < 0.0001 vs. P < 0.003). A complete fusion rate was obtained in 100% of group A vs. 65% of group B. CONCLUSIONS Our study indicates that percutaneous instrumentation and anterior fusion or an expandable cage lead to excellent long-term clinical and radiologic outcomes with a lower complication rate and higher fusion rate than those of open posterior approaches.
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Affiliation(s)
- Julien Todeschi
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France
| | - Mario Ganau
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France
| | - Ismail Zaed
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France.
| | - Maria Teresa Bozzi
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France
| | - Charles-Henry Mallereau
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France
| | - Paolo Gallinaro
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France
| | - Helene Cebula
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France
| | - Irene Ollivier
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France
| | - Giogio Spatola
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France
| | - Dominique Chaussemy
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France
| | - Hugo-Andres Coca
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France
| | - François Proust
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France
| | - Salvatore Chibbaro
- Department of Neurosurgery, Hautepierre Regional Hospital, University of Strasbourg, Strasbourg, France
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Kim CH, Ju CI, Lee SM, Kim SW. Efficacy of Antibiotic-Loaded Cement Augmentation for Correcting Low Grade Pedicle Screw Loosening. Korean J Neurotrauma 2021; 17:41-47. [PMID: 33981642 PMCID: PMC8093028 DOI: 10.13004/kjnt.2021.17.e2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/23/2020] [Accepted: 12/08/2020] [Indexed: 12/18/2022] Open
Abstract
Objective Altered biomechanics and bone fragility can contribute to pedicle screw loosening. This study aimed to evaluate the efficacy of antibiotic-loaded cement augmentation for correcting symptomatic screw loosening as a minimally invasive alternative to open revision surgery. Methods Ten consecutive patients who underwent percutaneous cement augmentation for pedicle screw loosening were included in this study. Low grade pedicle screw loosening was deemed clinically relevant in cases of continuous back pain with significant radiolucent halo zones at a vertebral level without screw backing out or stripping. We analyzed the screw loosening at the main location of halo formation. All patients were treated by fluoroscopy-guided antibiotic-loaded cement augmentation of the loosened pedicle screws. Patient demographics and pre- and postoperative data were also assembled and analyzed. Results Most (80%) halo formation locations were the inferior type. Augmentation was technically feasible in all but one patient, in whom the procedure was unsuccessful due to access difficulty. This patient ultimately underwent percutaneous screw re-implantation via a different trajectory. The other nine patients in whom cement filling was satisfactory reported significant pain relief at the final follow-up. Moreover, no severe complications such as wound infection or repeated screw loosening occurred during the follow-up period. Conclusion The most common halo formation location was the inferior type. In cases without access difficulty, antibiotic-loaded cement augmentation for the treatment of low grade pedicle screw loosening can relieve pain and avoid extensive open surgery.
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Affiliation(s)
- Chi Ho Kim
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Chang Il Ju
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Sung Myung Lee
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Seok Won Kim
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
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Georg Schmorl Prize of the German Spine Society (DWG) 2020: new biomechanical in vitro test method to determine subsidence risk of vertebral body replacements. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:1117-1124. [PMID: 33730216 DOI: 10.1007/s00586-021-06764-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/15/2021] [Accepted: 02/02/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Prevention of implant subsidence in osteoporotic (thoraco)lumbar spines is still a major challenge in spinal surgery. In this study, a new biomechanical in vitro test method was developed to simulate patient activities in order to determine the subsidence risk of vertebral body replacements during physiologic loading conditions. METHODS The study included 12 (thoraco)lumbar (T11-L1, L2-L4) human specimens. After dorsal stabilisation and corpectomy, vertebral body replacements (VBR) with (a) round centrally located and (b) lateral end pieces with apophyseal support were implanted, equally distributed regarding segment, sex, mean BMD ((a) 64.2 mgCaHA/cm3, (b) 66.7 mgCaHA/cm3) and age ((a) 78 years, (b) 73.5 years). The specimens were then subjected to everyday activities (climbing stairs, tying shoes, lifting 20 kg) simulated by a custom-made dynamic loading simulator combining corresponding axial loads with flexion-extension and lateral bending movements. They were applied in oscillating waves at 0.5 Hz and raised every 100 cycles phase-shifted to each other by 50 N or 0.25°, respectively. The range of motion (ROM) of the specimens was determined in all three motion planes under pure moments of 3.75 Nm prior to and after implantation as well as subsequently following activities. Simultaneously, subsidence depth was quantified from fluoroscope films. A mixed model (significance level: 0.05) was established to relate subsidence risk to implant geometries and patients' activities. RESULTS With this new test method, simulating everyday activities provoked clinically relevant subsidence schemes. Generally, severe everyday activities caused deeper subsidence which resulted in increased ROM. Subsidence of lateral end pieces was remarkably less pronounced which was accompanied by a smaller ROM in flexion-extension and higher motion possibilities in axial rotation (p = 0.05). CONCLUSION In this study, a new biomechanical test method was developed that simulates physiologic activities to examine implant subsidence. It appears that the highest risk of subsidence occurs most when lifting heavy weights, and into the ventral part of the caudal vertebra. The results indicate that lateral end pieces may better prevent from implant subsidence because of the additional cortical support. Generally, patients that are treated with a VBR should avoid activities that create high loading on the spine.
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Comparative analysis of clinical factors associated with pedicle screw pull-out during or immediately after surgery between intraoperative cone-beam computed tomography and postoperative computed tomography. BMC Musculoskelet Disord 2021; 22:55. [PMID: 33422036 PMCID: PMC7797098 DOI: 10.1186/s12891-020-03916-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 12/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background No studies to date have elucidated the clinical factors associated with pedicle screw pull-out during or immediately after surgery. The aim of this study was to assess the frequency of pedicle screw pull-out by comparing intraoperative scans obtained using cone-beam computed tomography (CBCT) with postoperative scans obtained using computed tomography (CT). We also sought to determine the incidence of pedicle screw pull-out and identify relevant risk factors. Methods This was a retrospective analysis of prospectively collected data for 742 pedicle screws placed in 76 consecutive patients who underwent at least triple-level posterior fixation for thoracic or lumbar spinal injury, spinal metastasis, or pyogenic spondylitis between April 2014 and July 2020. Pedicle screw pull-out distance in the axial and sagittal planes was compared between CT scans obtained 2 days postoperatively and CBCT images acquired intraoperatively. Risk factors associated with pedicle screw pull-out were investigated by multivariate logistic regression analysis. Results Pedicle screw pull-out was seen with 58 pedicle screws (7.8%) in 26 patients (34.2%). There were significant differences in age, number of fused segments, frequency of diffuse idiopathic skeletal hyperostosis (DISH), and medical history of osteoporosis for pedicle screw pull-out. Risk factors for pedicle screw pull-out were older age (odds ratio 1.07, 95% confidence interval 1.02–1.130) and a diagnosis of DISH (odds ratio 3.35, 95% confidence interval 1.12–10.00). Several cases suggest that use of connecting rods was an important factor in intraoperative pedicle screw pull-out. Conclusions Our findings suggest that age, number of fused segments, presence of DISH, and medical history of osteoporosis are risk factors for pedicle screw pull-out, with the greatest being older age and DISH.
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Agarwal A, Mooney M, Agarwal AG, Jayaswal D, Saakyan G, Goel V, Wang JC, Anand N, Garfin S, Shendge V, Elgafy H. High Prevalence of Biofilms on Retrieved Implants from Aseptic Pseudarthrosis Cases. Spine Surg Relat Res 2021; 5:104-108. [PMID: 33842718 PMCID: PMC8026210 DOI: 10.22603/ssrr.2020-0147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/24/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Recent literature has associated pseudarthrosis and pedicle screw loosening with subchronic infection at the pedicle of the vertebra. The positive culture results of a previous retrieval analysis show that such patients have a high frequency of bacterial contamination. The objective of this study is to visually capture the architecture of these undiagnosed infections, which have been described in other studies as biofilms on supposedly "aseptic" screw loosening. METHODS Explants from 10 consecutive patients undergoing revision spine surgery for pseudarthrosis were collected and fixed in glutaraldehyde solution. Each of these implants was imaged thoroughly by using scanning electron microscopy and x-ray spectroscopy to evaluate the architecture of the biofilm. Additionally, eight patient swabs from tissues around the implants were sent for cultures to assess bacterial infiltration in tissues beyond the biofilm. The implants were also analyzed using energy dispersive x-ray spectroscopy. The exclusion criteria included clinically diagnosed infection (current or previous) and/or mechanical failure of the implant due to falls/accidents. RESULTS The study was successful in capturing the visual architecture of the biofilm on retrieved implants. A total of 77% of pseudarthrosis cases presented with loose pedicle screws, which were diagnosed by a preoperative computed tomography scan showing radiolucency along the screw track and were confirmed intraoperatively, and 72% of the cases showed biofilm on explants. CONCLUSIONS In the absence of the clinical presentation of infection, impregnated bacteria could form a biofilm around an implant, and this biofilm can remain undetected via contemporary diagnostic methods, including swabbing. Implant biofilm is frequently present in "aseptic" pseudarthrosis cases.
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Affiliation(s)
- Aakash Agarwal
- Department of Bioengineering and Orthopaedics Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, USA
| | - Megan Mooney
- Department of Bioengineering and Orthopaedics Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, USA
| | | | - Daksh Jayaswal
- Department of Bioengineering and Orthopaedics Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, USA
| | - Gayane Saakyan
- Department of Bioengineering and Orthopaedics Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, USA
| | - Vijay Goel
- Department of Bioengineering and Orthopaedics Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, USA
| | | | - Neel Anand
- Spine Center, Cedars Sinai Medical Center, Los Angeles, USA
| | - Steve Garfin
- Department of Orthopaedics, University of California, San Diego, USA
| | - Vithal Shendge
- Department of Bioengineering and Orthopaedics Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, USA
| | - Hossein Elgafy
- Department of Bioengineering and Orthopaedics Surgery, Colleges of Engineering and Medicine, University of Toledo, Toledo, USA
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Bokov AE, Bulkin AA, Bratsev IS, Kalinina SY, Mlyavykh SG, Anderson DG. Augmentation of Pedicle Screws Using Bone Grafting in Patients with Spinal Osteoporosis. Sovrem Tekhnologii Med 2021; 13:6-10. [PMID: 35265344 PMCID: PMC8858411 DOI: 10.17691/stm2021.13.5.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 11/14/2022] Open
Abstract
The aim of the study was to develop a new method of vertebral augmentation based on autologous and allogeneic bone chips to be used in pedicle screw fixation and to compare this method with the technique based on polymethyl methacrylate (PMMA).
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Affiliation(s)
- A E Bokov
- Head of the Department of Oncology and Neurosurgery, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - A A Bulkin
- Staff Neurosurgeon, Department of Oncology and Neurosurgery, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - I S Bratsev
- Staff Neurosurgeon, Department of Oncology and Neurosurgery, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - S Ya Kalinina
- Staff Neurosurgeon, Department of Oncology and Neurosurgery, Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - S G Mlyavykh
- Director of the Institute of Traumatology and Orthopedics Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - D G Anderson
- Professor, Departments of Orthopaedic and Neurological Surgery; Clinical Director of the Spine Section, Orthopaedic Research Laboratory Thomas Jefferson University, 130 S., 9 St., Philadelphia, PA, 19107, USA
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Odeh K, Rosinski A, Leasure J, Kondrashov D. Pedicle Screws Challenged: Lumbar Cortical Density and Thickness Are Greater in the Posterior Elements Than in the Pedicles. Global Spine J 2021; 11:34-43. [PMID: 32875847 PMCID: PMC7734267 DOI: 10.1177/2192568219889361] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
STUDY DESIGN Controlled laboratory study. OBJECTIVE To measure the total bone mineral density (BMD), cortical volume, and cortical thickness in seven different anatomical regions of the lumbar spine. METHODS Using computed tomography (CT) images, 3 cadaveric spines were digitally isolated by applying filters for cortical and cancellous bone. Each spine model was separated into 5 lumbar vertebrae, followed by segmentation of each vertebra into 7 anatomical regions of interest using 3-dimensional software modeling. The average Hounsfield units (HU) was determined for each region and converted to BMD with calibration phantoms of known BMD. These BMD measurements were further analyzed by the total volume, cortical volume, and cancellous volume. The cortical thickness was also measured. A similar analysis was performed by vertebral segment. St Mary's Medical Center's Institutional Review Board approved this study. No external funding was received for this work. RESULTS The lamina and inferior articular process contained the highest total BMD, thickest cortical shell, and largest percent volumes of cortical bone. The vertebral body demonstrated the lowest BMD. The BMDs of the L4 and L5 segments were lower; however, there were no statistically significant differences in BMD between the L1-L5 vertebral segments. CONCLUSION Extrapedicular regions of the lumbar vertebrae, including the lamina and inferior articular process, contain denser bone than the pedicles. Since screw pullout strength relies greatly on bone density, the lamina and inferior articular processes may offer stronger fixation of the lumbar spine.
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Affiliation(s)
- Khalid Odeh
- St Mary’s Medical Center, San Francisco Orthopaedic Residency Program, San Francisco, CA, USA
| | | | - Jeremi Leasure
- St Mary’s Medical Center, San Francisco Orthopaedic Residency Program, San Francisco, CA, USA,The Taylor Collaboration, San Francisco, CA, USA,Jeremi Leasure, MSE, San Francisco Orthopaedic Residency Program, 450 Stanyan Street, San Francisco, CA 94117, USA.
| | - Dimitriy Kondrashov
- St Mary’s Medical Center, San Francisco Orthopaedic Residency Program, San Francisco, CA, USA,San Francisco Spine Surgeons, San Francisco, CA, USA
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Can cavity-based pedicle screw augmentation decrease screw loosening? A biomechanical in vitro study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:2283-2291. [PMID: 33355707 DOI: 10.1007/s00586-020-06676-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 10/08/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE In an osteoporotic vertebral body, cement-augmented pedicle screw fixation could possibly be optimized by the creation of an initial cavity. The aim of this study is to compare three test groups with regard to their loosening characteristics under cyclic loading. METHODS Eighteen human, osteoporotic spine segments were divided in three groups. Flexibility tests and cyclic loading tests were performed with an internal fixator. The screws were fixed after creation a cavity and with cement (cavity-augmented group), without cavity and with cement (augmented group), and without cavity and without cement (control group). Cyclic loading up to 100,000 cycles was applied with a complex loading protocol. Screw loosening was measured with flexibility tests after implantation and after cyclic loading. Cement distribution was visualized from CT scans. RESULTS In all groups, range of motion increased during cyclic loading, representing significant screw loosening after 100,000 cycles. In both augmented groups, screw loosening was less pronounced than in the control group. The cavity-augmented group showed only a slight tendency of screw loosening, but with smaller variations compared to both other groups. This may be explained with a trend for a more equal and homogeneous cement volume around each tip for the cavity-augmented group. CONCLUSION This study demonstrated that creating a cavity may allow a more equal fixation of all pedicle screws with slight reduction of loosening. However, augmentation only through a cannulated screw is almost equivalent, if care is taken that enough cement volume can be pushed out around the tip of the screw.
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Weiser L, Sellenschloh K, Püschel K, Morlock MM, Viezens L, Lehmann W, Huber G. Cortical threaded pedicle screw improves fatigue strength in decreased bone quality. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:128-135. [DOI: 10.1007/s00586-020-06593-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 08/03/2020] [Accepted: 09/04/2020] [Indexed: 12/30/2022]
Abstract
Abstract
Purpose
Inadequate anchoring of pedicle screws in vertebrae with poor bone quality is a major problem in spine surgery. The aim was to evaluate whether a modified thread in the area of the pedicle could significantly improve the pedicle screw fatigue strength.
Methods
Fourteen human cadaveric vertebral bodies (L2 and L3) were used for in vitro testing. Bone density (BMD) was determined by quantitative computed tomography. Vertebral bodies were instrumented by standard pedicle screws with a constant double thread on the right pedicle and a partial doubling of the threads–quad thread–(cortical thread) in the area of the pedicle on the left pedicle. Pulsating sinusoidal, cyclic load (0.5 Hz) with increasing peak force (100 N + 0.1 N/cycles) was applied orthogonal to the screw axis. The baseline force remained constant (50 N). Fatigue test was terminated after exceeding 5.4-mm head displacement (~ 20° screw tilting).
Results
The mean fatigue load at failure was 264.9 N (1682 cycles) for the standard screws and was increased significantly to 324.7 N (2285 cycles) by the use of cortical threaded screws (p = 0.014). This effect is particularly evident in reduced BMD (standard thread 241.2 N vs. cortical thread 328.4 N; p = 0.016), whereas in the group of vertebrae with normal BMD no significant difference could be detected (standard thread 296.5 N vs. cortical thread 319.8 N; p = 0.463).
Conclusions
Compared to a conventional pedicle screw, the use of a cortical threaded pedicle screw promises superior fatigue load in vertebrae with reduced bone quality.
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Gazzeri R, Panagiotopoulos K, Galarza M, Bolognini A, Callovini G. Minimally invasive spinal fixation in an aging population with osteoporosis: clinical and radiological outcomes and safety of expandable screws versus fenestrated screws augmented with polymethylmethacrylate. Neurosurg Focus 2020; 49:E14. [DOI: 10.3171/2020.5.focus20232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 05/12/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe goal of this study was to compare the clinical and radiological outcomes between fenestrated pedicle screws augmented with cement and expandable pedicle screws in percutaneous vertebral fixation surgical procedures for the treatment of degenerative and traumatic spinal diseases in aging patients with osteoporosis.METHODSThis was a prospective, single-center study. Twenty patients each in the expandable and cement-augmented screw groups were recruited. Clinical outcomes included visual analog scale (VAS), Oswestry Disability Index (ODI), and satisfaction rates. Radiographic outcomes comprised radiological measurements on the vertebral motion segment of the treated levels. Intraoperative data including complications were collected. All patients completed the clinical and radiological outcomes. Outcomes were compared preoperatively and postoperatively.RESULTSAn average shorter operative time was found in procedures in which expandable screws were used versus those in which cement-augmented screws were used (p < 0.001). No differences resulted in perioperative blood loss between the 2 groups. VAS and ODI scores were significantly improved in both groups after surgery. There was no significant difference between the 2 groups with respect to baseline VAS or ODI scores. The satisfaction rate of both groups was more than 85%. Radiographic outcomes also showed no significant difference in segment stability between the 2 groups. No major complications after surgery were seen. There were 4 cases (20%) of approach-related complications, all in fenestrated screw procedures in which asymptomatic cement extravasations were observed. In 1 case the authors detected a radiologically evident osteolysis around a cement-augmented screw 36 months after surgery. In another case they identified a minor loosening of an expandable screw causing local back discomfort at the 3-year follow-up.CONCLUSIONSExpandable pedicle screws and polymethylmethacrylate augmentation of fenestrated screws are both safe and effective techniques to increase the pullout strength of screws placed in osteoporotic spine. In this series, clinical and radiological outcomes were equivalent between the 2 groups. To the authors’ knowledge, this is the first report comparing the cement augmentation technique versus expandable screws in the treatment of aging patients with osteoporosis.
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Affiliation(s)
- Roberto Gazzeri
- 1Department of Neurosurgery, San Giovanni–Addolorata Hospital, Rome
- 2Department of Neurosurgery, IRCCS Istituto Nazionale Tumori “Regina Elena,” Rome, Italy; and
| | | | - Marcelo Galarza
- 3Regional Service of Neurosurgery, “Virgen de la Arrixaca” University Hospital, Murcia, Spain
| | - Andrea Bolognini
- 1Department of Neurosurgery, San Giovanni–Addolorata Hospital, Rome
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Ishikawa Y, Watanabe K, Katsumi K, Ohashi M, Shibuya Y, Izumi T, Hirano T, Endo N, Kaito T, Yamashita T, Fujiwara H, Nagamoto Y, Matsuoka Y, Suzuki H, Nishimura H, Terai H, Tamai K, Tagami A, Yamada S, Adachi S, Yoshii T, Ushio S, Harimaya K, Kawaguchi K, Yokoyama N, Oishi H, Doi T, Kimura A, Inoue H, Inoue G, Miyagi M, Saito W, Nakano A, Sakai D, Nukaga T, Ikegami S, Shimizu M, Futatsugi T, Ohtori S, Furuya T, Orita S, Imagama S, Ando K, Kobayashi K, Kiyasu K, Murakami H, Yoshioka K, Seki S, Hongo M, Kakutani K, Yurube T, Aoki Y, Oshima M, Takahata M, Iwata A, Endo H, Abe T, Tsukanishi T, Nakanishi K, Watanabe K, Hikata T, Suzuki S, Isogai N, Okada E, Funao H, Ueda S, Shiono Y, Nojiri K, Hosogane N, Ishii K. Short- versus long-segment posterior spinal fusion with vertebroplasty for osteoporotic vertebral collapse with neurological impairment in thoracolumbar spine: a multicenter study. BMC Musculoskelet Disord 2020; 21:513. [PMID: 32738900 PMCID: PMC7395972 DOI: 10.1186/s12891-020-03539-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/27/2020] [Indexed: 11/10/2022] Open
Abstract
Background Vertebroplasty with posterior spinal fusion (VP + PSF) is one of the most widely accepted surgical techniques for treating osteoporotic vertebral collapse (OVC). Nevertheless, the effect of the extent of fusion on surgical outcomes remains to be established. This study aimed to evaluate the surgical outcomes of short- versus long-segment VP + PSF for OVC with neurological impairment in thoracolumbar spine. Methods We retrospectively collected data from 133 patients (median age, 77 years; 42 men and 91 women) from 27 university hospitals and their affiliated hospitals. We divided patients into two groups: a short-segment fusion group (S group) with 2- or 3-segment fusion (87 patients) and a long-segment fusion group (L group) with 4- through 6-segment fusion (46 patients). Surgical invasion, clinical outcomes, local kyphosis angle (LKA), and complications were evaluated. Results No significant differences between the two groups were observed in terms of neurological recovery, pain scale scores, and complications. Surgical time was shorter and blood loss was less in the S group, whereas LKA at the final follow-up and correction loss were superior in the L group. Conclusion Although less invasiveness and validity of pain and neurological relief are secured by short-segment VP + PSF, surgeons should be cautious regarding correction loss.
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Affiliation(s)
- Yuya Ishikawa
- Department of Orthopaedic Surgery, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata City, Niigata, 951-8510, Japan
| | - Kei Watanabe
- Department of Orthopaedic Surgery, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata City, Niigata, 951-8510, Japan.
| | - Keiichi Katsumi
- Department of Orthopaedic Surgery, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata City, Niigata, 951-8510, Japan
| | - Masayuki Ohashi
- Department of Orthopaedic Surgery, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata City, Niigata, 951-8510, Japan
| | - Yohei Shibuya
- Department of Orthopaedic Surgery, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata City, Niigata, 951-8510, Japan
| | - Tomohiro Izumi
- Department of Orthopaedic Surgery, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata City, Niigata, 951-8510, Japan
| | - Toru Hirano
- Department of Orthopaedic Surgery, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata City, Niigata, 951-8510, Japan
| | - Naoto Endo
- Department of Orthopaedic Surgery, Niigata University, 1-757 Asahimachidori, Chuo-ku, Niigata City, Niigata, 951-8510, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University, 2-2 Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Tomoya Yamashita
- Department of Orthopaedic Surgery, Osaka University, 2-2 Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Hiroyasu Fujiwara
- Department of Orthopaedic Surgery, Osaka University, 2-2 Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Yukitaka Nagamoto
- Department of Orthopaedic Surgery, Osaka University, 2-2 Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Yuji Matsuoka
- Department of Orthopaedic Surgery, Tokyo Medical University, 6-1-1 Shinjuku, Shinjuku-ku, Tokyo, 160-8402, Japan
| | - Hidekazu Suzuki
- Department of Orthopaedic Surgery, Tokyo Medical University, 6-1-1 Shinjuku, Shinjuku-ku, Tokyo, 160-8402, Japan
| | - Hirosuke Nishimura
- Department of Orthopaedic Surgery, Tokyo Medical University, 6-1-1 Shinjuku, Shinjuku-ku, Tokyo, 160-8402, Japan
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Osaka City University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Koji Tamai
- Department of Orthopaedic Surgery, Osaka City University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Atsushi Tagami
- Department of Orthopaedic Surgery, Nagasaki University, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Shuta Yamada
- Department of Orthopaedic Surgery, Nagasaki University, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Shinji Adachi
- Department of Orthopaedic Surgery, Nagasaki University, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Shuta Ushio
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Katsumi Harimaya
- Department of Orthopaedic Surgery, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Kenichi Kawaguchi
- Department of Orthopaedic Surgery, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Nobuhiko Yokoyama
- Department of Orthopaedic Surgery, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Hidekazu Oishi
- Department of Orthopaedic Surgery, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Toshiro Doi
- Department of Orthopaedic Surgery, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan
| | - Atsushi Kimura
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
| | - Hirokazu Inoue
- Department of Orthopaedic Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, 329-0498, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Masayuki Miyagi
- Department of Orthopaedic Surgery, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Wataru Saito
- Department of Orthopaedic Surgery, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Atsushi Nakano
- Department of Orthopedic Surgery, Osaka Medical College, 2-7 Daigakumachi, Takatsuki City, Osaka, 569-8686, Japan
| | - Daisuke Sakai
- Department of Orthopaedic Surgery, Tokai University, 143 Shimokasuya, Isehara City, Kanagawa, 259-1193, Japan
| | - Tadashi Nukaga
- Department of Orthopaedic Surgery, Tokai University, 143 Shimokasuya, Isehara City, Kanagawa, 259-1193, Japan
| | - Shota Ikegami
- Department of Orthopaedic Surgery, Shinshu University, 3-1-1, Asahi, Matsumoto City, Nagano, 390-8621, Japan
| | - Masayuki Shimizu
- Department of Orthopaedic Surgery, Shinshu University, 3-1-1, Asahi, Matsumoto City, Nagano, 390-8621, Japan
| | - Toshimasa Futatsugi
- Department of Orthopaedic Surgery, Shinshu University, 3-1-1, Asahi, Matsumoto City, Nagano, 390-8621, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, 260-8670, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, 260-8670, Japan
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, 260-8670, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, 466-8560, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, 466-8560, Japan
| | - Kazuyoshi Kobayashi
- Department of Orthopaedic Surgery, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, 466-8560, Japan
| | - Katsuhito Kiyasu
- Department of Orthopaedic Surgery, Kochi University, Oko-cho Kohasu, Nankoku City, Kochi, 783-8505, Japan
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan.,Department of Orthopaedic Surgery, Kanazawa University, 13-1 Takaramachi, Kanazawa City, Ishikawa, 920-8641, Japan
| | - Katsuhito Yoshioka
- Department of Orthopaedic Surgery, Kanazawa University, 13-1 Takaramachi, Kanazawa City, Ishikawa, 920-8641, Japan
| | - Shoji Seki
- Department of Orthopaedic Surgery, University of Toyama, 2630 Sugitani, Toyama City, Toyama, 930-0194, Japan
| | - Michio Hongo
- Department of Orthopaedic Surgery, Akita University, 1-1-1 Hondo, Akita City, 010-8543, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Kobe University, 7-5-1 Kusunoki-cho, chuou-ku, Kobe City, Hyogo, 650-0017, Japan
| | - Takashi Yurube
- Department of Orthopaedic Surgery, Kobe University, 7-5-1 Kusunoki-cho, chuou-ku, Kobe City, Hyogo, 650-0017, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Togane City, Chiba, 283-8686, Japan
| | - Masashi Oshima
- Department of Orthopaedic Surgery, Nihon University Itabashi Hospital, 30-1 Oyaguchikamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University, North-15, West-7, Kita-ku, Sapporo City, Hokkaido, 060-8638, Japan
| | - Akira Iwata
- Department of Orthopaedic Surgery, Hokkaido University, North-15, West-7, Kita-ku, Sapporo City, Hokkaido, 060-8638, Japan
| | - Hirooki Endo
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka City, Iwate, 020-8505, Japan
| | - Tetsuya Abe
- Department of Orthopaedic Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba City, Ibaraki, 305-8577, Japan
| | - Toshinori Tsukanishi
- Department of Orthopaedic Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba City, Ibaraki, 305-8577, Japan
| | - Kazuyoshi Nakanishi
- Department of Orthopaedic Surgery, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima City, Hiroshima, 734-8551, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Tomohiro Hikata
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Satoshi Suzuki
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Norihiro Isogai
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Mita, Minato-ku, Tokyo, 108-8329, Japan
| | - Eijiro Okada
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Mita, Minato-ku, Tokyo, 108-8329, Japan
| | - Seiji Ueda
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yuta Shiono
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kenya Nojiri
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Naobumi Hosogane
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Department of Orthopaedic Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa City, Saitama, 359-8513, Japan.,Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Mita, Minato-ku, Tokyo, 108-8329, Japan
| | - Ken Ishii
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Mita, Minato-ku, Tokyo, 108-8329, Japan
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Hamann I, Hempel U, Rotsch C, Leimert M. Biological Cell Investigation of Structured Nitinol Surfaces for the Functionalization of Implants. MATERIALS 2020; 13:ma13153264. [PMID: 32717837 PMCID: PMC7435443 DOI: 10.3390/ma13153264] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 11/16/2022]
Abstract
Expandable implants including shape memory alloy (SMA) elements have great potential to minimize the risk of implant loosening and to increase the primary stability of bone anchoring. Surface structuring of such elements may further improve these properties and support osteointegration and bone healing. In this given study, SMA sheets were processed by deploying additive and removal manufacturing technologies for 3D-printed surgical implants. The additive technology was realized by applying a new laser beam melting technology to print titanium structures on the SMA sheets. The removal step was realized as a standard process with an ultrashort-pulse laser. The morphology, metabolic activity, and mineralization patterns of human bone marrow stromal cells were examined to evaluate the biocompatibility of the new surface structures. It was shown that both surface structures support cell adhesion and the formation of a cytoskeleton. The examination of the metabolic activity of the marrow stromal cells on the samples showed that the number of cells on the laser-structured samples was lower when compared to the 3D-printed ones. The calcium phosphate accumulation, which was used to examine the mineralization of marrow stromal cells, was higher in the laser-structured samples than in the 3D-printed ones. These results indicate that the additive- and laser-structured SAM sheets seem biocompatible and that the macrostructure surface and manufacturing technology may have positive influences on the behavior of the bone formation. The use of the new additive technique and the resulting macrostructures seems to be a promising approach to combine increased anchorage stability with simultaneously enhanced osteointegration.
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Affiliation(s)
- Isabell Hamann
- Department of Medical Engineering, Fraunhofer Institute for Machine Tools and Forming Technology, Dresden, 01187 Saxony, Germany;
- Department of Spine Center, Asklepios Orthopädische Klinik Hohwald, Neustadt i. Sa., 01844 Saxony, Germany
- Correspondence: ; Tel.: +49-351-4772-2161
| | - Ute Hempel
- Institute of Physiological Chemistry, Medical Faculty Carl Gustav Carus TU Dresden, Dresden, 01307 Saxony, Germany;
| | - Christian Rotsch
- Department of Medical Engineering, Fraunhofer Institute for Machine Tools and Forming Technology, Dresden, 01187 Saxony, Germany;
| | - Mario Leimert
- Department of Neurosurgery and Spine Surgery, Sächsische Schweiz Kliniken GmbH, Sebnitz, 01855 Saxony, Germany;
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