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Maillot C, Gaume M, Zoghlami M, Chanteux L, Boukebous B, Rousseau MA. Comparison of Three Grafting Options for Anterior Cervical Corpectomy and Fusion: A Retrospective 3-Arms Case Control Study. World Neurosurg 2024; 187:e517-e524. [PMID: 38679377 DOI: 10.1016/j.wneu.2024.04.119] [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: 04/05/2024] [Accepted: 04/18/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Anterior cervical corpectomy and fusion achieves foraminal radicular and central medullary decompression and spinal stabilization in staged lesions. Many bone graft materials have been developed for the reconstruction of cervical lordosis and the restoration of intervertebral height after corpectomy. The PolyEtherKetoneEtherKetoneKetone (PEKEKK) is a semicrystalline thermoplastic polymer that can be reinforced with carbon fibers to create long and highly fenestrated rectangular cervical cages for corpectomy. This study aimed to evaluate the radiological outcomes of an innovative PEKEEKK cage compared with others grafting options. METHODS Forty-five consecutive patients who underwent surgery with PEKEKK cages between 2017 and 2019 at a spine institution, were matched with 15 patients with a titanium mesh cylindrical cage (TMC) and 15 patients with a tricortical structural iliac bone graft. The restoration of vertebral height and cervical lordosis postoperatively, and subsidence of the construct were evaluated. Complications were reported. RESULTS The minimal follow-up was 5.1±2years. A better, but nonsignificant, postoperative gain in height was observed for PEKEKK (+8.1 ± 20%) and TMC cages (+8.2 ± 16%) than for iliac crest autograft reconstruction (+2.3 ± 15%, P = 0.119). The mean subsidence at the last follow-up was greater for TMC cages (-10.2 ± 13%), but was not significant, with -6.1 ± 10% for PEKEKK cages and -4.1 ± 7% for iliac crest autografts (P = 0.223). The gain in segmental cervical lordosis was significant (P < 0.001) and remained stable in all the groups. CONCLUSIONS Although an improvement in radiologic anatomical parameters can be achieved with all cage groups, the PEKEKK cage can be considered as a safe alternative for reducing subsidence.
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Affiliation(s)
- Cedric Maillot
- Department of Orthopaedic and Traumatological Surgery, Beaujon Hospital, University of Paris, APHP, Paris, France
| | - Mathilde Gaume
- University Institute for Spine Surgery, Armand Trousseau Hospital, Sorbonne University, Paris, France.
| | - Mohamed Zoghlami
- Department of Orthopaedic and Traumatological Surgery, Beaujon Hospital, University of Paris, APHP, Paris, France
| | - Lucas Chanteux
- Department of Orthopaedic and Traumatological Surgery, Beaujon Hospital, University of Paris, APHP, Paris, France
| | - Baptiste Boukebous
- Department of Orthopaedic and Traumatological Surgery, Beaujon Hospital, University of Paris, APHP, Paris, France
| | - Marc-Antoine Rousseau
- Department of Orthopaedic and Traumatological Surgery, Beaujon Hospital, University of Paris, APHP, Paris, France
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Lescot T, Lebel-Cormier MA, Seniwal B, Gros-Louis P, Bellerive C, Landreville S, Beaulieu L, Fortin MA. Tumor Shape-Specific Brachytherapy Implants by 3D-Printing, Precision Radioactivity Painting, and Biomedical Imaging. Adv Healthc Mater 2023; 12:e2300528. [PMID: 37536742 DOI: 10.1002/adhm.202300528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/18/2023] [Indexed: 08/05/2023]
Abstract
In brachytherapy (BT), or internal radiation therapy, cancer is treated by radioactive implants. For instance, episcleral plaques (EPs) for the treatment of uveal melanoma, are designed according to generic population approximations. However, more personalized implants can enhance treatment precision through better adjustment of dose profiles to the contours of cancerous tissues. An original approach integrating biomedical imaging, 3D printing, radioactivity painting, and biomedical imaging, is developed as a workflow for the development of tumor shape-specific BT implants. First, computer-aided design plans of EP are prepared according to guidelines prescribed by the Collaborative Ocular Melanoma Study protocol. Polyetheretherketone (PEEK), a high-performance polymer suitable for permanent implants, is used to 3D-print plaques and the geometrical accuracy of the printed design is evaluated by imaging. The possibility to modulate the dose distribution in a tridimensional manner is demonstrated by painting the inner surfaces of the EPs with radioactive 103Pd, followed by dose profile measurements. The possibility to modulate dose distributions generated by these 3D-printed plaques through radioactivity painting is therefore confirmed. Ex vivo surgical tests on human eyeballs are performed as an assessment of manipulation ease. Overall, this work provides a solution for the fabrication of tumor-specific radioactive implants requiring higher dose precision.
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Affiliation(s)
- Théophraste Lescot
- Département de Génie des Mines, de la Métallurgie et des Matériaux and Centre de recherche sur les matériaux avancés (CERMA), Université Laval, Québec, G1V 0A6, Canada
- Axe Médecine Régénératrice, Centre de Recherche du Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Québec, G1V 4G2, Canada
- Centre de Recherche sur le Cancer (CRC) de l'Université Laval, Québec, G1R 3S3, Canada
| | - Marie-Anne Lebel-Cormier
- Centre de Recherche sur le Cancer (CRC) de l'Université Laval, Québec, G1R 3S3, Canada
- Département de Physique, de Génie Physique et d'Optique, Université Laval, Québec, G1V 0A6, Canada
- Service de physique médicale et radioprotection and Axe Oncologie, Centre de Recherche du Centre Hospitalier Universitaire de Québec-Université Laval, Québec, G1L 3L5, Canada
| | - Baljeet Seniwal
- Département de Génie des Mines, de la Métallurgie et des Matériaux and Centre de recherche sur les matériaux avancés (CERMA), Université Laval, Québec, G1V 0A6, Canada
- Axe Médecine Régénératrice, Centre de Recherche du Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Québec, G1V 4G2, Canada
- Centre de Recherche sur le Cancer (CRC) de l'Université Laval, Québec, G1R 3S3, Canada
| | - Philippe Gros-Louis
- Axe Médecine Régénératrice, Centre de Recherche du Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Québec, G1V 4G2, Canada
- Centre de Recherche sur le Cancer (CRC) de l'Université Laval, Québec, G1R 3S3, Canada
- Centre Universitaire d'Ophtalmologie (CUO) and Centre de Recherche du CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, Québec, G1S 4L8, Canada
| | - Claudine Bellerive
- Axe Médecine Régénératrice, Centre de Recherche du Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Québec, G1V 4G2, Canada
- Centre Universitaire d'Ophtalmologie (CUO) and Centre de Recherche du CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, Québec, G1S 4L8, Canada
| | - Solange Landreville
- Axe Médecine Régénératrice, Centre de Recherche du Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Québec, G1V 4G2, Canada
- Centre de Recherche sur le Cancer (CRC) de l'Université Laval, Québec, G1R 3S3, Canada
- Centre Universitaire d'Ophtalmologie (CUO) and Centre de Recherche du CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, Québec, G1S 4L8, Canada
| | - Luc Beaulieu
- Centre de Recherche sur le Cancer (CRC) de l'Université Laval, Québec, G1R 3S3, Canada
- Département de Physique, de Génie Physique et d'Optique, Université Laval, Québec, G1V 0A6, Canada
- Service de physique médicale et radioprotection and Axe Oncologie, Centre de Recherche du Centre Hospitalier Universitaire de Québec-Université Laval, Québec, G1L 3L5, Canada
| | - Marc-André Fortin
- Département de Génie des Mines, de la Métallurgie et des Matériaux and Centre de recherche sur les matériaux avancés (CERMA), Université Laval, Québec, G1V 0A6, Canada
- Axe Médecine Régénératrice, Centre de Recherche du Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Québec, G1V 4G2, Canada
- Centre de Recherche sur le Cancer (CRC) de l'Université Laval, Québec, G1R 3S3, Canada
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Chen JC, Chen CH, Chang KC, Liu SM, Ko CL, Shih CJ, Sun YS, Chen WC. Evaluation of the Grafting Efficacy of Active Biomolecules of Phosphatidylcholine and Type I Collagen on Polyether Ether Ketone: In Vitro and In Vivo. Polymers (Basel) 2021; 13:polym13132081. [PMID: 34202722 PMCID: PMC8271559 DOI: 10.3390/polym13132081] [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] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 01/17/2023] Open
Abstract
Biomolecule grafting on polyether ether ketone (PEEK) was used to improve cell affinity caused by surface inertness. This study demonstrated the sequence-polished (P) and sulfonated (SA) PEEK modification to make a 3D structure, active biomolecule graftings through PEEK silylation (SA/SI) and then processed with phosphatidylcholine (with silylation of SA/SI/PC; without SA/PC) and type I collagen (COL I, with silylation of SA/SI/C; without SA/C). Different modified PEEKs were implanted for 4, 8, and 12 weeks for histology. Sulfonated PEEK of SA showed the surface roughness was significantly increased; after the silylation of SA/SI, the hydrophilic nature was remarkably improved. The biomolecules were effectively grafted through silylation, and the cells showed improved attachment after 1 h. Furthermore, the SA/SI/PC group showed good in vitro mineralization. The new bone tissues were integrated into the 3D porous structures of SA/SI/PC and SA/SI/C in vivo making PEEK a potential alternative to metals in orthopedic implants.
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Affiliation(s)
- Jian-Chih Chen
- Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Chih-Hua Chen
- Advanced Medical Devices and Composites Laboratory, Department of Fiber and Composite Materials, Feng Chia University, Taichung 407, Taiwan; (C.-H.C.); (K.-C.C.); (S.-M.L.); (C.-L.K.)
| | - Kai-Chi Chang
- Advanced Medical Devices and Composites Laboratory, Department of Fiber and Composite Materials, Feng Chia University, Taichung 407, Taiwan; (C.-H.C.); (K.-C.C.); (S.-M.L.); (C.-L.K.)
| | - Shih-Ming Liu
- Advanced Medical Devices and Composites Laboratory, Department of Fiber and Composite Materials, Feng Chia University, Taichung 407, Taiwan; (C.-H.C.); (K.-C.C.); (S.-M.L.); (C.-L.K.)
| | - Chia-Ling Ko
- Advanced Medical Devices and Composites Laboratory, Department of Fiber and Composite Materials, Feng Chia University, Taichung 407, Taiwan; (C.-H.C.); (K.-C.C.); (S.-M.L.); (C.-L.K.)
| | - Chi-Jen Shih
- Department of Fragrance and Cosmetic Science, College of Pharmacy, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
- Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Ying-Sui Sun
- School of Dental Technology, College of Oral Medicine, Taipei Medical University, Taipei 110, Taiwan;
| | - Wen-Cheng Chen
- Advanced Medical Devices and Composites Laboratory, Department of Fiber and Composite Materials, Feng Chia University, Taichung 407, Taiwan; (C.-H.C.); (K.-C.C.); (S.-M.L.); (C.-L.K.)
- Department of Fragrance and Cosmetic Science, College of Pharmacy, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
- Dental Medical Devices and Materials Research Center, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Correspondence:
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Cui Y, Zhou Y, Liu J, Duan D, Gong L, Li W. ACDF plus Uncovertebrectomy versus ACDF alone for the Treatment of Cervical Spondylotic Radiculopathy: Minimum 5-Year Follow-Up. J Neurol Surg A Cent Eur Neurosurg 2021; 82:154-160. [PMID: 33386028 DOI: 10.1055/s-0040-1720992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The surgical approach for cervical spondylotic radiculopathy (CSR) is controversial. This study aims to investigate the effectiveness of the combined anterior cervical diskectomy and fusion (ACDF) and uncovertebrectomy for treatment of CSR. METHODS This is a retrospective case control study. One hundred and forty-six patients with CSR who underwent two different procedures (ACDF alone [group A]) and a combination of ACDF and uncovertebrectomy [group B]) from March 2008 to April 2013 were included. The operation time, blood loss, Visual Analog Scale scores of the neck (VAS-neck) and arm (VAS-arm), Neck Disability Index (NDI) score, 36-Item Short Form Health Survey (SF-36) score, fusion segment curvature, global cervical curvature, and the rate of surgical complication were evaluated. RESULTS There were no significant differences in the basic demographic and clinical characteristics between the two groups (p > 0.05). No significant differences were noticed in the fusion segment curvature and global cervical curvature between the two groups (p > 0.05). Whereas the operation time and blood loss in group B were greater than those in group A (p < 0.05), the VAS-neck, VAS-arm, NDI, and SF-36 scores were better in group B (p < 0.05). The surgical complication rate between the two groups was not significantly different (p > 0.05). CONCLUSIONS Clinical efficacy of ACDF plus uncovertebrectomy for the treatment of patients with CSR may be better than that of ACDF alone, but at the expense of more operation time and blood loss.
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Affiliation(s)
- Yaqing Cui
- Department of Orthopaedic, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Yongchun Zhou
- Department of Orthopaedic, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Jun Liu
- Department of Orthopaedic, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Dapeng Duan
- Department of Orthopaedic, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Liqun Gong
- Department of Orthopaedic, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Weiwei Li
- Department of Orthopaedic, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
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Byun SE, Vintimilla DR, Bedeir YH, Dean CS, Parry JA, Hak DJ, Mauffrey C. Evaluation of callus formation in distal femur fractures after carbon fiber composite versus stainless steel plate fixation. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1103-1107. [PMID: 32356122 DOI: 10.1007/s00590-020-02681-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Carbon-fiber-reinforced polyetheretherketone (CFR) composite plates have a more favorable stress modulus than stainless steel (SS) plates that may confer an advantage to bridge plating. The purpose of this study was to compare callus formation after CFR and SS plating of distal femur fractures. METHODS A retrospective review identified distal femoral fractures treated with CFR (n = 10) and SS (n = 21) plate fixation. Callus formation was measured using the modified Radiographic Union Score for Tibia (mRUST) at 3- and 6-month follow-up by three orthopedic trauma surgeons. Loss of alignment, implant failure, and revision surgeries were reviewed. RESULTS At 3 months, the mRUST in the CFR and SS groups was 9.0 (range, 6.3-12.3) and 6.9 (range, 4.3-11.7), respectively (p = 0.01). At 6 months, the mRUST in the CFR and SS groups was 11.4 (range, 7.7-16.0) and 10.5 (range, 6.0-15.7), respectively (p = 0.3). CFR and SS groups had a loss of fracture alignment in 1 (10%) and 1 (5%) patient, respectively (p = 0.5), and an unplanned revision surgery in 0 (0%) and 3 (15%) patients, respectively (p = 0.2). All three revisions surgeries in the SS group were for nonunion repair. CONCLUSIONS Treatment of distal femur fractures with CFR versus SS plating resulted in greater callus formation at 3 months. At 6 months, there was no difference in callus formation between groups. A larger series of patients is necessary to determine if the observed early increased callus formation confers a benefit to clinical outcomes. LEVEL OF EVIDENCE Therapeutic level III.
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Affiliation(s)
| | | | - Yehia H Bedeir
- University of Alexandria Medical Center, El-Hadara University Hospital, Alexandria, Egypt
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Guzzini M, Princi G, Proietti L, Ferretti A. The use of Carbon-Peek volar plate after distal radius osteotomy for Kienbock's Disease in a volleyball athlete: a case report. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:152-155. [PMID: 31821300 PMCID: PMC7233714 DOI: 10.23750/abm.v90i12-s.8828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/31/2019] [Indexed: 11/23/2022]
Abstract
Kienbock’s Disease, or lunatomalacia, has uncertain etiopathogenesis, it is more common in male from 20 to 45-year-old. The Lichtman’s classification is the most used by authors and it divides Kienbock’s Disease in 4 stages according to radiographic parameters. In early stages could be performed a conservative treatment, but failure rate is high; various surgical techniques are available in case of failure or higher stages. We report a case of a 26-year-old female volleyball player affected by stage I Kienbock’s Disease who underwent distal radius osteotomy core decompression synthesized with Carbon-Peek plate fixation. Follow-up was performed with clinical evaluation (ROM analysis, VAS score, Quick Dash Score), wrist radiographs and wrist MRI. (www.actabiomedica.it)
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Affiliation(s)
- Matteo Guzzini
- Orthopaedic Unit and "Kirk Kilgour" Sports Injury Centre, S. Andrea Hospital, University of Rome "La Sapienza", Rome, Italy.
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Yang S, Yu Y, Liu X, Zhang Z, Hou T, Xu J, Wu W, Luo F. Clinical and radiological results comparison of allograft and polyetheretherketone cage for one to two-level anterior cervical discectomy and fusion: A CONSORT-compliant article. Medicine (Baltimore) 2019; 98:e17935. [PMID: 31702680 PMCID: PMC6855611 DOI: 10.1097/md.0000000000017935] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Recently, many kinds of cages for cervical fusion have been developed to avoid the related complications caused by tricortical iliac crest graft. The existing literature has reported the excellent clinical efficacy and superior fusion rate. However, various types of cages have their own disadvantages. Which bone graft material is the best choice for cage with the fewest complications? At present, there is still no conclusion. METHODS By reviewing patients with 1 to 2-level cervical degenerative disease in our hospital with a novel cage made of allograft or polyetheretherketone (PEEK), we evaluated the efficacy and reliability of the new cage in anterior cervical discectomy and fusion (ACDF). From 2015 to 2016, a prospective review of 58 and 49 consecutive cases with spondylotic radiculopathy or myelopathy undergoing ACDF using allograft (group A) and PEEK (group B) cage were performed. The follow-up ranged from 12 to 40 months. Intraoperative index, clinical outcome and complications were recorded. Radiographs evaluated segmental and overall cervical lordosis, the height of the intervertebral space, interbody height ratio (IHR), cage positioning, and fusion state. RESULTS A total of 134 cages were implanted. Compared to preoperatively, the visual analog scale (VAS) and neck disability index (NDI) were reduced postoperatively without any change during the subsequent follow-up in both groups. There was no migration or extrusion of the cages at the latest follow-up. There were 2 and 4 patients suffering dysphagia respectively. In both groups, the intervertebral height, IHR, segmental and overall cervical lordosis were significantly greater than pre-operation (P < .05) and were maintained at the last follow-up, but were not statistically significant (P > .05). The allograft group achieved a fusion rate of 100% (58/58) according to CT scans at 3 months post-operation, while PEEK group was 91.8% (45/49), which reached 95.9% (47/49) at 6 months and 100% at 12 months. In addition, the fusion state was maintained in all patients at the last follow-up. CONCLUSION Our data showed that the new allograft cage is superior to the PEEK cage in providing a high fusion rate and fewer complications after 1-level and 2-level ACDF procedures. It may represent an excellent alternative to other cages.
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Affiliation(s)
- Sen Yang
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing
| | - Yang Yu
- Department of Orthopaedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Xun Liu
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing
| | - Zehua Zhang
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing
| | - TianYong Hou
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing
| | - Jianzhong Xu
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing
| | - Wenjie Wu
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing
| | - Fei Luo
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing
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Iunes EA, Barletta EA, Barba Belsuzarri TA, Onishi FJ, Cavalheiro S, Joaquim AF. Correlation Between Different Interbody Grafts and Pseudarthrosis After Anterior Cervical Discectomy and Fusion Compared with Control Group: Systematic Review. World Neurosurg 2019; 134:272-279. [PMID: 31669245 DOI: 10.1016/j.wneu.2019.10.100] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 10/15/2019] [Accepted: 10/16/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cervical spine degenerative disease is one of the main causes of myelopathy. Anterior cervical discectomy and fusion (ACDF) is the most common surgical procedure used to treat cervical myelopathy. Therefore, it is important to study pseudarthrosis rates after ACDF and correlate them with the graft used. METHODS We performed a systematic review to evaluate the relationship between pseudarthrosis after ACDF and the interbody graft used. RESULTS A total of 3732 patients were evaluated in 46 studies. The mean age of the included patients was 51.5 ± 4.18 years (range, 42-59.6 years). ACDF is most often perforemd as single-level surgery and the level most impaired is C5-C6. The use of titanium cages, zero profile, recombinant human bone morphogenetic protein 2, and carbon cages was seen as a protective factor for pseudarthrosis compared with the autograft group (control group); with an odds ratio of 0.29, 0.51, 0.03, and 0.3, respectively; the results were statistically relevant. The use of polyetheretherketone, poly(methyl methacrylate), and trabecular metal was a risk factor for development of pseudarthrosis compared with the control group, with an odds ratio of 1.7, 8.7, and 6.8, respectively; the results were statistically relevant. Radiologic follow-up was an important factor for the pseudarthrosis rate; paradoxically, a short follow-up (<1 year) had lower rates of pseudarthrosis and follow-up >2 years increased the chance of finding pseudarthrosis. CONCLUSIONS Different types of grafts lead to a significant difference in pseudarthrosis rates. Follow-up time is also an important factor that affects the rate of pseudarthrosis after ACDF.
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Affiliation(s)
- Eduardo Augusto Iunes
- Department of Neurosurgery, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | | | - Telmo Augusto Barba Belsuzarri
- Department of Neurosurgery, Pontifical Catholic University of Campinas and Post-Graduation Program, Masters in Health Sciences, Pontifical Catholic University of Campinas, Campinas, Brazil
| | - Franz Jooji Onishi
- Department of Neurosurgery, Federal University of São Paulo, Medical School, São Paulo, Brazil
| | - Sergio Cavalheiro
- Department of Neurosurgery, Federal University of São Paulo, Medical School, São Paulo, Brazil
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Pang H, Tian H, Qiu S, Wang N, Wang YQ. Progress of titanium strut for cervical reconstruction with nano-graphene oxide loaded hydroxyapatite/polyamide composite and interbody fusion after corpectomy with anterior plate fixation. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2019; 47:3094-3100. [PMID: 31343278 DOI: 10.1080/21691401.2019.1637883] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Hongli Pang
- Department of Neurosurgery, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang, China
| | - Hailong Tian
- Department of Neurosurgery, Qilu Hospital (Qingdao), Shandong University, Qingdao, China
| | - Shaobo Qiu
- Department of Neurosurgery, Weifang brain Hospital, WeiFang, China
| | - Ning Wang
- Department of Neurosurgery, Jinan Fourth People’s Hospital, Jinan, China
| | - Yu-Qiang Wang
- Department of Orthopedic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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10
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Kani KK, Chew FS. Anterior cervical discectomy and fusion: review and update for radiologists. Skeletal Radiol 2018; 47:7-17. [PMID: 29058045 DOI: 10.1007/s00256-017-2798-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 10/06/2017] [Accepted: 10/11/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The goals of this article are to describe the various types of interbody grafts and anterior cervical plating systems, techniques for optimizing evaluation of cervical spine metallic implants on CT and MR imaging, expected appearance and complications of ACDF on postoperative imaging and imaging assessment of fusion. Optimization for optimizing metal induced artifacts. CONCLUSION Currently, ACDF is the most commonly performed surgical procedure for degenerative cervical spine disease. Interbody fusion is performed with bone grafts or interbody spacers, and may be supplemented with anterior cervical plating. Compressive pathologies at the vertebral body level may be addressed by simultaneous corpectomy. Postoperatively, imaging plays an integral role in routine screening of asymptomatic individuals, fusion assessment and evaluation of complications.
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Affiliation(s)
- Kimia Khalatbari Kani
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Felix S Chew
- Department of Radiology, University of Washington, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
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Di Maggio B, Sessa P, Mantelli P, Maniscalco P, Rivera F, Calori GM, Bisogno L, Scaravilli G, Caforio M. PEEK radiolucent plate for distal radius fractures: multicentre clinical results at 12 months follow up. Injury 2017; 48 Suppl 3:S34-S38. [PMID: 29025607 DOI: 10.1016/s0020-1383(17)30655-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Open reduction and internal fixation (ORIF) with plate and screws represents the recommended treatment for unstable intra-articular distal radius fractures. Although significant progresses in surgical technique have been made, anatomical reconstruction of radio-carpal articular surface still represent a difficult task, especially in multifragmentary fractures. Available PEEK reinforced-carbon fiber composite radiolucent devices allow both an easier and more careful assessment of intra-operative reduction of the articular surface of distal radius and prompt correction of any residual step deformity. MATERIALS AND METHODS We retrospectively reviewed clinical and radiological multicentre results of 71 consecutive AO B and C fracture pattern of distal radius treated using the same PEEK reinforced-carbon fiber composite radiolucent plate. RESULTS Three patients lost at final follow up and 4 cases with incomplete radiological documentations were excluded from the study. 64 patients (38 females, 26 males) were available and formed the basis of this report. Fracture types included 9 patients with 23-B, 13 patients 23-B2,15 patients with 23-B3,10 patients with 23-C1, 7 patients with 23-C2 and 10 patients with 23-C3. Mean Modified Mayo wrist Score was on average 38.11 (SD 10.1; range 24-75, 95%CI 34.7-41.4), 67.22 (SD 9.6, range 50-90, 95%CI 64-70.4), 90.54 (SD 6.3, range 75-100, 95%CI 88.4-92.6) at one, two and twelve months of follow-up, respectively. A statistically significant difference was found between mean scores at different follow-up periods (p = 0.001). We noted 1 case of distal screw fixation aseptic loosening at 5 months post surgical intervention. CONCLUSIONS PEEK reinforced-carbon fiber composite radiolucent plate represents a useful device for treatment of complex distal radius fractures in the adult population. It possesses unique biomechanical properties and allows for an easier anatomical reduction during surgical intervention.
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Affiliation(s)
- Bruno Di Maggio
- UOC ortopedia e Traumatologia Presidio Ospedaliero Piedimonte Matese (CE)
| | | | - Patrizia Mantelli
- Orthopaedic and Traumatology Department - G. da Saliceto Hospital, Piacenza
| | - Pietro Maniscalco
- Orthopaedic and Traumatology Department - G. da Saliceto Hospital, Piacenza
| | | | - Giorgio Maria Calori
- C.O.R. Orthopaedic Reparative Surgery Department - ASST Pini/CTO, University of Milan
| | - Luigi Bisogno
- Orthopaedic and Traumatology Department - Scarnati Clinic, Cosenza
| | | | - Marco Caforio
- Orthopaedic and Traumatology Department - G. da Saliceto Hospital, Piacenza.
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[PEEK cage fusion after anterior cervical corpectomy : Clinical and radiological results in patients with spondylotic myelopathy]. DER ORTHOPADE 2016; 46:242-248. [PMID: 27783108 DOI: 10.1007/s00132-016-3345-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Anterior cervical corpectomy and fusion (ACCF) has become a standard procedure for patients with spondylotic myelopathy due to multisegmental stenosis of the cervical canal. In addition to the fusion technique using autogenous bone grafts and titanium implants, synthetic polyetheretherketone (PEEK) cages have been used increasingly during the last years. However, limited evidence on the clinical and radiological results of PEEK cages for ACCF exists in the literature. The study presented here is the largest series to date reporting clinical and radiological outcome as well as complication rates after one to three-level ACCF using PEEK cages augmented by an anterior plate-screw osteosynthesis. MATERIALS AND METHODS Retrospective study on 101 patients after stand-alone PEEK cage-ACCF with a minimum follow-up of 6 months. The number of hardware failures and implant-related surgical revisions were determined. The rate of subsidence and fusion and the course of lordotic alignment were analysed. The neck disability index (NDI) and the European myelopathy score (EMS) were assessed. RESULTS Screw complications were detected in 8/101 cases and 3 cases of cage dislocation occurred, resulting in an overall implant related revision rate of 2.9 % (all revision cases showed cage dislocation). The rate of cage subsidence >3 mm was 12 % and solid fusion was achieved in 82 % of the patients. NDI, EMS and lordotic alignment improved significantly. CONCLUSIONS PEEK cages are a safe and effective alternative to titanium cages or autogenous bone graft for ACCF. Further randomized evaluation of different fusion techniques in ACCF is still necessary.
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Hartmann S, Tschugg A, Obernauer J, Neururer S, Petr O, Thomé C. Cervical corpectomies: results of a survey and review of the literature on diagnosis, indications, and surgical technique. Acta Neurochir (Wien) 2016; 158:1859-67. [PMID: 27557956 DOI: 10.1007/s00701-016-2908-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 07/27/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Cervical corpectomy is an uncommon procedure and there are only limited data on the procedure's indications, surgical approaches, and complications. The diagnosis, indications, surgical planning, and complications of cervical corpectomy were therefore surveyed to clarify the treatment strategies used by spinal surgeons in central Europe, with special attention to preoperative planning and decision-making for additional dorsal approaches in multilevel cases. MATERIALS AND METHODS An online survey with 18 questions on the preoperative, intraoperative, and postoperative management of cervical corpectomies was conducted. The relevant specialist societies in Germany and Austria provided 1137 contacts for surgeons, and the responses were compared with recent literature reports. RESULTS In all, 302 surgeons (27 %) completed the survey, with wide variability in the treatment options offered. Most (51 %) perform fewer than five anterior cervical corpectomy and fusion (ACCF) procedures per year; 35 % do 5-20 per year. Anterior cervical discectomy and fusion (ACDF) was preferred by 41 % of the participants to laminoplasty/laminectomy (19 %/16 %) and ACCF (12 %). Most indications for ACCF involved degenerative (27 %), traumatic (17 %), and neoplastic (20 %) conditions. Intraoperative and postoperative complications were mainly associated with hardware failure. One-third of the surgeons tend to use an additional dorsal approach to increase the corpectomy construct's stability for either two-level or three-level corpectomies. CONCLUSIONS There is no current consensus in central Europe on the treatment of complex cervical disease and cervical corpectomy. The procedure is still rare, and the need for additional dorsal fixation is unclear. Further studies are needed in order to establish evidence-based standards for patient care.
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Panayotov IV, Orti V, Cuisinier F, Yachouh J. Polyetheretherketone (PEEK) for medical applications. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2016; 27:118. [PMID: 27259708 DOI: 10.1007/s10856-016-5731-4] [Citation(s) in RCA: 223] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 05/24/2016] [Indexed: 05/22/2023]
Abstract
Polyetheretherketone (PEEK) is a polyaromatic semi-crystalline thermoplastic polymer with mechanical properties favorable for bio-medical applications. Polyetheretherketone forms: PEEK-LT1, PEEK-LT2, and PEEK-LT3 have already been applied in different surgical fields: spine surgery, orthopedic surgery, maxillo-facial surgery etc. Synthesis of PEEK composites broadens the physicochemical and mechanical properties of PEEK materials. To improve their osteoinductive and antimicrobial capabilities, different types of functionalization of PEEK surfaces and changes in PEEK structure were proposed. PEEK based materials are becoming an important group of biomaterials used for bone and cartilage replacement as well as in a large number of diverse medical fields. The current paper describes the structural changes and the surface functionalization of PEEK materials and their most common biomedical applications. The possibility to use these materials in 3D printing process could increase the scientific interest and their future development as well.
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Affiliation(s)
- Ivan Vladislavov Panayotov
- Laboratoire de Bioingénierie et Nanosciences EA 4203, UFR Odontologie, Université de Montpellier, 545 Avenue du Professeur Jean-Louis Viala, 34193, Montpellier Cedex 5, France.
| | - Valérie Orti
- Laboratoire de Bioingénierie et Nanosciences EA 4203, UFR Odontologie, Université de Montpellier, 545 Avenue du Professeur Jean-Louis Viala, 34193, Montpellier Cedex 5, France
| | - Frédéric Cuisinier
- Laboratoire de Bioingénierie et Nanosciences EA 4203, UFR Odontologie, Université de Montpellier, 545 Avenue du Professeur Jean-Louis Viala, 34193, Montpellier Cedex 5, France
| | - Jacques Yachouh
- Laboratoire de Bioingénierie et Nanosciences EA 4203, UFR Odontologie, Université de Montpellier, 545 Avenue du Professeur Jean-Louis Viala, 34193, Montpellier Cedex 5, France
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Long-term results of anterior cervical corpectomy and fusion with nano-hydroxyapatite/polyamide 66 strut for cervical spondylotic myelopathy. Sci Rep 2016; 6:26751. [PMID: 27225189 PMCID: PMC4880938 DOI: 10.1038/srep26751] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/09/2016] [Indexed: 01/07/2023] Open
Abstract
To assess the long-term clinical and radiographic outcomes of anterior cervical corpectomy and fusion (ACCF) with a neotype nano-hydroxyapatite/polyamide 66 (n-HA/PA66) strut in the treatment of cervical spondylotic myelopathy (CSM). Fifty patients with CSM who underwent 1- or 2-level ACCF with n-HA/PA66 struts were retrospectively investigated. With a mean follow-up of 79.6 months, the overall mean JOA score, VAS and cervical alignment were improved significantly. At last follow-up, the fusion rate was 98%, and the subsidence rate of the n-HA/PA66 strut was 8%. The "radiolucent gap" at the interface between the n-HA/PA66 strut and the vertebra was further noted to evaluate the osteoconductivity and osseointegration of the strut, and the incidence of it was 62% at the last follow-up. Three patients suffered symptomatic adjacent segment degeneration (ASD). No significant difference was detected in the outcomes between 1- and 2-level corpectomy at follow-ups. In conclusion, the satisfactory outcomes in this study indicated that the n-HA/PA66 strut was an effective graft for cervical reconstruction. Moreover, the osteoconductivity and osseointegration of the strut is still need to be optimized for future clinical application owing to the notably presence of "radiolucent gap" in present study.
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Gao S, Gao S, Xu B, Yu H. Effects of Different pH-Values on the Nanomechanical Surface Properties of PEEK and CFR-PEEK Compared to Dental Resin-Based Materials. MATERIALS 2015; 8:4751-4767. [PMID: 28793469 PMCID: PMC5455519 DOI: 10.3390/ma8084751] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 07/13/2015] [Accepted: 07/22/2015] [Indexed: 02/05/2023]
Abstract
The study determines the stability and durability of polyetheretherketone (PEEK) and a carbon fiber-reinforced PEEK (CFR-PEEK) with 30% short carbon fibers, a dental composite based on Bis-GMA and polymethylmethacrylate (PMMA) under the influence of different pH-values of the oral environment in vitro. Nanomechanical properties were investigated by nanoindentation and nanoscratch tests before and after incubation of the specimens at 37 °C for 30 days in artificial saliva with pH-values of 3, 7 and 10, respectively. Nanoindentation and nanoscratching tests were performed using the Hysitron TI950 TriboIndenter to evaluate the reduced elastic moduli, nanohardness, viscoelasticity, friction coefficient and residual scratch profiles. After treatment, the nanomechanical properties of unfilled PEEK did not change. The reduced elastic moduli and nanohardness of the carbon fiber-reinforced PEEK increased significantly. The reduced elastic moduli and nanohardness of CHARISMA decreased. The plasticity of all materials except that of the unfilled PEEK increased. This indicates that different pH-values of the artificial saliva solutions had no obvious influences on the nanomechanical properties of the PEEK matrix. Therefore, the aging resistance of the unfilled PEEK was higher than those of other materials. It can be deduced that the PEEK matrix without filler was more stable than with filler in the nanoscale.
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Affiliation(s)
- Shuai Gao
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, NO. 14, 3rd Section of Ren Min Nan Road, Chengdu 610041, China.
| | - Shanshan Gao
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, NO. 14, 3rd Section of Ren Min Nan Road, Chengdu 610041, China.
| | - Baohua Xu
- China-Japan Friendship Hospital, Yinghua Road, Chaoyang District, Beijing 100020, China.
| | - Haiyang Yu
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, NO. 14, 3rd Section of Ren Min Nan Road, Chengdu 610041, China.
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Abdullah MR, Goharian A, Abdul Kadir MR, Wahit MU. Biomechanical and bioactivity concepts of polyetheretherketone composites for use in orthopedic implants-a review. J Biomed Mater Res A 2015; 103:3689-702. [DOI: 10.1002/jbm.a.35480] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/22/2015] [Accepted: 04/06/2015] [Indexed: 01/13/2023]
Affiliation(s)
- Mohamed Ruslan Abdullah
- Centre for Composites; Department of Applied Mechanics and Design; Universiti Teknologi Malaysia (UTM); 81310 Skudai, Johor Malaysia
| | - Amirhossein Goharian
- Medical Devices & Technology Group; Faculty of Biosciences & Medical Engineering, Universiti Teknologi Malaysia (UTM); 81310 Skudai, Johor Malaysia
- R&D Department; Leonix Sdn. Bhd.; Penang 11960 Malaysia
| | - Mohammed Rafiq Abdul Kadir
- Medical Devices & Technology Group; Faculty of Biosciences & Medical Engineering, Universiti Teknologi Malaysia (UTM); 81310 Skudai, Johor Malaysia
| | - Mat Uzir Wahit
- Center for Composites, Institute of Vehicle System and Engineering (IVeSE), Universiti Teknologi Malaysia (UTM); 81310 Skudai, Johor Malaysia
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Tarallo L, Mugnai R, Adani R, Zambianchi F, Catani F. A new volar plate made of carbon-fiber-reinforced polyetheretherketon for distal radius fracture: analysis of 40 cases. J Orthop Traumatol 2014; 15:277-83. [PMID: 25017027 PMCID: PMC4244565 DOI: 10.1007/s10195-014-0311-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Accepted: 06/27/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Implants based on the polyetheretherketon (PEEK) polymer have been developed in the last decade as an alternative to conventional metallic devices. PEEK devices may provide several advantages over the use of conventional orthopedic materials, including the lack of metal allergies, radiolucency, low artifacts on magnetic resonance imaging scans and the possibility of tailoring mechanical properties. The purpose of this study was to evaluate the clinical results at 12-month follow-up using a new plate made of carbon-fiber-reinforced polyetheretherketon for the treatment of distal radius fractures. MATERIALS AND METHODS We included 40 consecutive fractures of AO types B and C that remained displaced after an initial attempt at reduction. The fractures were classified according to the AO classification: 21 fractures were type C1, 9 were type C2, 2 were type C3, 2 were type B1 and 6 were type B2. RESULTS At a 12-month follow-up no cases of hardware breakage or loss of the surgically achieved fracture reduction were documented. All fractures healed, and radiographic union was observed at an average of 6 weeks. The final Disabilities of Arm, Shoulder and Hand score was 6.0 points. The average grip strength, expressed as a percentage of the contralateral limb, was 92 %. Hardware removal was performed only in one case, for the occurrence of extensor tenosynovitis. CONCLUSION At early follow-up this device showed good clinical results and allowed maintenance of reduction in complex, AO fractures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Luigi Tarallo
- Orthopaedics and Traumatology Department, Modena Policlinic, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy,
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Kao TH, Wu CH, Chou YC, Chen HT, Chen WH, Tsou HK. Risk factors for subsidence in anterior cervical fusion with stand-alone polyetheretherketone (PEEK) cages: a review of 82 cases and 182 levels. Arch Orthop Trauma Surg 2014; 134:1343-51. [PMID: 25099076 PMCID: PMC4168225 DOI: 10.1007/s00402-014-2047-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION To determine risk factors for subsidence in patients treated with anterior cervical discectomy and fusion (ACDF) and stand-alone polyetheretherketone (PEEK) cages. MATERIALS AND METHODS Records of patients with degenerative spondylosis or traumatic disc herniation resulting in radiculopathy or myelopathy between C2 and C7 who underwent ACDF with stand-alone PEEK cages were retrospectively reviewed. Cages were filled with autogenous cancellous bone harvested from iliac crest or hydroxyapatite. Subsidence was defined as a decrease of 3 mm or more of anterior or posterior disc height from that measured on the postoperative radiograph. Eighty-two patients (32 males, 50 females; 182 treatment levels) were included in the analysis. RESULTS Most patients had 1-2 treatment levels (62.2 %), and 37.8 % had 3-4 treatment levels. Treatment levels were from C2-7. Of the 82 patients, cage subsidence occurred in 31 patients, and at 39 treatment levels. Multivariable analysis showed that subsidence was more likely to occur in patients with more than two treatment levels, and more likely to occur at treatment levels C5-7 than at levels C2-5. Subsidence was not associated with postoperative alignment change but associated with more disc height change (relatively oversized cage). CONCLUSION Subsidence is associated with a greater number of treatment levels, treatment at C5-7 and relatively oversized cage use.
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Affiliation(s)
- Ting-Hsien Kao
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC ,Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan, ROC ,Department of Acupressure Technology, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli County, Taiwan, ROC
| | - Chen-Hao Wu
- Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Yu-Ching Chou
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Hsien-Te Chen
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan, ROC ,Department of Orthopaedic Surgery, China Medical University Hospital, Taichung, Taiwan, ROC
| | - Wen-Hsien Chen
- Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC ,Department of Medical Imaging and Radiological Sciences, College of Heath Sciences, Central Taiwan University of Science and Technology, Taichung, Taiwan, ROC
| | - Hsi-Kai Tsou
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC ,Department of Early Childhood Care and Education, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli County, Taiwan, ROC
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