1
|
Toop N, Dhaliwal J, Grossbach A, Gibbs D, Reddy N, Keister A, Mallory N, Xu D, Viljoen S. Subsidence Rates Associated With Porous 3D-Printed Versus Solid Titanium Cages in Transforaminal Lumbar Interbody Fusion. Global Spine J 2024; 14:1889-1898. [PMID: 36786680 DOI: 10.1177/21925682231157762] [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] [Indexed: 02/15/2023] Open
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVE To determine whether 3D-printed porous titanium (3DPT) interbody cages offer any clinical or radiographic advantage over standard solid titanium (ST) interbody cages in transforaminal lumbar interbody fusions (TLIF). METHODS A consecutive series of adult patients undergoing one- or two-level TLIF with either 3DPT or ST "banana" cages were analyzed for patient reported outcome measures (PROMs), radiographic complications, and clinical complications. Exclusion criteria included clinical or radiographic follow-up less than 1 year. RESULTS The final cohort included 90 ST interbody levels from 74 patients, and 73 3DPT interbody levels from 50 patients for a total of 124 patients. Baseline demographic variables and comorbidity rates were similar between groups (P > .05). Subsidence of any grade occurred more frequently in the ST group compared with the 3DPT group (24.4% vs 5.5%, respectively, P = .001). Further, the ST group was more likely to have higher grades of subsidence than the 3DPT group (P = .009). All PROMs improved similarly after surgery and revision rates did not differ between groups (both P > .05). On multivariate analysis, significant positive correlators with increasing subsidence grade included greater age (P = .015), greater body mass index (P = .043), osteoporosis/osteopenia (P < .027), and ST cage type (P = .019). CONCLUSIONS When considering interbody material for TLIF, both ST and 3DPT cages performed well; however, 3DPT cages were associated with lower rates of subsidence. The clinical relevance of these findings deserves further randomized, prospective investigation.
Collapse
Affiliation(s)
- Nathaniel Toop
- Department of Neurosurgery, Ohio State University School of Medicine, Columbus, OH, USA
| | - Joravar Dhaliwal
- Department of Neurosurgery, Ohio State University School of Medicine, Columbus, OH, USA
| | - Andrew Grossbach
- Department of Neurosurgery, Ohio State University School of Medicine, Columbus, OH, USA
| | - David Gibbs
- Ohio State University School of Medicine, Columbus, OH, USA
| | - Nihaal Reddy
- Ohio State University School of Medicine, Columbus, OH, USA
| | | | - Noah Mallory
- Ohio State University School of Medicine, Columbus, OH, USA
| | - David Xu
- Department of Neurosurgery, Ohio State University School of Medicine, Columbus, OH, USA
| | - Stephanus Viljoen
- Department of Neurosurgery, Ohio State University School of Medicine, Columbus, OH, USA
| |
Collapse
|
2
|
De Salvatore S, Longo UG, Vincenzi B, Pantano F, Zollo G, Calabrese G, Denaro V. Clinical performance of implanted devices used in surgical treatment of patients with spinal tumors: a systematic review. BMC Musculoskelet Disord 2024; 25:650. [PMID: 39160506 PMCID: PMC11331752 DOI: 10.1186/s12891-024-07623-7] [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: 05/29/2023] [Accepted: 06/24/2024] [Indexed: 08/21/2024] Open
Abstract
PURPOSE Implanted devices used in metastatic spine tumor surgery (MSTS) include pedicle screws, fixation plates, fixation rods, and interbody devices. A material to be used to fabricate any of these devices should possess an array of properties, which include biocompatibility, no toxicity, bioactivity, low wear rate, low to moderate incidence of artifacts during imaging, tensile strength and modulus that are comparable to those of cortical bone, high fatigue strength/long fatigue life, minimal or no negative impact on radiotherapy (RT) planning and delivery, and high capability for fusion to the contiguous bone. The shortcomings of Ti6Al4V alloy for these applications with respect to these desirable properties are well recognized, opening the field for an investigation about novel biomaterials that could replace the current gold standard. Previously published reviews on this topic have exhibited significant shortcomings in the studies they included, such as a small, heterogenous sample size and the lack of a cost-benefit analysis, extremely useful to understand the practical possibility of applying a novel material on a large scale. Therefore, this review aims to collect information about the clinical performance of these biomaterials from the most recent literature, with the objective of deliberating which could potentially be better than titanium in the future, with particular attention to safety, artifact production and radiotherapy planning interference. The significant promise showed by analyzing the clinical performance of these devices warrants further research through prospective studies with a larger sample size also taking into account each aspect of the production and use of such materials. METHODS The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to improve the reporting of the review. The search was performed from March 2022 to September 2023. RESULTS At the end of the screening process, 20 articles were considered eligible for this study. Polyetheretherketone (PEEK), Carbon-fibre reinforced polyetheretherketone (CFR-PEEK), long carbon fiber reinforced polymer (LCFRP), Polymethylmethacrylate (PMMA), and carbon screw and rods were used in the included studies. CONCLUSION CFR-PEEK displays a noninferior safety and efficacy profile to titanium implanted devices. However, it also has other advantages. By decreasing artifact production, it is able to increase detection of local tumor recurrence and decrease radiotherapy dose perturbation, ultimately bettering prognosis for patients necessitating adjuvant treatment. Nonetheless, its drawbacks have not been explored fully and still require further investigation in future studies. This does not exclude the fact that CFR-PEEK could be a valid alternative to titanium in the near future.
Collapse
Affiliation(s)
- Sergio De Salvatore
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, Roma, 00128, Italy
- Department of Orthopedics, Children's Hospital Bambino Gesù, Palidoro, Rome, 00165, Italy
| | - Umile Giuseppe Longo
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, Roma, 00128, Italy.
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, Roma, 00128, Italy.
| | - Bruno Vincenzi
- Dipartimento di Oncologia Medica, Università Campus Bio-Medico di Roma, Rome, 00128, Italy
| | - Francesco Pantano
- Dipartimento di Oncologia Medica, Università Campus Bio-Medico di Roma, Rome, 00128, Italy
| | - Giuliano Zollo
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, Roma, 00128, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, Roma, 00128, Italy
| | - Giovanni Calabrese
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, Roma, 00128, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, Roma, 00128, Italy
| | - Vincenzo Denaro
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, Roma, 00128, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, Roma, 00128, Italy
| |
Collapse
|
3
|
Peng YN, Liu ZZ, Qiao L. The Applicability of Polyetheretherketone and Titanium Mesh in Cranioplasty: A Retrospective Comparative Analysis. J Craniofac Surg 2024:00001665-990000000-01735. [PMID: 38949256 DOI: 10.1097/scs.0000000000010432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 05/28/2024] [Indexed: 07/02/2024] Open
Abstract
OBJECTIVE To compare the clinical application effect and safety of polyetheretherketone (PEEK) and titanium mesh (TM) in cranioplasty. METHODS Four-year retrospective comparison of patients (96 cases) undergoing synthetic cranioplasty with PEEK or TM. The patients were divided into the PEEK group (24 cases) and the TM group (72 cases) according to the implants, and the patient demographics, general conditions before the operation, postoperative complications, length of postoperative hospital stay, total costs, satisfaction with shaping and long-term complications were compared between the 2 groups. RESULTS Patients in the PEEK group were younger than those in the TM group (P=0.019). Hospitalization costs were significantly higher in the PEEK group than in the TM group (P<0.001). The incidence of postoperative subcutaneous effusion was 33% in the PEEK group and 6.9% in the TM group, which suggests that patients in the PEEK group had a higher risk of postoperative subcutaneous effusion (P=0.001). There was no significant difference in the incidence of long-term complications and cosmetic satisfaction between the 2 groups at 4 years postoperatively. CONCLUSIONS In this study, both titanium mesh and PEEK are reliable implants for cranioplasty. Titanium mesh is widely used in cranioplasty due to its cost-effective performance. PEEK has gradually gained recognition due to the characteristics of the material and surgical procedure, but the price needs to be further reduced, and attention should be paid to the occurrence and treatment of early postoperative subcutaneous effusion.
Collapse
Affiliation(s)
- Yao-Nan Peng
- Department of Neurosurgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhen-Zhen Liu
- Department of Rehabilitation Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Liang Qiao
- Department of Neurosurgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| |
Collapse
|
4
|
Katiyar P, Malka M, Reyes JL, Lombardi JM, Lenke LG, Sardar ZM. Innovative technologies in thoracolumbar and lumbar spine surgery failing to reach standard of care: state-of-art review. Spine Deform 2024:10.1007/s43390-024-00898-9. [PMID: 38795313 DOI: 10.1007/s43390-024-00898-9] [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: 11/01/2023] [Accepted: 05/15/2024] [Indexed: 05/27/2024]
Abstract
PURPOSE To evaluate previously popular technologies in the field of spine surgery, and to better understand their advantages and limitations to the current standards of care. Spine surgery is an ever-evolving field that serves to resolve various spinal pathologies in patients of all ages. While there are established treatments for various conditions, such as lumbar spinal stenosis, idiopathic scoliosis, and degenerative lumbar disease, there is always further research and development in these areas to produce innovative technologies that can lead to better outcomes. As this process progresses, we must remind ourselves of previously tried and tested inventions and their outcomes that have fallen short of becoming a standard to ensure we are able to learn lessons from the past. METHODS A thorough literature review was conducted with the aim of compiling literature of previously utilized technologies in spine surgery. Biomedical databases were utilized to gather relevant articles including PubMed, MEDLINE, and EMBASE. Emphasis was placed on gathering articles with technologies or therapeutics aimed at treating common spinal pathologies including lumbar spinal stenosis (LSS), adolescent idiopathic scoliosis (AIS), and other degenerative lumbar spine diseases. The keywords used were: "failed technologies", "historical technologies", "spine surgery", "spinal stenosis", "adolescent idiopathic scoliosis", and "degenerative lumbar spine disease". A total of 47 articles were gathered after initial review. RESULTS Different technologies pertaining to spine surgery were identified and critically evaluated. Some of these technologies included X-STOP, Vertiflex, Vertebral Body Stapling, and Dynesys. These technologies were evaluated for their strengths and limitations across their spinal pathology applications. While each type of technology had their benefits, the data tended to be mixed with various limitations across studies. CONCLUSION These technologies have been trialed in the field of spine surgery across various spinal pathologies, but still prove of limited efficacy and shortcomings to the current standards of care.
Collapse
Affiliation(s)
- Prerana Katiyar
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, Och Spine Hospital, New York-Presbyterian/Allen, New York, USA
| | - Matan Malka
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, Och Spine Hospital, New York-Presbyterian/Allen, New York, USA
| | - Justin L Reyes
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, Och Spine Hospital, New York-Presbyterian/Allen, New York, USA.
| | - Joseph M Lombardi
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, Och Spine Hospital, New York-Presbyterian/Allen, New York, USA
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, Och Spine Hospital, New York-Presbyterian/Allen, New York, USA
| | - Zeeshan M Sardar
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, Och Spine Hospital, New York-Presbyterian/Allen, New York, USA
| |
Collapse
|
5
|
Tribst JPM, Dal Piva AMDO, Blom EJ, Kleverlaan CJ, Feilzer AJ. Dental biomechanics of root-analog implants in different bone types. J Prosthet Dent 2024; 131:905-915. [PMID: 36428106 DOI: 10.1016/j.prosdent.2022.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/25/2022] [Accepted: 10/25/2022] [Indexed: 11/24/2022]
Abstract
STATEMENT OF PROBLEM When implants are applied to restore oral function, the masticatory load on the crown will lead to stress development in all parts of the crown-abutment-implant-bone system. An optimal design of the whole system will be important for sustained function. PURPOSE The purpose of this 3-dimensional (3D) finite element analysis (FEA) study was to evaluate the influence of the root-analog implant (RAI) design in molar rehabilitation and bone type. MATERIAL AND METHODS Twelve 3D models of single posterior implant-supported restorations were created according to the zirconia implant design (monotype, 2-piece, or RAI) and bone type (D1, D2, D3, and D4, according to the Misch classification). The models were composed of cortical bone, cancellous bone, implant, cement layers, and a monolithic ceramic crown. For the 2-piece zirconia implant model, the titanium base, prosthetic screw, and framework were also designed. All materials were assumed to behave elastically throughout the entire analysis. The bone was fixed, and an axial loading of 600 N was applied to the contacts on the occlusal surface of the crowns. Results for the crown and implant were obtained in maximum principal stress, as well as the von Mises stress for the model and bone microstrain. RESULTS High stress concentration was observed at the intaglio surface of the crowns near the loading region. Regardless of the design, the stress trend in the implant was similar, increasing proportionally to the bone type (D1>D2>D3>D4). RAI showed a homogeneous stress field near the values calculated for the conventional designs, but with lower magnitudes. The 2-piece zirconia model showed the highest stress magnitude regardless of the bone type and, therefore, the highest failure risk. All models showed a higher strain in the cortical bone than in the cancellous bone, located predominantly in the cervical region. A strain analysis showed that both conventional implant models presented similar behavior for D1 and D2 bone types, with an increasing difference for D3 and D4. RAI showed the lowest strain regardless of the bone type. CONCLUSIONS Root-analog zirconia implants present a promising biomechanical behavior for dissipating the masticatory load in comparison with conventional screw-shaped implants.
Collapse
Affiliation(s)
- João Paulo M Tribst
- Assistant Professor, Department of Oral Regenerative Medicine, Academic Centre for Dentistry Amsterdam (ACTA), Universiteit van Amsterdam and Vrije Universiteit, Amsterdam, the Netherlands.
| | - Amanda Maria de O Dal Piva
- Assistant Professor, Department of Dental Materials Science, Academic Centre for Dentistry Amsterdam (ACTA), Universiteit van Amsterdam and Vrije Universiteit, Amsterdam, the Netherlands
| | - Erik J Blom
- Associate Professor, Department of Oral Regenerative Medicine, Academic Centre for Dentistry Amsterdam (ACTA), Universiteit van Amsterdam and Vrije Universiteit, Amsterdam, the Netherlands
| | - Cornelis J Kleverlaan
- Professor, Department of Dental Materials Science, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam & Vrije Universiteit, Amsterdam, the Netherlands
| | - Albert J Feilzer
- Professor, Department of Oral Regenerative Medicine, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam & Vrije Universiteit, Amsterdam, the Netherlands
| |
Collapse
|
6
|
Kumar N, Hui SJ, Lee R, Athia S, Rothenfluh DA, Tan JH. Implant and construct decision-making in metastatic spine tumour surgery: a review of current concepts with a decision-making algorithm. 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 2024; 33:1899-1910. [PMID: 38289374 DOI: 10.1007/s00586-023-07987-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 08/15/2023] [Accepted: 10/02/2023] [Indexed: 06/18/2024]
Abstract
STUDY DESIGN Narrative Review. OBJECTIVE Metastatic spine tumour surgery (MSTS) is an important treatment modality of metastatic spinal disease (MSD). Increase in MSTS has been due to improvements in our oncological treatment, as patients have increased longevity and even those with poorer comorbidities are now being considered for surgery. However, there is currently no guideline on how MSTS surgeons should select the appropriate levels to instrument, and which type of implants should be utilised. METHODS The current literature on MSTS was reviewed to study implant and construct decision making factors, with a view to write this narrative review. All studies that were related to instrumentation in MSTS were included. RESULTS A total of 58 studies were included in this review. We discuss novel decision-making models that should be taken into account when planning for surgery in patients undergoing MSTS. These factors include the quality of bone for instrumentation, the extent of the construct required for MSTS patients, the use of cement augmentation and the choice of implant. Various studies have advocated for the use of these modalities and demonstrated better outcomes in MSTS patients when used appropriately. CONCLUSION We have established a new instrumentation algorithm that should be taken into consideration for patients undergoing MSTS. It serves as an important guide for surgeons treating MSTS, with the continuous evolvement of our treatment capacity in MSD. LEVEL OF EVIDENCE IV
Collapse
Affiliation(s)
- Naresh Kumar
- Department of Orthopaedic Surgery, University Spine Centre, National University Health System, Level 11, 1E Lower Kent Ridge Road, Singapore, 119228, Singapore.
| | - Si Jian Hui
- Department of Orthopaedic Surgery, University Spine Centre, National University Health System, Level 11, 1E Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Renick Lee
- Department of Orthopaedic Surgery, University Spine Centre, National University Health System, Level 11, 1E Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Sahil Athia
- Department of Orthopaedic Surgery, University Spine Centre, National University Health System, Level 11, 1E Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Dominique A Rothenfluh
- Centre for Spinal Surgery, CHUV University Hospital Lausanne, Rue du Bugnon 46, 1005, Lausanne, Switzerland
| | - Jiong Hao Tan
- Department of Orthopaedic Surgery, University Spine Centre, National University Health System, Level 11, 1E Lower Kent Ridge Road, Singapore, 119228, Singapore
| |
Collapse
|
7
|
Schmidt Morgen S, Alfthan Madsen EB, Skive Weiland A, Dahl B, Gehrchen M. Carbon Instrumentation in Patients with Metastatic Spinal Cord Compression. Cancers (Basel) 2024; 16:736. [PMID: 38398127 PMCID: PMC10887085 DOI: 10.3390/cancers16040736] [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: 12/30/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
Recently carbon spinal implants have been introduced in the treatment of patients with metastatic spinal cord compression (MSCC). This is expected to decrease the deflection of radiation and improve diagnostic imaging and radiotherapy when compared to titanium implants. The aim of this study was to determine the safety and effectiveness of spinal carbon instrumentation (CI) in patients with MSCC in a large cohort study. A total of 163 patients received instrumentation between 1 January 2017 and 31 December 2021. A total of 80 were stabilized with CI and 83 with TI. The outcome measures were surgical revision, postsurgical survival, peri-operative bleeding, and surgery time. The peri-operative blood loss in the CI-group was significantly lower than that in the TI-group: 450mL vs. 630mL, (p = 0.02). There were no significant differences between the groups in mean survival (CI 9.9) vs. (TI 12.9) months (p = 0.39), or the number of patients needing a revision (CI 6) vs. (TI 10), (p = 0.39). The median duration of surgery was 121 min, (p = 0.99) with no significant difference between the two groups. Surgical treatment with CI for MSCC is safe and an equally sufficient treatment when compared to TI.
Collapse
Affiliation(s)
- Søren Schmidt Morgen
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, DK-2100 Copenhagen, Denmark (A.S.W.); (B.D.); (M.G.)
| | | | | | | | | |
Collapse
|
8
|
Long J, Zhang J, Kang J, Fan Y, Zhang Z, Shi J, Zhang Z, Huang Y, Liu S. Customed 3D-printed Polyetheretherketone (PEEK) Implant for Secondary Salvage Reconstruction of Mandibular Defects: Case Report and Literature Review. J Craniofac Surg 2023; 34:2460-2463. [PMID: 37264507 DOI: 10.1097/scs.0000000000009420] [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: 01/11/2023] [Accepted: 03/30/2023] [Indexed: 06/03/2023] Open
Abstract
Given the insufficient height of single-barrel fibula and inadequate bone volume of double-barrel vascularized fibula in mandibular reconstruction, it is a better choice to combine the upper full-thickness vascularized fibula with the lower half-thickness nonvascularized fibula. However, the nonvascularized fibula may fail due to complications, affecting the facial shape and occlusal function. Polyetheretherketone is a thermoplastic polymer used for bone defect reconstruction due to its good mechanical properties and biocompatibility. This case report mainly presents a secondary salvage reconstruction of the mandible by using customed 3-dimensional-printing polyetheretherketone, which restored the continuity and symmetry of the mandible, improved the patient's facial shape, and restored functional occlusion through dental implants. After a 28-month follow-up, no complications occurred, and the patient was satisfied with the final restoration.
Collapse
Affiliation(s)
- Jiazhen Long
- Stomatological Hospital, Southern Medical University, Guangzhou, Guangdong
| | - Jie Zhang
- Department of Oral and Maxillofacial Surgery, Center of Stomatology, Xiangya Hospital, Central South University, Changsha, Hunan
| | - Jianfeng Kang
- School of Mechatronic Engineering and Automation, Foshan University, Foshan, Guangdong, China
| | - Yunjian Fan
- Stomatological Hospital, Southern Medical University, Guangzhou, Guangdong
| | - Zhaoqiang Zhang
- Stomatological Hospital, Southern Medical University, Guangzhou, Guangdong
| | - Jiayu Shi
- Stomatological Hospital, Southern Medical University, Guangzhou, Guangdong
| | - Zhen Zhang
- Stomatological Hospital, Southern Medical University, Guangzhou, Guangdong
| | - Yuanjin Huang
- Stomatological Hospital, Southern Medical University, Guangzhou, Guangdong
| | - Shuguang Liu
- Stomatological Hospital, Southern Medical University, Guangzhou, Guangdong
| |
Collapse
|
9
|
Chen J, Xiao J, Han X, Sima X, Guo W. An HA/PEEK scaffold with modified crystallinity via 3D-bioprinting for multiple applications in hard tissue engineering. Biomed Mater 2023; 18:065021. [PMID: 37852224 DOI: 10.1088/1748-605x/ad0476] [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: 06/06/2023] [Accepted: 10/18/2023] [Indexed: 10/20/2023]
Abstract
Hard tissues, especially teeth and bones, are highly mineralized and the large-scale defect or total loss of them is irreversible. There is still no ideal strategy for the reconstruction of various hard tissue defects that can achieve the balance between biological and mechanical properties. Polyether ether ketone (PEEK) has the potential to substitute for natural hard tissue in defect areas but is limited by its biological inertness. The addition of hydroxyapatite (HA) can significantly improve the osteogenic properties and osteointegration of PEEK materials. But the mechanical properties of HA/PEEK scaffolds are far from satisfaction making scaffolds easy to fracture. We put forward a strategy to balance the mechanical and biological properties of HA/PEEK scaffolds via the regulation of the inner crystallinity and HA mixing ratio and we systematically evaluated the modified HA/PEEK scaffolds through material characterization,in vitroandin vivoexperiments. And we found that the 20%HA/PEEK scaffolds with low crystallinity achieved the required strength and elasticity, and exhibited the characteristics of promoting the proliferation, migration and osteogenic differentiation of bone marrow mesenchymal stem cells. The results of the implantation of beagles' teeth, mandible and rib showed that the 20%HA/PEEK scaffold with low crystallinity could well withstand the local complex force in the defect area and combine well with natural bone tissue, which made it a candidate for a practical versatile hard tissue engineering scaffold.
Collapse
Affiliation(s)
- Jiahao Chen
- State Key Laboratory of Oral Disease & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- National Engineering Laboratory for Oral Regenerative Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- Department of Pediatric Dentistry, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- Frontier Innovation Center for Dental Medicine Plus, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
| | - Jingyi Xiao
- State Key Laboratory of Oral Disease & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- National Engineering Laboratory for Oral Regenerative Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- Department of Pediatric Dentistry, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- Frontier Innovation Center for Dental Medicine Plus, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
| | - Xue Han
- State Key Laboratory of Oral Disease & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- National Engineering Laboratory for Oral Regenerative Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- Department of Pediatric Dentistry, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- Frontier Innovation Center for Dental Medicine Plus, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
| | - Xiutian Sima
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, People's Republic of China
| | - Weihua Guo
- State Key Laboratory of Oral Disease & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- National Engineering Laboratory for Oral Regenerative Medicine, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- Department of Pediatric Dentistry, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- Frontier Innovation Center for Dental Medicine Plus, West China Hospital of Stomatology, Sichuan University, Chengdu, People's Republic of China
- Yunnan Key Laboratory of Stomatology, Affiliated Hospital of Stomatology, School of Stomatology, Kunming Medical University, Kunming, People's Republic of China
| |
Collapse
|
10
|
Kumar N, Alathur Ramakrishnan S, Lopez KG, Wang N, Vellayappan BA, Hallinan JTPD, Fuh JYH, Kumar AS. Novel 3D printable PEEK-HA-Mg 2SiO 4 composite material for spine implants: biocompatibility and imaging compatibility assessments. 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 2023; 32:2255-2265. [PMID: 37179256 DOI: 10.1007/s00586-023-07734-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE To develop a novel 3D printable polyether ether ketone (PEEK)-hydroxyapatite (HA)-magnesium orthosilicate (Mg2SiO4) composite material with enhanced properties for potential use in tumour, osteoporosis and other spinal conditions. We aim to evaluate biocompatibility and imaging compatibility of the material. METHODS Materials were prepared in three different compositions, namely composite A: 75 weight % PEEK, 20 weight % HA, 5 weight % Mg2SiO4; composite B: 70 weight% PEEK, 25 weight % HA, 5 weight % Mg2SiO4; and composite C: 65 weight % PEEK, 30 weight % HA, 5 weight % Mg2SiO4. The materials were processed to obtain 3D printable filament. Biomechanical properties were analysed as per ASTM standards and biocompatibility of the novel material was evaluated using indirect and direct cell cytotoxicity tests. Cell viability of the novel material was compared to PEEK and PEEK-HA materials. The novel material was used to 3D print a standard spine cage. Furthermore, the CT and MR imaging compatibility of the novel material cage vs PEEK and PEEK-HA cages were evaluated using a phantom setup. RESULTS Composite A resulted in optimal material processing to obtain a 3D printable filament, while composite B and C resulted in non-optimal processing. Composite A enhanced cell viability up to ~ 20% compared to PEEK and PEEK-HA materials. Composite A cage generated minimal/no artefacts on CT and MR imaging and the images were comparable to that of PEEK and PEEK-HA cages. CONCLUSION Composite A demonstrated superior bioactivity vs PEEK and PEEK-HA materials and comparable imaging compatibility vs PEEK and PEEK-HA. Therefore, our material displays an excellent potential to manufacture spine implants with enhanced mechanical and bioactive property.
Collapse
Affiliation(s)
- Naresh Kumar
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore.
| | - Sridharan Alathur Ramakrishnan
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Keith Gerard Lopez
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Niyou Wang
- Department of Mechanical Engineering, National University of Singapore, 9 Engineering Drive 1, Singapore, 117575, Singapore
| | - Balamurugan A Vellayappan
- Department of Radiation Oncology, National University Health System, Level 7, Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - James Thomas Patrick Decourcy Hallinan
- Department of Diagnostic Imaging, National University Hospital, National University Hospital Main Building, Level 2, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
| | - Jerry Ying Hsi Fuh
- Department of Mechanical Engineering, National University of Singapore, #04-18 Block EA, 9 Engineering Drive 1, Singapore, 117575, Singapore
| | - A Senthil Kumar
- Department of Mechanical Engineering, National University of Singapore, #05-26 Block EA, 9 Engineering Drive 1, Singapore, 117575, Singapore
| |
Collapse
|
11
|
Kumar N, Alathur Ramakrishnan S, Lopez KG, Wang N, Madhu S, Vellayappan BA, Tpd Hallinan J, Fuh JYH, Kumar AS. Design and 3D printing of novel titanium spine rods with lower flexural modulus and stiffness profile with optimised imaging compatibility. 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 2023; 32:1953-1965. [PMID: 37052651 DOI: 10.1007/s00586-023-07674-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 03/07/2023] [Accepted: 03/18/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE To manufacture and test 3D printed novel design titanium spine rods with lower flexural modulus and stiffness compared to standard solid titanium rods for use in metastatic spine tumour surgery (MSTS) and osteoporosis. METHODS Novel design titanium spine rods were designed and 3D printed. Three-point bending test was performed to assess mechanical performance of rods, while a French bender was used to assess intraoperative rod contourability. Furthermore, 3D printed spine rods were tested for CT & MR imaging compatibility using phantom setup. RESULTS Different spine rod designs generated includes shell, voronoi, gyroid, diamond, weaire-phelan, kelvin, and star. Tests showed 3D printed rods had lower flexural modulus with reduction ranging from 2 to 25% versus standard rod. Shell rods exhibited highest reduction in flexural modulus of 25% (~ 77.4 GPa) and star rod exhibited lowest reduction in flexural modulus of 2% (100.8GPa). 3D printed rod showed reduction in stiffness ranging from 40 to 59%. Shell rod displayed highest reduction in stiffness of 59% (179.9 N/mm) and gyroid had least reduction in stiffness of 40% (~ 259.2 N/mm). Rod bending test showed that except gyroid, other rod designs demonstrated lesser bending difficulty versus standard rod. All 3D printed rods demonstrated improved CT/MR imaging compatibility with reduced artefacts versus standard rod. CONCLUSION By utilising novel design approach, we successfully generated a spine rod design portfolio with lower flexural modulus/stiffness profile and better CT/MR imaging compatibility for potential use in MSTS/other conditions such as osteoporosis. Thus, exploration of new rod designs in surgical application could enhance treatment outcome and improve quality of life for patients.
Collapse
Affiliation(s)
- Naresh Kumar
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore.
| | - Sridharan Alathur Ramakrishnan
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Keith Gerard Lopez
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Niyou Wang
- Department of Mechanical Engineering, National University of Singapore, 9 Engineering Drive 1, Singapore, 117575, Singapore
| | - Sirisha Madhu
- Department of Orthopaedic Surgery, National University Health System, Level 11 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - Balamurugan A Vellayappan
- Department of Radiation Oncology, National University Health System, Level 7 Tower Block, 1E, Lower Kent Ridge Road, Singapore, 119228, Singapore
| | - James Tpd Hallinan
- Department of Diagnostic Imaging, National University Hospital, Level 2 National University Hospital Main Building, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
| | - Jerry Ying Hsi Fuh
- Department of Mechanical Engineering, National University of Singapore, #04-18 Block EA, 9 Engineering Drive 1, Singapore, 117575, Singapore
| | - A Senthil Kumar
- Department of Mechanical Engineering, National University of Singapore, #05-26 Block EA, 9 Engineering Drive 1, Singapore, 117575, Singapore
| |
Collapse
|
12
|
Wang J, Yu W, Shi R, Yang S, Zhang J, Han X, Zhou Z, Gao W, Li Y, Zhao J. Osseointegration behavior of carbon fiber reinforced polyetheretherketone composites modified with amino groups: An in vivo study. J Biomed Mater Res B Appl Biomater 2023; 111:505-512. [PMID: 36191250 DOI: 10.1002/jbm.b.35167] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 08/31/2022] [Accepted: 09/14/2022] [Indexed: 01/21/2023]
Abstract
Polyetheretherketone (PEEK) has become increasingly popular in dentistry and orthopedics due to its excellent chemical stability, reliable biosafety, and low elastic modulus. However, PEEK's biomechanical strength and bioactivity are limited and need to be increased as an implant material. The previous study in vitro has shown that the amino-functionalized carbon fiber reinforced PEEK (A-30%-CPEEK) possessed enhanced mechanical property and bioactivity. This study aims to evaluate the effect of amino groups modification on the osseointegration behavior of carbon fiber reinforced PEEK (30%-CPEEK) in rabbits. Herein, 30%-CPEEK and A-30%-CPEEK implant discs were implanted in rabbit skulls for 5 weeks, with pure titanium implants serving as a control. The bone-forming ability and osseointegration in vivo were systematically investigated by micro-computed tomography analysis, scanning electron microscope observation, and histological evaluation. Our results showed that all detection parameters were significantly different between the A-30%-CPEEK and 30%-CPEEK groups, favoring those in the A-30%-CPEEK, whose appraisal parameters were equal to or better than pure titanium. Therefore, this study supported the importance of amino groups in facilitating the new bone formation and bone-implant integration, suggesting that A-30%-CPEEK with enhanced osseointegration will be a promising material for dental or orthopedic implants.
Collapse
Affiliation(s)
- Junyan Wang
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun, China.,Jilin Provincial Key Laboratory of Tooth Development and Bone Remodeling, Hospital of Stomatology, Jilin University, Changchun, China
| | - Wanqi Yu
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun, China
| | - Ruining Shi
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun, China
| | - Shihui Yang
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun, China
| | - Jingjie Zhang
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun, China
| | - Xiao Han
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun, China
| | - Zhe Zhou
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun, China
| | - Weijia Gao
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun, China
| | - Yongli Li
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun, China
| | - Jinghui Zhao
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun, China.,Jilin Provincial Key Laboratory of Tooth Development and Bone Remodeling, Hospital of Stomatology, Jilin University, Changchun, China
| |
Collapse
|
13
|
Newsom ET, Sadeghpour A, Entezari A, Vinzons JLU, Stanford RE, Mirkhalaf M, Chon D, Dunstan CR, Zreiqat H. Design and evaluation of 3D-printed Sr-HT-Gahnite bioceramic for FDA regulatory submission: A Good Laboratory Practice sheep study. Acta Biomater 2023; 156:214-221. [PMID: 35063706 DOI: 10.1016/j.actbio.2022.01.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/13/2021] [Accepted: 01/14/2022] [Indexed: 01/18/2023]
Abstract
There is an unmet clinical need for a spinal fusion implant material that recapitulates the biological and mechanical performance of natural bone. We have developed a bioceramic, Sr-HT-Gahnite, which has been identified as a potential fusion device material. This material has the capacity to transform the future of the global interbody devices market, with follow on social, economic, and environmental benefits, rooted in its remarkable combination of mechanical properties and bioactivity. In this study, and in line with FDA requirements, the in vivo preclinical systemic biological safety of a Sr-HT-Gahnite interbody fusion device is assessed over 26 weeks in sheep under good laboratory practice (GLP). Following the in-life phase, animals are assessed for systemic biological effects via blood haematology and clinical biochemistry, strontium dosage analysis in the blood and wool, and histopathology examination of the distant organs including adrenals, brain, heart, kidneys, liver, lungs and bronchi, skeletal muscle, spinal nerves close to the implanted sites, ovaries, and draining lymph nodes. Our results show that no major changes in blood haematology or biochemistry parameters are observed, no systemic distribution of strontium to the blood and wool, and no macroscopic or histopathological abnormalities in the distant organs when Sr-HT-Gahnite was implanted, compared to baseline and control values. Together, these results indicate the systemic safety of the Sr-HT-Gahnite interbody fusion device. The results of this study extend to the systemic safety of other Sr-HT-Gahnite implanted medical devices in contact with bone or tissue, of similar size and manufactured using the described processes. STATEMENT OF SIGNIFICANCE: This paper is considered original and innovative as it is the first that thoroughly reports the systemic biological safety of previously undescribed bioceramic material, Sr-HT-Gahnite. The study has been performed under good laboratory practice, in line with FDA requirements for assessment of a new interbody fusion device, making the results broadly applicable to the translation of sheep models to the human cervical spine; and also the translation of Sr-HT-Gahnite as a biomaterial for use in additional applications. We expect this study to be of broad interest to the readership of Acta Biomaterilia. Its findings are directly applicable to researchers and clinicians working in bone repair and the development of synthetic biomaterials.
Collapse
Affiliation(s)
- Ellen T Newsom
- Allegra Orthopaedics, 18-20 Orion Rd, Lane Cove West, NSW, 2066, Australia; Biomaterials and Tissue Engineering Research Unit, School of Biomedical Engineering, The University of Sydney, NSW, 2006, Australia
| | - Ameneh Sadeghpour
- Allegra Orthopaedics, 18-20 Orion Rd, Lane Cove West, NSW, 2066, Australia
| | - Ali Entezari
- Allegra Orthopaedics, 18-20 Orion Rd, Lane Cove West, NSW, 2066, Australia; Biomaterials and Tissue Engineering Research Unit, School of Biomedical Engineering, The University of Sydney, NSW, 2006, Australia
| | | | - Ralph E Stanford
- Faculty of Medicine, University of New South Wales, NSW, 2052, Australia
| | - Mohammad Mirkhalaf
- Biomaterials and Tissue Engineering Research Unit, School of Biomedical Engineering, The University of Sydney, NSW, 2006, Australia; Australian Research Council Training Centre for Innovative Bioengineering, Sydney, NSW, 2006, Australia
| | - Daniel Chon
- CTL Amedica, 4550 Excel Pkwy #300, Addison, TX, 75001, United States
| | - Colin R Dunstan
- Biomaterials and Tissue Engineering Research Unit, School of Biomedical Engineering, The University of Sydney, NSW, 2006, Australia; Australian Research Council Training Centre for Innovative Bioengineering, Sydney, NSW, 2006, Australia
| | - Hala Zreiqat
- Biomaterials and Tissue Engineering Research Unit, School of Biomedical Engineering, The University of Sydney, NSW, 2006, Australia; Australian Research Council Training Centre for Innovative Bioengineering, Sydney, NSW, 2006, Australia.
| |
Collapse
|
14
|
Kuah T, Vellayappan BA, Makmur A, Nair S, Song J, Tan JH, Kumar N, Quek ST, Hallinan JTPD. State-of-the-Art Imaging Techniques in Metastatic Spinal Cord Compression. Cancers (Basel) 2022; 14:3289. [PMID: 35805059 PMCID: PMC9265325 DOI: 10.3390/cancers14133289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 12/23/2022] Open
Abstract
Metastatic Spinal Cord Compression (MSCC) is a debilitating complication in oncology patients. This narrative review discusses the strengths and limitations of various imaging modalities in diagnosing MSCC, the role of imaging in stereotactic body radiotherapy (SBRT) for MSCC treatment, and recent advances in deep learning (DL) tools for MSCC diagnosis. PubMed and Google Scholar databases were searched using targeted keywords. Studies were reviewed in consensus among the co-authors for their suitability before inclusion. MRI is the gold standard of imaging to diagnose MSCC with reported sensitivity and specificity of 93% and 97% respectively. CT Myelogram appears to have comparable sensitivity and specificity to contrast-enhanced MRI. Conventional CT has a lower diagnostic accuracy than MRI in MSCC diagnosis, but is helpful in emergent situations with limited access to MRI. Metal artifact reduction techniques for MRI and CT are continually being researched for patients with spinal implants. Imaging is crucial for SBRT treatment planning and three-dimensional positional verification of the treatment isocentre prior to SBRT delivery. Structural and functional MRI may be helpful in post-treatment surveillance. DL tools may improve detection of vertebral metastasis and reduce time to MSCC diagnosis. This enables earlier institution of definitive therapy for better outcomes.
Collapse
Affiliation(s)
- Tricia Kuah
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
| | - Balamurugan A. Vellayappan
- Department of Radiation Oncology, National University Cancer Institute Singapore, National University Hospital, Singapore 119074, Singapore;
| | - Andrew Makmur
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - Shalini Nair
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
| | - Junda Song
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
| | - Jiong Hao Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E Lower Kent Ridge Road, Singapore 119228, Singapore; (J.H.T.); (N.K.)
| | - Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, 1E Lower Kent Ridge Road, Singapore 119228, Singapore; (J.H.T.); (N.K.)
| | - Swee Tian Quek
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | - James Thomas Patrick Decourcy Hallinan
- Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; (A.M.); (S.N.); (J.S.); (S.T.Q.); (J.T.P.D.H.)
- Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| |
Collapse
|