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Guan J, Feng N, Yu X, Yang K. Comparison of robot-assisted versus fluoroscopy-guided transforaminal lumbar interbody fusion (TLIF) for lumbar degenerative diseases: a systematic review and meta-analysis of randomized controlled trails and cohort studies. Syst Rev 2024; 13:170. [PMID: 38970142 PMCID: PMC11227242 DOI: 10.1186/s13643-024-02600-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 06/30/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND As an emerging technology in robot-assisted (RA) surgery, the potential benefits of its application in transforaminal lumbar interbody fusion (TLIF) lack substantial support from current evidence. OBJECTIVE We aimed to investigate whether the RA TLIF is superior to FG TLIF in the treatment of lumbar degenerative disease. METHODS We systematically reviewed studies comparing RA versus FG TLIF for lumbar degenerative diseases through July 2022 by searching PubMed, Embase, Web of Science, CINAHL (EBSCO), Chinese National Knowledge Infrastructure (CNKI), WanFang, VIP, and the Cochrane Library, as well as the references of published review articles. Both cohort studies (CSs) and randomized controlled trials (RCTs) were included. Evaluation criteria included the accuracy of percutaneous pedicle screw placement, proximal facet joint violation (FJV), radiation exposure, duration of surgery, estimated blood loss (EBL), and surgical revision. Methodological quality was assessed using the Cochrane risk of bias and ROBINS-I Tool. Random-effects models were used, and the standardized mean difference (SMD) was employed as the effect measure. We conducted subgroup analyses based on surgical type, the specific robot system used, and the study design. Two investigators independently screened abstracts and full-text articles, and the certainty of evidence was graded using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. RESULTS Our search identified 539 articles, of which 21 met the inclusion criteria for quantitative analysis. Meta-analysis revealed that RA had 1.03-folds higher "clinically acceptable" accuracy than FG (RR: 1.0382, 95% CI: 1.0273-1.0493). And RA had 1.12-folds higher "perfect" accuracy than FG group (RR: 1.1167, 95% CI: 1.0726-1.1626). In the case of proximal FJV, our results indicate a 74% reduction in occurrences for patients undergoing RA pedicle screw placement compared to those in the FG group (RR: 0.2606, 95%CI: 0.2063- 0.3293). Seventeen CSs and two RCTs reported the duration of time. The results of CSs suggest that there is no significant difference between RA and FG group (SMD: 0.1111, 95%CI: -0.391-0.6131), but the results of RCTs suggest that the patients who underwent RA-TLIF need more surgery time than FG (SMD: 3.7213, 95%CI: 3.0756-4.3669). Sixteen CSs and two RCTs reported the EBL. The results suggest that the patients who underwent RA pedicle screw placement had fewer EBL than FG group (CSs: SMD: -1.9151, 95%CI: -3.1265-0.7036, RCTs: SMD: -5.9010, 95%CI: -8.7238-3.0782). For radiation exposure, the results of CSs suggest that there is no significant difference in radiation time between RA and FG group (SMD: -0.5256, 95%CI: -1.4357-0.3845), but the patients who underwent RA pedicle screw placement had fewer radiation dose than FG group (SMD: -2.2682, 95%CI: -3.1953-1.3411). And four CSs and one RCT reported the number of revision case. The results of CSs suggest that there is no significant difference in the number of revision case between RA and FG group (RR: 0.4087,95% CI 0.1592-1.0495). Our findings are limited by the residual heterogeneity of the included studies, which may limit the interpretation of the results. CONCLUSION In TLIF, RA technology exhibits enhanced precision in pedicle screw placement when compared to FG methods. This accuracy contributes to advantages such as the protection of adjacent facet joints and reductions in intraoperative radiation dosage and blood loss. However, the longer preoperative preparation time associated with RA procedures results in comparable surgical duration and radiation time to FG techniques. Presently, FG screw placement remains the predominant approach, with clinical surgeons possessing greater proficiency in its application. Consequently, the integration of RA into TLIF surgery may not be considered the optimal choice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42023441600.
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Affiliation(s)
- Jianbin Guan
- Honghui-Hospital, Xi'an Jiaotong University, Xi'an, 710054, China
- Shannxi Key Laboratory of Spine Bionic Treatment, Xi'an, China
| | - Ningning Feng
- Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Xing Yu
- Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, 100700, China
| | - Kaitan Yang
- Honghui-Hospital, Xi'an Jiaotong University, Xi'an, 710054, China.
- Truma Rehabilitation Department, Honghui-Hospital, Xi'an Jiaotong University, Xi'an, 710054, China.
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Gaihre B, Bharadwaz A, Unagolla JM, Jayasuriya AC. Evaluation of the optimal dosage of BMP-9 through the comparison of bone regeneration induced by BMP-9 versus BMP-2 using an injectable microparticle embedded thermosensitive polymeric carrier in a rat cranial defect model. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 127:112252. [PMID: 34225891 PMCID: PMC8260961 DOI: 10.1016/j.msec.2021.112252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 05/03/2021] [Accepted: 06/07/2021] [Indexed: 01/07/2023]
Abstract
Bone morphogenetic proteins (BMPs) are well known as enhancers and facilitators of osteogenesis during bone regeneration. The use of recombinant BMP-2 (rhBMP-2) in bone defect healing has drawbacks, which has driven the scouting for alternatives, such as recombinant BMP-9 (rhBMP-9), to provide comparable new bone formation. However, the dosage of rhBMP-9 is quintessential for the facilitation of adequate bone defect healing. Therefore, this study has been designed to evaluate the optimal dosage of BMP-9 by comparing the bone defect healing induced by rhBMP-9 over rhBMP-2. The chitosan (CS) microparticles (MPs), coated with BMPs, were embedded in a thermoresponsive methylcellulose (MC) and calcium alginate (Alg) based injectable delivery system containing a dosage of either 0.5 μg or 1.5 μg of the respective rhBMP per bone defect. A 5 mm critical-sized cranial defect rat model has been used in this study, and bone tissues were harvested at eight weeks post-surgery. The standard tools for comparing the new bone regeneration included micro computerized tomography (micro-CT) and histological analysis. A novel perspective of analyzing the new bone quality and crystallinity was employed by using Raman spectroscopy, along with its elastic modulus quantified through Atomic Force Microscopy (AFM). Results showed that the rhBMP-9 administered at a dosage of 1.5 μg per bone defect, using this delivery system, can adequately facilitate the bone void filling with ample new bone mineralization and crystallinity as compared to rhBMP-2, thus approving the hypothesis for a viable rhBMP-2 alternative.
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Affiliation(s)
- Bipin Gaihre
- Biomedical Engineering Program, Department of Bioengineering, College of Engineering, The University of Toledo, Toledo, OH 43607, USA
| | - Angshuman Bharadwaz
- Biomedical Engineering Program, Department of Bioengineering, College of Engineering, The University of Toledo, Toledo, OH 43607, USA
| | - Janitha M Unagolla
- Biomedical Engineering Program, Department of Bioengineering, College of Engineering, The University of Toledo, Toledo, OH 43607, USA
| | - Ambalangodage C Jayasuriya
- Biomedical Engineering Program, Department of Bioengineering, College of Engineering, The University of Toledo, Toledo, OH 43607, USA; Department of Orthopaedic Surgery, College of Medicine and Life Sciences, The University of Toledo, Toledo, OH 43614, USA.
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Shahrestani S, Ballatori AM, Chen X, Ton A, Wang JC, Buser Z. The Impact of Osteobiologic Subtype Selection on Perioperative Complications and Hospital-Reported Charges in Single- and Multi-Level Lumbar Spinal Fusion. Int J Spine Surg 2021; 15:654-662. [PMID: 34266932 DOI: 10.14444/8086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Over the last several decades, various osteobiologics including allograft, synthetics, and growth factors have been used for lumbar spinal fusion surgery. However, the data on these osteobiologic products remain controversial with conflicting evidence in the literature. This study evaluates the influence of osteobiologic type selection on perioperative complications and hospital-reported charges in single-level and multilevel lumbar fusion. METHODS Using the 2016 and 2017 Nationwide Readmission Database, we conducted a retrospective cohort analysis of 125,143 patients who received lumbar fusion with either autologous tissue substitute, nonautologous tissue substitute, or synthetic substitute. This cohort was split into single-level and multilevel fusion procedures, and one-to-one age and sex propensity score matching was implemented. This resulted in cohorts each consisting of 1967 patients for single-level fusion, and cohorts each consisting of 1657 patients for multilevel fusion. Statistical analysis included one-way analysis of variance and Tukey multiple comparisons of means. RESULTS Autologous single-level fusion resulted in significantly more postoperative pain at 30-, 90-, and 180-day follow-up compared to fusion with nonautologous graft (P < .05). Multilevel fusion with autologous graft had higher rates of acute postsurgical anemia compared with synthetic (P = .021) and nonautologous (P = .016) alternatives, and less postsurgical infection when compared with nonautologous fusion (P = .0020). In addition, procedures using autologous osteobiologics were associated with significantly more neurological complications at 30 days (P = .049) and 90 days (P = .048) for multi-level fusion and at 30 days (P = .044) for single-level fusion compared with the nonautologous group. Lastly, for both cohorts, the total accrued inpatient hospital charges during admission for patients receiving nonautologous grafts were the most expensive and those for patients receiving autologous grafts were the least expensive. CONCLUSION Significant differences were found between the groups with respect to rates of complications, including infection, postoperative pain, and neurologic injury. Furthermore, the hospital-reported charges of each procedure varied significantly. As the field of biologics continues to expand, it is important to continually evaluate the safety, efficacy, and cost-effectiveness of these novel materials and techniques. LEVEL OF EVIDENCE 3 CLINICAL RELEVANCE: With increased utilization of osteobiologics and spinal fusion being a common procedure, longitudinal data on readmissions, and post-operative complications are critical in guiding evidence-based practice.
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Affiliation(s)
- Shane Shahrestani
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.,Department of Medical Engineering, California Institute of Technology, Pasadena, California
| | - Alexander M Ballatori
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Xiao Chen
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Andy Ton
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Li Y, Yu Y, Hou TY, Zhang ZH, Xing JC, Lu HW, Zhou R, Cheng P, Xu JZ, Wu WJ, Luo F. Efficacy of Biocage in treating single-segment lumbar degenerative disease in patients with high risk of non-fusion: a prospective controlled study with at least 2 years' follow-up. J Int Med Res 2021; 48:300060520945500. [PMID: 32962480 PMCID: PMC7518008 DOI: 10.1177/0300060520945500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective To evaluate the clinical efficacy of an allogeneic bone cage (Biocage; Beijing Datsing Bio-Tech Co., Ltd., Beijing, China) for treatment of single-segment lumbar degenerative disease in patients with a high risk of non-fusion. Methods From January 2013 to December 2016, 67 patients who underwent lumbar fusion were divided into the Biocage group (n = 33) and polyether ether ketone (PEEK) group (n = 34). The patients were followed up for 24 to 48 months. The mean intervertebral height of the fusion level, fusion rate, height of the intervertebral foramen, visual analog scale score, and Oswestry disability index were compared. Results The PEEK group had a lower fusion rate than the Biocage group (88.24% vs. 90.91%), although the difference was not statistically significant. During follow-up, the height of the intervertebral space was similar between the Biocage and PEEK groups (12.88 ± 0.45 and 12.84 ± 1.01 mm, respectively). The height of the intervertebral foramen was larger in the Biocage than PEEK group (20.67 ± 1.34 vs. 20.00 ± 2.05 mm). Good clinical efficacy was achieved in both groups. Conclusion The Biocage is efficient and safe for treatment of single-segment lumbar degenerative disease in patients with a high risk of non-fusion.
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Affiliation(s)
- Yang Li
- National & Regional Engineering Laboratory of Tissue Engineering, Department of Orthopedics, The First Affiliated Hospital to Army Medical University (Southwest Hospital), Chongqing, China
| | - Yang Yu
- Department of Orthopedics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Tian-Yong Hou
- National & Regional Engineering Laboratory of Tissue Engineering, Department of Orthopedics, The First Affiliated Hospital to Army Medical University (Southwest Hospital), Chongqing, China
| | - Ze-Hua Zhang
- National & Regional Engineering Laboratory of Tissue Engineering, Department of Orthopedics, The First Affiliated Hospital to Army Medical University (Southwest Hospital), Chongqing, China
| | - Jun-Chao Xing
- National & Regional Engineering Laboratory of Tissue Engineering, Department of Orthopedics, The First Affiliated Hospital to Army Medical University (Southwest Hospital), Chongqing, China
| | - Hong-Wei Lu
- National & Regional Engineering Laboratory of Tissue Engineering, Department of Orthopedics, The First Affiliated Hospital to Army Medical University (Southwest Hospital), Chongqing, China
| | - Rui Zhou
- National & Regional Engineering Laboratory of Tissue Engineering, Department of Orthopedics, The First Affiliated Hospital to Army Medical University (Southwest Hospital), Chongqing, China
| | - Peng Cheng
- National & Regional Engineering Laboratory of Tissue Engineering, Department of Orthopedics, The First Affiliated Hospital to Army Medical University (Southwest Hospital), Chongqing, China
| | - Jian-Zhong Xu
- National & Regional Engineering Laboratory of Tissue Engineering, Department of Orthopedics, The First Affiliated Hospital to Army Medical University (Southwest Hospital), Chongqing, China
| | - Wen-Jie Wu
- National & Regional Engineering Laboratory of Tissue Engineering, Department of Orthopedics, The First Affiliated Hospital to Army Medical University (Southwest Hospital), Chongqing, China
| | - Fei Luo
- National & Regional Engineering Laboratory of Tissue Engineering, Department of Orthopedics, The First Affiliated Hospital to Army Medical University (Southwest Hospital), Chongqing, China
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Patient Perceptions of Iliac Crest Bone Grafting in Minimally Invasive Transforaminal Lumbar Interbody Fusion. Clin Spine Surg 2019; 32:430-434. [PMID: 31790370 DOI: 10.1097/bsd.0000000000000781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE The objective of this study was to determine patients' perception of iliac crest bone graft (ICBG) harvesting and donor site pain following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA The incidence of donor site pain has been debated in the literature because of the varying techniques associated with its harvest. METHODS Patients undergoing primary, single-level MIS TLIF with ICBG were retrospectively identified. ICBG harvesting was performed using a percutaneous technique with a tubular retractor. A survey was administered to assess if patients could accurately describe which side of their iliac crest they believed was harvested, and if they were experiencing any pain perceived to be originating from the donor site. Patient characteristics were compared using χ analysis and independent t test. RESULTS In total, 82 patients were included. The majority of patients had the ICBG harvested from the left iliac crest (97.5%). Approximately half of the patients correctly identified the side of harvest (50.6%). 48.1% of patients reported they were not confident or had guessed on their response. Patients that reported pain from the ICBG were more likely to feel confident or somewhat confident in their harvest site identification (57.9% vs. 46.3%) but less likely to be correct (36.8% vs. 63.4%) than patients without pain. 22 patients (27.8%) correctly identified the side of harvest without guessing. Of these, 11 (13.9%) reported pain. CONCLUSIONS Approximately half of patients undergoing MIS TLIF with ICBG are able to correctly identify which side of their iliac crest was harvested. However, the majority of patients reporting pain were unable to correctly identify the side of harvest. This suggests that most patients are likely attributing other sources of pain to their ICBG. Therefore, rates of donor site pain may be over-reported in the current literature with contemporary harvesting techniques.
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Greene AC, Hsu WK. Orthobiologics in minimally invasive lumbar fusion. JOURNAL OF SPINE SURGERY 2019; 5:S11-S18. [PMID: 31380488 DOI: 10.21037/jss.2019.04.15] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Minimally invasive (MI) spine surgery continues to gain popularity with patients and surgeons for its potential to decrease operative time and avoid complications commonly associated with open surgery. In the face of a changing surgical landscape, selecting the appropriate implant material to be used in MI lumbar fusion procedures will remain critically important. Various orthobiologic materials are available for use, including autologous and allogeneic bone graft, bone marrow aspirate (BMA), demineralized bone matrix (DBM), ceramics, and growth factors. The purpose of this review is to summarize the use and efficacy of currently available products, as well as highlight the development of novel therapeutic options.
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Affiliation(s)
- Allison C Greene
- Northwestern University Department of Orthopaedic Surgery, Chicago, IL, USA.,Simpson Querrey Institute, Northwestern University, Chicago, IL, USA
| | - Wellington K Hsu
- Northwestern University Department of Orthopaedic Surgery, Chicago, IL, USA.,Simpson Querrey Institute, Northwestern University, Chicago, IL, USA
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Hsieh PC, Buser Z, Skelly AC, Brodt ED, Brodke D, Meisel HJ, Park JB, Yoon ST, Wang JC. Allogenic Stem Cells in Spinal Fusion: A Systematic Review. Global Spine J 2019; 9:22S-38S. [PMID: 31157144 PMCID: PMC6512196 DOI: 10.1177/2192568219833336] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES To review, critically appraise, and synthesize evidence on the use of allogenic stem cell products for spine fusion compared with other bone graft materials. METHODS Systematic searches of PubMed/MEDLINE, through October 31, 2018 and of EMBASE and ClinicalTrials.gov through April 13, 2018 were conducted for literature comparing allogenic stem cell sources for fusion in the lumbar or cervical spine with other fusion methods. In the absence of comparative studies, case series of ≥10 patients were considered. RESULTS From 382 potentially relevant citations identified, 6 publications on lumbar fusion and 5 on cervical fusion met the inclusion criteria. For lumbar arthrodesis, mean Oswestry Disability Index (ODI), visual analogue scale (VAS) pain score, and fusion rates were similar for anterior lumbar interbody fusion (ALIF) using allogenic multipotent adult progenitor cells (Map3) versus recombinant human bone morphogenetic protein-2 (rhBMP-2) in the one comparative lumbar study (90% vs 92%). Across case series of allogenic stem cell products, function and pain were improved relative to baseline and fusion occurred in ≥90% of patients at ≥12 months. For cervical arthrodesis across case series, stem cell products improved function and pain compared with baseline at various time frames. In a retrospective cohort study fusion rates were not statistically different for Osteocel compared with Vertigraft allograft (88% vs 95%). Fusion rates varied across time frames and intervention products in case series. CONCLUSIONS The overall quality (strength) of evidence of effectiveness and safety of allogenic stem cells products for lumbar and cervical arthrodesis was very low, meaning that we have very little confidence that the effects seen are reflective of the true effects.
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Affiliation(s)
| | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA
| | | | | | - Darrel Brodke
- University of Utah School of Medicine, Salt Lake City, UT, USA
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Schmitz P, Cornelius Neumann C, Neumann C, Nerlich M, Dendorfer S. Biomechanical analysis of iliac crest loading following cortico-cancellous bone harvesting. J Orthop Surg Res 2018; 13:108. [PMID: 29739435 PMCID: PMC5941784 DOI: 10.1186/s13018-018-0822-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Iliac crest bone harvesting is a frequently performed surgical procedure widely used to treat bone defects. The objective of this study is to assess the biomechanical quantities related to risk for pelvic fracture after harvesting an autologous bone graft at the anterior iliac crest. METHODS Finite element models with a simulated harvest site (sized 15 × 20 mm, 15 × 35 mm, 30 × 20 mm and 30 × 35 mm) in the iliac wing are created. The relevant loading case is when the ipsilateral leg is lifted off the ground. Musculoskeletal analysis is utilized to compute the muscle and joint forces involved in this motion. These forces are used as boundary conditions for the finite element analyses. Bone tissue stress is analyzed. RESULTS Critical stress peaks are located between the anterior superior iliac spine (ASIS) and the anterior edge of the harvest site. Irrespective of the graft size, the iliac wing does not show any significant stress peaks with the harvest site being 20 to 25 mm posterior to the ASIS. The harvest area itself inhibits the distribution of the forces applied on the ASIS to extend to the posterior iliac wing. This leads to a lack of stress posterior to the harvest site. A balanced stress distribution with no stress peaks appears when the bone graft is taken below the iliac crest. CONCLUSION A harvest site located at least 20 to 25 mm posterior to the ASIS should be preferred to minimize the risk of iliac fatigue fracture.
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Affiliation(s)
- Paul Schmitz
- Clinic of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany.
| | - Christoph Cornelius Neumann
- Regensburg Center of Biomedical Engineering, Ostbayerische Technische Hochschule, Galgenbergstrasse 30, D-93053, Regensburg, Germany
| | - Carsten Neumann
- Clinic of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Michael Nerlich
- Clinic of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Sebastian Dendorfer
- Regensburg Center of Biomedical Engineering, Ostbayerische Technische Hochschule, Galgenbergstrasse 30, D-93053, Regensburg, Germany
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