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Hsieh MK, Lee DM, Chen WP, Li YD, Kao FC, Lin YC, Tsai TT, Lai PL, Tai CL. Forcefully engaging rods into tulips with gap discrepancy leading to pedicle screw loosening-a biomechanical analysis using long porcine spine segments. Spine J 2024:S1529-9430(24)00118-9. [PMID: 38499068 DOI: 10.1016/j.spinee.2024.03.008] [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: 11/29/2023] [Revised: 02/05/2024] [Accepted: 03/12/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND CONTEXT Long-segment pedicle screw instrumentation is widely used to treat complex spinal disorders. Rods are routinely precontoured to maximize assistance on the correcting side of the deformity, but there often exists a residual gap discrepancy between the precontoured rods and screw tulips. No previous research has investigated the diminished pullout strength of the most proximal or distal pedicle screw resulting from a mismatched rod in long-segment pedicle screw instrumentation. PURPOSE The present study aimed to investigate the decreased pullout force of pedicle screws affected by the gap discrepancy when forcefully engaging a mismatched rod into a tulip in a normal-density porcine spine. STUDY DESIGN The pedicle screw fixation strength under axial pullout force was compared among three different gap discrepancies between rods and tulips using long porcine spine segments. METHODS Twelve porcine lumbar vertebrae (L3-L6) were implanted with pedicle screws and rods. Screws on one side had no gap between the tulip and rod (0-mm group), while the most proximal screw on the other side had an intentional gap of 3 mm (3-mm group) or 6 mm (6-mm group). Three hours after forcefully engaging the rod into the tulips at room temperature, the set screws in all specimens were loosened, and each specimen was dissected into individual vertebrae for subsequent pullout testing. RESULTS The control group exhibited significantly greater pullout strength (1987.68 ± 126.80 N) than the groups from different rod-tulip configurations (p<.05), with significantly greater strength in the 3-mm group (945.62 ± 97.43 N) than the 6-mm group (655.30 ± 194.49 N) (p<.05). Only 47.6% and 33.0% of the pullout strength was retained in the 3-mm and 6-mm groups, respectively, compared to the control group. CONCLUSIONS Gap discrepancies between rods and tulips can significantly reduce pedicle screw pullout strength, with a correlation between decreased strength and increased gaps. Surgeons should avoid forcefully engaging mismatched rods and consider well-fitted contoured rods in spinal surgery to minimize the risk of screw loosening. CLINICAL SIGNIFICANCE The gap discrepancy between rod and tulip significantly affected pullout strength, with greater gaps leading to reduced strength. Forcefully engaging mismatched rods into tulips in degenerative spinal surgery should be avoided to minimize the risk of early screw pullout.
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Affiliation(s)
- Ming-Kai Hsieh
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fushing St., Kweishan Dist., Taoyuan City 33305, Taiwan
| | - De-Mei Lee
- Department of Mechanical Engineering, Chang Gung University, No. 259, Wenhua 1(st) Rd., Kweishan Dist., Taoyuan City 33302, Taiwan
| | - Weng-Pin Chen
- Department of Mechanical Engineering, National Taipei University of Technology, No. 1, Sec. 3, Zhongxiao E. Rd., Daan Dist., Taipei City 10608, Taiwan
| | - Yun-Da Li
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fushing St., Kweishan Dist., Taoyuan City 33305, Taiwan; Department of Biomedical Engineering, Chang Gung University, No. 259, Wenhua 1(st) Rd., Kweishan Dist., Taoyuan City 33302, Taiwan
| | - Fu-Cheng Kao
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fushing St., Kweishan Dist., Taoyuan City 33305, Taiwan
| | - Yue-Chen Lin
- Department of Mechanical Engineering, Chang Gung University, No. 259, Wenhua 1(st) Rd., Kweishan Dist., Taoyuan City 33302, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fushing St., Kweishan Dist., Taoyuan City 33305, Taiwan
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fushing St., Kweishan Dist., Taoyuan City 33305, Taiwan
| | - Ching-Lung Tai
- Department of Orthopaedic Surgery, Spine Section, Bone and Joint Research Center, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 5, Fushing St., Kweishan Dist., Taoyuan City 33305, Taiwan; Department of Biomedical Engineering, Chang Gung University, No. 259, Wenhua 1(st) Rd., Kweishan Dist., Taoyuan City 33302, Taiwan.
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Zygogiannis K, Tanaka M, Sake N, Arataki S, Fujiwara Y, Taoka T, Uotani K, Askar AEKA, Chatzikomninos I. Our C-Arm-Free Minimally Invasive Technique for Spinal Surgery: The Thoracolumbar and Lumbar Spine-Based on Our Experiences. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2116. [PMID: 38138219 PMCID: PMC10744646 DOI: 10.3390/medicina59122116] [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: 10/12/2023] [Revised: 11/17/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: The implementation of intraoperative imaging in the procedures performed under the guidance of the same finds its history dating back to the early 1990s. This practice was abandoned due to many deficits and practicality. Later, fluoroscopy-dependent techniques were developed and have been used even in the present time, albeit with several disadvantages. With the recent advancement of several complex surgical techniques, which demand higher accuracy and are in conjunction with the existence of radiation exposure hazard, C-arm-free techniques were introduced. In this review study, we aim to demonstrate the various types of these techniques performed in our hospital. Materials and Methods: We have retrospectively analyzed and collected imaging data of C-arm-free, minimally invasive techniques performed in our hospital. The basic steps of the procedures are described, following with a discussion, along with the literature of findings, enlisting the merits and demerits. Results: MIS techniques of the thoracolumbar and lumbar spine that do not require the use of the C-arm can offer excellent results with high precision. However, several disadvantages may prevail in certain circumstances such as the navigation accuracy problem where in the possibility of perioperative complications comes a high morbidity rate. Conclusions: The accustomedness of performing these techniques requires a steep learning curve. The increase in accuracy and the decrease in radiation exposure in complex spinal surgery can overcome the burden hazards and can prove to be cost-effective.
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Affiliation(s)
- Konstantinos Zygogiannis
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (K.Z.); (N.S.); (S.A.); (Y.F.); (T.T.); (K.U.); (A.E.K.A.A.)
- Department of Scoliosis and Spine, KAT Hospital, 14561 Athens, Greece;
| | - Masato Tanaka
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (K.Z.); (N.S.); (S.A.); (Y.F.); (T.T.); (K.U.); (A.E.K.A.A.)
| | - Naveen Sake
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (K.Z.); (N.S.); (S.A.); (Y.F.); (T.T.); (K.U.); (A.E.K.A.A.)
| | - Shinya Arataki
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (K.Z.); (N.S.); (S.A.); (Y.F.); (T.T.); (K.U.); (A.E.K.A.A.)
| | - Yoshihiro Fujiwara
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (K.Z.); (N.S.); (S.A.); (Y.F.); (T.T.); (K.U.); (A.E.K.A.A.)
| | - Takuya Taoka
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (K.Z.); (N.S.); (S.A.); (Y.F.); (T.T.); (K.U.); (A.E.K.A.A.)
| | - Koji Uotani
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (K.Z.); (N.S.); (S.A.); (Y.F.); (T.T.); (K.U.); (A.E.K.A.A.)
| | - Abd El Kader Al Askar
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan; (K.Z.); (N.S.); (S.A.); (Y.F.); (T.T.); (K.U.); (A.E.K.A.A.)
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Cho J, Ryu S, Jang HJ, Park JY, Ha Y, Kuh SU, Chin DK, Kim KS, Cho YE, Kim KH. Clinical Effect of Transverse Process Hook with K-Means Clustering-Based Stratification of Computed Tomography Hounsfield Unit at Upper Instrumented Vertebra Level in Adult Spinal Deformity Patients. J Korean Neurosurg Soc 2023; 66:44-52. [PMID: 36050868 PMCID: PMC9837488 DOI: 10.3340/jkns.2022.0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE This study aimed to investigate the efficacy of transverse process (TP) hook system at the upper instrumented vertebra (UIV) for preventing screw pullout in adult spinal deformity surgery using the pedicle Hounsfield unit (HU) stratification based on K-means clustering. METHODS We retrospectively reviewed 74 patients who underwent deformity correction surgery between 2011 and 2020 and were followed up for >12 months. Pre- and post-operative data were used to determine the incidence of screw pullout, UIV TP hook implementation, vertebral body HU, pedicle HU, and patient outcomes. Data was then statistically analyzed for assessment of efficacy and risk prediction using stratified HU at UIV level alongside the effect of the TP hook system. RESULTS The screw pullout rate was 36.4% (27/74). Perioperative radiographic parameters were not significantly different between the pullout and non-pullout groups. The vertebral body HU and pedicle HU were significantly lower in the pullout group. K-means clustering stratified the vertebral body HU ≥205.3, <137.2, and pedicle HU ≥243.43, <156.03. The pullout rate significantly decreases in patients receiving the hook system when the pedicle HU was from ≥156.03 to < 243.43 (p<0.05), but the difference was not statistically significant in the vertebra HU stratified groups and when pedicle HU was ≥243.43 or <156.03. The postoperative clinical outcomes improved significantly with the implementation of the hook system. CONCLUSION The UIV hook provides better clinical outcomes and can be considered a preventative strategy for screw-pullout in the certain pedicle HU range.
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Affiliation(s)
- Jongwon Cho
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungjun Ryu
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurosurgery, National Health Insurance Service Hospital, Goyang, Korea
| | - Hyun-Jun Jang
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Yoon Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ha
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Uk Kuh
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Kyu Chin
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Keun-Su Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Eun Cho
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Hyun Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Weidling M, Heilemann M, Schoenfelder S, Heyde CE. Influence of thread design on anchorage of pedicle screws in cancellous bone: an experimental and analytical analysis. Sci Rep 2022; 12:8051. [PMID: 35577852 PMCID: PMC9110386 DOI: 10.1038/s41598-022-11824-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 04/28/2022] [Indexed: 11/12/2022] Open
Abstract
Threads of modern pedicle screws can vary greatly in design. It is difficult to assess which interplay of design features is particularly advantageous for screw anchorage. This study aims to increase the understanding of the anchorage behaviour between screw and cancellous bone. Pull-out tests of six pedicle screws in two sizes each were performed on three densities of biomechanical test material. More general screw characteristics were derived from the screw design and evaluated using the test data. Selected screws were tested on body donor material. Some screw characteristics, such as compacting, are well suited to compare the different thread designs of screws with tapered core. The combination of two characteristics, one representing bone compacting and one representing thread flank area, appears to be particularly advantageous for assessing anchorage behaviour. With an equation derived from these characteristics, the pull-out strength could be calculated very accurately (mean deviation 1%). Furthermore, findings are corroborated by tests on donor material. For screws with tapered core, the design demands for good anchorage against pull-out from cancellous bone change with material density. With sufficient bone quality, screws with a high compacting effect are advantageous, while with low bone density a high thread flank area also appears necessary for better screw anchorage.
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Xia C, Yang S, Liu J, Lu J, Shang D, Fu D, Zhao Z, Wang X. Finite element study on whether posterior upper wall fracture is a risk factor for the failure of short-segment pedicle screw fixation in the treatment of L1 burst fracture. Injury 2021; 52:3253-3260. [PMID: 34521540 DOI: 10.1016/j.injury.2021.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/04/2021] [Accepted: 08/13/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To establish the finite element model of T12 and L2 (T12-L2) pedicle screw fixation for severe L1 burst fracture, and quantitatively simulate and analyze the screw stress and vertebral displacement in different degrees of L1 posterior upper wall fracture (PUWF), and evaluate whether PUWF degree is a risk factor for fixation failure. METHODS The data of 6 healthy volunteers were used to establish a finite element model of T12-L2 pedicle screw fixation for type A severe burst fractures. The stress and displacement of the conventional and Schanz pedicle screws for the different degrees of PUWF (including the anterior upper wall of the vertebral canal and the bipedicle) were evaluated. RESULTS The maximum stress and L1 displacement of conventional and Schanz pedicle screws were positively correlated with the severity of the PUWF (P<0.05). During anterior flexion, the maximum stress of conventional pedicle screws for 70% type I were 538.3±59.75MPa and the maximum stress of Schanz pedicle screws for 90% type Ⅱ, 90% type Ⅲ and 70% type IV fractures were close to the fatigue threshold. The maximum stress during anterior flexion were significantly higher than those during posterior extension, bending and rotation (P<0.05). CONCLUSION The posterior upper wall fracture of vertebral body (VB) of type A burst fracture is not an independent risk factor for the failure of short-segment pedicle screw fixation (SSPSF). Anterior flexion of type A fractures combined with severe PUWF of VB was a risk factor for the failure of SSPSF.
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Affiliation(s)
- Chunyang Xia
- Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, 6 Jiefang Street, Dalian, Liaoning 116001, China.
| | - Sheng Yang
- Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, 6 Jiefang Street, Dalian, Liaoning 116001, China.
| | - Jifeng Liu
- Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, 6 Jiefang Street, Dalian, Liaoning 116001, China; Department of Orthopaedics, Yantai Hospital of Shandong Wendeng Orthrpaedics & Traumatology, Shanhai South Road, Laishan district, Yantai 264003, Shandong Province, China.
| | - Jianmin Lu
- Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, 6 Jiefang Street, Dalian, Liaoning 116001, China.
| | - Depeng Shang
- Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, 6 Jiefang Street, Dalian, Liaoning 116001, China.
| | - Dapeng Fu
- Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, 6 Jiefang Street, Dalian, Liaoning 116001, China.
| | - Zhenhua Zhao
- Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, 6 Jiefang Street, Dalian, Liaoning 116001, China.
| | - Xiahua Wang
- Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, 6 Jiefang Street, Dalian, Liaoning 116001, China.
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