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Du S, Li X, Wei C, Ma Y, Liu J, Wu Y. Comparison of the operation safety and biomechanical stability of sacral alar-iliac vs. sacroiliac screws in the fixation of sacroiliac joint in simulated models of low bone density. Injury 2024; 55:111191. [PMID: 37972487 DOI: 10.1016/j.injury.2023.111191] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/12/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Sacral alar-iliac screws (SAISs) have been used for sacroiliac joint and are superiority to traditional sacroiliac screws (SISs) in patients with low bone density. The aim of this study was to investigate the operation safety and biomechanical stability of the SIS, transsacral-transiliac screw (TSTIS), S1AIS and S2AIS in the treatment of sacroiliac joint in simulated models of low bone density. METHODS CT data from 80 normal pelvic structures were employed to measure the anatomical parameters, including the safety zones of the S1AIS and S2AIS at the insertion point and the trajectory lengths of the SIS, TSTIS, S1AIS and S2AIS. Sixteen synthetic pelvises with simulated osteoporotic bone structure were used to simulate type C Tile lesions and divided into 4 groups with an anterior plate and posterior fixation using one of the following: 1) one SIS on each side, 2) one TSTIS fixing both sides, 3) one S1AIS on each side, or 4) one S2AIS on each side. The stiffness and maximum load of the specimens were analyzed using a biomechanical machine under vertical loading. RESULTS The safety zone of S1AIS was larger than that of S2AIS (p < 0.05). The TSTIS had the largest trajectory length, followed by the S1AIS and S2AIS, and the SIS had the smallest trajectory length (p < 0.05). However, the lengths of the TSTIS (26.1 ± 1.7 mm) and SIS (27.8 ± 1.8 mm) trajectories on the short side (the iliac side) were smaller than those of S1AIS (40.4 ± 3.8 mm) and S2AIS (39.1 ± 3.8 mm), thus indicating significant differences (p < 0.05). The stiffness and maximum load of S1AIS and S2AIS were similar and the greatest, followed by TSTIS and SIS (p < 0.05). CONCLUSION The stability of S1AIS and S2AIS is similar, both stronger than that of SIS and TSTIS, which have shorter lengths of the screw trajectories on the ilium side. However, the safety zone of S2AIS at the insertion point is smaller than that of S1AIS. Therefore, considering both safety and stability, S1AIS is the preferred choice for fixation of sacroiliac joint dislocation in simulated models of low bone density.
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Affiliation(s)
- Shihao Du
- Department of Orthopaedics, Wuxi No.9 People's Hospital Affiliated to Soochow University, Wuxi, 214062, Jiangsu, China
| | - Xin Li
- Department of Orthopaedics, Wuxi No.9 People's Hospital Affiliated to Soochow University, Wuxi, 214062, Jiangsu, China
| | - Changbao Wei
- Department of Orthopaedics, Wuxi No.9 People's Hospital Affiliated to Soochow University, Wuxi, 214062, Jiangsu, China
| | - Yunhong Ma
- Department of Orthopaedics, Wuxi No.9 People's Hospital Affiliated to Soochow University, Wuxi, 214062, Jiangsu, China.
| | - Jun Liu
- Department of Orthopaedics, Wuxi No.9 People's Hospital Affiliated to Soochow University, Wuxi, 214062, Jiangsu, China
| | - Yongwe Wu
- Department of Orthopaedics, Wuxi No.9 People's Hospital Affiliated to Soochow University, Wuxi, 214062, Jiangsu, China
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Elgafy H, Lempert N, Stirton J, Zak P, Semaan H. Pedicle Screw Track Augmentation With Fibular Allograft for Significant Bone Loss in Revision Fixation. Global Spine J 2023; 13:409-415. [PMID: 33626945 PMCID: PMC9972260 DOI: 10.1177/2192568221997076] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To report the clinical and radiological outcomes for screw track augmentation with fibular allograft in revision of loose pedicle screws associated with significant bone loss along the screw track. METHODS Thirty consecutive patients, 18 men (60%) and 12 women (40%), with a mean age 52 years (range 34- 68). Fibular allograft was prepared by cutting it into longitudinal strips 50 mm in length. Three allograft struts were inserted into the screw track. Six mm tap used to tap between the 3 fibular struts. Eight- or 9-mm diameter, and 45 or 50 mm in length screw was then inserted. The clinical outcomes were assessed by means of the Oswestry Disability Index (ODI), and visual analog scale (VAS) for back and leg pain for clinical outcome. Computed tomography scan (CT) performed at 12 months postoperative visit to assess fibular graft incorporation along the pedicle screw track, any screw loosening and the interbody as well as posterolateral fusion. RESULTS At a mean follow up of 29 months, there were statically significant improvement in the ODI and VAS for back and leg pain. CT scan obtained at last follow-up showed incorporation of fibular allograft and solid fusion in all patients except one. CONCLUSION The fibular allograft augmentation of the pedicle screw track in revision of loose pedicle screws associated with significant bone loss is a viable option. It allows for biologic fixation at the screw-bone interface and has some key advantages when compared to currently available methods.
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Affiliation(s)
- Hossein Elgafy
- Department of Orthopaedic Surgery and
Radiology, University of Toledo Medical Center, Toledo, OH, USA
- Hossein Elgafy, Department of Orthopaedic Surgery,
University of Toledo Medical Center, 3065 Arlington Avenue, Toledo, OH 43614, USA.
| | - Nathaniel Lempert
- Department of Orthopaedic Surgery and
Radiology, University of Toledo Medical Center, Toledo, OH, USA
| | - Jacob Stirton
- Department of Orthopaedic Surgery and
Radiology, University of Toledo Medical Center, Toledo, OH, USA
| | - Peter Zak
- Department of Orthopaedic Surgery and
Radiology, University of Toledo Medical Center, Toledo, OH, USA
| | - Hassan Semaan
- Department of Orthopaedic Surgery and
Radiology, University of Toledo Medical Center, Toledo, OH, USA
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Albers CE, Zderic I, Kastner P, Gueorguiev B, Tosounidis TH, Keel MJB, Bastian JD. The ideal site of cement application in cement augmented sacroiliac screw fixation: the biomechanical perspective. Eur J Trauma Emerg Surg 2022; 49:1449-1458. [DOI: 10.1007/s00068-022-02187-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
Abstract
Purpose
To compare construct stability of cement augmented sacroiliac screws using two different cementation sites in a biomechanical fragility fracture model of the pelvis.
Methods
A fracture model with an incomplete fracture of the sacral ala and complete fracture of the anterior pelvic ring mimicking a FFP IIB fragility fracture of the pelvis was established in five fresh frozen human cadaveric pelvises. Sacral fracture stabilization was achieved with bilateral 7.3 mm fully threaded sacroiliac screws. Cement augmentation was performed at the tip of the screw (body of S1; Group A) on one side, and at the midshaft of the screw (sacral ala; Group B) on the contralateral side. Biomechanical testing was conducted separately on both sides comprising cyclic loading of axial forces transferred through the tested hemipelvis from L5 to the ipsilateral acetabulum. Combined angular displacement in flexion and internal rotation (“gap angle”), angular displacement of the ilium in relation to the screw (“screw tilt ilium”), and screw tip cutout were evaluated.
Results
Relative interfragmentary movements were associated with significantly higher values in group A versus group B for “gap angle” (2.4° vs. 1.4°; p < 0.001), and for “screw tilt ilium” (3.3° vs. 1.4°; p < 0.001), respectively. No significant difference was indicated for screw tip cutout between the two groups (0.6 mm [Group A] vs. 0.8 mm [Group B]; p = 0.376).
Conclusion
The present study demonstrated less fragment and screw displacements in a FFP IIB fracture model under physiologic cyclic loading by cement augmentation of sacroiliac screws at the level of the lateral mass compared to the center of vertebral body of S1.
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Ellmerer AE, Küper MA, Rollmann MF, Herath SC, Histing T. [Cement augmentation in pelvic ring fractures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:443-451. [PMID: 35925151 DOI: 10.1007/s00113-022-01186-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 06/15/2023]
Abstract
Cement augmentation of sacroiliac (SI) screws in the posterior pelvic ring has been shown to provide greater biomechanical stability in cadaveric studies. Pelvic ring fractures are relatively rare compared to the total number of fractures. Nevertheless, the 1‑year mortality rate of up to 27% is very high, especially for geriatric pelvic ring fractures and is also largely associated with reduced mobility due to the fracture. The primary goal of treatment is therefore the restoration of patient mobility. This requires the achievement of sufficient stability of the pelvic ring. As osteoporosis is often a causative factor for the pelvic ring fracture, a more stable anchoring of the implants in the osteoporotic bone can be achieved by cement augmentation. This article presents the possibilities of cement augmentation of the pelvic ring and describes the technique of cement-augmented SI screws.
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Affiliation(s)
- Andreas E Ellmerer
- Klinik für Unfall- und Wiederherstellungschirurgie an der Eberhard Karls Universität, BG Unfallklinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Markus A Küper
- Klinik für Unfall- und Wiederherstellungschirurgie an der Eberhard Karls Universität, BG Unfallklinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Mika F Rollmann
- Klinik für Unfall- und Wiederherstellungschirurgie an der Eberhard Karls Universität, BG Unfallklinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Steven C Herath
- Klinik für Unfall- und Wiederherstellungschirurgie an der Eberhard Karls Universität, BG Unfallklinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Tina Histing
- Klinik für Unfall- und Wiederherstellungschirurgie an der Eberhard Karls Universität, BG Unfallklinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland.
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Çınaroğlu S, Keleş H. A new technique for preparing cadavers using PMMA: Rat and mouse example. Ann Anat 2022; 242:151919. [PMID: 35278657 DOI: 10.1016/j.aanat.2022.151919] [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: 11/09/2021] [Revised: 02/03/2022] [Accepted: 02/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Polymethyl methacrylate is a member of the acrylic polymer family with superior optical properties. It is used in dentistry, hospital incubators, lenses, and various surgical fields, especially orthopedics. In this preliminary study, we aimed to prepare cadavers using the industrial form of polymethyl methacrylate. METHODS The new technique consists of fixation, washing, purification, impregnation, and polymerization. For the study, two whole rat bodies, two rat front legs and two rat hind legs, one half rat body, two whole mouse bodies, and all internal organs were used. Wistar albino rats and BALB/c mice were used. After the cadaver samples were fixed and washed, they were passed through an alcohol series starting from 50%, completing the purification process. In the next step, a solution was prepared by mixing 100 ml of Thinner into 1000 ml of a mixture containing styrene, methyl methacrylate, and Co(II)2-ethyl hexanoate. The samples were immersed in the solution under negative pressure (from 10 mmHg to 400 mmHg), allowing the samples to absorb the solution thoroughly. They were then treated with methyl ethyl ketone peroxide and the polymerization step was terminated. RESULTS The cadaver samples obtained using polymer were hard, they maintained the given shape, and showed a relatively transparent quality. The production of these materials took 35 days, excluding fixation. The tissue samples were odorless in the process after polymerization. Also, there was no decay in the samples after the production stage and they could be stored under room conditions. CONCLUSION This study determined that cadavers could be prepared using polymethyl methacrylate and methyl ethyl ketone peroxide. The polymer used here cost about $5. The cadavers can be safely exhibited in room conditions for five years without requiring special conditions like pools or cold storage. Further research should compare this technique with the plastination technique in terms of texture, color, weight, application time, and cost.
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Affiliation(s)
- Selim Çınaroğlu
- Department of Anatomy, Faculty of Medicine, Niğde Ömer Halisdemir University, TR-51240 Niğde, Turkey.
| | - Hacı Keleş
- Department of Anatomy, Faculty of Medicine, Niğde Ömer Halisdemir University, TR-51240 Niğde, Turkey.
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Suero EM, Greiner A, Becker CA, Cavalcanti Kußmaul A, Weidert S, Pfeufer D, Woiczinski M, Braun C, Flatz W, Böcker W, Kammerlander C. Biomechanical stability of sacroiliac screw osteosynthesis with and without cement augmentation. Injury 2021; 52:2707-2711. [PMID: 32033807 DOI: 10.1016/j.injury.2020.01.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/26/2020] [Accepted: 01/28/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Percutaneous sacroiliac (SI) screw fixation is the standard operative treatment of traumatic disruptions to the posterior pelvic ring. The technique offers good outcomes and early postoperative mobilization, which is vital in elderly patients with fragility fractures of the pelvis. While a double-screw technique has been shown to provide optimal biomechanical stability compared to a single-screw construct, anatomic variations and patient-specific characteristics may prevent the safe insertion of two SI screws. We aimed to determine whether cement augmentation of a single SI screw would provide biomechanical stability comparable to that of the double-screw technique. METHODS Three sacroiliac screw osteosynthesis configurations were tested on 10 human cadaveric pelvis specimens: a single cannulated screw; two cannulated screws; and a single, cement-augmented cannulated screw. Displacement and stiffness of the anterior and posterior pelvic ring after fixation with each technique were measured under axial load. Results where compared using linear regression and paired t-tests. RESULTS A single uncemented screw offered significantly worse stability in the anterior pelvis compared to a double-screw technique (P < 0.05) and to a single cement-augmented screw technique (P < 0.05). There was no significant difference in anterior pelvic ring stability between the single cement-augmented screw technique and the double-screw technique (P > 0.05). There was no significant difference in the stability of the posterior pelvic ring between the three techniques (P > 0.05). CONCLUSIONS A single cement-augmented cannulated sacroiliac screw provides biomechanical stability similar to that of a non-augmented double-screw technique in the treatment of posterior pelvic ring fractures.
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Affiliation(s)
- Eduardo M Suero
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany.
| | - Axel Greiner
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Christopher A Becker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany.
| | - Adrian Cavalcanti Kußmaul
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Simon Weidert
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Daniel Pfeufer
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Matthias Woiczinski
- Department of Orthopedic Surgery, Physical medicine and Rehabilitation, University Hospital, LMU Munich, Munich, Germany
| | - Christian Braun
- Institute of Legal and Forensic Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Wilhelm Flatz
- Institute for Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang Böcker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Christian Kammerlander
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
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Hartensuer R, Lodde MF, Keller J, Eveslage M, Stolberg-Stolberg J, Riesenbeck O, Raschke MJ. Safety, Effect and Feasibility of Percutaneous SI-Screw with and without Augmentation-A 15-Year Retrospective Analysis on over 640 Screws. J Clin Med 2020; 9:jcm9082660. [PMID: 32824548 PMCID: PMC7463525 DOI: 10.3390/jcm9082660] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/11/2020] [Accepted: 08/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Minimally invasive sacroiliac-screw (SI-screw) fixation of the pelvis is used in energy trauma (Arbeitsgemeinschaft für Osteosynthesefragen (AO) classified) and fragility fractures (Fragility Fracture of the Pelvis (FFP) classified). However, available clinical data are based on small case series and biomechanical data seem to be contradictory. METHODS The present single center retrospective cohort study investigated percutaneous SI-screw fixation and augmentation over 15 years. Groups were compared concerning the general epidemiological data, mobilization, complication rates, duration of stay, and safety of SI-screw insertion. Multivariable analyses were performed using logistic regression. RESULTS Between 2005 and March 2020, 448 patients with 642 inserted SI-screws were identified. Iatrogenic neurological impairment was documented in 2.47% and correlated with screw misplacement. There was an increased complication risk in patients with AO type C over patients with AO type B and in FFP II over FFP III/IV patients. Cement-augmented FFP patients showed a 25% reduced stay in hospital and a reduced complication risk. Cement-associated complications were seen in 22% without correlation to neurologic impairment. CONCLUSIONS The present study confirms the safety and usability of percutaneous SI-screw fixation, despite specific risks. Cement augmentation seems to reduce the complication risk in FFP patients and shorten hospital stay for some reasons, without increased specific complications or correlated neurological impairment.
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Affiliation(s)
- René Hartensuer
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
- Correspondence: ; Tel.: +49-251-83-59204
| | - Moritz F. Lodde
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
| | - Jonas Keller
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
| | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Muenster, 48149 Münster, Germany;
| | - Josef Stolberg-Stolberg
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
| | - Oliver Riesenbeck
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
| | - Michael J. Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
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Cement augmentation of sacroiliac screws in fragility fractures of the pelvic ring-A synopsis and systematic review of the current literature. Injury 2019; 50:1411-1417. [PMID: 31301810 DOI: 10.1016/j.injury.2019.06.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/29/2019] [Accepted: 06/24/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fragility fractures of the pelvis (FFP) show a notable rise in prevalence. Minimally invasive surgical fixation of FFP is increasingly advocated for its obvious advantages with reference to early mobilization and weight bearing. Concerns regarding the holding power of osteosynthetic materials in osteoporotic bone led to the development of cementing techniques. However, the role of cement augmentation in the surgical treatment of FFP has yet to be defined. Therefore, the aim of this study was to conduct a systematic review of the current literature concerning studies that are comparing the performance of cement augmented versus non-augmented sacroiliac (SI) screws. METHODS We conducted a systematic literature review from 01/01/2000 onwards. Inclusion criteria were randomized controlled studies, case series (n>3), biomechanical studies and reviews, comparing augmented and non-augmented SI screws. Only papers in German or English language were included. RESULTS Out of 1247 initial hits, eleven studies met the inclusion criteria. Out of those, six were biomechanical studies and five were clinical case series. Most biomechanical studies showed cement augmented screws to have a greater mechanical stability, both regarding pull-out force and resistance to cyclic loading. The five case studies reported on a total of 98 patients with 122 screw fixations. Three cases of cement leakage into neuroforamina occurred, however, none of these patients showed clinical symptoms. CONCLUSION In clinical case series, cement augmentation of SI screws appears to be a safe surgical technique without relevant complications and biomechanical studies demonstrate greater pull-out forces of augmented SI screws but no advantage in regard of cyclic loading. Hence, applicability of the mechanical testing results on the clinical situation are debatable. So far, there are neither retrospective nor randomized controlled studies comparing the performance of cemented and non-cemented SI screws in FFP. Therefore, the clinical benefit of SI screw cement augmentation is unclear and their use remains experimental.
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Yin S, Du H, Zhao W, Ma S, Zhang M, Guan M, Liu M. Inhibition of both endplate nutritional pathways results in intervertebral disc degeneration in a goat model. J Orthop Surg Res 2019; 14:138. [PMID: 31096992 PMCID: PMC6521378 DOI: 10.1186/s13018-019-1188-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/03/2019] [Indexed: 11/10/2022] Open
Abstract
Background The vertebral endplate route was demonstrated to be the main pathway for nutrition to the intervertebral disc. However, it is still a controversial issue on whether the blocking of the endplate nutritional pathway could result in intervertebral disc degeneration (IDD) in animal models. The aim was therefore to investigate the effect of the inhibition of both endplate nutritional pathways by bone cement injection on the IDD in a goat model. Methods Two lumbar intervertebral discs (L2–3 and L3–4) in eight 24-month-old goats were blocked in both endplate nutritional pathways by cement injection, and the other two lumbar intervertebral discs (L1–2 and L4–5) remained intact as normal controls. Effective blocking area percentage in nucleus pulposus (NP) was calculated, and X-rays, magnetic resonance imaging (MRI), and histology studies were performed at 4, 12, 24, and 48 weeks after operation. Results The mean effective blocking area percentage was 60.7 ± 5.3%. Imaging examinations at the time of 48 weeks after blocking the endplate nutritional pathways showed obvious IDD, with larger disc height reduction and higher degrees of disc degeneration grading compared with the normal controls. Histological examinations including HE, Masson’s trichrome, Sirius Red, and proteoglycan stainings also confirmed the degenerative changes of the blocked discs. Conclusions The endplate nutritional route could be inhibited by blocking both endplate pathways with cement injection in a goat model. The severe inhibition in the endplate nutritional pathways may result in IDD.
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Affiliation(s)
- Si Yin
- Department of Orthopaedic Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Room 1501, Inpatient Building, No. 277, Road Yantawest, Xi'an, 710061, Shaanxi Province, China
| | - Heng Du
- Department of Orthopaedic Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Room 1501, Inpatient Building, No. 277, Road Yantawest, Xi'an, 710061, Shaanxi Province, China.
| | - Weigong Zhao
- Department of Orthopaedic Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Room 1501, Inpatient Building, No. 277, Road Yantawest, Xi'an, 710061, Shaanxi Province, China
| | - Shaohui Ma
- Department of Medical Imaging, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi Province, China
| | - Ming Zhang
- Department of Medical Imaging, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi Province, China
| | - Min Guan
- Department of Medical Imaging, Henan Provincial People's Hospital, Zhengzhou, 450003, Henan Province, China
| | - Miao Liu
- Department of Orthopaedic Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Room 1501, Inpatient Building, No. 277, Road Yantawest, Xi'an, 710061, Shaanxi Province, China
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Pieroh P, Lenk M, Hohmann T, Grunert R, Wagner D, Josten C, Höch A, Böhme J. Intra- and interrater reliabilities and a method comparison of 2D and 3D techniques in cadavers to determine sacroiliac screw loosening. Sci Rep 2019; 9:3141. [PMID: 30816290 PMCID: PMC6395688 DOI: 10.1038/s41598-019-40052-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 01/22/2019] [Indexed: 12/02/2022] Open
Abstract
Sacroiliac (SI) screw loosening may indicate persistent instability, non-union and contribute to pain. Yet, there is no reliable objective measurement technique to detect and monitor SI screw loosening. In 9 cadaveric pelvises one of two SI screw was turned back approximately 20 mm and subsequently assessed by optical measurement, fluoroscopy and a 3D scan using an image intensifier. CTs were segmented and a contour-based registration of the 3D models and the fluoroscopies was performed to measure SI backing out (X-ray module). Three independent observers performed measurements with three repetitions. Deviation of the measurement techniques to the 3D scan, intra- and interrater reliabilities and method equivalence to the 3D scan were assessed. The X-ray module and two fluoroscopic measurement techniques yielded a difference less than 5 mm compared to the 3D scan and equivalence to the 3D scan. Intrarater reliability was for two observers and almost all techniques very good. Three fluoroscopic measurement techniques and optical measurements displayed a very good interrater reliability. The 3D scan and X-ray module yielded the most precise values for SI screw loosening but only the fluoroscopic measurement of the inlet lateral loosening displayed a good reliability and equivalence to the 3D scan.
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Affiliation(s)
- Philipp Pieroh
- Department of Orthopaedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany. .,Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Grosse Steinstrasse 52, 06097, Halle, Saale, Germany.
| | - Maximilian Lenk
- Department of Orthopaedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Tim Hohmann
- Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Grosse Steinstrasse 52, 06097, Halle, Saale, Germany
| | - Ronny Grunert
- Department of Orthopaedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.,Fraunhofer Institute for Machine Tools and Forming Technology IWU, Noethnitzer Strasse 44, 01187, Dresden, Germany
| | - Daniel Wagner
- Department of Orthopaedics and Traumatology, University Medical Centre Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Christoph Josten
- Department of Orthopaedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Andreas Höch
- Department of Orthopaedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Jörg Böhme
- Department of Orthopaedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.,Hospital St. Georg gGmbH, Clinic of Trauma, Orthopaedic and Septic Surgery, Delitzscher Strasse 141, Leipzig, 04129, Germany
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11
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Hammer N, Scholze M, Kibsgård T, Klima S, Schleifenbaum S, Seidel T, Werner M, Grunert R. Physiological in vitro sacroiliac joint motion: a study on three-dimensional posterior pelvic ring kinematics. J Anat 2018; 234:346-358. [PMID: 30536830 DOI: 10.1111/joa.12924] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2018] [Indexed: 12/28/2022] Open
Abstract
The sacroiliac joint (SIJ) is a well-known source of low back and pelvic pain, of increasing interest for both conservative and surgical treatment. Alterations in the kinematics of the pelvis have been hypothesized as a major cause of SIJ-related pain. However, definitions of both the range and the extent of physiological movement are controversial, and there are no clear baseline data for pathological alterations. The present study combined a novel biomechanical setup allowing for physiological motion of the lumbosacral transition and pelvis without restricting the SIJ movement in vitro, combined with optical image correlation. Six fresh human pelvises (81 ± 10 years, three females, three males) were tested, with bodyweight-adapted loading applied to the fifth lumbar vertebra and both acetabula. Deformation at the lumbopelvises was determined computationally from three-dimensional image correlation data. Sacroiliac joint motion under the loading of 100% bodyweight primarily consisted of a z-axis rotation (0.16°) and an inferior translation of the sacrum relative to the ilium (0.32 mm). Sacroiliac joint flexion-extension rotations were minute (< 0.02°). Corresponding movements of the SIJ were found at the lumbosacral transition, with an anterior translation of L5 relative to the sacrum of -0.97 mm and an inferior translation of 0.11 mm, respectively. Moreover, a flexion of 1.82° was observed at the lumbosacral transition. Within the innominate bone and at the pubic symphysis, small complementary rotations were seen around a vertical axis, accounting for -0.10° and 0.11°, respectively. Other motions were minute and accompanied by large interindividual variation. The present study provides evidence of different SIJ motions than reported previously when exerted by physiological loading. Sacroiliac joint kinematics were in the sub-degree and sub-millimeter range, in line with previous in vivo and in vitro findings, largely limited to the sagittal rotation and an inferior translation of the sacrum relative to the ilium. This given physiological loading scenario underlines the relevance of the lumbosacral transition when considering the overall motion of the lumbopelvis, and how relatively little the other segments contribute to overall motion.
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Affiliation(s)
- Niels Hammer
- Department of Anatomy, University of Otago, Dunedin, New Zealand.,Department of Orthopedic and Trauma Surgery, University Clinics of Leipzig, Germany.,Fraunhofer Institute for Machine Tools and Forming Technology IWU, Dresden, Germany
| | - Mario Scholze
- Department of Anatomy, University of Otago, Dunedin, New Zealand.,Institute of Materials Science and Engineering, Chemnitz University of Technology, Chemnitz, Germany
| | - Thomas Kibsgård
- Department of Orthopedics, Oslo University Hospital, Oslo, Norway
| | - Stefan Klima
- Department of Orthopedic and Trauma Surgery, University Clinics of Leipzig, Germany.,Orthopaedicus Clinics, Leipzig, Germany
| | - Stefan Schleifenbaum
- Department of Orthopedic and Trauma Surgery, University Clinics of Leipzig, Germany
| | - Thomas Seidel
- Institute of Cellular and Molecular Physiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Michael Werner
- Fraunhofer Institute for Machine Tools and Forming Technology IWU, Dresden, Germany.,Department of Anatomy, University of Leipzig, Germany
| | - Ronny Grunert
- Fraunhofer Institute for Machine Tools and Forming Technology IWU, Dresden, Germany.,Department of Neurosurgery, University of Leipzig, Leipzig, Germany
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12
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Pelvic orthosis effects on posterior pelvis kinematics An in-vitro biomechanical study. Sci Rep 2018; 8:15980. [PMID: 30374032 PMCID: PMC6206162 DOI: 10.1038/s41598-018-34387-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/15/2018] [Indexed: 11/16/2022] Open
Abstract
The sacroiliac joint (SIJ) is a well-known source of low back pain, with increasing interest for both conservative and surgical treatment. Alterations in pelvis kinematics are hypothesized as a contributor to SIJ pain and pelvic orthoses one treatment option, but their effects on the pelvis are poorly understood. Alterations in movement patterns induced by the application of pelvic orthoses were determined in five human cadaveric pelvises. Deformations were obtained from the lumbosacral transition and the bilateral SIJ, using digital image correlation and a customized routine to compute the movements within the pelvis. Significant alterations were found for the movements at the SIJ, in particular a vast increase in axial (x-axis) rotation, accompanied by increased inferior (y-) translation of the sacrum relative to the ilium. Movement patterns at the lumbosacral transition changed, causing increases in axial rotation and decreased inferior translation of L5 relative to S1. Using a physiologic mode of load application gives novel insights into the potential effects of pelvic orthoses. The results of these in-vitro experiments vary markedly from previous experiments with loading limited to two or less axes. Furthermore, the influence of pelvic orthoses on the lumbosacral transition warrants further investigation.
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13
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Singh A, Scholze M, Hammer N. On the influence of surface coating on tissue biomechanics - effects on rat bones under routine conditions with implications for image-based deformation detection. BMC Musculoskelet Disord 2018; 19:387. [PMID: 30368235 PMCID: PMC6204271 DOI: 10.1186/s12891-018-2308-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 10/17/2018] [Indexed: 11/10/2022] Open
Abstract
Background Biomechanical testing using image-based deformation detection techniques such as digital image correlation (DIC) offer optical contactless methods for strain and displacement measurements of biological tissues. However, given the need of most samples to be speckled for image correlation using sprays, chemical alterations with impact on tissue mechanicals may result. The aim of this study was to assess the impact of such surface coating on the mechanical properties of rat bones, under routine laboratory conditions including multiple freeze-thaw cycles. Methods Two groups of rat bones, highly-uniform and mixed-effects, were assigned to six subgroups consisting of three types of surface coating (uncoated, commercially-available water- and solvent-based sprays) and two types of bone conditions (periosteum attached and removed). The mixed-effects group had undergone an additional freeze-thaw cycle at − 20 degrees. All bones underwent a three-point bending test ranging until material failure. Results Coating resulted in similar and non-significantly different mechanical properties of rat bones, indicated by elastic moduli, maximum force and bending stress. Scanning electron microscopy showed more pronounced mechanical alterations related to the additional freeze-thaw cycle, with fewer cracks being present in a bone from the highly-uniform group. Conclusions This study has concluded that surface coating with water- or solvent-based sprays for enhancing image correlation for DIC and having an additional freeze-thaw cycle do not significantly alter mechanical properties of rat bones. Therefore, this method may be recommended as an effective way of obtaining a speckled pattern.
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Affiliation(s)
- Aqeeda Singh
- Department of Anatomy, University of Otago, Lindo Ferguson Building, 270 Great King St, Dunedin, 9016, New Zealand
| | - Mario Scholze
- Department of Anatomy, University of Otago, Lindo Ferguson Building, 270 Great King St, Dunedin, 9016, New Zealand.,Institute of Materials Science and Engineering, Chemnitz University of Technology, Chemnitz, Germany
| | - Niels Hammer
- Department of Anatomy, University of Otago, Lindo Ferguson Building, 270 Great King St, Dunedin, 9016, New Zealand. .,Department of Orthopedic and Trauma Surgery, University Clinics of Leipzig, Leipzig, Germany. .,Fraunhofer IWU, Dresden, Germany.
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14
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Stewart R, Kieser DC, Scholze M, Hammer N, Stone B, Hooper G. Preliminary biomechanical results of a novel pin configuration for external fixation of vertical shear pelvic fractures. ANZ J Surg 2018; 88:1051-1055. [DOI: 10.1111/ans.14822] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/27/2018] [Accepted: 07/17/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Rebecca Stewart
- Department of Orthopaedic Surgery and MSM; Christchurch Hospital; Christchurch New Zealand
| | - David C. Kieser
- Department of Orthopaedic Surgery and MSM; Christchurch Hospital; Christchurch New Zealand
| | - Mario Scholze
- Anatomy-Biomechanics Laboratory, Department of Anatomy; University of Otago; Dunedin New Zealand
| | - Niels Hammer
- Anatomy-Biomechanics Laboratory, Department of Anatomy; University of Otago; Dunedin New Zealand
| | - Brad Stone
- Department of Orthopaedic Surgery and MSM; Christchurch Hospital; Christchurch New Zealand
| | - Gary Hooper
- Department of Orthopaedic Surgery and MSM; Christchurch Hospital; Christchurch New Zealand
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15
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Hack J, Krüger A, Masaeli A, Aigner R, Ruchholtz S, Oberkircher L. Cement-augmented sacroiliac screw fixation with cannulated versus perforated screws - A biomechanical study in an osteoporotic hemipelvis model. Injury 2018; 49:1520-1525. [PMID: 29914671 DOI: 10.1016/j.injury.2018.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/16/2018] [Accepted: 06/08/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cement-augmentation is a well-established way to improve the stability of sacroiliac screw fixation in osteoporosis-associated fragility fractures of the posterior pelvic ring. However, to date little is known about the influence of different techniques of cement augmentation on construct stability. The aim of this study was to evaluate the primary stability of cement-augmented sacroiliac screw fixation with cannulated versus perforated screws under cyclic loading. MATERIALS AND METHODS A total of eight fresh-frozen human cadaveric hemipelvis specimens with osteoporosis were used. After generating ventral osteotomies on both sides of the sacrum, each specimen was treated using a cement-augmented cannulated screw on one side and a cement-augmented perforated screw on the other side. Afterwards, axial cyclic loading was performed. RESULTS No statistically significant difference was found between cannulated and perforated screws concerning maximum load (356.25 N versus 368.75 N, p = 0.749), plastic deformation (1.95 mm versus 1.43 mm, p = 0.798) and stiffness (27.04 N/mm versus 40.40 N/mm, p = 0.645). CONCLUSIONS Considering the at least equivalent results for perforated screws, cement augmentation via perforated screws might be an interesting option in clinical practice because of potential advantages, e.g. radiological control before cement application, reduced risk of cement displacement and time saving.
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Affiliation(s)
- J Hack
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany.
| | - A Krüger
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany
| | - A Masaeli
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany
| | - R Aigner
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany
| | - S Ruchholtz
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany
| | - L Oberkircher
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany
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16
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Affiliation(s)
- Joey P Johnson
- Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, Loma Linda University, 11406 Loma Linda Drive, Suite 128, Loma Linda CA, 92354, USA.
| | | | - Peter V Giannoudis
- Department of Orthopedic Surgery, Division of Trauma and Related Services, Leeds General Infirmary, Leeds, UK
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17
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Wagner D, Hofmann A, Kamer L, Sawaguchi T, Richards RG, Noser H, Gruszka D, Rommens PM. Fragility fractures of the sacrum occur in elderly patients with severe loss of sacral bone mass. Arch Orthop Trauma Surg 2018; 138:971-977. [PMID: 29700604 DOI: 10.1007/s00402-018-2938-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Patients suffering from osteoporosis-associated fragility fractures of the sacrum (FFS; also termed sacral insufficiency fractures) are increasingly observed. They have typical fracture patterns with fracture lines located in the sacral ala. When treating these patients operatively, iliosacral screw loosening is not uncommon. We aimed to study the sacral bone mass in patients presenting with a FFS using 3D statistical models. MATERIALS AND METHODS 3D models of averaged Hounsfield units (HU) were generated based on CT scans from 13 patients with a unilateral FFS (mean age 79.6 years; 11 females, 2 males). The control group without fractures consisted of 28 males and 32 females (mean age of 68.3 years). A virtual bone probe along the trans-sacral corridors S1 and S2 was taken. RESULTS The bone mass distribution in the fractured sacra was similar to the control group, however, with overall lower HU. Large zones of negative HU were located in the sacral ala. In the fractured sacra, the HU in the sacral ala was significantly lower on the non-injured side when comparing to the fractured side (p < 0.001) as well as compared to the non-fractured group (p < 0.001). Low bone mass was observed in sacral body S1 (40 HU) and S2 (20 HU). CONCLUSIONS The extensive area of negative HU may explain the fracture location in the sacral ala. The low HU in the sacral bodies advocates the use of trans-sacral implants or augmented iliosacral screws to enhance the strength of fracture fixation. The increased HU in the fractured ala could be explained by fracture-asssociated hemorrhage and can be used as a diagnostic tool.
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Affiliation(s)
- Daniel Wagner
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany. .,AO Research Institute Davos, Davos, Switzerland.
| | - Alexander Hofmann
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Lukas Kamer
- AO Research Institute Davos, Davos, Switzerland
| | - Takeshi Sawaguchi
- Department of Orthopedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan
| | | | | | - Dominik Gruszka
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Pol M Rommens
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
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18
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Reuther G. CT-Guided Pelvic Osteosynthesis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:284. [PMID: 29739496 DOI: 10.3238/arztebl.2018.0284a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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19
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Höch A, Pieroh P, Henkelmann R, Josten C, Böhme J. In-screw polymethylmethacrylate-augmented sacroiliac screw for the treatment of fragility fractures of the pelvis: a prospective, observational study with 1-year follow-up. BMC Surg 2017; 17:132. [PMID: 29221479 PMCID: PMC5723042 DOI: 10.1186/s12893-017-0330-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 12/03/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The incidence of pelvic ring fractures in the elderly significantly increased. Because of persistent pain and immobilization associated with this injury, surgical treatment is recommended. To minimise comorbidities and surgical risk, percutaneous techniques are becoming more relevant. In-screw cement augmentation of sacroiliac screw fixation is a promising procedure; however, clinical follow-up data remain scarce. This study investigated the safety and possible complications of the procedure along with a 1-year follow-up. METHODS Thirty-four patients (treated with 43 screws) were prospectively included. Data on patients' age and sex, the mechanism of accident, fracture pattern, duration of hospital stay, surgery and adverse events were recorded. Data were obtained postoperatively on the reduction of pain and complications, such as infection, cement leakage and neurological deficits, and at 1-year follow-up on pain, quality of life according to the 12-Item Short Form Survey and mobility. Implant failure was defined as retraction or dislocation of screws and was also documented. RESULTS Screw-related complications occurred with 2 of 43 screws. None of these complications were related to cement augmentation. In-hospital adverse events occurred in 6 of 34 patients. Postoperative pain, measured by the visual analogue scale, was significantly reduced from 6.7 ± 1.4 preoperatively to 2.7 ± 1.0 postoperatively (p < 0.001). Although patients complained of pain at the 1-year follow-up, they reported a significant decline compared with pain at admission (3.4 ± 2.3; p < 0.001). Results on the quality of life were comparable with those for the age- and gender matched German population. All patients were mobile, and no implant failure was detected. CONCLUSIONS The results indicate that in-screw augmented sacroiliac screw fixation for fragility fractures of the pelvis is a safe technique. Pain was significantly reduced immediately after surgery compared to the preoperative state. Furthermore, significant pain reduction after one year compared to the preoperative state and quality of life was comparable to the age- and gender- matched German population. Thus, we recommend in-screw augmentation for screw fixation for sacral fragility fractures of the pelvis following failed conservative treatment.
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Affiliation(s)
- Andreas Höch
- Department of Orthopedics, Trauma and Plastic Surgery, Spine Center, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Philipp Pieroh
- Department of Orthopedics, Trauma and Plastic Surgery, Spine Center, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.,Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Grosse Steinstrasse 52, 06097, Halle (Saale), Germany
| | - Ralf Henkelmann
- Department of Orthopedics, Trauma and Plastic Surgery, Spine Center, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, Spine Center, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Jörg Böhme
- Department of Orthopedics, Trauma and Plastic Surgery, Spine Center, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.,Present address: Clinic of Trauma, Orthopedic and Septic Surgery, Hospital St.Georg GmbH, Delitzscher Str. 141, 04129, Leipzig, Germany
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