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Li S, Yan P, Fan Y, Wang R, Zhang C. Biomechanical analysis of the door-shaped titanium plate in single-level anterior cervical discectomy and fusion. J Orthop Surg Res 2023; 18:982. [PMID: 38129900 PMCID: PMC10734066 DOI: 10.1186/s13018-023-04474-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Analyse and discuss the immediate stability of the cervical spine after anterior cervical discectomy and fusion using a door-shaped titanium plate and compare it with the traditional titanium plate, to provide biomechanical evidence for the rationality and effectiveness of the door-shaped titanium plate in clinical applications. METHODS Ten adult goat C4/5 vertebral bodies were obtained, and models were prepared using denture base resin. Biomechanical experiments were performed on the specimens before internal fixation. MTS was used to conduct non-destructive biomechanical loading tests in six directions, including flexion, extension, left-right bending, and left-right torsion, recording the range of motion (ROM) and neutral zone (NZ) of each specimen. The specimens were then randomly divided into two groups: the study group was fixed with a door-shaped titanium plate, and the control group was fixed with a traditional titanium plate. ROM and NZ in each direction were measured again. After measurements, both groups were subjected to 0.5 Hz torsion loading with a torque of 2 N m for a total of 3000 cycles, followed by measuring ROM and NZ in six directions once more. RESULTS Compared to before fixation, ROM and NZ in both groups significantly decreased in all six directions after fixation, with statistical significance (P < 0.05); after fixation, the study group showed slightly lower values for various mechanical reference parameters compared to the control group, with no statistical significance (P > 0.05); after 3000 torsional loads, both internal fixation groups showed increased ROM and NZ compared to after fixation but to a lower extent, and no screw or titanium plate loosening was observed. Compared to before fixation, the differences were still statistically significant (P < 0.05), with the study group having slightly lower ROM and NZ values in all directions compared to the control group, with no statistical significance (P > 0.05). CONCLUSION The door-shaped titanium plate exhibits mechanical properties similar to the traditional titanium plate in all directions, and its smaller size and simpler surgical operation can be used for anterior cervical endoscopic surgery, reducing surgical trauma. It is clinically feasible and deserves further research and promotion.
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Affiliation(s)
- Senli Li
- Second Department of Orthopedics, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Peng Yan
- Second Department of Orthopedics, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Yanwei Fan
- Second Department of Orthopedics, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Ruibo Wang
- Second Department of Orthopedics, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Changjiang Zhang
- Second Department of Orthopedics, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
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McEntire BJ, Maslin G, Bal BS. Two-year results of a double-blind multicenter randomized controlled non-inferiority trial of polyetheretherketone (PEEK) versus silicon nitride spinal fusion cages in patients with symptomatic degenerative lumbar disc disorders. JOURNAL OF SPINE SURGERY 2020; 6:523-540. [PMID: 33102889 DOI: 10.21037/jss-20-588] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background During lumbar spinal fusion, spacer cages are implanted to provide vertebral stability, restore sagittal alignment, and maintain disc and foraminal height. Polyetheretherketone (PEEK) is commonly used by most spine surgeons. Silicon nitride (Si3N4) is a less well-known alternative although it was first used as a spacer in lumbar fusion over 30 years ago. The present study was designed to see if Si3N4 cages would perform similarly to PEEK in a randomized controlled trial. Methods A non-inferiority multicenter 100-patient study was designed where both the observer and patient were blinded. Single- or double-level transforaminal lumbar interbody fusion with pedicle screw fixation using an oblique PEEK or Si3N4 cage was performed. The primary non-inferiority outcome was the Roland-Morris Disability Questionnaire (RMDQ). Secondary measures included the Oswestry Disability Questionnaire, Visual Analogue Scales (VAS) for back and leg pain, SF-36 Physical and Mental Function indices, patient and surgeon Likert scores on perceived recovery, and X-ray and CT radiological evaluations for subsidence, segmental motion, and fusion. Follow-up evaluations occurred at 3, 6, 12, and 24 months. Results After exclusions for protocol violations and canceled surgeries, 92 patients were randomized (i.e., 48 for PEEK and 44 for Si3N4). There were no differences in baseline demographics, pre-operative disabilities, or pain scores between the groups. Both treatment arms showed significant improvements in disability, pain, and recovery scores. No significant differences were observed for subsidence, segmental motion, or fusion. For the primary outcome (i.e., RMDQ scores), the non-inferiority of Si3N4 compared to PEEK could not be established using the original protocol criteria. However, the comparison was undermined by larger than anticipated patient fallout coupled with higher than expected RMDQ score standard deviations. A post hoc analysis coupled with a more extensive review of the literature was conducted which resulted in the selection of a revised clinically justified non-inferiority margin; and using this method, the non-inferiority of Si3N4 was affirmed. Conclusions This study demonstrated that the use of either PEEK or Si3N4 cages is safe and effective for patients undergoing lumbar spine fusion for chronic degenerative disc disease.
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Affiliation(s)
| | - Greg Maslin
- Biomedical Statistical Consulting, Wynnewood, PA, USA
| | - B Sonny Bal
- SINTX Technologies, Inc., Salt Lake City, UT, USA
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Park PJ, Lehman RA. Optimizing the Spinal Interbody Implant: Current Advances in Material Modification and Surface Treatment Technologies. Curr Rev Musculoskelet Med 2020; 13:688-695. [PMID: 32816234 DOI: 10.1007/s12178-020-09673-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Interbody implants allow for fusion of the anterior column of the spine between vertebral body endplates. As rates of spinal fusion surgery have increased over the past several years, significant research has been devoted to optimizing both the mechanical and biologic properties of the interbody implant in order to promote bony fusion. The first interbody implants used decades ago were fashioned from cortical autograft. Currently, titanium alloy and polyetheretherketone (PEEK) are the most widely used and studied materials for this purpose. This review focuses on recent innovations in material modification and surface treatment techniques for both titanium and PEEK implants to maximize fusion rates in spinal surgery. RECENT FINDINGS Titanium has an elastic modulus much higher than native bone and however has better osseointegrative properties than PEEK. PEEK, however, has an elastic modulus closer to that of bone without any of the advantageous biologic properties that titanium has. Increasing porosity and surface roughness of titanium implants have been shown to improve the mechanical properties of titanium implants, while the biologic properties of PEEK have been enhanced using surface coating technology, either with titanium or with hydroxyapatite (HA). Techniques such as increasing porosity, surface roughening, and surface coating are just some of the recent innovations aimed at optimizing both mechanical and biologic properties of interbody implants to promote spinal fusion. The future of interbody implant design will rely on continued improvements of PEEK and titanium implants as well as exploring new implant materials altogether.
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Affiliation(s)
- Paul J Park
- The Spine Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, 5141 Broadway, 3 Field West-022, New York, NY, 10034, USA.
| | - Ronald A Lehman
- The Spine Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, 5141 Broadway, 3 Field West-022, New York, NY, 10034, USA
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Calvert GC, VanBuren Huffmon G, Rambo WM, Smith MW, McEntire BJ, Bal BS. Clinical outcomes for lumbar fusion using silicon nitride versus other biomaterials. JOURNAL OF SPINE SURGERY (HONG KONG) 2020; 6:33-48. [PMID: 32309644 PMCID: PMC7154368 DOI: 10.21037/jss.2019.12.11] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/12/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND In lumbar fusion surgery, intervertebral spacer cages made of silicon nitride (Si3N4) ceramic are an available option among other biomaterials. While the surface chemistry of Si3N4 is known to favor bone fusion, large-scale clinical studies attesting to its efficacy are lacking. This multicenter retrospective study compared lumbar fusion outcomes for Si3N4 cages to previously reported data for other cage materials. METHODS Pre-operative patient demographics, comorbidities, changes in visual analog scale (ΔVAS) pain scores, complications, adverse events, and secondary surgical interventions (SSI) were compiled from the records of 450 patients who underwent Si3N4 lumbar spinal fusion at four separate U.S. surgical centers. For comparison, MEDLINE/PubMed and Google Scholar searches identified studies reporting similar outcomes for other biomaterials. A total of 1,025 patients from 26 cohorts reported in 14 publications met inclusion criteria for this control group. RESULTS Overall, the mean last-follow-up for all patients was 341±293 days (11.4±9.8 months), with the longest follow-up being 6.4 years. Patients with Si3N4 implants were similar in gender and age distribution to the control group but had higher BMI values (30.9±6.1 vs. 25.8±4.1, P<0.01) and lower tobacco use (15.8% vs. 30.0%, P<0.01). Both the Si3N4 and control groups showed significant improvements in VAS pain scores from preoperative to last follow-up. For the Si3N4 group, ΔVAS was 36.8±35.4 points compared to 37.6±22.5 points (P=0.63) for the metadata group. Complications and reoperations for the Si3N4 and the control groups were similar (i.e., 9.8% and 3.1% versus 12.4% and 2.9%, P=0.16 and P=0.84, respectively). CONCLUSIONS Lumbar fusion with Si3N4 spacers compared favorably with the improvements reported with other commonly used biomaterial cages.
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Calvert GC, Huffmon GV, Rambo WM, Smith MW, McEntire BJ, Bal BS. Clinical outcomes for anterior cervical discectomy and fusion with silicon nitride spine cages: a multicenter study. JOURNAL OF SPINE SURGERY (HONG KONG) 2019; 5:504-519. [PMID: 32043001 PMCID: PMC6989924 DOI: 10.21037/jss.2019.11.17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 11/12/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Intervertebral spacers made of silicon nitride (Si3N4) are currently used in cervical and thoracolumbar fusion. While basic science data demonstrate several advantages of Si3N4 over other biomaterials, large-scale clinical results on its safety and efficacy are lacking. This multicenter retrospective study examined outcomes for anterior cervical discectomy and fusion (ACDF) using Si3N4 cages. Results were compared to compiled metadata for other ACDF materials. METHODS Pre-operative patient demographics, comorbidities, changes in visual analog scale (VAS) pain scores, complications, adverse events, and secondary surgical interventions were collected from the medical records of 860 patients who underwent Si3N4 ACDF at four surgical centers. For comparison, MEDLINE/PubMed and Google Scholar searches were performed for ACDF using other cage or spacer materials. Nine studies with 13 cohorts and 736 patients met the inclusion criteria for this control group. RESULTS Overall, the mean last-follow-up for all patients was 319±325 days (10.6±10.8 months), with the longest follow-up being 6.5 years. In comparison to the metadata, patients from the Si3N4 groups were older (57.9±12.2 vs. 56.8±11.1 y, P=0.06) and had higher BMI values (30.0±6.3 vs. 28.1±6.5, P<0.01), but gender and smoking were not different. The Si3N4 patients reported significant improvements in VAS pain scores at last follow-up (i.e., pre-op of 71.0±22.1 vs. follow-up of 36.4±31.5, P<0.01). Although both preoperative and last-follow-up pain scores were higher for Si3N4 patients than the control, the overall change in scores (ΔVAS) was similar. From pre-op to last-follow up, ΔVAS values were 35.4±34.3 for patients receiving the Si3N4 implants versus 34.4±27.3 for patients from the meta-analysis (P=0.56). The complication and reoperation rate for the Si3N4 and the metadata were also comparable (i.e., 7.39% and 0.31% versus 9.79% and 0%, P=0.17 and 0.25, respectively). CONCLUSIONS ACDF outcomes using Si3N4 implants matched the clinical efficacy of other cage biomaterials.
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Affiliation(s)
| | | | | | - Micah W. Smith
- Ortho Northeast, 11130 Parkview Plaza Dr., Fort Wayne, IN, USA
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Zanocco M, Boschetto F, Zhu W, Marin E, McEntire BJ, Bal BS, Adachi T, Yamamoto T, Kanamura N, Ohgitani E, Yamamoto K, Mazda O, Pezzotti G. 3D-additive deposition of an antibacterial and osteogenic silicon nitride coating on orthopaedic titanium substrate. J Mech Behav Biomed Mater 2019; 103:103557. [PMID: 32090951 DOI: 10.1016/j.jmbbm.2019.103557] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 11/07/2019] [Accepted: 11/25/2019] [Indexed: 12/29/2022]
Abstract
A 3D-additive manufacturing approach produced a dense Si3N4 ceramic coating on a biomedical grade commercially pure titanium (cp-Ti) substrate by an automatic laser-sintering procedure. Si3N4 coatings could be prepared with thicknesses from the single to the tens of microns. A coating thickness, t = 15 ± 5 μm, was selected for this study, based on projections of homogeneity and scratching resistance. The Si3N4 coating met the 20 N threshold required for biomaterial applications, according to the standard scratch testing (ASTM C1624-05). The Si3N4 coating imparted both the antibacterial and osteogenic properties of bulk Si3N4 to the cp-Ti substrate. Both properties were comparable to those previously described for bulk Si3N4 biomedical implants. The newly developed Si3N4-coating was applied to commercially available Ti-alloy acetabular shells for total hip arthroplasty. A "glowing" test based on luciferase gene transformation was applied to visualize the colonization of gram-negative Escherichia coli on Si3N4-coated and uncoated Ti-alloy acetabular shells. The results showed that the coating technology conferred resistance to Staphylococcus epidermidis and Escherichia coli adhesion onto the bulk acetabular sockets.
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Affiliation(s)
- Matteo Zanocco
- Ceramic Physics Laboratory, Kyoto Institute of Technology, Sakyo-ku, Matsugasaki, Kyoto, 606-8585, Japan; Department of Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, 465 Kajii-cho, Kyoto, 602-8566, Japan
| | - Francesco Boschetto
- Ceramic Physics Laboratory, Kyoto Institute of Technology, Sakyo-ku, Matsugasaki, Kyoto, 606-8585, Japan; Department of Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, 465 Kajii-cho, Kyoto, 602-8566, Japan
| | - Wenliang Zhu
- Ceramic Physics Laboratory, Kyoto Institute of Technology, Sakyo-ku, Matsugasaki, Kyoto, 606-8585, Japan
| | - Elia Marin
- Ceramic Physics Laboratory, Kyoto Institute of Technology, Sakyo-ku, Matsugasaki, Kyoto, 606-8585, Japan; Department of Dental Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Bryan J McEntire
- SINTX Technologies Corporation, 1885 West 2100 South, Salt Lake City, UT, 84119, USA
| | - B Sonny Bal
- SINTX Technologies Corporation, 1885 West 2100 South, Salt Lake City, UT, 84119, USA
| | - Tetsuya Adachi
- Department of Dental Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Toshiro Yamamoto
- Department of Dental Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Narisato Kanamura
- Department of Dental Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Eriko Ohgitani
- Department of Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, 465 Kajii-cho, Kyoto, 602-8566, Japan
| | - Kengo Yamamoto
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-ku, 160-0023, Tokyo, Japan
| | - Osam Mazda
- Department of Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, 465 Kajii-cho, Kyoto, 602-8566, Japan
| | - Giuseppe Pezzotti
- Ceramic Physics Laboratory, Kyoto Institute of Technology, Sakyo-ku, Matsugasaki, Kyoto, 606-8585, Japan; Department of Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, 465 Kajii-cho, Kyoto, 602-8566, Japan; Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-ku, 160-0023, Tokyo, Japan; The Center for Advanced Medical Engineering and Informatics, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0854, Japan.
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Abstract
Patients with symptomatic instability of the spine may be treated surgically with interbody fusion. Cost and complexity in this procedure arises owing to the implanted materials involved with facilitating fusion such as titanium or polyetheretherketone. Surface modifications have been developed to augment these base materials such as plasma-spraying polyetheretherketone with titanium or coating implants with hydroxyapatite. Although some evidence has been gathered on these novel materials, additional study is needed to establish the true efficacy of surface modifications for interbody fusion devices in improving long-term patient outcomes.
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Affiliation(s)
- Jacob J Enders
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Daniel Coughlin
- Center for Spine Health, Cleveland Clinic, Desk S40, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Thomas E Mroz
- Center for Spine Health, Cleveland Clinic, Desk S40, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Shaleen Vira
- Center for Spine Health, Cleveland Clinic, Desk S40, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Adjacent segment motion following multi-level ACDF: a kinematic and clinical study in patients with zero-profile anchored spacer or plate. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2408-2416. [DOI: 10.1007/s00586-019-06109-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 07/14/2019] [Accepted: 08/08/2019] [Indexed: 02/08/2023]
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Mostofi K, Moghaddam BG, Peyravi M, Khouzani RK. Preliminary results of anterior cervical arthroplasty by porous alumina ceramic cage for cervical disc herniation surgery. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2019; 9:223-226. [PMID: 30787587 PMCID: PMC6364365 DOI: 10.4103/jcvjs.jcvjs_95_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective Anterior cervical arthroplasty (ACA) is the gold standard surgery in severe or unresponsive cases of cervical disc herniation, uncarthrosis, and foraminal stenosis. The aim of this study is to establish the impact and outcome evaluations of managing the patients operated for cervical arthroplasty by the intersomatic porous alumina ceramic cervical cages (PACC). The authors describe their experience in the area to allow the comparison of effectiveness of ceramic cages versus other interbody fusion cages. Materials and Methods Between April 2015 and September 2018, we operated 118 for ACA by using PACC. Among them, 52 were female and 66 were male, with an average age of 46.78 years. Results The mean symptoms duration was 14.1 months. The most frequent level of the disorder was C5-C6 followed by C6-C7 level. Mean follow-up was 3.3 years. The Neck Disability Index (NDI) and the visual analog scale (VAS) were used to evaluate the patients status. No significant differences were observed between our results and literature data regarding operative time, duration of hospitalization, and NDI; however, we observed a shorter period and higher rate of bony fusion. Conclusion The results from the present study corroborate that implementing of PACC is a good alternative treatment for the patient operated by ACA for cervical disc herniation or foraminal cervical stenosis.
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Affiliation(s)
- Keyvan Mostofi
- Department of Neurosurgery, Center Clinical, Chirurgie de Rachis, Soyaux, France
| | | | - Morad Peyravi
- Department of Neurosurgery, Werner Forssmann Hospital, Academic Hospital of Charité-Universitätsmedizin Berlin, Rudolf-Breitscheid, Eberswalde, Germany
| | - Reza Karimi Khouzani
- Department of Orthopedics, Rottal-Inn-Kliniken GmbH, Eggenfelden, Bayern, Germany
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