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Hayward S, Keogh PS, Miles AW, Gheduzzi S. The effect of structural changes on the low strain rate behaviour of the intervertebral disc. Proc Inst Mech Eng H 2024:9544119241272915. [PMID: 39180367 DOI: 10.1177/09544119241272915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2024]
Abstract
The annuus fibrosus (AF) and nucleus pulposus (NP) of the intervertebral disc (IVD) work in conjunction to dissipate spinal loads. In this study we have isolated the contribution of the NP to the overall response of the disc and investigated the effect of extreme structural changes to the disc on the mechanical behaviour. Linear stiffness, overall load range, hysteresis area and total energy were used to evaluate the impact of these changes on the spine and surrounding structures. Six porcine lumbar isolated disc specimens were tested in 6 DOFs with a 400 N compressive axial preload at low strain rates in three conditions: intact (IN), after total nucleotomy (NN) and after the injection of bone cement into the nuclear void (SN). The latter two conditions, NN and SN, were chosen to emulate the effect of extreme changes to the NP on disc behaviour. When comparing with intact specimens, significant changes were noted primarily in axial compression-extension, mediolateral bending and flexion-extension. NN and SN cases demonstrated significant increases in linear stiffness, overall load range and total energy for mediolateral bending and flexion-extension compared to the intact (IN) state. SN also demonstrated a significant increase in total energy for axial compression-extension, and significant decreases in the elastic contribution to total energy in all axes except flexion-extension. These changes to total energy indicate that surrounding spinal structures would incur additional loading to produce the same motion in vivo after structural changes to the disc.
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Affiliation(s)
- Samantha Hayward
- Department of Mechanical Engineering, University of Bath, Bath, UK
| | - Patrick S Keogh
- Department of Mechanical Engineering, University of Bath, Bath, UK
| | - Anthony W Miles
- Department of Mechanical Engineering, University of Bath, Bath, UK
| | - Sabina Gheduzzi
- Department of Mechanical Engineering, University of Bath, Bath, UK
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2
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Park SS, Lim H, Lee BT. In vivo evaluation of hyaluronic acid-polyethylene glycol amended PMMA bone cement for orthopaedic application. JOURNAL OF BIOMATERIALS SCIENCE. POLYMER EDITION 2024; 35:1947-1962. [PMID: 38815001 DOI: 10.1080/09205063.2024.2359789] [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: 04/09/2024] [Accepted: 05/21/2024] [Indexed: 06/01/2024]
Abstract
The utilization of polymethyl methacrylate (PMMA) bone cement is employed for the purpose of stabilizing fractured vertebral bodies. The existence of a mechanical imbalance in hard polymethylmethacrylate (PMMA) bone cement has the potential to increase the likelihood of a fracture occurring in the neighbouring vertebral body. In order to reduce potential difficulties, the primary goal of this study is to investigate the potential benefits of increasing PMMA bone cement's bioactivity and lowering its elastic modulus. The incorporation of a 10% volume fraction of hyaluronic acid (HyA) and polyethylene glycol (PEG) into the bone cement led to an improvement in the bioactivity and decreasing of elastic modulus of polymethylmethacrylate (PMMA). The integration of HyPE gel phase presents several advantages over pure PMMA bone cement, including enhanced setting parameters, improved degradability, and increased biocompatibility. The gel phase is additionally accountable for a reduction in the elastic modulus of polymethylmethacrylate (PMMA) bone cement. In addition, the existence of a porous structure that arises from the degradation of the HyPE gel phase delivers a significant amount of room, thereby enhancing the process of bone regeneration when implanted in the femur of rabbits. The utilization of HyPE in PMMA has been shown through comprehensive µ-CT analysis to enhance bone formation, thereby promoting osteointegration at the implantation site. Furthermore, the histological analysis demonstrated the existence of osteogenic activity in the PMMA polyethylene glycol supplemented with 10% HyA and 10% PEG after a 2-month period subsequent to implantation.
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Affiliation(s)
- Seong-Su Park
- Department of Regenerative Medicine, College of Medicine, Soonchunhyang University, Cheonan, South Korea
| | - Hansung Lim
- Department of Regenerative Medicine, College of Medicine, Soonchunhyang University, Cheonan, South Korea
| | - Byong-Taek Lee
- Department of Regenerative Medicine, College of Medicine, Soonchunhyang University, Cheonan, South Korea
- Institute of Tissue Regeneration, College of Medicine, Soonchunhyang University, Cheonan, South Korea
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3
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Ghandour S, Hong L, Aramesh M, Persson C. Mechanical characterization and cytocompatibility of linoleic acid modified bone cement for percutaneous cement discoplasty. J Mech Behav Biomed Mater 2024; 158:106662. [PMID: 39096682 DOI: 10.1016/j.jmbbm.2024.106662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 06/25/2024] [Accepted: 07/20/2024] [Indexed: 08/05/2024]
Abstract
Minimally invasive spine treatments have been sought after for elderly patients with comorbidities suffering from advanced degenerative disc disease. Percutaneous cement discoplasty (PCD) is one such technique where cement is injected into a degenerated disc with a vacuum phenomenon to relieve patients from pain. Adjacent vertebral fractures (AVFs) are however an inherent risk, particularly for osteoporotic patients, due to the high stiffness of the used cements. While low-modulus cements have been developed for vertebroplasty through the addition of linoleic acid, there are no such variations with a high-viscosity base cement, which is likely needed for the discoplasty application. Therefore, a low-modulus polymethyl methacrylate was developed by the addition of 12%vol. linoleic acid to a high-viscosity bone cement (hv-LA-PMMA). Initial experimental validation of the cement was performed by mechanical testing under compression over a period of 24 weeks, after storage in 37 °C phosphate buffer saline (PBS) solution. Furthermore, cement extracts were used to evaluate residual monomer release and the cytotoxicity of hv-LA-PMMA using fibroblastic cells. Relative to the base commercial cement, a significant reduction of Young's modulus and compressive strength of 36% and 42% was observed, respectively. Compression-tension fatigue tests at 5 MPa gave an average fatigue limit of 31,078 cycles. This was higher than another low-modulus cement and comparable to the fatigue properties of the disc annulus tissue. Monomer release tests showed that hv-LA-PMMA had a significantly higher release between 24 h and 7 days compared to the original bone cement, similarly to other low-modulus cements. Also, the control cement showed cytocompatibility at all time points of extract collection for 20-fold dilution, while hv-LA-PMMA only showed the same for extract collections at day 7. However, the 20-fold dilution was needed for both the control and the hv-LA-PMMA extracts to demonstrate more than 70% fibroblast viability at day 7. In conclusion, the mechanical testing showed promise in the use of linoleic acid in combination with a high-viscosity PMMA cement to achieve properties adequate to the application. Further testing and in vivo studies are however required to fully evaluate the mechanical performance and biocompatibility of hv-LA-PMMA for possible future clinical application.
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Affiliation(s)
- Salim Ghandour
- Div. of Biomedical Engineering, Dept. of Materials Science and Engineering, Uppsala University, Sweden
| | - Linglu Hong
- Div. of Biomedical Engineering, Dept. of Materials Science and Engineering, Uppsala University, Sweden
| | - Morteza Aramesh
- Div. of Biomedical Engineering, Dept. of Materials Science and Engineering, Uppsala University, Sweden
| | - Cecilia Persson
- Div. of Biomedical Engineering, Dept. of Materials Science and Engineering, Uppsala University, Sweden.
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Csakany T, Varga P, Gueorguiev B, Lakatos E, Kurutz M. Biomechanical Behavior of Injected Cement Spacers versus Traditional Cages in Low-Density Lumbar Spine under Compression Loading. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1155. [PMID: 39064584 PMCID: PMC11278875 DOI: 10.3390/medicina60071155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 06/22/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Osteoporosis renders the use of traditional interbody cages potentially dangerous given the high risk of damage in the bone-implant interface. Instead, injected cement spacers can be applied as interbody devices; however, this technique has been mainly used in cervical spine surgery. This study aimed at investigating the biomechanical behavior of cement spacers versus traditional cages in lumbar spine surgery. Materials and Methods: Destructive monotonic axial compression testing was performed on 20 human cadaveric low-density lumbar segments from elderly donors (14 f/6 m, 70.3 ± 12.0 y) treated with either injected cement spacers (n = 10) or traditional cages (n = 10) without posterior instrumentation. Stiffness, failure load and displacement were compared. The effects of bone density, vertebral geometry and spacer contact area were evaluated. Results: Cement spacers demonstrated higher stiffness, significantly smaller displacement (p < 0.001) and a similar failure load compared to traditional cages. In the cage group, stiffness and failure load depended strongly on bone density and vertebral height, whereas failure displacement depended on vertebral anterior height. No such correlations were identified with cement spacers. Conclusions: Cement spacers used in lumbar interbody stabilization provided similar compression strength, significantly smaller failure displacement and a stiffer construct than traditional cages that provided benefits mainly for large and strong vertebrae. Cement stabilization was less sensitive to density and could be more beneficial also for segments with smaller and less dense vertebrae. In contrast to the injection of cement spacers, the optimal insertion of cages into the irregular intervertebral space is challenging and risks damaging bone. Further studies are required to corroborate these findings and the treatment selection thresholds.
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Affiliation(s)
- Tibor Csakany
- National Center for Spinal Disorders, 1126 Budapest, Hungary
| | - Peter Varga
- AO Research Institute Davos, 7270 Davos, Switzerland
| | | | - Eva Lakatos
- Department of Structural Mechanics, Faculty of Civil Engineering, Budapest University of Technology and Economics, 1111 Budapest, Hungary (M.K.)
| | - Marta Kurutz
- Department of Structural Mechanics, Faculty of Civil Engineering, Budapest University of Technology and Economics, 1111 Budapest, Hungary (M.K.)
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Mondal S, MacManus DB, Banche-Niclot F, Vitale-Brovarone C, Fiorilli S, McCarthy HO, Dunne N. Finite element analysis of vertebroplasty in the osteoporotic T11-L1 vertebral body: Effects of bone cement formulation. J Biomed Mater Res B Appl Biomater 2024; 112:e35359. [PMID: 38247244 DOI: 10.1002/jbm.b.35359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 08/24/2023] [Accepted: 11/27/2023] [Indexed: 01/23/2024]
Abstract
Vertebral compression fractures are one of the most severe clinical consequences of osteoporosis and the most common fragility fracture afflicting 570 and 1070 out of 100,000 men and women worldwide, respectively. Vertebroplasty (VP), a minimally invasive surgical procedure that involves the percutaneous injection of bone cement, is one of the most efficacious methods to stabilise osteoporotic vertebral compression fractures. However, postoperative fracture has been observed in up to 30% of patients following VP. Therefore, this study aims to investigate the effect of different injectable bone cement formulations on the stress distribution within the vertebrae and intervertebral discs due to VP and consequently recommend the optimal cement formulation. To achieve this, a 3D finite element (FE) model of the T11-L1 vertebral body was developed from computed tomography scan data of the spine. Osteoporotic bone was modeled by reducing the Young's modulus by 20% in the cortical bone and 74% in cancellous bone. The FE model was subjected to different physiological movements, such as extension, flexion, bending, and compression. The osteoporotic model caused a reduction in the average von Mises stress compared with the normal model in the T12 cancellous bone and an increment in the average von Mises stress value at the T12 cortical bone. The effects of VP using different formulations of a novel injectable bone cement were modeled by replacing a region of T12 cancellous bone with the materials. Due to the injection of the bone cement at the T12 vertebra, the average von Mises stresses on cancellous bone increased and slightly decreased on the cortical bone under all loading conditions. The novel class of bone cements investigated herein demonstrated an effective restoration of stress distribution to physiological levels within treated vertebrae, which could offer a potential superior alternative for VP surgery as their anti-osteoclastogenic properties could further enhance the appeal of their fracture treatment and may contribute to improved patient recovery and long-term well-being.
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Affiliation(s)
- Subrata Mondal
- School of Mechanical and Manufacturing Engineering, Dublin City University, Dublin 9, Ireland
| | - David B MacManus
- School of Mechanical and Manufacturing Engineering, Dublin City University, Dublin 9, Ireland
- BRAIN Lab, School of Mechanical & Materials Engineering, University College Dublin, Dublin 4, Ireland
| | | | | | - Sonia Fiorilli
- Department of Applied Science and Technology, Politecnico di Torino, Turin, Italy
| | - Helen O McCarthy
- School of Pharmacy, Queen's University Belfast, Belfast, BT9 7 BL, UK
| | - Nicholas Dunne
- School of Mechanical and Manufacturing Engineering, Dublin City University, Dublin 9, Ireland
- Centre for Medical Engineering Research, Dublin City University, Dublin 9, Ireland
- Department of Mechanical and Manufacturing Engineering, School of Engineering, Trinity College Dublin, Dublin 2, Ireland
- Advanced Manufacturing Research Centre (I-Form), School of Mechanical and Manufacturing Engineering, Dublin City University, Dublin 9, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), Trinity College Dublin, Dublin 2, Ireland
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland
- Advanced Processing Technology Research Centre, Dublin City University, Dublin 9, Ireland
- Biodesign Europe, Dublin City University, Dublin 9, Ireland
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Miao X, Yang S, Zhu J, Gong Z, Wu D, Hong J, Cai K, Wang J, Fang X, Lu J, Jiang G. Bioactive mineralized small intestinal submucosa acellular matrix/PMMA bone cement for vertebral bone regeneration. Regen Biomater 2023; 10:rbad040. [PMID: 37250976 PMCID: PMC10224805 DOI: 10.1093/rb/rbad040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/30/2023] [Accepted: 04/15/2023] [Indexed: 05/31/2023] Open
Abstract
Polymethylmethacrylate (PMMA) bone cement extensively utilized for the treatment of osteoporotic vertebral compression fractures due to its exceptional handleability and mechanical properties. Nevertheless, the clinical application of PMMA bone cement is restricted by its poor bioactivity and excessively high modulus of elasticity. Herein, mineralized small intestinal submucosa (mSIS) was incorporated into PMMA to prepare a partially degradable bone cement (mSIS-PMMA) that provided suitable compressive strength and reduced elastic modulus compared to pure PMMA. The ability of mSIS-PMMA bone cement to promote the attachment, proliferation and osteogenic differentiation of bone marrow mesenchymal stem cells was shown through cellular experiments carried out in vitro, and an animal osteoporosis model validated its potential to improve osseointegration. Considering these benefits, mSIS-PMMA bone cement shows promising potential as an injectable biomaterial for orthopedic procedures that require bone augmentation.
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Affiliation(s)
| | | | | | - Zhe Gong
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, Zhejiang, China
- Key Laboratory of Musculoskeletal System, Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, Zhejiang, China
| | - Dongze Wu
- Department of Spinal Surgery, The First Affiliated Hospital of Ningbo University, Ningbo 315000, Zhejiang, China
| | - Juncong Hong
- Department of Anesthesiology, The First People’s Hospital of Linping District, Hangzhou 311100, Zhejiang, China
| | - Kaiwen Cai
- Department of Spinal Surgery, The First Affiliated Hospital of Ningbo University, Ningbo 315000, Zhejiang, China
| | - Jiying Wang
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, Zhejiang, China
- Key Laboratory of Musculoskeletal System, Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou 310016, Zhejiang, China
| | | | - Jiye Lu
- Correspondence address. E-mail: (G.J.); (J.L.); (X.F.)
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Lin J, Fan Y, Hutchinson DJ, Malkoch M. Soft Hydroxyapatite Composites Based on Triazine-Trione Systems as Potential Biomedical Engineering Frameworks. ACS APPLIED MATERIALS & INTERFACES 2023; 15:7329-7339. [PMID: 36695708 PMCID: PMC9923673 DOI: 10.1021/acsami.2c16235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/09/2023] [Indexed: 06/17/2023]
Abstract
Composites of triazine-trione (TATO) thiol-ene networks and hydroxyapatite (HA) have shown great potential as topological fixation materials for complex bone fractures due to their high flexural modulus, biocompatibility, and insusceptibility to forming soft-tissue adhesions. However, the rigid mechanical properties of these composites make them unsuitable for applications requiring softness. The scope of these materials could therefore be widened by the design of new TATO monomers that would lead to composites with a range of mechanical properties. In this work, four novel TATO-based monomers, decorated with either ester or amide linkages as well as alkene or alkyne end groups, have been proposed and synthesized via fluoride-promoted esterification (FPE) chemistry. The ester-modified monomers were then successfully formulated along with the thiol TATO monomer tris [2-(3-mercaptopropionyloxy)ethyl] isocyanurate (TEMPIC) and HA to give soft composites, following the established photo-initiated thiol-ene coupling (TEC) or thiol-yne coupling (TYC) chemistry methodologies. The most promising composite shows excellent softness, with a flexural modulus of 57 (2) MPa and εf at maximum σf of 11.8 (0.3)%, which are 117 and 10 times softer than the previously developed system containing the commercially available tri-allyl TATO monomer (TATATO). Meanwhile, the surgically convenient viscosity of the composite resins and their excellent cytotoxicity profile allow them to be used in the construction of soft objects in a variety of shapes through drop-casting suitable for biomedical applications.
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Ghandour S, Pazarlis K, Lewin S, Isaksson P, Försth P, Persson C. An ex-vivo model for the biomechanical assessment of cement discoplasty. Front Bioeng Biotechnol 2022; 10:939717. [PMID: 36118564 PMCID: PMC9478659 DOI: 10.3389/fbioe.2022.939717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/27/2022] [Indexed: 12/05/2022] Open
Abstract
Percutaneous Cement Discoplasty (PCD) is a surgical technique developed to relieve pain in patients with advanced degenerative disc disease characterized by a vacuum phenomenon. It has been hypothesized that injecting bone cement into the disc improves the overall stability of the spinal segment. However, there is limited knowledge on the biomechanics of the spine postoperatively and a lack of models to assess the effect of PCD ex-vivo. This study aimed to develop a biomechanical model to study PCD in a repeatable and clinically relevant manner. Eleven ovine functional spinal units were dissected and tested under compression in three conditions: healthy, injured and treated. Injury was induced by a papain buffer and the treatment was conducted using PMMA cement. Each sample was scanned with micro-computed tomography (CT) and segmented for the three conditions. Similar cement volumes (in %) were injected in the ovine samples compared to volumes measured on clinical PCD CT images. Anterior and posterior disc heights decreased on average by 22.5% and 23.9% after injury. After treatment, the anterior and posterior disc height was restored on average to 98.5% and 83.6%, respectively, of their original healthy height. Compression testing showed a similar stiffness behavior between samples in the same group. A decrease of 51.5% in segment stiffness was found after injury, as expected. The following PCD treatment was found to result in a restoration of stiffness—showing only a difference of 5% in comparison to the uninjured state. The developed ex-vivo model gave an adequate representation of the clinical vacuum phenomena in terms of volume, and a repeatable mechanical response between samples. Discoplasty treatment was found to give a restoration in stiffness after injury. The data presented confirm the effectiveness of the PCD procedure in terms of restoration of axial stiffness in the spinal segment. The model can be used in the future to test more complex loading scenarios, novel materials, and different surgical techniques.
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Affiliation(s)
- Salim Ghandour
- Division of Biomedical Engineering, Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
| | - Konstantinos Pazarlis
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
- Stockholm Spine Center, Stockholm, Sweden
| | - Susanne Lewin
- Division of Biomedical Engineering, Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
| | - Per Isaksson
- Division of Applied Mechanics, Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
| | - Peter Försth
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Cecilia Persson
- Division of Biomedical Engineering, Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
- *Correspondence: Cecilia Persson,
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Techens C, Eltes PE, Lazary A, Cristofolini L. Critical Review of the State-of-the-Art on Lumbar Percutaneous Cement Discoplasty. Front Surg 2022; 9:902831. [PMID: 35620196 PMCID: PMC9127498 DOI: 10.3389/fsurg.2022.902831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/19/2022] [Indexed: 11/30/2022] Open
Abstract
Interbody fusion is the gold standard surgery to treat lumbar disc degeneration disease but can be a high-risk procedure in elderly and polymorbid patients. Percutaneous Cement Discoplasty (PCD) is a minimally invasive technique developed to treat advanced stage of disc degeneration exhibiting a vacuum phenomenon. A patient-specific stand-alone spacer is created by filling the disc with polymethylmethacrylate cement, allowing to recover the disc height and improve the patient’s conditions. As it has recently been introduced in the lumbar spine, this review aims to present a transversal state-of-the-art of the surgery from its clinical practice and outcome to biomechanical and engineering topics. The literature was searched across multiple databases using predefined keywords over no limited period of time. Papers about vertebroplasty were excluded. Among 466 identified papers, the relevant ones included twelve clinical papers reporting the variations of the surgical technique, follow-up and complications, four papers reporting biomechanical ex vivo and numerical tests, and four letters related to published clinical papers. Papers presenting the operative practice are reported, as well as follow-ups up to four years. The papers found, consistently reported that PCD significantly improved the clinical status of the patients and maintained it after two years. Spine alignment was impacted by PCD: the sacral slope was significantly reduced, and disc height increased. The foramen opening correlated to the volume of injected cement. Substitutes to the acrylic cement exhibited better osteointegration and mechanical properties closer to bone tissue. Finally, limitations and risks of the surgery are discussed as well as potential improvements such as the development of new filling materials with better mechanical properties and biological integration or the investigation of the inner disc.
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Affiliation(s)
- Chloé Techens
- Department of Industrial Engineering, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- In silico Biomechanics Laboratory, National Center for Spinal Disorders, Budapest, Hungary
- Department of Orthopaedics, Department of Spine Surgery, Semmelweis University, Budapest, Hungary
| | - Peter Endre Eltes
- In silico Biomechanics Laboratory, National Center for Spinal Disorders, Budapest, Hungary
- Department of Orthopaedics, Department of Spine Surgery, Semmelweis University, Budapest, Hungary
| | - Aron Lazary
- In silico Biomechanics Laboratory, National Center for Spinal Disorders, Budapest, Hungary
- Department of Orthopaedics, Department of Spine Surgery, Semmelweis University, Budapest, Hungary
- Correspondence: Aron Lazary Luca Cristofolini
| | - Luca Cristofolini
- Department of Industrial Engineering, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
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