The effect of capacitively coupled (CC) electrical stimulation on human disc nucleus pulposus cells and the relationship between CC and BMP-7.

PURPOSE: An in vitro study using human intervertebral disc nucleus pulposus cells to evaluate the effects of CC stimulation on disc-matrix macromolecule production. METHODS: Nucleus pulposus cells were cultured in alginate beads and treated with CC stimulation. The effect of BMP on CC stimulation of the cells was evaluated by applying a BMP blocker (noggin) or by applying additional BMP-7 to the culture. The mRNA levels of the disc extracellular matrix genes (collagen I, II, aggrecan) and BMPs were measured by real-time PCR. The protein levels of aggrecan, collagen II, and BMPs were determined by ELISAs and Western blots. Sulfated glycosaminoglycan (sGAG) content was assayed using the DMMB method. RESULTS: (1) CC stimulation upregulates the production of the disc-matrix macromolecular components: sGAG, aggrecan and collagen II; (2) CC stimulation increases the ratio of mRNA expression levels of collagen II to collagen I; (3) CC stimulation induces the expression of endogenous BMP-4 and BMP-7; (4) inhibition of BMP activity (using noggin) reduces CC-mediated upregulation of aggrecan and collagen II; (5) CC and BMP-7 act in synergy to increase the upregulation of disc-matrix macromolecules. CONCLUSION: CC stimulation upregulates the production of the intervertebral disc-matrix macromolecules aggrecan, collagen II, and sGAG by a mechanism involving BMPs. CC stimulation acts in synergy with BMP-7 to increase the upregulation of these disc-matrix macromolecules.

The combination of tibial anterior translation and axial rotation into a single biomechanical factor improves the prediction of patient satisfaction over each factor alone in patients with ACL reconstructed knees.

PURPOSE: The purpose of this study was to identify biomechanical factors, in both reconstructed and healthy knees, that correlate with patient satisfaction after ACL reconstruction. METHODS: Seventeen patients who had undergone unilateral ACL reconstruction were reviewed 9 years post-op. Patients completed subjective questionnaires and underwent manual knee laxity testing (Lachman-Trillat, KT-1000, and pivot shift) and automated laxity testing. During automated testing, both legs were rotated into external rotation and then internal rotation until peak rotational torque reached 5.65 Nm. Load-deformation curves were generated from torque and rotation data. Features of the curves were extracted for analysis. Total leg rotation and anterior laxity during KT-1000 testing were combined into a single factor (Joint Play Envelope or JPE). Patients were divided into groups based on patient satisfaction scores (Group 1: Higher Satisfaction, Group 2: Lower Satisfaction, Group 3: Unsatisfied). Load-deformation curve features and manual laxity testing results were compared between groups 1 and 2 to determine which biomechanical factors could distinguish between the groups. Diagnostic screening values were calculated for KT-1000 testing, the pivot shift test, total leg rotation and JPE. RESULTS: During manual testing, no significant differences in biomechanical factors were found when comparing reconstructed knees in group 1 and group 2. When comparing the reconstructed and healthy knees within group 2, the reconstructed knees had a significantly higher displacement during the KT-1000 manual maximum test (p < 0.002). When considering the reconstructed knees alone, neither the result of the pivot shift test nor KT-1000 testing could distinguish between group 1 and group 2. During automated testing, there were no significant differences between the groups when comparing the reconstructed lower limbs. The healthy lower limbs in group 2 had more maximum external rotation (p < 0.02) and decreased stiffness at maximum external rotation (p < 0.02) when compared to the healthy lower limbs in group 1. Total leg rotation was unable to distinguish between group 1 and group 2. JPE could distinguish between group 1 and group 2 when considering the reconstructed limb alone (p < 0.02). All four diagnostic screening values for JPE were equal or higher than in the other criteria. JPE also showed the most significant correlation with patient satisfaction. CONCLUSIONS: Joint Play Envelope is an objective measure that demonstrated improved predictive value as compared to other tests when used as a measure of satisfaction in patients with ACL reconstructed knees.

Biomechanical effects of rotator interval closure in shoulder arthroplasty.

BACKGROUND: Subscapularis dysfunction remains a significant problem after shoulder arthroplasty. Published techniques have variable recommendations for placing a rotator interval closing suture in attempts to off-load the subscapularis repair site, the implications of which have yet to be examined in the literature. The goals of this study were to investigate the biomechanical benefit of the rotator interval closing suture on the subscapularis repair strength and to analyze the effect on shoulder range of motion. METHODS: Sixteen matched cadaveric shoulders underwent a subscapularis tenotomy and shoulder arthroplasty. The subscapularis tenotomy was repaired, and motion at physiologic torsional force was recorded. One of each matched pair was randomly assigned to receive an additional rotator interval closure suture. Each specimen then underwent a standardized cyclic loading with measurement of gap formation and load to failure. RESULTS: The rotator interval closing suture significantly increased the ultimate load to failure of the subscapularis repair (452 N vs. 219 N; P = .002) and decreased gap formation at the subscapularis repair site. Measurement of the shoulder motion showed no significant difference between shoulders with and without the rotator interval closing suture. DISCUSSION: We report the additional biomechanical benefit that the rotator interval closing suture provides to the subscapularis repair site after shoulder arthroplasty. This suture acts to improve the load to failure of the subscapularis repair and to decrease gap formation under cyclic load. Furthermore, it does not detrimentally affect shoulder external rotation or overall arc of rotation. Our findings support the application of this off-loading technique after subscapularis repair during shoulder arthroplasty.

The effect of hubbing on the pull-out strength of lateral mass screws in the cervical spine: a biomechanical experiment.

STUDY DESIGN: This was a cadaveric biomechanical experiment. OBJECTIVE: To compare the pull-out strength of polyaxial screws that are either hubbed or not hubbed when inserted into the lateral mass. SUMMARY OF BACKGROUND DATA: It has been shown in a study on pedicle screws in the thoracic spine that "hubbing" the head of the screw against the dorsal laminar cortex results in significantly lower pull-out strength of the screws. MATERIALS AND METHODS: Fifteen segments of the human cervical spine (from C3 to C7) were prepared. Polyaxial screws 3.5 mm in diameter were used. On one side screws 12 mm in length were inserted until the screw head touched the lateral mass; they were then turned 2.5 more times until they were fully hubbed (hubbed screws). On the other side screws 14 mm in length were inserted until the screw head just touched the lateral mass (nonhubbed screws). The 2 mm difference in length was to ensure that the screws were buried to the same length. All screws inserted into the lateral masses underwent tensile pull-out by applying a tensile force down the long axis of the screw. The difference in pull-out strength between the 2 groups was evaluated using a nonparametric paired test (the Wilcoxon signed rank test), which compared side to side on each vertebra. RESULTS: One specimen was excluded because of cement breakage during the biomechanical test. A total of 14 vertebrae were tested. Four vertebrae in the hubbed group showed small fractures or cracks around the screw hole after screw insertion. In a side to side comparison, the hubbed screws had significantly lower pull-out strengths as compared with the nonhubbed screws (P=0.033). CONCLUSIONS: Hubbing of lateral mass screws lowers the potential pull-out strength of the screws as compared with the pull-out strength of nonhubbed screws. Thus, hubbing of lateral mass screws, on the basis of the parameters applied in this study, is not recommended.

Robotic axial lower leg testing: repeatability and reproducibility.

PURPOSE: The purpose of this study was to determine the test-retest reliability and the repeatability over multiple days of a robotic testing device when used to measure laxity of the lower leg during a simulated dial test. METHODS: Ten healthy subjects were evaluated using an instrumented robotic lower leg testing system over 4 days. Three testing cycles were performed each day. Each leg was rotated into external and then internal rotation by servomotors until a torque threshold of 5.65 N m was reached. Load-deformation curves were generated from torque and rotation data. Both average-measure and single-measure intraclass correlation coefficients (ICC) were compared across the curves. ICC scores were also compared for features of the curves including: maximum external rotation at -5.65 N m of torque, maximum internal rotation at 5.65 N m of torque, rotation at torque 0, compliance (slope of load-deformation curve) at torque 0, endpoint compliance in external rotation, endpoint compliance in internal rotation, and play at torque 0. Play at torque 0 was defined as the width of the hysteresis curve at torque 0. RESULTS: Average-measure ICC scores and test-retest scores were >0.95 along the entire load-deformation curve except around zero torque. ICC scores at maximum internal and external rotation ranged from 0.87 to 0.99 across the left and right knees. ICC scores for the other features of the curves ranged from 0.61 to 0.98. The standard error of the mean ranged from 0.0497 to 1.1712. CONCLUSIONS: The robotic testing device in this study proved to be reliable for testing a subject multiple times both within the same day and over multiple days. These findings suggest that the device can provide a level of reliability in rotational testing that allows for clinical use of test results. Objective laxity data can improve consistency and accuracy in diagnosing knee injuries and may enable more effective treatment.

Link protein N-terminal peptide binds to bone morphogenetic protein (BMP) type II receptor and drives matrix protein expression in rabbit intervertebral disc cells.

Intervertebral disc (IVD) degeneration and associated spinal disorders are leading sources of morbidity, and they can be responsible for chronic low back pain. Treatments for degenerative disc diseases continue to be a challenge. Intensive research is now focusing on promoting regeneration of degenerated discs by stimulating production of the disc matrix. Link protein N-terminal peptide (LPP) is a proteolytic fragment of link protein, an important cross-linker and stabilizer of the major structural components of cartilage, aggrecan and hyaluronan. In this study we investigated LPP action in rabbit primary intervertebral disc cells cultured ex vivo in a three-dimensional alginate matrix. Our data reveal that LPP promotes disc matrix production, which was evidenced by increased expression of the chondrocyte-specific transcription factor SOX9 and the extracellular matrix macromolecules aggrecan and collagen II. Using colocalization and pulldown studies we further document a noggin-insensitive direct peptide-protein association between LPP and BMP-RII. This association mediated Smad signaling that converges on BMP genes leading to expression of BMP-4 and BMP-7. Furthermore, through a cell-autonomous loop BMP-4 and BMP-7 intensified Smad1/5 signaling though a feedforward circuit involving BMP-RI, ultimately promoting expression of SOX9 and downstream aggrecan and collagen II genes. Our data define a complex regulatory signaling cascade initiated by LPP and suggest that LPP may be a useful therapeutic substitute for direct BMP administration to treat IVD degeneration and to ameliorate IVD-associated chronic low back pain.

Microendoscopic lateral decompression for lumbar foraminal stenosis: a biomechanical study.

STUDY DESIGN: A biomechanical study. OBJECTIVE: How much of the facet joint and the pars interarticularis (PI) can be removed in microendoscopic lateral decompression (MELD) for lumbar foraminal stenosis (LFS)? SUMMARY OF BACKGROUND DATA: MELD is a surgical modality for patients with LFS. In severe degenerative cases, unilateral facet joint resection or unilateral removal of the lateral part of the PI are sometimes needed to decompress the nerve root adequately. METHODS: Twelve human lumbar motion segments were tested according to the following loading protocol: axial compression, flexion, extension, lateral bending to the right and left, and axial rotation to the right and left. This loading protocol was applied to each motion segment after MELD in 2 experiments: (1) unilateral graded facetectomy was performed in stages of 25%, 50%, 75%, and 100% using 3 segments of L3/L4 and 3 segments of L5/S1; (2) unilateral removal of the lateral part of the PI was performed in stages of 25%, 50%, 75%, and 100% using 3 segments of L3/L4 and 3 segments of L5/S1. The relative stiffness of each motion segments was determined each time. RESULTS: (1) Unilateral facet joint resection of >75% can lead to a significant reduction in stiffness in axial rotation at both L3/L4 and L5/S1. (2) Unilateral removal of 75% of the lateral part of the PI can lead to significant reduction in stiffness in right and left rotation at L3/L4 and in left rotation at L5/S1. (3) Unilateral removal of 100% of the lateral part of the PI can lead to a significant reduction in stiffness in right axial rotation at L5/S1. CONCLUSIONS: It would seem judicious to remove no >50% of the facet joint or the lateral part of the PI in order to prevent postoperative instability when using MELD for LFS.

Pedicle screws can be 4 times stronger than lateral mass screws for insertion in the midcervical spine: a biomechanical study on strength of fixation.

STUDY DESIGN: A biomechanical study. OBJECTIVE: To compare, in cervical vertebrae (C3-C6), the pullout strengths of pedicle screws and lateral mass screws after both types of screw had been subjected to a period of cyclic loading in 2 planes. SUMMARY OF BACKGROUND DATA: In posterior subaxial cervical fixation systems, screws are usually inserted into the lateral mass. As an alternative to lateral mass fixation, pedicle screw fixation became popular in the 1990s and was first used for lower cervical spine trauma cases. However, it is controversial as to whether lateral mass screw fixation in the upper-middle cervical spine offers as much biomechanical security as compared with pedicle screw fixation. METHODS: For each of the 32 vertebrae, 1 side was randomly chosen to receive a pedicle screw and the other side a lateral mass screw. The pedicle or lateral mass screws inserted into the first 16 vertebrae were cyclically loaded to simulate torsion and the remaining 16 vertebrae were cyclically loaded to simulate flexion/extension of the spine. At the end of the cyclic loading each screw was pulled out along its long axis. RESULTS: For the torsion group, the mean pullout strength of the pedicle screws was nearly 4 times greater than the mean pullout strength of the lateral mass screws (cf 762 N with 191 N). In contrast, the mean pullout strength of the pedicle screws in the flexion/extension group was only twice the mean pullout strength of the lateral mass screws (cf 571 N with 289 N). CONCLUSIONS: Not forgetting the potential risks of inserting pedicle screws in cervical vertebrae, pedicle screws are a better biomechanical choice than lateral mass screws for cervical fixation at the levels C3 through to C6.

Comparison of screw trajectory on stability of oblique scaphoid fractures: a mechanical study.

PURPOSE: To determine whether a screw placed perpendicular to the fracture line in an oblique scaphoid fracture will provide fixation strength that is comparable with that of a centrally placed screw. METHODS: Oblique osteotomies were made along the dorsal sulcus of 8 matched pairs of cadaveric scaphoids. One scaphoid from each pair was randomized to receive a screw placed centrally down the long axis. In the other scaphoid, a screw was placed perpendicular to the osteotomy. Each scaphoid underwent cyclic loading from 80 N to 120 N at 1 Hz. Cyclic loading was carried out until 2 mm of fracture displacement occurred or 4,000 cycles was reached. The specimens that reached the 4,000-cycle limit were then loaded to failure. Screw length, number of cycles, and load to failure were compared between the groups. RESULTS: We found no difference in number of cycles or load to failure between the 2 groups. Screws placed perpendicular to the fracture line were significantly shorter than screws placed down the central axis. CONCLUSIONS: A perpendicularly placed screw provides equivalent strength to one placed along the central axis. CLINICAL RELEVANCE: Compared with a screw placed centrally in an oblique scaphoid fracture, a screw placed perpendicular to the fracture line allows the use of a shorter screw without sacrificing strength of fixation.

Two fixation methods for acromioclavicular joint reduction during coracoclavicular ligament reconstruction: a biomechanical analysis.

One specimen from each of six pairs of cadaveric shoulders underwent a semitendinosus coracoclavicular ligament reconstruction with a hook plate used for acromioclavicular joint reduction, while on the other specimen a polydioxanone (PDS) suture braid was utilized. Cyclical loading followed by maximal load-to-failure testing was performed. Displacement during cyclical loading, loads to 50% and 100% displacement, stiffness, and maximal load to failure were determined for all specimens. Results showed that the locking hook plate allowed significantly less displacement of the coracoclavicular interval during cyclical loading (3.41 vs. 9.67 mm, p = .0081) and withstood significantly higher loads before both 50% (225.5 vs. 107.7 N, p = .0197) and 100% displacement (410.6 vs. 240.1 N, p = .0077). The locking hook plate was found to be significantly stiffer than the PDS suture braid (28.2 vs. 18.4 N/mm, p = .0029), but there was no difference in maximal load to failure between the two fixation methods (hook plate, 434.4 N; PDS, 476.7 N; p = .76).

Changes of number of cells expressing proliferation and progenitor cell markers with age in rabbit intervertebral discs.

Basic knowledge about the normal regeneration process within the intervertebral disc (IVD) is important to the understanding of the underlying biology. The presence of progenitor and stem cells in IVD has been verified. However, changes of number of progenitor and stem cells with age are still unknown. In this study, changes of cell proliferation and progenitor cell markers with age in IVD cells from rabbits of two different ages were investigated using flow cytometry, immunohistochemistry, real-time polymerase chain reaction, and western blot analysis. Proliferating cell nuclear antigen (PCNA) was chosen as a marker for proliferation, and Notch1, Jagged1, C-KIT, CD166 were chosen as stem/progenitor cell markers. Cell cycle analysis showed that cell number in the G2/M phase of the young rabbits was significantly higher than that of mature rabbits. Immunohistochemical staining demonstrated the expression of PCNA, C-KIT, CD166, Notch1, and Jagged1 in both young and mature annulus fibrosus (AF). Protein expressions of these cell markers in the young rabbits were all significantly higher than those in the mature rabbits. The expression levels of PCNA, CD166, C-KIT, Jagged1 were significantly higher in the AF, and PCNA, C-KIT in the nucleus pulposus from young rabbits than those from the mature rabbits. These findings demonstrated that both proliferation and progenitor cells exist in rabbit IVDs and the number of cells expressing proliferation and progenitor cell markers decreases with age in the rabbit IVD cells. Methods that are designed to maintain the endogenous progenitor cells and stimulate their proliferation could be successful in preventing or inhibiting degenerative disc disease.

Pulsed Electromagnetic Field (PEMF) plus BMP-2 upregulates intervertebral disc-cell matrix synthesis more than either BMP-2 alone or PEMF alone.

STUDY DESIGN: An in vitro study using human intervertebral disc (IVD) cells. OBJECTIVES: To determine if pulsed electromagnetic field (PEMF) plus bone morphogenetic protein (BMP)-2 could upregulate IVD-cell matrix synthesis more than either BMP-2 alone or PEMF alone. SUMMARY OF BACKGROUND DATA: BMP-7 and BMP-2 can both upregulate IVD-cell matrix synthesis. There are problems associated with using either BMP-2 or BMP-7. They can diffuse away rather quickly after injection into the IVD space, they cost a lot, and they have side effects such as soft-tissue inflammation and swelling. PEMF has been reported to stimulate various types of cells. PEMF is safe, inexpensive, and noninvasive, thus multiple use is possible. However, PEMF alone has a rather weak effect on disc cells. We decided to carry out an experiment whereby we combined PEMF with BMP-2. Our thoughts were that BMP-2 plus PEMF could be better than either alone. METHODS: The PEMF signal used was similar to that used in the clinical treatment of fracture nonunions or delayed fracture healing. Human disc cells were treated with BMP-2 alone or PEMF alone or PEMF plus BMP-2. Quantitative real-time PCR was performed to determine mRNA expression levels of aggrecan, collagen-2, transforming growth factor (TGF)-ß, BMP-2, and BMP-7. Sulfated glycosaminoglycansynthesis was analyzed using the dimethylmethylene blue method. Western blot analysis was performed to determine the protein levels of TGF-ß, BMP-2, and BMP-7. RESULTS: PEMF plus BMP-2 upregulates IVD-cell matrix synthesis more than BMP-2 alone or PEMF alone, and the effect seems to be synergistic. Also, PEMF plus BMP-2 induces more endogenous BMP-7 and BMP-2 mRNA levels as well as protein levels, as compared with either PEMF alone or BMP-2 alone. CONCLUSIONS: PEMF plus BMP-2 acts in synergy to upregulate intervertebral disc-cell matrix synthesis more than either BMP-2 alone or PEMF alone.

Upregulation of intervertebral disc-cell matrix synthesis by pulsed electromagnetic field is mediated by bone morphogenetic proteins.

STUDY DESIGN: An in vitro study on the effects of pulsed electromagnetic field (PEMF) on intervertebral disc-cell matrix synthesis. OBJECTIVES: The objective of the study was to determine whether (1) PEMF can upregulate intervertebral disc-cell matrix synthesis and (2) any upregulation obtained is through transforming growth factor (TGF)-ß or bone morphogenetic proteins (BMPs). SUMMARY OF BACKGROUND DATA: PEMF has been reported to produce cell proliferation, enhance cell function, and upregulate matrix synthesis in cell types such as osteoblasts, chondroblasts, endothelial cells, and fibroblasts through the upregulation of several growth factors. PEMF has been used clinically in the treatment of delayed bone union. However, PEMF has never been tested on human intervertebral disc cells. METHODS: The PEMF signal used was similar to that used in the clinical treatment of delayed fracture healing. Human disc cells were treated with PEMF for 8 hours per day for 3 days. Quantitative real-time polymerase chain reaction was performed to determine mRNA expression levels of aggrecan, collagen-2, TGF-ß, BMP-2, and BMP-7. Sulfated glycosaminoglycan synthesis was analyzed using the dimethylmethylene blue (DMMB) method. Western blot analysis was performed to determine the protein levels of TGF-ß, BMP-2, and BMP-7. To determine whether any action of PEMF was through BMP, recombinant human Noggin was used at a dose of 100 ng/mL to block BMP. RESULTS: PEMF could upregulate intervertebral disc-cell matrix synthesis. BMP-7 was markedly upregulated by PEMF and was upregulated much more than BMP-2. TGF-ß was not upregulated by PEMF. The effect of PEMF on disc-cell matrix was entirely inhibited in the presence of Noggin. CONCLUSIONS: PEMF acts through BMPs to upregulate intervertebral disc-cell matrix synthesis.

Arthroscopic repair of triangular fibrocartilage tears: a biomechanical comparison of a knotless suture anchor and the traditional outside-in repairs.

PURPOSE: To compare the biomechanical strength of a knotless suture anchor repair and the traditional outside-in repair of peripheral triangular fibrocartilage complex (TFCC) tears in a cadaveric model. METHODS: We dissected the distal ulna and TFCC from 6 matched cadaveric wrist pairs and made iatrogenic complete peripheral TFCC tears in each wrist. In 6 wrists, the TFCC tears were repaired using the standard outside-in technique using 2 2-0 polydioxane sutures placed in a vertical mattress fashion. In the other 6 wrists, we repaired the TFCC tears using mini-pushlock suture anchors to the fovea. The strength of the repairs was then determined using a materials testing machine with the load placed across the repair site. We loaded the repairs until a gap of 2 mm formed across the repair site, and then subsequently loaded them to failure. Thus, for each repair we obtained the load at 2-mm gap formation, load to failure, and mode of failure. RESULTS: At the 2-mm gap formation, the suture anchor repairs were statistically stronger than the outside-in repairs. For load to failure, the suture anchor repairs were also statistically stronger than the outside-in repairs. Failure in both techniques occurred most commonly as suture pull-out from the soft tissues. CONCLUSIONS: The all-arthroscopic suture anchor TFCC repair was biomechanically stronger than an outside-in repair. CLINICAL RELEVANCE: The suture anchor technique allows for repair of both the superficial and deep layers of the articular disk directly to bone, restoring the native TFCC anatomy. By being knotless, the suture anchor repair avoids irritation to the surrounding soft tissues by suture knots.

Functional and Sequence-Specific Screening Protocols for the Detection of Novel Antimicrobial Resistance Genes in Metagenomic DNA.

Antimicrobial resistance (AMR) is an increasingly important global challenge for healthcare systems as well as agricultural food production systems. Our ability to prepare for, and respond to, emerging AMR threats is dependent on our knowledge of genes able to confer AMR that are circulating within various environmental, animal, and human microbiomes. Targeted, sequence-specific, detection of AMR genes and functional resistance assays, described here, carried out on metagenomic DNA gives us unique insights into the presence of AMR genes and how these are associated with mobile genetic elements that may be responsible for their dissemination and can also provide important information about the mechanisms of resistance underpinning the phenotype.

Complete genome sequence of mcr-9 containing Leclercia adecarboxylata.

Here, we provide the genome sequence of a Leclercia adecarboxylata isolated from a screen of an environmental bacterial isolate library for resistance to the plant flavonoid berberine. We detected the colistin resistance gene mcr-9, located on an IncFII(pECLA) plasmid.

Lateral femoral cortical breach during anterior cruciate ligament reconstruction: a biomechanical analysis.

PURPOSE: The purpose of our study was to determine whether secondary fixation is needed when lateral femoral wall breach occurs and whether the diameter of the femoral tunnel affects the cyclical and ultimate load to failure of 3 different suspensory fixation devices. METHODS: Sixty fresh-frozen porcine femora were dissected to isolate the anterior cruciate ligament (ACL) footprint. Femoral ACL tunnels were then drilled at diameters of 7, 8, 9, and 10 mm. We conducted 5 separate cyclical and ultimate load testing trials, at each tunnel diameter, for 3 different cortical suspension devices. RESULTS: The mean load to failure decreased as the tunnel size enlarged for all 3 devices. In 7-mm tunnels, mean failure load ranged from 1,163.7 to 1,455.0 N across the 3 devices; in 8-mm tunnels, 1,154.7 to 1,643.2 N; in 9-mm tunnels, 820.8 to 1,125.21 N; and in 10-mm tunnels, 314.7 to 917.8 N. Modes of failure also varied as the tunnel sizes enlarged. The ultimate load was not different among the 3 manufacturers (P = .08), but there was a difference in the ultimate load across the 4 tunnel diameters (P < .05), except when we compared the 7-mm tunnel with the 8-mm tunnel (P = .91). CONCLUSIONS: With 7- and 8-mm-diameter tunnels, failure loads with each of the suspensory devices tested exceeded the documented interference screw load to failure. CLINICAL RELEVANCE: Our findings suggest that, for soft-tissue ACL grafts, femoral tunnels of 8 mm or less can be drilled through the lateral femoral cortex while still using a suspensory device for graft fixation. With pediatric, double-bundle, and anatomic ACL reconstructions, smaller and shorter tunnels are routinely used. Thus, breaching the lateral cortex when using suspensory fixation may increase tunnel length while still achieving stable fixation.

The effect of spinal shortening after total en bloc spondylectomy: a biomechanical study in the thoracic spine.

STUDY DESIGN: A biomechanical study using human cadaveric thoracic spine specimens. OBJECTIVE: To evaluate and compare the biomechanical effects of spinal shortening and cross-links in reconstruction after total en bloc spondylectomy (TES). SUMMARY OF BACKGROUND DATA: There have been no studies that have examined the biomechanical effects of spinal reconstruction after multilevel TES or the biomechanical effects of spinal shortening in reconstruction after TES. METHODS: Eight human cadaveric spines (T2-T9) were used. After the intact specimen had been biomechanically tested to determine the stiffness in compression, flexion, extension, left and right lateral bending, and left and right axial rotation, a TES at T5-6 was carried out. Three reconstruction methods were tested biomechanically (same as for the intact specimen) for their ability to restore stiffness to the specimen: (1) anterior short cage and multilevel posterior instrumentation at T3-8 with 2 cross-links (S2C), (2) anterior short cage and multilevel posterior instrumentation at T3-8 with 1 cross-link (S1C), and (3) anterior long cage and multilevel posterior instrumentation at T3-8 with 2 cross-links (L2C). A cage that was 6-10 mm shorter in height than the space created by the TES at T5-6 was selected as the "short cage" and a cage 10 mm taller in height than the short cage was selected as the "long cage" in each specimen. RESULTS: All 3 reconstruction methods using an anterior cage and multilevel posterior instrumentation provides a stiffer construct than that shown by the intact specimen. The reconstruction method using the 10-mm shorter cage (S2C vs. L2C) provided more stiffness than the one using the longer cage. The reconstruction using 2 cross-links (S2C vs. S1C) did not provide a stiffer construct than the one using 1 cross-link. CONCLUSIONS: The reconstructions using an anterior cage and multilevel posterior instrumentation provided a stiffer construct than that shown by the intact specimen. The reconstruction using a 10-mm shorter cage provided a stiffer construct than the reconstruction using the longer cage.

A biomechanical study of two different pedicle screw methods for fixation in osteoporotic and nonosteoporotic vertebrae.

In reconstruction of the osteoporotic spine, patients often show poor outcome because of pedicle screw failure. This study used osteoporotic and nonosteoporotic vertebrae to determine the difference in fixation strength between pedicle screws inserted straight forward and pedicle screws inserted in an upward trajectory toward the superior end plate (i.e., end-plate screws). There is some evidence to suggest that end-plate screws have a strength advantage. The particular focus was on osteoporotic vertebrae. Thirty-three vertebrae (T10-L2) were harvested. The bone mineral density (BMD) was measured: 15 vertebrae were greater than 0.8 g/cm(2) and designated as nonosteoporotic (average BMD 1.146 ± 0.186 g/cm(2)) and 18 vertebrae were designated as osteoporotic (average BMD 0.643 ± 0.088 g/cm(2)). On one pedicle the screw was inserted straight forward and on the other pedicle the screw was inserted as an end-plate screw. The torque of insertion was measured (Proto 6106 torque screwdriver). Using an MTS Mini Bionix, two types of mechanical testing were carried out on each pedicle: (a) cephalocaudad toggling was first carried out to simulate some physiological type loading: 500 cycles at 0.3 Hz, at ±50 N; and (b) then each pedicle screw was pulled out at a displacement rate of 12.5 cm/min.There was no difference in pullout force between the pedicle screws inserted straight forward and the pedicle screws inserted as end-plate screws. This result applies whether the vertebrae were osteoporotic or nonosteoporotic. For both the straight-forward screws and the end-plate screws, a statistically significant correlation was observed between torque of insertion and pullout force. The results of this experiment indicate that pedicle screws inserted as end-plate screws do not provide a strength advantage over pedicle screws inserted straight forward, whether the vertebrae are osteoporotic or not.

Spinous process wiring versus lateral mass fixation for the treatment of anterior cervical pseudarthrosis: a biomechanical comparison.

Our objective was to compare the stiffness of lateral mass screws versus two different spinous process wiring constructs in a cadaveric model of plated anterior cervical pseudoarthrosis. When treating an anterior plated pseudoarthrosis via a posterior approach, it is unclear whether the added expense, muscle exposure, and risk of lateral mass fixation are justified biomechanically versus a simpler, cheaper, and potentially less morbid wiring technique, because the presence of the anterior plate likely reduces motion over the unplated situation. Seven cadaveric cervical spines were loaded in compression, flexion, extension, lateral bending, and torsion. Each load sequence was applied to: 1) the intact spine; 2) after application of a plated ACDF construct (pACDF); and 3) after the insertion of lateral mass (LM) screws, ``modified'' triple wiring (TW), or Roger's wiring (RW), in alternating order for each specimen. For each sequence, load deformation curves and stiffness were obtained. Supplemental LM fixation significantly (p ≤ 0.05) increased stiffness versus pACDF in all six modes tested. TW significantly increased stiffness versus pACDF in compression, flexion, and torsion, but not in extension, or lateral bending. RW significantly increased stiffness versus pACDF only in axial torsion. When comparing LM to the wiring constructs, LM fixation was significantly stiffer than RW in flexion, extension, and lateral bending; LM fixation was stiffer than TW in lateral bending. LM fixation produced the stiffest overall constructs in stabilizing a plated pseudarthrosis ACDF model. It was significantly stiffer in more modes versus RW than TW.