Influence of preoperative factors on timing for bilateral shoulder arthroplasty.

INTRODUCTION: In bilateral shoulder arthroplasty patients, it is unclear what features are responsible for the timing of their contralateral shoulder arthroplasty. This study hypothesized that patient factors (age, gender, and hand dominance), disease factors (diagnosis and radiographic severity of contralateral shoulder), and surgical factors (type of arthroplasty) impact the timing to contralateral surgery. METHODS: A retrospective review of 332 patients treated with bilateral anatomic (TSA) or reverse (RSA) shoulder arthroplasty (172 TSA/TSA, 107 RSA/RSA, or 53 TSA/RSA) were divided into groups depending on the interval timing between arthroplasty surgeries: group 1, n = 142 (≤1 year); group 2, n = 62 (1-2 years); and group 3, n = 128 (≥2 years). Preoperative factors were analyzed to determine associations between different time groups, including age, gender, hand dominance, diagnosis, radiographic severity of contralateral shoulder, and type of surgery. Bilateral diagnoses included 211 osteoarthritis (OA), 36 cuff tear arthropathy (CTA), 13 inflammatory arthritis, 12 massive cuff tears without OA, and 4 avascular necrosis. RESULTS: OA patients had their contralateral shoulder arthroplasty sooner than CTA patients (P = .035). OA patients with arthritic changes on contralateral radiographs before the first arthroplasty had their contralateral arthroplasty sooner than those without contralateral radiographs (P < .0001). Patients who had TSA first had their contralateral arthroplasty sooner than patients who had RSA first (P = .037). DISCUSSION: This study confirmed our hypothesis identifying preoperative variables associated with different time intervals between arthroplasties. The preoperative factors associated with the highest likelihood of having contralateral shoulder arthroplasty within 1 year included OA, radiographic bilateral shoulder disease, and TSA for the first surgery.

Skin dose in radiation treatment of the left breast: Analysis in the context of prone versus supine treatment technique.

PURPOSE: To determine how the skin dose varies in patients receiving radiation treatment for breast cancer in the prone and supine positions. METHODS: Fifty patients were scanned in the prone and supine positions. A radiation treatment plan was created for the left breast using a 6-MV beam for a prescribed dose of 42.66 Gy in 16 fractions. The dose was calculated using 1- and 2.5-mm calculation grid sizes and the surface dose was compared in both techniques. RESULTS: The median gantry angles relative to the skin surface at the central axis were 8 and 52 degrees for treatment in the prone and supine positions, respectively. The mean dose difference between the prone and supine techniques was statistically significant from 3- to 5-mm depth for both grid sizes. For the 1-mm calculation grid size, the doses at 3-, 4-, and 5-mm depths in the prone and supine techniques were 87.80% and 89.10% (P < 0.003), 91.92% and 94.50% (P < 0.00), and 95.30% and 98.20% (P < 0.00), respectively; for the 2.5-mm grid size, the respective doses were 87.10% and 88.59% (P < 0.00), 91.60% and 94.63% (P < 0.00), and 95.10% and 97.80% (P < 0.00), respectively. CONCLUSIONS: This study demonstrates that the prone technique facilitates a relatively lower skin dose than the supine technique. This observation is probably due to the beam angle. The beam is more perpendicular to the skin surface in the prone technique, whereas it is more tangential in the supine technique, which may deliver a higher skin dose. Thus, the dose to the skin should be evaluated in the prone technique, and if desired, the skin dose could be carefully augmented via a bolus or beam spoiler.

On the stoichiometry of zirconium carbide.

The dependencies of the enhanced thermomechanical properties of zirconium carbide (ZrCx) with sample purity and stoichiometry are still not understood due to discrepancies in the literature. Multiple researchers have recently reported a linear relation between the carbon to zirconium atomic ratio (C/Zr) and the lattice parameter, in contrast with a more established relationship that suggests that the lattice parameter value attains a maximum value at a C/Zr ~ 0.83. In this study, the relationship between C/Zr atomic ratio and the lattice parameter is critically assessed: it is found that recent studies reporting the thermophysical properties of ZrCx have unintentionally produced and characterised samples containing zirconium oxycarbide. To avoid such erroneous characterization of ZrCx thermophysical properties in the future, we propose a method for the accurate measurement of the stoichiometry of ZrCx using three independent experimental techniques, namely: elemental analysis, thermogravimetric analysis and nuclear magnetic resonance spectroscopy. Although a large scatter in the results (ΔC/Zr = 0.07) from these different techniques was found when used independently, when combining the techniques together consistent values of x in ZrCx were obtained.

An investigation of the long-range and local structure of sub-stoichiometric zirconium carbide sintered at different temperatures.

ZrC1-x (sub-stoichiometric zirconium carbide), a group IV transition metal carbide, is being considered for various high temperature applications. Departure from stoichiometry changes the thermo-physical response of the material. Reported thermo-physical properties exhibit, in some cases, a degree of scatter with one likely contributor to this being the uncertainty in the C/Zr ratio of the samples produced. Conventional, methods for assigning C/Zr to samples are determined either by nominal stochiometric ratios or combustion carbon analysis. In this study, a range of stoichiometries of hot-pressed ZrC1-x were examined by SEM, XRD, Raman spectroscopy and static 13C NMR spectroscopy and used as a basis to correct the C/Zr. Graphite, amorphous, and ZrC1-x carbon signatures are observed in the 13C NMR spectra of samples and are determined to vary in intensity with sintering temperature and stoichiometry. In this study a method is outlined to quantify the stoichiometry of ZrC1-x and free carbon phases, providing an improvement over the sole use and reliance of widely adopted bulk carbon combustion analysis. We report significantly lower C/Zr values determined by 13C NMR analysis compared with carbon analyser and nominal methods. Furthermore, the location of carbon disassociated from the ZrC1-x structure is analysed using SEM and Raman spectroscopy.

Biological Indices Evaluation of Various Treatment Techniques for Left-Sided Breast Treatment.

PURPOSE: To compare dose to organs at risk (OARs) and biological evaluation using normal tissue complication probability (NTCP) for left-sided breast radiation therapy in 4 techniques: supine free breathing (SFB), supine deep inspiration breath hold (SDIBH), prone free breathing (PFB), and prone deep inspiration breath hold (PDIBH). METHODS AND MATERIALS: Twenty-five patients with left-sided breast cancer suitable for this study underwent a computed tomography scan using SFB, SDIBH, PFB, and PDIBH. One radiation oncologist contoured the planning target volume and OAR (cardiac components). Dose-volume histograms and NTCPs for the heart, left ventricle (LV), left anterior descending artery (LAD), and left lung were calculated for all 4 techniques. RESULTS: The mean heart dose in PDIBH is 0.77 Gy, which is statistically significantly lower than in SFB (1.88 Gy, P < .0001), SDIBH (0.97 Gy, P < .001), and PFB (0.85 Gy, P < .001). The mean left lung dose is 0.69 Gy in PFB and 0.88 Gy in PDIBH. PFB and PDIBH have statistically significantly lower doses compared with SFB (6.09 Gy, P < .0001) and SDIBH (5.41 Gy, P < .0001). The mean NTCP in SFB for the heart, LV, and LAD is 0.27%, 0.62%, and 4.23%, respectively, and it is negligible for other techniques. CONCLUSIONS: We found that PDIBH had a dosimetrically lower mean dose for the heart and LV compared with the other 3 techniques. In addition, SDIBH, PFB and PDIBH had statistically significantly lower NTCP for the heart, LV, and LAD compared with SFB. NTCP for the left lung was statistically significantly lower for prone techniques compared with supine techniques. Therefore we concluded that, compared with SDIBH, PDIBH provides the added benefit of sparing the heart while keeping the benefit of sparing the lung as in the prone technique.

Stoichiometry deviation in amorphous zirconium dioxide.

Amorphous zirconia (a-ZrO2) has been simulated using a synergistic combination of state-of-the-art methods: employing reverse Monte-Carlo, molecular dynamics and density functional theory together. This combination has enabled the complex chemistry of the amorphous system to be efficiently investigated. Notably, the a-ZrO2 system was observed to accommodate excess oxygen readily - through the formation of neutral peroxide (O2 2-) defects - a result that has implications not only in the a-ZrO2 system, but also in other systems employing network formers, intermediates and modifiers. The structure of the a-ZrO2 system was also determined to have edge-sharing characteristics similar to structures reported in the amorphous TeO2 system and other chalcogenide-containing glasses.

Atomic-scale description of interfaces in rutile/sodium silicate glass-crystal composites.

In this work interfaces between (Na2O)x(SiO2)1-x glasses (for x = 0.0, 0.1 and 0.2) and TiO2 crystals are simulated using molecular dynamics and empirical potentials. Interfaces are presented for the distinct terminating surfaces of TiO2 with Miller indices ≤2, the properties of which have been investigated using atomistic models. Simulations showed that partially ordered layers had been induced in the glass close to the interfaces, with successive oxygen-rich and cation-rich planes being noted. The first silicate layer in contact with the crystal tended to be highly-structured, with Si ions occupying well-defined positions that depend on the orientation of the crystal at the interface, and showing 2-dimensional ordering depending on glass composition. Finally, interface energies were calculated. These indicated that the interface formation may stabilise a crystal surface in comparison to maintaining a free surface. Results are presented suggesting that the structural flexibility of the glass network allows it to conform to the crystal, thereby providing charge compensation and avoiding large relaxation of the crystal structure close to the interfaces. Such interfacial properties could be crucial to improving phenomenological models of glass-crystal composite properties.

Investigating the highest melting temperature materials: A laser melting study of the TaC-HfC system.

TaC, HfC and their solid solutions are promising candidate materials for thermal protection structures in hypersonic vehicles because of their very high melting temperatures (>4000 K) among other properties. The melting temperatures of slightly hypostoichiometric TaC, HfC and three solid solution compositions (Ta1-xHfxC, with x = 0.8, 0.5 and 0.2) have long been identified as the highest known. In the current research, they were reassessed, for the first time in the last fifty years, using a laser heating technique. They were found to melt in the range of 4041-4232 K, with HfC having the highest and TaC the lowest. Spectral radiance of the hot samples was measured in situ, showing that the optical emissivity of these compounds plays a fundamental role in their heat balance. Independently, the results show that the melting point for HfC0.98, (4232 ± 84) K, is the highest recorded for any compound studied until now.

Synthesis and Characterization of an Alumina Forming Nanolaminated Boride: MoAlB.

The 'MAlB' phases are nanolaminated, ternary transition metal borides that consist of a transition metal boride sublattice interleaved by monolayers or bilayers of pure aluminum. However, their synthesis and properties remain largely unexplored. Herein, we synthesized dense, predominantly single-phase samples of one such compound, MoAlB, using a reactive hot pressing method. High-resolution scanning transmission electron microscopy confirmed the presence of two Al layers in between a Mo-B sublattice. Unique among the transition metal borides, MoAlB forms a dense, mostly amorphous, alumina scale when heated in air. Like other alumina formers, the oxidation kinetics follow a cubic time-dependence. At room temperature, its resistivity is low (0.36-0.49 µΩm) and - like a metal - drops linearly with decreasing temperatures. It is also a good thermal conductor (35 Wm(-1)K(-1) at 26 °C). In the 25-1300 °C temperature range, its thermal expansion coefficient is 9.5 × 10(-6 )K(-1). Preliminary results suggest the compound is stable to at least 1400 °C in inert atmospheres. Moderately low Vickers hardness values of 10.6 ± 0.3 GPa, compared to other transition metal borides, and ultimate compressive strengths up to 1940 ± 103 MPa were measured at room temperature. These results are encouraging and warrant further study of this compound for potential use at high temperatures.

Synthesis and DFT investigation of new bismuth-containing MAX phases.

The Mn + 1AXn phases (M = early transition metal; A = group A element and X = C and N) are materials exhibiting many important metallic and ceramic properties. In the present study powder processing experiments and density functional theory calculations are employed in parallel to examine formation of Zr2(Al1-xBix)C (0 ≤ x ≤ 1). Here we show that Zr2(Al1-xBix)C, and particularly with x ≈ 0.58, can be formed from powders even though the end members Zr2BiC and Zr2AlC seemingly cannot. This represents a significant extension of the MAX phase family, as this is the first report of a bismuth-based MAX phase.

Crystal Structures of Al-Nd Codoped Zirconolite Derived from Glass Matrix and Powder Sintering.

Zirconolite is a candidate host for immobilizing long-lived radionuclides. Zirconolite-based glass-ceramics in the CaO-SiO2-Al2O3-TiO2-ZrO2-Nd2O3-Na2O matrix are a potential waste form for immobilizing actinide radionuclides and can offer double barriers to immobilize radioactive elements. However, the X-ray diffraction patterns of the zirconolite derived from the glass matrix (glass ceramic, GC) are significantly different from those prepared by powder sintering (PS). In this Article, the crystal structures of Al-Nd codoped zirconolite grown via the glass matrix route and the powder sintering route are investigated in detail. Two samples of Al-Nd codoped zirconolite were prepared: one was grown from a CaO-SiO2-Al2O3-TiO2-ZrO2-Nd2O3-Na2O glass matrix, and the other was prepared with a Ca0.75Nd0.25ZrTi1.75Al0.25O7 composition by powder sintering. The samples were then characterized using powder X-ray diffraction (PXRD), scanning electron microscopy (SEM), transmission electron microscopy-energy dispersive X-ray spectroscopy (TEM-EDX), and selected area electron diffraction (SAED). The chemical composition of the 100-500 nm zirconolite crystals grown from a glass matrix was determined by TEM-EDX to be Ca0.83Nd0.25Zr0.85Ti1.95Al0.11O7. PXRD and SAED results showed that these two Al-Nd codoped zirconolite phases were crystallized in space group C12/c1. The HRTEM images and SAED results showed that there were heavy stacking faults in the zirconolite crystals grown from the glass matrix. In contrast, far fewer defects were found in the zirconolite crystals prepared by powder sintering. The split-atom model was adopted for the first time to construct the Al-Nd codoped zirconolite structure grown from glass during the Rietveld refinement. The isostructural method assisted by Rietveld refinement was used to resolve the Al-Nd codoped zirconolite structures prepared by different methods. The occupancies of the cation sites were identified, and the distribution behavior of Nd(3+) was further investigated. The results indicate that the heavy stacking faults may lead to substantial differences in the Al-Nd codoped zirconolite structures prepared by these two fabrication routes.

The current testing protocols for biomechanical evaluation of lumbar spinal implants in laboratory setting: a review of the literature.

In vitro biomechanical investigations have become a routinely employed technique to explore new lumbar instrumentation. One of the most important advantages of such investigations is the low risk present when compared to clinical trials. However, the best use of any experimental data can be made when standard testing protocols are adopted by investigators, thus allowing comparisons among studies. Experimental variables, such as the length of the specimen, operative level, type of loading (e.g., dynamic versus quasistatic), magnitude, and rate of load applied, are among the most common variables controlled during spinal biomechanical testing. Although important efforts have been made to standardize these protocols, high variability can be found in the current literature. The aim of this investigation was to conduct a systematic review of the literature to identify the current trends in the protocols reported for the evaluation of new lumbar spinal implants under laboratory setting.

Balancing rigidity and safety of pedicle screw fixation via a novel expansion mechanism in a severely osteoporotic model.

Many successful attempts to increase pullout strength of pedicle screws in osteoporotic bone have been accompanied with an increased risk of catastrophic damage to the patient. To avoid this, a single-armed expansive pedicle screw was designed to increase fixation strength while controlling postfailure damage away from the nerves surrounding the pedicle. The screw was then subsequently tested in two severely osteoporotic models: one representing trabecular bone (with and without the presence of polymethylmethacrylate) and the other representing a combination of trabecular and cortical bone. Maximum pullout strength, stiffness, energy to failure, energy to removal, and size of the resulting block damage were statistically compared among conditions. While expandable pedicle screws produced maximum pullout forces less than or comparable to standard screws, they required a higher amount of energy to be fully removed from both models. Furthermore, damage to the cortical layer in the composite test blocks was smaller in all measured directions for tests involving expandable pedicle screws than those involving standard pedicle screws. This indicates that while initial fixation may not differ in the presence of cortical bone, the expandable pedicle screw offers an increased level of postfailure stability and safety to patients awaiting revision surgery.

A regenerating ultrasensitive electrochemical impedance immunosensor for the detection of adenovirus.

We report on the development of a regenerable sensitive immunosensor based on electrochemical impedance spectroscopy for the detection of type 5 adenovirus. The multi-layered immunosensor fabrication involved successive modification steps on gold electrodes: (i) modification with self-assembled layer of 1,6-hexanedithiol to which gold nanoparticles were attached via the distal thiol groups, (ii) formation of self-assembled monolayer of 11-mercaptoundecanoic acid onto the gold nanoparticles, (iii) covalent immobilization of monoclonal anti-adenovirus 5 antibody, with EDC/NHS coupling reaction on the nanoparticles, completing the immunosensor. The immunosensor displayed a very good detection limit of 30 virus particles/ml and a wide linear dynamic range of 10(5). An electrochemical reductive desorption technique was employed to completely desorb the components of the immunosensor surface, then re-assemble the sensing layer and reuse the sensor. On a single electrode, the multi-layered immunosensor could be assembled and disassembled at least 30 times with 87% of the original signal intact. The changes of electrode behavior after each assembly and desorption processes were investigated by cyclic voltammetry, electrochemical impedance spectroscopy and X-ray photoelectron spectroscopy techniques.

Biomechanical comparison of an interspinous fusion device and bilateral pedicle screw system as additional fixation for lateral lumbar interbody fusion.

BACKGROUND: This investigation compares an interspinous fusion device with posterior pedicle screw system in a lateral lumbar interbody lumbar fusion. METHODS: We biomechanically tested six cadaveric lumbar segments (L1-L2) under an axial preload of 50N and torque of 5Nm in flexion-extension, lateral bending and axial rotation directions. We quantified range of motion, neutral zone/elastic zone stiffness in the following conditions: intact, lateral discectomy, lateral cage, cage with interspinous fusion, and cage with pedicle screws. FINDINGS: A complete lateral discectomy and annulectomy increased motion in all directions compared to all other conditions. The lateral cage reduced motion in lateral bending and flexion/extension with respect to the intact and discectomy conditions, but had minimal effect on extension stiffness. Posterior instrumentation reduced motion, excluding interspinous augmentation in axial rotation with respect to the cage condition. Interspinous fusion significantly increased flexion and extension stiffness, while pedicle screws increased flexion/extension and lateral bending stiffness, with respect to the cage condition. Both posterior augmentations performed equivalently throughout the tests except in lateral bending stiffness where pedicle screws were stiffer in the neutral zone. INTERPRETATION: A lateral discectomy and annulectomy generates immediate instability. Stand-alone lateral cages restore a limited amount of immediate stability, but posterior supplemental fixation increases stability. Both augmentations are similar in a single level lateral fusion in-vitro model, but pedicle screws are more equipped for coronal stability. An interspinous fusion is a less invasive alternative than pedicle screws and is potentially a conservative option for various interbody cage scenarios.

Thermostable cross-protective subunit vaccine against Brucella species.

A subunit vaccine candidate was produced from Brucella suis 145 (biovar 4; expressing both the A antigen of Brucella abortus and the M antigen of Brucella melitensis). The preparation consisted mostly of polysaccharide (PS; >90% [wt/wt]; both cell-associated PS and exo-PS were combined) and a small amount of protein (1 to 3%) with no apparent nucleic acids. Vaccinated mice were protected (these had a statistically significant reduction in bacterial colonization compared to that of unvaccinated controls) when challenged with representative strains of three Brucella species most pathogenic for humans, i.e., B. abortus, B. melitensis, and B. suis. As little as 1 ng of the vaccine, without added adjuvant, protected mice against B. suis 145 infection (5 × 10(5) CFU), and a single injection of 1 µg of this subunit vaccine protected mice from B. suis 145 challenge for at least 14 months. A single immunization induced a serum IgG response to Brucella antigens that remained elevated for up to 9 weeks. The use of heat (i.e., boiling-water bath, autoclaving) in the vaccine preparation showed that it was thermostable. This method also ensured safety and security. The vaccine produced was immunogenic and highly protective against multiple strains of Brucella and represents a promising candidate for further evaluation.

Designs and techniques that improve the pullout strength of pedicle screws in osteoporotic vertebrae: current status.

Osteoporosis is a medical condition affecting men and women of different age groups and populations. The compromised bone quality caused by this disease represents an important challenge when a surgical procedure (e.g., spinal fusion) is needed after failure of conservative treatments. Different pedicle screw designs and instrumentation techniques have been explored to enhance spinal device fixation in bone of compromised quality. These include alterations of screw thread design, optimization of pilot hole size for non-self-tapping screws, modification of the implant's trajectory, and bone cement augmentation. While the true benefits and limitations of any procedure may not be realized until they are observed in a clinical setting, axial pullout tests, due in large part to their reproducibility and ease of execution, are commonly used to estimate the device's effectiveness by quantifying the change in force required to remove the screw from the body. The objective of this investigation is to provide an overview of the different pedicle screw designs and the associated surgical techniques either currently utilized or proposed to improve pullout strength in osteoporotic patients. Mechanical comparisons as well as potential advantages and disadvantages of each consideration are provided herein.

A regenerating self-assembled gold nanoparticle-containing electrochemical impedance sensor.

We report on the development of an electrochemical reductive desorption protocol for repeated regeneration of gold electrodes modified with multi-layers of self-assembled surfaces for use in electrochemical sensing. The gold electrodes were first modified with 1,6-hexanedithiol to which gold nanoparticles were attached in a subsequent modification step. Attachment of thiolated single-stranded nucleic acid oligomers to the gold nanoparticles completed the electrochemical sensor. The changes of electrode behavior after each assembly and desorption processes were investigated by cyclic voltammetry, electrochemical impedance spectroscopy and X-ray photoelectron spectroscopy techniques. The self-assembled sensor showed a wide dynamic range (0.1-100 nM), a low detection limit (20 pM) and high reproducibility (4.4% RSD) for complementary nucleic acid target molecules, along with reusability. On a single gold electrode, the complete sensor-target structure could be assembled and disassembled at least four times with 90% of its original signal intact.

In vitro evaluation of a lateral expandable cage and its comparison with a static device for lumbar interbody fusion: a biomechanical investigation.

OBJECT: Through in vitro biomechanical testing, the authors compared the performance of a vertically expandable lateral lumbar interbody cage (EC) under two different torque-controlled expansions (1.5 and 3.0 Nm) and with respect to an equivalent lateral lumbar static cage (SC) with and without pedicle screw fixation. METHODS: Eleven cadaveric human L2-3 segments were evaluated under the following conditions: 1) intact; 2) discectomy; 3) EC under 1.50 Nm of torque expansion (EC-1.5Nm); 4) EC under 3.00 Nm of torque expansion (EC-3.0Nm); 5) SC; and 6) SC with a bilateral pedicle screw system (SC+BPSS). Load-displacement behavior was evaluated for each condition using a combination of 100 N of axial preload and 7.5 Nm of torque in flexion and extension (FE), lateral bending (LB), and axial rotation (AR). Range of motion (ROM), neutral zone stiffness (NZS), and elastic zone stiffness (EZS) were statistically compared among conditions using post hoc Wilcoxon signed-rank comparisons after Friedman tests, with a significance level of 0.05. Additionally, any cage height difference between interbody devices was evaluated. When radiographic subsidence was observed, the specimen's data were not considered for the analysis. RESULTS: The final cage height in the EC-1.5Nm condition (12.1 ± 0.9 mm) was smaller (p < 0.001) than that in the EC-3.0Nm (13.9 ± 1.1 mm) and SC (13.4 ± 0.8 mm) conditions. All instrumentation reduced (p < 0.01) ROM with respect to the injury and increased (p ≤ 0.01) NZS in flexion, extension, and LB as well as EZS in flexion, LB, and AR. When comparing the torque expansions, the EC-3.0Nm condition had smaller (p < 0.01) FE and AR ROM and greater (p ≤ 0.04) flexion NZS, extension EZS, and AR EZS. The SC condition performed equivalently (p ≥ 0.10) to both EC conditions in terms of ROM, NZS, and EZS, except for EZS in AR, in which a marginal (p = 0.05) difference was observed with respect to the EC-3.0Nm condition. The SC+BPSS was the most rigid construct in terms of ROM and stiffness, except for 1) LB ROM, in which it was comparable (p = 0.08) with that of the EC-1.5Nm condition; 2) AR NZS, in which it was comparable (p > 0.66, Friedman test) with that of all other constructs; and 3) AR EZS, in which it was comparable with that of the EC-1.5Nm (p = 0.56) and SC (p = 0.08) conditions. CONCLUSIONS: A 3.0-Nm torque expansion of a lateral interbody cage provides greater immediate stability in FE and AR than a 1.5-Nm torque expansion. Moreover, the expandable device provides stability comparable with that of an equivalent (in size, shape, and bone-interface material) SC. Specifically, the SC+BPSS construct was the most stable in FE motion. Even though an EC may seem a better option given the minimal tissue disruption during its implantation, there may be a greater chance of endplate collapse by over-distracting the disc space because of the minimal haptic feedback from the expansion.