The Effects of Unitizing Nail-Plate Constructs in Distal Femur Fractures: A Biomechanical Study.

OBJECTIVES: To assess the biomechanical differences between linked and unlinked constructs in young and osteoporotic cadavers in addition to osteoporotic sawbones. METHODS: Intraarticular distal femur fractures with comminuted metaphyseal regions were created in three young matched pair cadavers, three osteoporotic matched pair cadavers, and six osteoporotic sawbones. Precontoured distal femur locking plates were placed in addition to a standardized retrograde nail, with unitized constructs having one 4.5 mm locking screw placed distally through the nail. Nonunitized constructs had seven 4.5 mm locking screws placed through the plate around the nail, with one 5 mm distal interlock placed through the nail alone. Cadaveric specimens were subjected to axial fatigue loads between 150 and 1500 N (R Ratio = 10) with 1 Hx frequency for 10,000 cycles. Sawbones were axially loaded at 50% of the ultimate load for fatigue testing to achieve runout, with testing performed with 30 and 300 N (R Ratio = 10) loads with 1 Hz frequency for 10,000 cycles. RESULTS: In young cadavers, there was no difference in the mean cyclic displacement of the unitized constructs (1.51 ± 0.62mm) compared to the non-unitized constructs (1.34 ± 0.47mm) (Figure 4A), (p = 0.722). In osteoporotic cadavers, there was no difference in the mean cyclic displacement of the unitized constructs (2.46 ± 0.47mm) compared to the non-unitized constructs (2.91 ± 1.49mm) (p =0.639). There was statistically no significant difference in cyclic displacement between the unitized and non-unitized groups in osteoporotic sawbones(p = 0.181). CONCLUSIONS: Linked constructs did not demonstrate increased axial stiffness or decreased cyclical displacement in comparison to unlinked constructs in young cadaveric specimens, osteoporotic cadaveric specimens, or osteoporotic sawbones.

A feasibility cadaver study for placing screws in various pelvic osseous fracture pathways using a robotic arm.

INTRODUCTION: The use of a robotic system for the placement of pedicle screws in spine surgeries is well documented in the literature. However, there is only a single report in the United States describing the use of a robotic system to place two screws in osseous fixation pathways (OFPs) commonly used in the treatment of pelvic and acetabular fractures in a simulated bone model. The purpose of this study was to demonstrate the use of a robotic system to place screws in multiple, clinically relevant OFPs in a cadaveric model and to quantitatively measure accuracy of screw placement relative to the preoperative plan. METHODS: A single cadaveric specimen was obtained for the purpose of this study. All surrounding soft tissues were left intact. Screws were placed in OFPs, namely iliosacral (IS), trans-sacral (TS), Lateral Compression-II (LC-II), antegrade anterior column (AC) and antegrade posterior column (PC) of the right hemipelvis using standard, fluoroscopically assisted percutaneous or mini-open technique. Following the placement of screws into the right hemipelvis using standard techniques, screws were planned and placed in the same OFPs of the contralateral hemipelvis using the commercially available ExcelsiusGPS® robotic system (Globus Medical Inc., Audubon, PA). After robotic-assisted screw placement, a post-procedure CT scan was obtained to evaluate actual screw placement against the pre-procedure plan. A custom-made image analysis program was devised to measure screw tip/tail offset and angular offset on axial and sagittal planes. RESULTS: For different OFPs, the mean tip offset, tail offset and angular offsets were 1.6 ± 0.9 mm (Range 0.0-3.6 mm), 1.4 ± 0.4 mm (Range 0.3-2.5 mm) and 1.1 ± 0.4° (Range 0.5-2.1), respectively. CONCLUSION: In this feasibility study, surgeons were able to place screws into the clinically relevant fracture pathways of the pelvis using ExcelsiusGPS® for robotic-assisted surgery. The measured accuracy was encouraging; however, further investigation is needed to demonstrate that robotic-assisted surgery can be used to successfully place the screws in the bony corridors of the pelvis to treat traumatic pelvic injuries.

Percutaneous Juxtapedicular Cement Salvage of Failed Spinal Instrumentation? Institutional Experience and Cadaveric Biomechanical Study.

BACKGROUND AND OBJECTIVES: Instrumented spinal fusion constructs sometimes fail because of fatigue loading, frequently necessitating open revision surgery. Favorable outcomes after percutaneous juxtapedicular cement salvage (perc-cement salvage) of failing instrumentation have been described; however, this approach is not widely known among spine surgeons , and its biomechanical properties have not been evaluated. We report our institutional experience with perc-cement salvage and investigate the relative biomechanical strength of this technique as compared with 3 other common open revision techniques. METHODS: A retrospective chart review of patients who underwent perc-cement salvage was conducted. Biomechanical characterization of revision techniques was performed in a cadaveric model of critical pedicle screw failure. Three revision cohorts involved removal and replacement of hardware: (1) screw upsizing, (2) vertebroplasty, and (3) fenestrated screw with cement augmentation. These were compared with a cohort with perc-cement salvage performed using a juxtapedicular trajectory with the failed primary screw remaining engaged in the vertebral body. RESULTS: Ten patients underwent perc-cement salvage from 2018 to 2022 to address screw haloing and/or endplate fracture threatening construct integrity. Pain palliation was reported by 8/10 patients. Open revision surgery was required in 4/10 patients, an average of 8.9 months after the salvage procedure (range 6.2-14.7 months). Only one revision was due to progressive hardware dislodgement. The remainder avoided open revision surgery through an average of 1.9 years of follow-up. In the cadaveric study, there were no significant differences in pedicle screw pullout strength among any of the revision cohorts. CONCLUSION: Perc-cement salvage of failing instrumentation is reasonably efficacious. The technique is biomechanically noninferior to other revision strategies that require open surgery for removal and replacement of hardware. Open revision surgery may be avoided by perc-cement salvage in select cases.

Robotic-Assisted Navigation for Stereotactic Neurosurgery: A Cadaveric Investigation of Accuracy, Time, and Radiation.

BACKGROUND AND OBJECTIVES: Despite frequent use, stereotactic head frames require manual coordinate calculations and manual frame settings that are associated with human error. This study examines freestanding robot-assisted navigation (RAN) as a means to reduce the drawbacks of traditional cranial stereotaxy and improve targeting accuracy. METHODS: Seven cadaveric human torsos with heads were tested with 8 anatomic coordinates selected for lead placement mirrored in each hemisphere. Right and left hemispheres of the brain were randomly assigned to either the traditional stereotactic arc-based (ARC) group or the RAN group. Both target accuracy and trajectory accuracy were measured. Procedural time and the radiation required for registration were also measured. RESULTS: The accuracy of the RAN group was significantly greater than that of the ARC group in both target (1.2 ± 0.5 mm vs 1.7 ± 1.2 mm, P = .005) and trajectory (0.9 ± 0.6 mm vs 1.3 ± 0.9 mm, P = .004) measurements. Total procedural time was also significantly faster for the RAN group than for the ARC group (44.6 ± 7.7 minutes vs 86.0 ± 12.5 minutes, P < .001). The RAN group had significantly reduced time per electrode placement (2.9 ± 0.9 minutes vs 5.8 ± 2.0 minutes, P < .001) and significantly reduced radiation during registration (1.9 ± 1.1 mGy vs 76.2 ± 5.0 mGy, P < .001) compared with the ARC group. CONCLUSION: In this cadaveric study, cranial leads were placed faster and with greater accuracy using RAN than those placed with conventional stereotactic arc-based technique. RAN also required significantly less radiation to register the specimen's coordinate system to the planned trajectories. Clinical testing should be performed to further investigate RAN for stereotactic cranial surgery.

In vitro coupled motions of the whole human thoracic and lumbar spine with rib cage.

Study design: In vitro biomechanical study investigating the coupled motions of the whole normative human thoracic spine (TS) and lumbar spine (LS) with rib cage. Objective: To quantify the region-specific coupled motion patterns and magnitudes of the TS, thoracolumbar junction (TLJ), and LS simultaneously. Background: Studying spinal coupled motions is important in understanding the development of complex spinal deformities and providing data for validating computational models. However, coupled motion patterns reported in vitro are controversial, and no quantitative data on region-specific coupled motions of the whole human TS and LS are available. Methods: Pure, unconstrained bending moments of 8 Nm were applied to seven fresh-frozen human cadaveric TS and LS specimens (mean age: 70.3 ± 11.3 years) with rib cages to elicit flexion-extension (FE), lateral bending (LB), and axial rotation (AR). During each primary motion, region-specific rotational range of motion (ROM) data were captured. Results: No statistically significant, consistent coupled motion patterns were observed during primary FE. During primary LB, there was significant (p < 0.05) ipsilateral AR in the TS and a general pattern of contralateral coupled AR in the TLJ and LS. There was also a tendency for the TS to extend and the LS to flex. During primary AR, significant coupled LB was ipsilateral in the TS and contralateral in both the TLJ and LS. Significant coupled flexion in the LS was also observed. Coupled LB and AR ROMs were not significantly different between the TS and LS or from one another. Conclusions: The findings support evidence of consistent coupled motion patterns of the TS and LS during LB and AR. These novel data may serve as reference for computational model validations and future in vitro studies investigating spinal deformities and implants.

Decreasing the Pedicle Screw Misplacement Rate in the Thoracic Spine With Robot-guided Navigation.

STUDY DESIGN: A retrospective chart review. OBJECTIVE: The aim of this study was to evaluate the screw accuracy of thoracic pedicle screws placed with a robot-guided navigation system. SUMMARY OF BACKGROUND DATA: Thoracic pedicles are smaller in diameter than lumbar pedicles, making pedicle screw placement difficult. Misplaced pedicle screws may present complications including decreased construct stability, and increased risks of neurological deficits and blood vessel perforation. There is a dearth of knowledge on thoracic pedicle screw accuracy placed with a robot. MATERIALS AND METHODS: A retrospective analysis of the robot-assisted placement of thoracic pedicle screws was performed. Preoperative and postoperative computed tomography (CT) scans of the implanted thoracic screws were collected to assess screw placement accuracy, pedicle breadth, and placement deviations. A CT-based Gertzbein and Robbins System was used to classify pedicle screw accuracy in 2 mm increments. A custom image overlay software was used to determine the deviations between the preoperatively planned trajectory of pedicle screws and final placement at screw entry (tail), and tip in addition to the angular deviation. RESULTS: Seventy-five thoracic pedicle screws were implanted by navigated robotic guidance in 17 patients, only 1.3% (1/75) were repositioned intraoperatively. Average patient age and body mass index were 57.5 years and 25.9 kg/m 2 , respectively, with 52.9% female patients. Surgery diagnoses were degenerative disk disease (47.1%) and adjacent segment disease (17.6%). There were zero complications, with no returns to the operating room. According to the CT-based Gertzbein and Robbins pedicle screw breach classification system, 93.3% (70/75) screws were grade A or B, 6.6% (5/75) were grade C, and 0% were grade D or E. The average deviation from the preoperative plan to actual final placement was 1.8±1.3 mm for the screw tip, 1.6±0.9 mm for the tail, and 2.1±1.5 degrees of angulation. CONCLUSIONS: The current investigation found a 93.3% accuracy of pedicle screw placement in the thoracic spine. Navigated robot assistance is a useful system for placing screws in the smaller pedicles of the thoracic spine. LEVEL OF EVIDENCE: Level III-retrospective nonexperimental study.

An investigation of range of motion preservation in fusionless anterior double screw and cord constructs for scoliosis correction.

PURPOSE: To evaluate the motion-preserving properties of vertebral body tethering with varying cord/screw constructs and cord thicknesses in cadaveric thoracolumbar spines. METHODS: In vitro flexibility tests were performed on six fresh-frozen human cadaveric spines (T1-L5) (2 M, 4F) with a median age of 63 (59-to-80). An ± 8 Nm load was applied to determine range of motion (ROM) in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) in the thoracic and lumbar spine. Specimens were tested with screws (T5-L4) and without cords. Single (4.0 mm and 5.0 mm) and double (4.0 mm) cord constructs were sequentially tensioned to 100 N and tested: (1) Single 4.0 mm and (2) 5.0 mm cords (T5-T12); (3) Double 4.0 mm cords (T5-12); (4) Single 4.0 mm and (5) 5.0 mm cord (T12-L4); (6) Double 4.0 mm cords (T12-L4). RESULTS: In the thoracic spine (T5-T12), 4.0-5.0 mm single-cord constructs showed slight reductions in FE and 27-33% reductions in LB compared to intact, while double-cord constructs showed reductions of 24% and 40%, respectively. In the lumbar spine (T12-L4), double-cord constructs had greater reductions in FE (24%), LB (74%), and AR (25%) compared to intact, while single-cord constructs exhibited reductions of 2-4%, 68-69%, and 19-20%, respectively. CONCLUSIONS: The present biomechanical study found similar motion for 4.0-5.0 mm single-cord constructs and the least motion for double-cord constructs in the thoracic and lumbar spine suggesting that larger diameter 5.0 mm cords may be a more promising motion-preserving option, due to their increased durability compared to smaller cords. Future clinical studies are necessary to determine the impact of these findings on patient outcomes.

An In Vitro Biomechanical Analysis of Contralateral Sacroiliac Joint Motion Following Unilateral Sacroiliac Stabilization with and without Lumbosacral Fixation.

STUDY DESIGN: Cadaveric biomechanics study. PURPOSE: This study investigated the effects of unilateral sacroiliac joint (SIJ) fixation for fusion with/without L5-S1 fixation on contralateral SIJ range of motion (ROM). OVERVIEW OF LITERATURE: SIJ fusion raises concerns that unilateral SIJ stabilization for fusion may increase contralateral SIJ mobility, leading to accelerated SIJ degeneration. Also, prior lumbosacral fixation may lead to accelerated SIJ degeneration, due to adjacent level effects. SIJ fixation biomechanics have been evaluated, showing a reduced-ROM, but SIJ fixation effects on contralateral nonfixated SIJ remain unknown. METHODS: Seven human lumbopelvic spines were used, each affixed to six-degrees-of-freedom testing apparatus; 8.5-Nm pure unconstrained bending moments applied in flexion-extension, lateral bending, and axial rotation. The ROM of left and right SIJ was measured using a motion analysis system. Each specimen tested as (1) intact, (2) injury (left), (3) L5-S1 fixation, (4) unilateral stabilization (left), (5) unilateral stabilization+L5-S1 fixation, (6) bilateral stabilization, and (7) bilateral stabilization+L5-S1 fixation. Both left-sided iliosacral and posterior ligaments were cut for injury condition to model SIJ instability before surgery. RESULTS: There were no statistical differences between fixated and contralateral nonfixated SIJ ROM following unilateral stabilization with/without L5-S1 fixation for all loading directions (p>0.930). Injured condition and L5-S1 fixation provided the largest motion increases across both joints; no significant differences were recorded between SIJs in any loading direction (p>0.850). Unilateral and bilateral stabilization with/without L5-S1 fixation reduced ROM compared with the injured condition for both SIJs, with bilateral stabilization providing maximum stability. CONCLUSIONS: In the cadaveric model, unilateral SIJ stabilization with/without lumbosacral fixation did not lead to significant contralateral SIJ hypermobility; long-term changes and in vivo response may differ.

A Dual-Screw Technique for Vertebral Compression Fractures via Robotic Navigation in the Osteopenic Lumbar Spine: An In-Vitro Biomechanical Analysis.

STUDY DESIGN: Biomechanical cadaveric study. OBJECTIVES: Multi-rod constructs maximize posterior fixation, but most use a single pedicle screw (PS) anchor point to support multiple rods. Robotic navigation allows for insertion of PS and cortical screw (CS) within the same pedicle, providing 4 points of bony fixation per vertebra. Recent studies demonstrated radiographic feasibility for dual-screw constructs for posterior lumbar spinal fixation; however, biomechanical characterization of this technique is lacking. METHODS: Fourteen cadaveric lumbar specimens (L1-L5) were divided into 2 groups (n = 7): PS, and PS + CS. VCF was simulated at L3. Bilateral posterior screws were placed from L2-L4. Load control (±7.5Nm) testing performed in flexion-extension (FE), lateral bending (LB), axial rotation (AR) to measure ROM of: (1) intact; (2) 2-rod construct; (3) 4-rod construct. Static compression testing of 4-rod construct performed at 5 mm/min to measure failure load, axial stiffness. RESULTS: Four-rod construct was more rigid than 2-rod in FE (P < .001), LB (P < .001), AR (P < .001). Screw technique had no significant effect on FE (P = .516), LB (P = .477), or AR (P = .452). PS + CS 4-rod construct was significantly more stable than PS group (P = .032). Stiffness of PS + CS group (445.8 ± 79.3 N/mm) was significantly greater (P = .019) than PS (317.8 ± 79.8 N/mm). Similarly, failure load of PS + CS group (1824.9 ± 352.2 N) was significantly greater (P = .001) than PS (913.4 ± 309.8 N). CONCLUSIONS: Dual-screw, 4-rod construct may be more stable than traditional rod-to-rod connectors, especially in axial rotation. Axial stiffness and ultimate strength of 4-rod, dual-screw construct were significantly greater than rod-to-rod. In this study, 4-rod construct was found to have potential biomechanical benefits of increased strength, stiffness, stability.

Selecting the lowest instrumented vertebra in a multilevel posterior cervical fusion across the cervicothoracic junction: a biomechanical investigation.

OBJECTIVE: Posterior cervical fusion is a common surgical treatment for patients with myeloradiculopathy or regional deformity. Several studies have found increased stresses at the cervicothoracic junction (CTJ) and significantly higher revision surgery rates in multilevel cervical constructs that terminate at C7. The purpose of this study was to investigate the biomechanical effects of selecting C7 versus T1 versus T2 as the lowest instrumented vertebra (LIV) in multisegmental posterior cervicothoracic fusion procedures. METHODS: Seven fresh-frozen cadaveric cervicothoracic spines (C2-L1) with ribs intact were tested. After analysis of the intact specimens, posterior rods and lateral mass screws were sequentially added to create the following constructs: C3-7 fixation, C3-T1 fixation, and C3-T2 fixation. In vitro flexibility tests were performed to determine the range of motion (ROM) of each group in flexion-extension (FE), lateral bending (LB), and axial rotation (AR), and to measure intradiscal pressure of the distal adjacent level (DAL). RESULTS: In FE, selecting C7 as the LIV instead of crossing the CTJ resulted in the greatest increase in ROM (2.54°) and pressure (29.57 pound-force per square inch [psi]) at the DAL in the construct relative to the intact specimen. In LB, selecting T1 as the LIV resulted in the greatest increase in motion (0.78°) and the lowest increase in pressure (3.51 psi) at the DAL relative to intact spines. In AR, selecting T2 as the LIV resulted in the greatest increase in motion (0.20°) at the DAL, while selecting T1 as the LIV resulted in the greatest increase in pressure (8.28 psi) in constructs relative to intact specimens. Although these trends did not reach statistical significance, the observed differences were most apparent in FE, where crossing the CTJ resulted in less motion and lower intradiscal pressures at the DAL. CONCLUSIONS: The present biomechanical cadaveric study demonstrated that a cervical posterior fixation construct with its LIV crossing the CTJ produces less stress in its distal adjacent discs compared with constructs with C7 as the LIV. Future clinical testing is necessary to determine the impact of this finding on patient outcomes.

Impaction grafting of lumbar pedicle defects: a biomechanical study of a novel technique for pedicle screw revision.

OBJECTIVE: The two most common revision options available for the management of loose pedicle screws are larger-diameter screws and cement augmentation into the vertebral body for secondary fixation. An alternative revision method is impaction grafting (pedicoplasty) of the failed pedicle screw track. This technique uses the impaction of corticocancellous bone into the pedicle and vertebral body through a series of custom funnels to reconstitute a new pedicle wall and a neomedullary canal. The goal of this study was to compare the biomechanics of screws inserted after pedicoplasty (impaction grafting) of a pedicle defect to those of an upsized screw and a cement-augmented screw. METHODS: For this biomechanical cadaveric study the investigators used 10 vertebral bodies (L1-5) that were free of metastatic disease or primary bone disease. Following initial screw insertion, each screw was subjected to a pullout force that was applied axially along the screw trajectory at 5 mm per minute until failure. Each specimen was instrumented with a pedicoplasty revision using the original screw diameter, and on the contralateral side either a fenestrated screw with cement augmentation or a screw upsized by 1 mm was inserted in a randomized fashion. These revisions were then pulled out using the previously mentioned methods. RESULTS: Initial screw pullout values for the paired upsized screw and pedicoplasty were 717 ± 511 N and 774 ± 414 N, respectively (p = 0.747) (n = 14). Revised pullout values for the paired upsized screw and pedicoplasty were 775 ± 461 N and 762 ± 320 N, respectively (p = 0.932). Initial pullout values for the paired cement augmentation and pedicoplasty were 792 ± 434 N and 880 ± 558 N, respectively (p = 0.649). Revised pullout values for the paired cement augmentation and pedicoplasty were 1159 ± 300 N and 687 ± 213 N, respectively (p < 0.001). CONCLUSIONS: Pedicle defects are difficult to manage. Reconstitution of the pedicle and creation of a neomedullary canal appears to be possible through the use of pedicoplasty. Biomechanically, screws that have been used in pedicoplasty have equivalent pullout strength to an upsized screw, and have greater insertional torques than those with the same diameter that have not been used in pedicoplasty, yet they are not superior to cement augmentation. This study suggests that although cement augmentation appears to have superior pullout force, the novel pedicoplasty technique offers promise as a viable biological revision option for the management of failed pedicle screws compared with the option of standard upsized screws in a cadaveric model. These findings will ultimately need to be further assessed in a clinical setting.

A quantitative accuracy assessment of the use of a rigid robotic arm in navigated placement of 726 pedicle screws.

BACKGROUND: Traditional minimally invasive fluoroscopy-based techniques for pedicle screw placement utilize guidance, which may require fluoroscopic shots. Computerized tomography (CT) navigation results in more accurate screw placement. Robotic surgery seeks to establish access and trajectory with greater accuracy. OBJECTIVE: This study evaluated the screw placement accuracy of a robotic platform. METHODS: Demographic data, preoperative/postoperative CT scans, and complication rates of 127 patients who underwent lumbosacral pedicle screw placement with minimally invasive navigated robotic guidance using preoperative CT were analyzed. RESULTS: On the GRS scale, 97.9% (711/726) of screws were graded A or B, 1.7% (12/726) of screws graded C, 0.4% (3/726) of screws graded D, and 0% graded E. Average offset from preoperative plan to final screw placement was 1.9 ± 1.5 mm from tip, 2.2 ± 1.4 mm from tail and 2.9 ± 2.3° of angulation. CONCLUSIONS: Robotic-assisted surgery utilizing preoperative CT workflow with intraoperative fluoroscopy-based registration improves pedicle screw placement accuracy within a patient's pedicles.

A Critical Analysis of Lateral Versus Central Endpoint in Distal Tibia Nailing: Does It Affect Alignment?

OBJECTIVES: To evaluate the effect of a traditional "center-center" end point for distal tibia nailing in comparison with a lateral-of-center end point on fracture malalignment in a cadaver model. METHODS: Nine matched pairs of human cadaveric lower-extremity specimens were used to model the effect of nail end point on fracture alignment in extra-articular distal tibia fractures. After simulation of the fracture through a standardized osteotomy, 1 member of each pair was fixed with an intramedullary nail using a "center-center" end point, whereas a lateral-of-center end point was used for the other member of the pair. Specimens were stripped of soft tissue, and digital calipers were used to measure fracture translation and gap medially, laterally, anteriorly, and posteriorly. Coronal plane angulation at each fracture was measured on the final mortise image. RESULTS: The average coronal angulation was 7.0 degrees of valgus (with a SD of 4.1) in central-end point specimens versus 0.2 degrees of valgus (SD = 1.5) in lateral-end point specimens ( P < 0.001). Lateral-end point specimens also demonstrated significantly less fracture gap medially (mean 0.2 vs. 3.1 mm for central-end point specimens, P < 0.001), anteriorly (mean 0.1 vs. 1.3 mm, P = 0.003), and posteriorly (mean 0.3 vs. 2.2 mm, P = 0.003). Lateral-end point specimens also showed less lateral translation (mean 0.6 vs. 1.6 mm, P = 0.006). CONCLUSIONS: Lateral-of-center nail end points may help surgeons restore native alignment in extra-articular distal tibia fractures and avoid valgus malalignment.

Fixation Strength of Modified Iliac Screw Trajectory Compared to Traditional Iliac and S2 Alar-Iliac Trajectories: A Cadaveric Study.

OBJECTIVE: Traditional iliac (TI) screws require extensive dissection, involve offset-connectors, and have prominent screw heads that may cause patient discomfort. S2 alar-iliac (S2AI) screws require less dissection, do not need offset connectors, and are less prominent. However, the biomechanical consequences of S2AI screws crossing the alar-iliac joint is unknown. The present study investigates the fixation strength of a modified iliac (MI) screw, which has a more medial entry point and reduced screw prominence, but does not cross the alar-iliac joint. METHODS: Eighteen sacropelvic spines were divided into 3 groups (n = 6): TI, S2AI, and MI. Each specimen was fixed unilaterally with S1 pedicle screws and pelvic fixation according to its group. Screws were loaded at ±10 Nm at 3Hz for 1000 cycles. Motion of each screw and rod strain above and below the S1 screw was measured. RESULTS: Toggle of the S1 screw was lowest for the TI group, followed by the MI and S2AI groups, but there were no significant differences (P = 0.421). Toggle of the iliac screw relative to the pelvis was also lowest for the TI group, followed by the MI group, and was greatest for the S2AI group, without significant differences (P = 0.179). Rod strain was similar across all groups. CONCLUSIONS: No statistically significant differences were found between the TI, S2AI, and MI techniques with regard to screw toggle or rod strain. Advantages of the MI screw include its lower profile and a medialized starting point eliminating the need for offset-connectors.

The Effect of Sacroiliac Fusion and Pelvic Fixation on Rod Strain in Thoracolumbar Fusion Constructs: A Biomechanical Investigation.

STUDY DESIGN: In vitro biomechanical study. OBJECTIVE: Investigate effects of sacroiliac joint (SIJ) fusion and iliac fixation on distal rod strain in thoracolumbar fusions. SUMMARY OF BACKGROUND DATA: Instrument failure is a multifactorial, challenging problem frequently encountered by spinal surgeons. Increased rod strain may lead to instrumentation failure and rod fracture. METHODS: Seven fresh frozen human cadaveric specimens (T9-pelvis) used. Six operative constructs tested to investigate changes in rod strain at L5-S1 and S1-Ilium rods, posterior pedicle screws/rods from T10-S1 (PS), PS + bilateral iliac screw fixation, PS + unilateral iliac screw fixation (UIS), PS+UIS+3 unilateral SIJ screws, PS + 3 unilateral SIJ screws, and PS +6 bilateral SIJ screws. Uniaxial strain gauges were used to measure surface strain of rods during flexion-extension. RESULTS: In flexion-extension, bilateral iliac screws added significant strain to L5-S1 compared with long fusion constructs ending at S1 (PS) (P < 0.05). Unilateral iliac fixation exhibited highest strain to L5-S1 ipsilateral rod, was significantly higher compared with bilateral iliac fixation and PS construct. Unilateral and bilateral SIJ fusion did not significantly change L5-S1 rod strain compared with PS. When measuring S1-Ilium rod strain, unilateral pelvic fixation had highest reported rod strain, approached significance compared with bilateral iliac screws (P = 0.054). Addition of contralateral SIJ fusion did not affect rod strain at S1-ilium on side with unilateral fixation. CONCLUSION: Results showed additional fixation below S1 to pelvis added significant rod strain. Unilateral pelvic screws had highest rod strain; SIJ fusion did not affect rod strain. Findings can help guide surgeons when associated risk of rod failure is a consideration.Level of Evidence: N/A.

Biomechanical investigation of potential prophylactic scoliosis treatments following various sizes of chest wall resection.

BACKGROUND: A well-known problematic sequela of chest wall resections is development of scoliosis. Despite the seriousness and frequency of scoliosis following chest well resection, the etiology and biomechanical information needed to understand this progression aren't well-known. METHODS: Range of motion of six specimen (C7-L2) was captured using a custom-built six degrees-of-freedom machine in each of three physiological rotation axes. Left posterior ribs were sequentially resected 7cm from the rib head, starting at the 5th rib and continuing until the 10th rib. Injured specimen were instrumented with unilateral anterior rod fixation and then with additional unilateral posterior fixation, each starting at T4 and then extended distally as ribs were resected. Relative motion between the constructs' proximal and distal ends was measured in all three axes for the intact, injured, unilateral anterior, and unilateral anterior with unilateral posterior constructs. FINDINGS: Raw motion of the injured specimen increased in a stepwise manner as ribs were resected. Averaged across all injury sizes, the unilateral anterior construct significantly reduced motion by 47.0±13.4% in lateral bending (P=.001). The combined anterior-posterior construct significantly reduced motion by 57.6±15.9% in flexion/extension (P<.001), 70.3±12.2% in lateral bending (P<.001), and 51.1±14.5% in axial rotation (P<.001). Combined anterior-posterior fixation was significantly more stable than anterior-only fixation in flexion/extension (P=.002). INTERPRETATION: Regardless of injury size, posterior rib resection did not create significant immediate instability of the thoracic spine. Concurrent spinal stabilization was shown to maintain thoracic spine stability. Combined anterior-posterior fixation proved to be significantly more rigid than an anterior-only construct.

Comparison of 3D-printed titanium-alloy, standard titanium-alloy, and PEEK interbody spacers in an ovine model.

BACKGROUND CONTEXT: Osseointegration is a pivotal process in achieving a rigid fusion and ultimately a successful clinical outcome following interbody fusion surgery. Advancements in 3D printing technology permit commonly used titanium interbody spacers to be designed with unique architectures, such as a highly interconnected and specific porous structure that mimics the architecture of trabecular bone. Interbody implants with a microscale surface roughness and biomimetic porosity may improve bony ongrowth and ingrowth compared to traditional materials. PURPOSE: The purpose of this study was to compare the osseointegration of lumbar interbody fusion devices composed of surgical-grade polyetheretherketone (PEEK), titanium-alloy (TAV), and 3D-printed porous, biomimetic TAV (3DP) using an in vivo ovine model. STUDY DESIGN: In Vivo Preclinical Animal Study METHODS: Eighteen sheep underwent two-level lateral lumbar interbody fusion randomized with either 3DP, PEEK, or TAV interbody spacers (n=6 levels for each spacer per time point). Postoperative time points were 6 and 12 weeks. Microcomputed tomography and histomorphometry were used to quantify bone volume (BV) within the spacers (ingrowth) and the surface bone apposition ratio (BAR) (ongrowth), respectively. RESULTS: The 3DP-treatment group demonstrated significantly higher BV than the PEEK and TAV groups at 6 weeks (77.3±44.1 mm3, 116.9±43.0 mm3, and 108.7±15.2 mm3, respectively) (p<.05). At 12 weeks, there were no BV differences between groups (p>.05). BV increased in all groups from the 6- to 12-week time points (p<.05). At both time points, the 3DP-treated group (6w: 23.6±10.9%; 12w: 36.5±10.9%) had significantly greater BAR than the PEEK (6w: 8.6±2.1%; 12w: 14.0±5.0%) and TAV (6w: 6.0±5.7%; 12w: 4.1±3.3%) groups (p<.05). CONCLUSIONS: 3DP interbody spacers facilitated greater total bony ingrowth at 6 weeks, and greater bony ongrowth postoperatively at both 6 and 12 weeks, in comparison to solid PEEK and TAV implants. CLINICAL SIGNIFICANCE: Based on these findings, the 3DP spacers may be a reasonable alternative to traditional PEEK and TAV spacers in various clinical applications of interbody fusion.

Lumbar Intervertebral Spacer With Cement Augmentation of Endplates and Integrated Screws as a Fixation Device in an Osteoporotic Model: An In Vitro Kinematic and Load-to-Failure Study.

BACKGROUND: Integrated lateral lumbar interbody fusion (LLIF) devices have been shown to successfully stabilize the spine and avoid complications related to posterior fixation. However, LLIF has increased subsidence risk in osteoporotic patients. Cement augmentation through cannulated pedicle screws enhances pedicle fixation and cage-endplate interface yet involves a posterior approach. Lateral application of cement with integrated LLIF fixation has been introduced and requires characterization. The present study set out to evaluate kinematic and load-to-failure properties of a novel cement augmentation technique with an integrated LLIF device, alone and with unilateral pedicle fixation, compared with bilateral pedicle screws and nonintegrated LLIF (BPS + S). METHODS: Twelve specimens (L3-S1) underwent discectomy at L4-L5. Specimens were separated into 3 groups: (1) BPS + S; (2) polymethyl methacrylate (PMMA) augmentation, integrated LLIF, and unilateral pedicle screws (PMMA + UPS + iS); and (3) PMMA and integrated LLIF (PMMA + iSA) without posterior fixation. Flexion-extension, lateral bending, and axial rotation were applied. A compressive load was applied to L4-L5 segments until failure. An analysis was performed (P < .05). RESULTS: Operative constructs significantly reduced motion relative to intact specimens in all motion planes (P < .05). BPS + S provided the most stability, reducing motion by 71.6%-86.4%, followed by PMMA + UPS + iS (68.1%-79.4%) and PMMA + iSA (62.9%-81.9%); no significant differences were found (P > .05). PMMA + UPS + iS provided the greatest resistance to failure (2290 N), followed by PMMA + iSA (1970 N) and BPS + S (1390 N); no significant differences were observed (P > .05). CONCLUSIONS: Cement augmentation of vertebral endplates via the lateral approach with integrated LLIF moderately improved cage-endplate strength compared to BPS + S in an osteoporotic model; unilateral pedicle fixation further improved failure load. Reconstruction before and after application of unilateral pedicle screws and rods was biomechanically equivalent to anteroposterior reconstruction. Overall, initial results suggest that integrated LLIF with cement augmentation may be a viable alternative in the presence of osteoporosis.

Laterally Placed Expandable Interbody Spacers With and Without Adjustable Lordosis Improve Radiographic and Clinical Outcomes: A Two-Year Follow-Up Study.

Introduction Interbody spacers are necessary for achieving disc height restoration when surgical intervention is used for the treatment of severe degenerative disc disease. Minimally invasive lateral lumbar interbody fusion (MIS LLIF) is a popular surgical approach that historically uses large static interbody spacers through a lateral approach. However, static spacers have been associated with iatrogenic distraction and excessive impaction forces, which may increase the risk of subsidence and loss of lordosis, compromising stability. Expandable interbody spacers with or without adjustable lordosis may help address these concerns by maximizing segmental lordosis and aiding in sagittal balance correction. This study describes the clinical and radiographic outcomes of patients treated with expandable interbody spacers with or without adjustable lordosis, for MIS LLIF. Materials and methods This is retrospective, single-surgeon Institutional Review Board-exempt chart review was of 103 consecutive patients who had undergone MIS LLIF at one to two contiguous level(s) utilizing expandable interbody spacers with or without adjustable lordosis (66/103 patients had adjustable lordosis spacers). Collection of clinical and radiographic functional outcomes occurred at preoperative and postoperative time points through 24 months. Results One-hundred and three consecutive patients were evaluated-average age, 58.2 ± 12.1 years; 42.1% (45/107) were female. There were 78.6% (81/103) one-level cases and 21.4% (22/103) two-level cases for a total of 125 levels; 44.8% (56/125) were performed at L4-5 and 34.4% (43/125) at L3-4. The average estimated blood loss was 24.6 ± 12.3cc. Mean operative time was 61.0 ± 19.1 min, and mean fluoroscopic time was 28.2 ± 14.6 sec. Visual Analog Scale (VAS) back and leg pain scores decreased significantly by an average of 7.1 ± 1.0 points at 24 months (p<0.001). Oswestry Disability Index (ODI) scores significantly decreased by a mean of 67.4 ± 8.9 points at 24 months (p<0.001). Lumbar lordosis significantly improved by a mean of 3.1 ± 8.8° at 24 months (p=0.001). Anterior, middle, and posterior disc height significantly increased at 24 months by averages of 4.7 ± 3.1, 4.0 ± 3.0, and 2.1 ± 2.2mm, respectively (p<0.001). Neuroforaminal height had significantly increased at 24 months by a mean of 3.0 ± 3.6mm (p<0.001). Segmental lordosis significantly improved by 3.7 ± 2.9° at 24 months (p<0.001). There were 51 patients with abnormal preoperative Pelvic Incidence-Lumbar Lordosis (PI-LL) measurements that significantly improved by 9.1 ± 4.9° (p<0.001) and 52 patients with normal preoperative PI-LL measurements that improved by 0.2 ± 4.6° (p=0.748) at 24 months. One-hundred percent fusion occurred at all levels, and no findings of radiolucency were observed. One case of subsidence (1/125, 0.8%) was reported at 24 months. No implanted-related complications were reported, with 0% pseudoarthrosis and no secondary surgery required at the operative levels. Conclusion Indirect decompression and sagittal correction were achieved and maintained through a 24-month follow-up. Functional clinical outcomes significantly improved based on decreased VAS pain and ODI scores at 24 months. This study resulted in positive clinical and radiographic outcomes for patients who underwent MIS LLIF with expandable interbody spacers with or without adjustable lordosis.

A Mechanical Comparison of the Compressive Force Generated by Various Headless Compression Screws and the Impact of Fracture Gap Size.

Background: There is evidence that interfragmentary fracture gap size may affect the compression achievable with a modern headless compression screw (HCS). This mechanical study compared the compression achieved by 3 commercial HCS systems through various fracture gaps: CAPTIVATE Headless (Globus Medical, Inc, Audubon, Pennsylvania), Synthes (DePuy Synthes, Westchester, Pennsylvania), and Acumed Acutrak 2 (Acumed LLC, Hillsboro, Oregon). Methods: Screws were inserted into a custom test fixture composed of polyurethane synthetic bone foam fragments, separated by a layer of easily compressible polyurethane foam simulating a fracture gap. Compression was measured after final insertion and countersinking. The effect of the interfragmentary fracture gap size on the compression generated was also investigated. Results: The CAPTIVATE Headless 3.0 mm screw (70.1 ± 5.7 N) and the Synthes 3.0 mm screw (64.9 ± 7.3 N) achieved similar compressive forces after final countersink. Similar comparisons were found for the CAPTIVATE Headless 2.5 mm and Synthes 2.4 mm screws, and the CAPTIVATE Headless 4.0 mm and Acutrak 2 Standard screws. The final compression of the CAPTIVATE Headless 2.5 mm and Synthes 2.4 mm screws was not significantly affected when the fracture gap was doubled from 2 to 4 mm, but was reduced significantly by 95.9% with the Acutrak 2 Micro screw. Conclusion: When comparing like-sized screws, the CAPTIVATE, Synthes, and Acutrak 2 HCS systems demonstrated similar potential compressive forces. However, compared with the CAPTIVATE Headless and Synthes HCS systems, which are inserted with a compression sleeve that is not gap distance-dependent, the Acutrak 2 HCS system demonstrated less compression when the simulated fracture gap size was increased to 4 mm.