Finite Element Analysis and Biomechanical Comparison of Short Posterior Spinal Instrumentation with Divergent Bridge Construct versus Parallel Tension Band Construct for Thoracolumbar Spine Fractures.

The ideal treatment for unstable thoracolumbar fractures remains controversial with posterior reduction and stabilization, anterior reduction and stabilization, combined posterior and anterior reduction and stabilization, and even nonoperative management advocated. Short segment posterior osteosynthesis of these fractures has less comorbidities compared with the other operative approaches but settles into kyphosis over time. Biomechanical comparison of the divergent bridge construct versus the parallel tension band construct was performed for anteriorly destabilized T11-L1 spine segments using three different models: (1) finite element analysis (FEA), (2) a synthetic model, and (3) a human cadaveric model. Outcomes measured were construct stiffness and ultimate failure load. Our objective was to determine if the divergent pedicle screw bridge construct would provide more resistance to kyphotic deforming forces. All three modalities showed greater stiffness with the divergent bridge construct. The FEA calculated a stiffness of 21.6 N/m for the tension band construct versus 34.1 N/m for the divergent bridge construct. The synthetic model resulted in a mean stiffness of 17.3 N/m for parallel tension band versus 20.6 N/m for the divergent bridge (p = 0.03), whereas the cadaveric model had an average stiffness of 15.2 N/m in the parallel tension band compared with 18.4 N/m for the divergent bridge (p = 0.02). Ultimate failure load with the cadaveric model was found to be 622 N for the divergent bridge construct versus 419 N (p = 0.15) for the parallel tension band construct. This study confirms our clinical experience that the short posterior divergent bridge construct provides greater stiffness for the management of unstable thoracolumbar fractures.

Biomechanical analysis of chlorhexidine power irrigation to disinfect contaminated anterior cruciate ligament grafts.

BACKGROUND: Accidental graft contamination is a likely complication to occur in an orthopaedic sports medicine surgeon's career. There are no clinical outcome studies to direct management, and a recent survey showed that preferred management varied. Three liters of 2% chlorhexidine power irrigation has been shown to be an efficient and effective disinfection protocol; however, the biomechanical sequelae of this disinfection protocol to the graft are unknown. PURPOSE: The purpose of this study was to determine if 3 L of 2% chlorhexidine power irrigation used to disinfect contaminated anterior cruciate ligament (ACL) grafts significantly weakens the graft at time zero. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh bovine superficial digital flexor tendons underwent disinfection protocol with 3 L of 2% chlorhexidine power irrigation. Contralateral tendons served as the control. Tendons were preconditioned and loaded to failure. RESULTS: The average ultimate failure load for the control tendons and disinfected tendons was 4081 ± 654.4 N and 4146 ± 723.2 N, respectively. The average ultimate failure stress for the control tendons and disinfected tendons was 97.10 ± 12.03 MPa and 95.18 ± 11.79 MPa, respectively. The average stiffness for the control tendons and disinfected tendons was 546.20 ± 28.16 N/mm and 539.2 ± 25.93 N/mm, respectively. The P values for ultimate failure load, ultimate failure stress, and stiffness showed no statistically significant difference between the chlorhexidine and control tendons. CONCLUSION: Disinfecting tendons with 3 L of 2% chlorhexidine power irrigation does not adversely weaken the tendon's tensile mechanical properties. CLINICAL RELEVANCE: Three liters of 2% chlorhexidine power irrigation can effectively disinfect a contaminated ACL graft without weakening the graft.

Effect of oxygen levels on proteoglycan synthesis by intervertebral disc cells.

STUDY DESIGN: the response of cells from the annulus fibrosus (AF) and nucleus pulposus (NP) to varying oxygen (O2) concentrations was examined when cultured in alginate. OBJECTIVE: to study the effect of O2 concentration on AF and NP cells. SUMMARY OF BACKGROUND DATA: AF and NP cells possess different metabolic profiles in situ. However, it is not clear whether this difference is maintained in in vitro culture conditions. AF and NP cells can respond differently in the different systems, which may differ from the in vivo environment in terms of nutrient supply and O2 levels. In vivo, O2 levels vary from 1% to 5% within the intervertebral disc, and there is evidence that disc cell metabolism can vary with O2 concentrations. METHODS: an alginate scaffold was seeded with bovine AF or NP cells and maintained in culture for up to 18 days under different O2 concentrations. The sulfated glycosaminoglycan (GAG) content in the culture medium and the expression of aggrecan, type I (COL1A2) and II (COL2A1) collagen genes were analyzed at day 9 and day 18. RESULTS: in both NP and AF cells cultured either in normoxia (21% O2) or in hypoxia (5% and 1% O2), the GAG content of the culture medium increased with time, though the rate of increase was diminished in 5% O2. With a decrease in O2 levels, the expression of aggrecan mRNA increased in NP cells. There was little effect of O2 on aggrecan mRNA level in AF cells. However, there was a slight decrease with time. Interestingly, aggrecan mRNA levels did not reflect GAG release for either NP or AF cells. There was no effect with time or O2 levels on COL2A1 message in NP cells. The highest Aggrecan/COL2 message ratio for NP cells was with 1% O2, suggesting this to be the best condition for maintaining the NP phenotype. COL1A2 gene expression in NP and AF cells increased with time, but showed little change with O2 levels in NP cells. The highest COL2/COL1 ratio in NP cells was also observed with 1% O2. Finally, NP cells tended to remain localized in the alginate beads, whereas AF cells tended to migrate from the beads. CONCLUSION: both NP and AF cells showed little change in GAG production with O2 levels ranging from 1% to 21%. Disc cell metabolism is not impaired at low O2 concentrations, which appear beneficial to matrix composition. Furthermore, low oxygen may promote a gelatinous NP matrix, whereas increased oxygen levels may promote a fibrous matrix.

Risk of periprosthetic femoral neck fracture after hip resurfacing arthroplasty: valgus compared with anatomic alignment. A biomechanical and clinical analysis.

BACKGROUND: Early clinical results of hip resurfacing arthroplasty have led to the recommendation to achieve a neck-shaft angle of 140 degrees when inserting the femoral component. In addition, the idea of adhering to an absolute angle when inserting instrumentation in hips with excessive anatomic varus or valgus neck-shaft angles has raised concern. A biomechanical analysis was completed in order to determine if the achieved valgus orientation of the femoral component reduced the risk of periprosthetic fracture. METHODS: Twenty fresh-frozen cadaveric femora were blindly assigned to be implanted with a neutral or valgus-oriented hip-resurfacing femoral component. Bone mineral density scans were acquired for all femora. All specimens were loaded axially to failure at a rate of 0.21 mm per second. Radiographs of the specimens were measured in order to determine the relative valgus orientation of the femoral components and the change in offset. RESULTS: There was a significant increase in the ultimate failure load for the valgus-oriented components. While the bone density scans revealed that the bone mineral densities measured in the neutral and valgus-oriented femoral components were almost identical, the ultimate failure load was found to be significantly increased for the valgus-oriented components (6955 N) compared with the neutral-oriented components (5254 N). For the valgus-oriented femoral components, two had failure at the subcapital level, seven had vertical shear fractures, and one had an anterior shear fracture. For the neutral-oriented components, five subcapital fractures and five vertical shear failures were observed. CONCLUSIONS: The study suggests that a valgus orientation decreases the risk of periprosthetic femoral neck fracture following hip resurfacing. It also brings into question the use of an absolute angle for all patients. Obtaining the maximum possible valgus angle, while avoiding notching, may in fact provide the optimum protection from periprosthetic femoral neck fractures.

Effect of vertebral shell on injection pressure and intravertebral pressure in vertebroplasty.

STUDY DESIGN: An experimental biomechanical study conducted on osteoporotic cadaveric vertebrae. OBJECTIVES: 1) To measure the intravertebral shell pressure and injection pressure; and 2) to determine the effect of the vertebral shell on the intravertebral shell pressure and on the injection pressure. SUMMARY OF BACKGROUND DATA: Forces that govern cement flow are an essential component of the cement injection process in vertebroplasty. The vertebral shell may play a significant role in confining the flow of cement in the vertebral body and thereby affecting the intravertebral pressure and injection pressure. METHODS: A small fenestration was created in the left lateral vertebral shell of 14 vertebrae. A valve to open and close the fenestration and a sensor to measure the intravertebral pressure were attached to the opening. A closed fenestration simulated an intact shell, whereas an open fenestration represented a vented shell. Injection pressure and intravertebral pressure at the shell were recorded during a controlled injection. RESULTS: A closed fenestration resulted in a significant increase in the intravertebral pressure at the shell. During the injection, the shell pressure increased on average to approximately 3.54 +/- 2.91 kPa. Conversely, an open fenestration resulted in an instant relaxation of the shell pressure to the ambient pressure of 0 kPa. Additionally, the injection pressure was approximately 97 times higher than the shell pressure. CONCLUSION: The presence of vertebral shell seems to be important for intravertebral pressure. However, the intravertebral shell pressure adds very little to the injection pressure.