Cortical bone trajectory for lumbar pedicle screws.

BACKGROUND CONTEXT: Achieving solid implant fixation to osteoporotic bone presents a clinical challenge. New techniques and devices are being designed to increase screw-bone purchase of pedicle screws in the lumbar spine via a novel cortical bone trajectory that may improve holding screw strength and minimize loosening. Preliminary clinical evidence suggests that this new trajectory provides screw interference that is equivalent to the more traditionally directed trajectory for lumbar pedicle screws. However, a biomechanical study has not been performed to substantiate the early clinical results. PURPOSE: Evaluate the mechanical competence of lumbar pedicle screws using a more medial-to-lateral path (ie, "cortical bone trajectory") than the traditionally used path. STUDY DESIGN: Human cadaveric biomechanical study. METHODS: Each vertebral level (L1-L5) was dual-energy X-ray absorptiometry (DXA) scanned and had two pedicle screws inserted. On one side, the traditional medially directed trajectory was drilled and tapped. On the contralateral side, the newly proposed cortical bone trajectory was drilled and tapped. After qCT scanning, screws were inserted into their respective trajectories and pullout and toggle testing ensued. In uniaxial pullout, the pedicle screw was withdrawn vertically from the constrained bone until failure occurred. The contralateral side was tested in the same manner. In screw toggle testing, the vertebral body was rigidly constrained and a longitudinal rod was attached to each screw head. The rod was grasped using a hydraulic grip and a quasi-static, upward displacement was implemented until construct failure. The contralateral pedicle screw was tested in the same manner. Yield pullout (N) and stiffness (N/mm) as well as failure moment (N-m) were compared and bone mineral content and bone density data were correlated with the yield pullout force. RESULTS: New cortical trajectory screws demonstrated a 30% increase in uniaxial yield pullout load relative to the traditional pedicle screws (p=0.080), although mixed loading demonstrated equivalency between the two trajectories. No significant difference in construct stiffness was noted between the two screw trajectories in either biomechanical test or were differences in failure moments (p=0.354). Pedicle screw fixation did not appear to depend on bone quality (DXA) yet positive correlations were demonstrated between trajectory and bone density scans (qCT) and pullout force for both pedicle screws. CONCLUSIONS: The current study demonstrated that the new cortical trajectory and screw design have equivalent pullout and toggle characteristics compared with the traditional trajectory pedicle screw, thus confirming preliminary clinical evidence. The 30% increase in failure load of the cortical trajectory screw in uniaxial pullout and its juxtaposition to higher quality bone justify its use in patients with poor trabecular bone quality.

Ileostomy and colostomy support groups.

The first organized ostomy support group in the world was formed at The Mount Sinai Hospital, in 1950, through the efforts of a surgeon and the patients themselves. Later, similar groups were set up in other locations and some even took the name of Mount Sinai's first such society (QT). These groups had two major functions: Psychological: reassurance and understanding from other ostomates before and after the operation; advice on how to deal with oneself and others. Educational: instruction on the details of stoma management; information for surgeons on the proper location and other details of fashioning a stoma; information to the public on the existence and needs of ostomates. In order to extend services to more people and with more individual attention, a special clinic was established at The Mount Sinai Hospital devoted entirely to patients with ileostomy and colostomy. It too was the first of its kind anywhere. Years later, two surgeons arranged an all-day convention of the ostomy groups in the greater New York City, New Jersey, and Connecticut areas, at the New York Academy of Medicine. At the convention, the idea of a national society was conceived. In the following years - in Detroit, then Cleveland, and finally Los Angeles - the United Ostomy Association was developed, structured, and incorporated. The educational uses of the ostomy groups were later supplemented and partly replaced by enterostomal therapists who originally were trained and practiced in Cleveland. Now the therapists, the societies, and the ostomates themselves are available to patients with various types of stomas, whether recent or longstanding, before and after surgery.

The design and development of a triaxial wear-testing joint simulator.

Most of the existing wear testers created to wear test total hip replacements, specifically the acetabular component, are designed to exert only an axial force and provide rotation in a close approximation of the actual femoral movement. The Rocky Mountain Joint Simulator was designed to exert three orthogonal forces and provide rotations about the X-, Y- and Z-axes to more closely simulate the physiological forces and motions found in the human gait cycle. The RMJS was also designed with adaptability for other joints, such as knees or canine hips, through the use of hydraulics and a computer-programmable control system. Such adaptability and functionality allows the researcher to more closely model a gait cycle, thereby obtaining wear patterns that resemble those found in retrieved implants more closely than existing simulators. Research is ongoing into the tuning and evaluation of the machine and preliminary acetabular component wear test results will be presented at the conference.