Comparison of in vivo measured loads in knee, hip and spinal implants during level walking.

Walking is a task that we seek to understand because it is the most relevant human locomotion. Walking causes complex loading patterns and high load magnitudes within the human body. This work summarizes partially published load data collected in earlier in vivo measurement studies on 9 patients with telemeterized knee endoprostheses, 10 with hip endoprostheses and 5 with vertebral body replacements. Moreover, for the 19 endoprosthesis patients, additional simultaneously measured and previously unreported ground reaction forces are presented. The ground reaction force and the implant forces in the knee and hip exhibited a double peak during each step. The maxima of the ground reaction forces ranged from 100% to 126% bodyweight. In comparison, the greatest implant forces in the hip (249% bodyweight) and knee (271% bodyweight) were much greater. The mean peak force measured in the vertebral body replacement was 39% bodyweight and occurred at different time points of the stance phase. We concluded that walking leads to high load magnitudes in the knee and hip, whereas the forces in the vertebral body replacement remained relatively low. This indicates that the first peak force was greater in the hip than in the knee joint while this was reversed for the second peak force. The forces in the spinal implant were considerably lower than in the knee and hip joints.

Estimation of loads on human lumbar spine: A review of in vivo and computational model studies.

Spinal loads are recognized to play a causative role in back disorders and pain. Knowledge of lumbar spinal loads is required in proper management of various spinal disorders, effective risk prevention and assessment in the workplace, sports and rehabilitation, realistic testing of spinal implants as well as adequate loading in in vitro studies. During the last few decades, researchers have used a number of techniques to estimate spinal loads by measuring in vivo changes in the intradiscal pressure, body height, or forces and moments transmitted via instrumented vertebral implants. In parallel, computational models have been employed to estimate muscle forces and spinal loads under various static and dynamic conditions. Noteworthy is the increasing growth in latter computational investigations. This paper aims to review, compare and critically evaluate the existing literature on in vivo measurements and computational model studies of lumbar spinal loads to lay the foundation for future biomechanical studies. Towards this goal, the paper reviews in separate sections models dealing with static postures (standing, sitting, lying) as well as slow and fast dynamic activities (lifting, sudden perturbations and vibrations). The findings are helpful in many areas such as work place safety design and ergonomics, injury prevention, performance enhancement, implant design and rehabilitation management.

In vivo loads on a vertebral body replacement during different lifting techniques.

The repeated lifting of heavy weights has been identified as a risk factor for low back pain (LBP). Whether squat lifting leads to lower spinal loads than stoop lifting and whether lifting a weight laterally results in smaller forces than lifting the same weight in front of the body remain matters of debate. Instrumented vertebral body replacements (VBRs) were used to measure the in vivo load in the lumbar spine in three patients at level L1 and in one patient at level L3. Stoop lifting and squat lifting were compared in 17 measuring sessions, in which both techniques were performed a total of 104 times. The trunk inclination and amount of knee bending were simultaneously estimated from recorded images. Compared with the aforementioned lifting tasks, the patients additionally lifted a weight laterally with one hand 26 times. Only a small difference (4%) in the measured resultant force was observed between stoop lifting and squat lifting, although the knee-bending angle (stoop 10°, squat 45°) and trunk inclination (stoop 52°, squat 39°) differed considerably at the time points of maximal resultant forces. Lifting a weight laterally caused 14% less implant force on average than lifting the same weight in front of the body. The current in vivo biomechanical study does not provide evidence that spinal loads differ substantially between stoop and squat lifting. The anterior-posterior position of the lifted weight relative to the spine appears to be crucial for spinal loading.

Spinal loads as influenced by external loads: a combined in vivo and in silico investigation.

Knowledge of in vivo spinal loads and muscle forces remains limited but is necessary for spinal biomechanical research. To assess the in vivo spinal loads, measurements with telemeterised vertebral body replacements were performed in four patients. The following postures were investigated: (a) standing with arms hanging down on sides, (b) holding dumbbells to subject the patient to a vertical load, and (c) the forward elevation of arms for creating an additional flexion moment. The same postures were simulated by an inverse static model for validation purposes, to predict muscle forces, and to assess the spinal loads in subjects without implants. Holding dumbbells on sides increased implant forces by the magnitude of the weight of the dumbbells. In contrast, elevating the arms yielded considerable implant forces with a high correlation between the external flexion moment and the implant force. Predictions agreed well with experimental findings, especially for forward elevation of arms. Flexion moments were mainly compensated by erector spinae muscles. The implant altered the kinematics and, thus, the spinal loads. Elevation of both arms in vivo increased spinal axial forces by approximately 100N; each additional kg of dumbbell weight held in the hands increased the spinal axial forces by 60N. Model predictions suggest that in the intact situation, the force increase is one-third greater for these loads. In vivo measurements are essential for the validation of analytical models, and the combination of both methods can reveal unquantifiable data such as the spinal loads in the intact non-instrumented situation.

In vivo implant forces acting on a vertebral body replacement during upper body flexion.

Knowledge about in vivo spinal loads is required for the identification of risk factors for low back pain and for realistic preclinical testing of spinal implants. Therefore, the aim of the present study was to measure the in vivo forces on a vertebral body replacement (VBR) during trunk flexion and to analyze in detail the typical relationship between trunk inclination and spinal load. Telemeterized VBRs were implanted in five patients. In vivo loads were measured 135 times during flexion while standing or sitting. The trunk inclination was simultaneously recorded. To reveal elementary differences between flexion while standing and sitting, the force increases at the maximal inclination, as compared to the upright position, were also determined. Approximately 90% of all standing trials showed a characteristic inclination-load relationship, with an initial increase of the resultant force followed by a plateau or even a decrease of the force at an inclination of approximately 33°. Further flexion to the average maximal inclination angle of 53° only marginally affected the implant loads (~450N). Maximal forces were measured during the return to the initial standing position (~565N). Flexion during standing led to a greater force increase (~330N) than during sitting (~200N) when compared to the respective upright positions. The force plateau at greater inclination angles might be explained by abdominal load support, complex stabilization of active and passive spinal structures or intricate load sharing within the implant complex. The data presented here aid in understanding the loads acting on an instrumented lumbar spine.

Age-related loss of lumbar spinal lordosis and mobility--a study of 323 asymptomatic volunteers.

BACKGROUND: The understanding of the individual shape and mobility of the lumbar spine are key factors for the prevention and treatment of low back pain. The influence of age and sex on the total lumbar lordosis and the range of motion as well as on different lumbar sub-regions (lower, middle and upper lordosis) in asymptomatic subjects still merits discussion, since it is essential for patient-specific treatment and evidence-based distinction between painful degenerative pathologies and asymptomatic aging. METHODS AND FINDINGS: A novel non-invasive measuring system was used to assess the total and local lumbar shape and its mobility of 323 asymptomatic volunteers (age: 20-75 yrs; BMI <26.0 kg/m2; males/females: 139/184). The lumbar lordosis for standing and the range of motion for maximal upper body flexion (RoF) and extension (RoE) were determined. The total lordosis was significantly reduced by approximately 20%, the RoF by 12% and the RoE by 31% in the oldest (>50 yrs) compared to the youngest age cohort (20-29 yrs). Locally, these decreases mostly occurred in the middle part of the lordosis and less towards the lumbo-sacral and thoraco-lumbar transitions. The sex only affected the RoE. CONCLUSIONS: During aging, the lower lumbar spine retains its lordosis and mobility, whereas the middle part flattens and becomes less mobile. These findings lay the ground for a better understanding of the incidence of level- and age-dependent spinal disorders, and may have important implications for the clinical long-term success of different surgical interventions.

Measurement of the number of lumbar spinal movements in the sagittal plane in a 24-hour period.

PURPOSE: Little is known about the number of spinal movements in the sagittal plane in daily life, mainly due to the lack of adequate techniques to assess these movements. Our aim was to measure these movements in asymptomatic volunteers. METHODS: Two sensor strips based on strain gauge technology (Epionics SPINE system) were fixed on the skin surface of the back parallel to the spine on a total of 208 volunteers without back pain. First, the lordosis angle was determined during relaxed standing. The volunteers were then released to daily life. The increases and decreases in the back lumbar lordosis angle over a period of 24 h were determined and classified into 5° increments. Changes in the lordosis angle greater than 5° were considered. RESULTS: The median number of spinal movements performed within 24 h was approximately 4,400. Of these movements, 66 % were between 5° and 10°. The proportions of higher-magnitude lordosis angle changes were much lower (e.g., 3 % for the 20-25° movement bin). Surprisingly, the median total number of movements was significantly higher (29 %) in women than in men. Large inter-individual differences were observed in the number of movements performed. The volunteers spent a median of 4.9 h with the lumbar spine flexed between 20° and 30° and only 24 min with the spine extended relative to the reference standing position. A median of 50 movements reached or exceeded full-flexion angle and zero movements full-extension angle. CONCLUSIONS: These data illustrate the predominantly small range of movement of the spine during daily activities and the small amount of time spent in extension. These unique data strongly contribute to the understanding of patients' everyday behavior, which might affect the development and testing of spinal implants and the evaluation of surgical and nonsurgical treatments.

Spinal loads during post-operative physiotherapeutic exercises.

After spinal surgery, physiotherapeutic exercises are performed to achieve a rapid return to normal life. One important aim of treatment is to regain muscle strength, but it is known that muscle forces increase the spinal loads to potentially hazardous levels. It has not yet been clarified which exercises cause high spinal forces and thus endanger the surgical outcome. The loads on vertebral body replacements were measured in 5 patients during eleven physiotherapeutic exercises, performed in the supine, prone, or lateral position or on all fours (kneeling on the hands and knees). Low resultant forces on the vertebral body replacement were measured for the following exercises: lifting one straight leg in the supine position, abduction of the leg in the lateral position, outstretching one leg in the all-fours position, and hollowing the back in the all-fours position. From the biomechanical point of view, these exercises can be performed shortly after surgery. Implant forces similar or even greater than those for walking were measured during: lifting both legs, lifting the pelvis in the supine position, outstretching one arm with or without simultaneously outstretching the contralateral leg in the all-fours position, and arching the back in the all-fours position. These exercises should not be performed shortly after spine surgery.

Activities of everyday life with high spinal loads.

Activities with high spinal loads should be avoided by patients with back problems. Awareness about these activities and knowledge of the associated loads are important for the proper design and pre-clinical testing of spinal implants. The loads on an instrumented vertebral body replacement have been telemetrically measured for approximately 1000 combinations of activities and parameters in 5 patients over a period up to 65 months postoperatively. A database containing, among others, extreme values for load components in more than 13,500 datasets was searched for 10 activities that cause the highest resultant force, bending moment, torsional moment, or shear force in an anatomical direction. The following activities caused high resultant forces: lifting a weight from the ground, forward elevation of straight arms with a weight in hands, moving a weight laterally in front of the body with hanging arms, changing the body position, staircase walking, tying shoes, and upper body flexion. All activities have in common that the center of mass of the upper body was moved anteriorly. Forces up to 1650 N were measured for these activities of daily life. However, there was a large intra- and inter-individual variation in the implant loads for the various activities depending on how exercises were performed. Measured shear forces were usually higher in the posterior direction than in the anterior direction. Activities with high resultant forces usually caused high values of other load components.

Spinal loads during cycling on an ergometer.

Cycling on an ergometer is an effective exercise for improving fitness. However, people with back problems or previous spinal surgery are often not aware of whether cycling could be harmful for them. To date, little information exists about spinal loads during cycling. A telemeterized vertebral body replacement allows in vivo measurement of implant loads during the activities of daily living. Five patients with a severe compression fracture of a lumbar vertebral body received these implants. During one measurement session, four of the participants exercised on a bicycle ergometer at various power levels. As the power level increased, the maximum resultant force and the difference between the maximum and minimum force (force range) during each pedal revolution increased. The average maximum-force increases between the two power levels 25 and 85 W were 73, 84, 225 and 75 N for the four patients. The corresponding increases in the force range during a pedal revolution were 84, 98, 166 and 101 N. There were large variations in the measured forces between the patients and also within the same patient, especially for high power levels. In two patients, the maximum forces during high-power cycling were higher than the forces during walking measured on the same day. Therefore, the authors conclude that patients with back problems should not cycle at high power levels shortly after surgery as a precaution.

Biomechanical behavior of MRI-signal-inducing bone cements after vertebroplasty in osteoporotic vertebral bodies: An experimental cadaver study.

BACKGROUND: Conventional water-free polymethylmethacrylate cements are not MRI visible due to the lack of free protons. A new MRI-visible bone cement was developed through the addition of a contrast agent and either a saline solution or a hydroxyapatite (Wichlas et al., 2010). The purposes of the study were to examine the influence of the two MRI-signal-inducing cements on the biomechanical behavior of cadaveric osteoporotic vertebral bodies after vertebroplasty and to compare the performance of the cements with conventional polymethylmethacrylate cement. METHODS: Three different cements were used: standard polymethylmethacrylate cement and two modified MRI-signal-inducing cements that were mixed with either a 0.9% saline solution or a hydroxyapatite. The modulus of elasticity for the standard polymethylmethacrylate cement was 2040MPa, and the moduli for the MRI-signal-inducing cements that were mixed with a 0.9% saline solution and a hydroxyapatite were 1477 and 1225MPa, respectively. The lumbar vertebral bodies from nine osteoporotic spines (mean age=87 years, range=78-99 years) of female cadavers were examined. Three groups were formed: polymethylmethacrylate cement with saline solution (n=14), polymethylmethacrylate cement with hydroxyapatite (n=12) and polymethylmethacrylate cement (n=13). The vertebral bodies were biomechanically tested before and after vertebroplasty. Stiffness was chosen as the primary biomechanical parameter. FINDINGS: The vertebral body stiffness was nearly two-fold greater after vertebroplasty, and this increase was statistically significant for every group. All the groups had similar vertebral body stiffness value before and after the vertebroplasty. The UNIANOVA test for multivariate analysis of variance showed no influence of lumbar level, injected cement volume and initial vertebral body stiffness. INTERPRETATION: The elastic moduli of the cements appear to exert little influence on the biomechanical values when the cement is in the vertebral body. Based on the direct comparison with the classic polymethylmethacrylate cement, we believe that the implementation of such cements for MRI-guided vertebroplasties is feasible.

Investigation of different cage designs and mechano-regulation algorithms in the lumbar interbody fusion process - a finite element analysis.

Lumbar interbody fusion cages are commonly used to treat painful spinal degeneration and instability by achieving bony fusion. Many different cage designs exist, however the effect of cage morphology and material properties on the fusion process remains largely unknown. This finite element model study aims to investigate the influence of different cage designs on bone fusion using two mechano-regulation algorithms of tissue formation. It could be observed that different cages play a distinct key role in the mechanical conditions within the fusion region and therefore regulate the time course of the fusion process.

Discrepancies in anthropometric parameters between different models affect intervertebral rotations when loading finite element models with muscle forces from inverse static analyses.

In only a few published finite element (FE) simulations have muscle forces been applied to the spine. Recently, muscle forces determined using an inverse static (IS) model of the spine were transferred to a spinal FE model, and the effect of methodical parameters was investigated. However, the sensitivity of anthropometric differences between FE and IS models, such as body height and spinal orientation, was not considered. The aim of this sensitivity study was to determine the influence of those differences on the intervertebral rotations (IVRs) following the transfer of muscle forces from an IS model to a FE model. Muscle forces were estimated for 20° flexion and 10° extension of the upper body using an inverse static musculoskeletal model. These forces were subsequently transferred to a nonlinear FE model of the spino-pelvic complex, which includes 243 muscle fascicles. Deviations of body height (±10 cm), spinal orientation in the sagittal plane (±10°), and body weight (±10 kg) between both models were intentionally generated, and their influences on IVRs were determined. The changes in each factor relative to their corresponding reference value of the IS model were calculated. Deviations in body height, spinal orientation, and body weight resulted in maximum changes in the IVR of 19.2%, 26% and 4.2%, respectively, relative to T12-S1 IVR. When transferring muscle forces from an IS to a FE model, it is crucial that both models have the same spinal orientation and height. Additionally, the body weight should be equal in both models.

Standardized loads acting in knee implants.

The loads acting in knee joints must be known for improving joint replacement, surgical procedures, physiotherapy, biomechanical computer simulations, and to advise patients with osteoarthritis or fractures about what activities to avoid. Such data would also allow verification of test standards for knee implants. This work analyzes data from 8 subjects with instrumented knee implants, which allowed measuring the contact forces and moments acting in the joint. The implants were powered inductively and the loads transmitted at radio frequency. The time courses of forces and moments during walking, stair climbing, and 6 more activities were averaged for subjects with I) average body weight and average load levels and II) high body weight and high load levels. During all investigated activities except jogging, the high force levels reached 3,372-4,218N. During slow jogging, they were up to 5,165N. The peak torque around the implant stem during walking was 10.5 Nm, which was higher than during all other activities including jogging. The transverse forces and the moments varied greatly between the subjects, especially during non-cyclic activities. The high load levels measured were mostly above those defined in the wear test ISO 14243. The loads defined in the ISO test standard should be adapted to the levels reported here. The new data will allow realistic investigations and improvements of joint replacement, surgical procedures for tendon repair, treatment of fractures, and others. Computer models of the load conditions in the lower extremities will become more realistic if the new data is used as a gold standard. However, due to the extreme individual variations of some load components, even the reported average load profiles can most likely not explain every failure of an implant or a surgical procedure.

In vivo measurements of the effect of whole body vibration on spinal loads.

PURPOSE: It is assumed that whole body vibration (WBV) improves muscle strength, bone density, blood flow and mobility and is therefore used in wide ranges such as to improve fitness and prevent osteoporosis and back pain. It is expected that WBV produces large forces on the spine, which poses a potential risk factor for the health of the spine. Therefore, the aim of the study was to measure the effect of various vibration frequencies, amplitudes, device types and body positions on the loads acting on a lumbar vertebral body replacement (VBR). METHODS: Three patients suffering from a fractured lumbar vertebral body were treated using a telemeterized VBR. The implant loads were measured during WBV while the patients stood on devices with vertically and seesaw-induced vibration. Frequencies between 5 and 50 Hz and amplitudes of 1, 2 and 4 mm were tested. The patients stood with their knees straight, slightly bent, or bent at 60°. In addition, they stood on their forefeet. RESULTS: The peak resultant forces on the implant increased due to vibration by an average of 24% relative to the forces induced without vibration. The average increase of the peak implant force was 27% for vertically induced vibration and 15% for seesaw vibration. The forces were higher when the legs were straight than when the knees were bent. Both the vibration frequency and the amplitude had only a minor effect on the measured forces. CONCLUSIONS: The force increase due to WBV is caused by an activation of the trunk muscles and by the acceleration forces. The forces produced during WBV are usually lower than those produced during walking. Therefore, the absolute magnitude of the forces produced during WBV should not be harmful, even for people with osteoporosis.

Automatic distinction of upper body motions in the main anatomical planes.

The assessment of spinal mobility and function is gaining clinical importance for the diagnosis and monitoring of low back pain, but its measurement and evaluation remains difficult. As a critical step towards non-supervised assessment of spinal functional, the aim of this study was to assess the efficacy of symmetrical sensors fixed to the sides of the spinal column to distinguish between different upper body movements in the main anatomical planes. 429 healthy volunteers underwent a defined choreography including repeated upper body flexion, extension, lateral bending and axial rotation exercises. The movements were assessed using the Epionics SPINE sensor system. Two pattern recognition models were developed and applied to distinguish between the different movements in a frame-by-frame manner, as well as for whole motion sequences. On average, it was possible to differentiate between different upper body movements with a sensitivity of over 96% for both modelling approaches. The largest type II error was the incorrect identification of extension, possibly due to deviations from the reference standing posture during measurements and small changes in the lordotic angle during extension. The use of two sagittal sensors attached symmetrically to the back therefore seems to allow the distinction of upper body movements in a robust manner, and therefore opens perspectives for the unsupervised recognition of movements and functional activity over extended periods.

Parameters influencing the outcome after total disc replacement at the lumbosacral junction. Part 2: distraction and posterior translation lead to clinical failure after a mean follow-up of 5 years.

PURPOSE: The aim of the second part of the study was to investigate the influence of parameters that lead to increased facet joint contact or capsule tensile forces (disc height, lordosis, and sagittal misalignment) on the clinical outcome after total disc replacement (TDR) at the lumbosacral junction. METHODS: A total of 40 patients of a prospective cohort study who received TDR because of degenerative disc disease or osteochondrosis L5/S1 were invited to an additional follow-up for clinical (ODI and VAS for overall, back, and leg pain) and radiographic analysis (a change in disc height, lordosis, or sagittal vertebral misalignment compared with the preoperative state). Based on the final ODI, patients were retrospectively distributed into groups N (normal: <25 %) or F (failure ≥ 25 %) for radiographic parameter comparison. A correlation analysis was performed between the clinical and radiological results. RESULTS: A total of 34 patients were available at a mean follow-up of 59.5 months. Both groups (N = 24; F = 10 patients) presented a significant improvement in overall pain, back pain, and ODI over time. At the final follow-up, higher clinical scores correlated with a larger disc height, increased lordosis, and posterior translation of the superior vertebra, which was also reflected by significant differences in these parameters in the group comparison. CONCLUSIONS: Parameters associated with increased facet joint capsule tensile forces lead to an inferior clinical outcome at mid-term follow-up. When performing TDR, we therefore suggest avoiding iatrogenic posterior translation and overdistraction (and consecutive lordosis).

What have we learned from finite element model studies of lumbar intervertebral discs in the past four decades?

Finite element analysis is a powerful tool routinely used to study complex biological systems. For the last four decades, the lumbar intervertebral disc has been the focus of many such investigations. To understand the disc functional biomechanics, a precise knowledge of the disc mechanical, structural and biochemical environments at the microscopic and macroscopic levels is essential. In response to this need, finite element model studies have proven themselves as reliable and robust tools when combined with in vitro and in vivo measurements. This paper aims to review and discuss some salient findings of reported finite element simulations of lumbar intervertebral discs with special focus on their relevance and implications in disc functional biomechanics. Towards this goal, the earlier investigations are presented, discussed and summarized separately in three distinct groups of elastic, multi-phasic transient and transport model studies. The disc overall response as well as the relative role of its constituents are markedly influenced by loading rate, magnitude, combinations/preloads and posture. The nucleus fluid content and pressurizing capacity affect the disc compliance, annulus strains and failure sites/modes. Biodynamics of the disc is affected by not only the excitation characteristics but also preloads, existing mass and nucleus condition. The role of fluid pressurization and collagen fiber stiffening diminish with time during diurnal loading. The endplates permeability influences the time-dependent response of the disc in both loaded and unloaded recovery phases. The transport of solutes is substantially influenced by the disc size, tissue diffusivity and endplates permeability.

Computational biomechanics of a lumbar motion segment in pure and combined shear loads.

Anterior shear has been implicated as a risk factor in spinal injuries. A 3D nonlinear poroelastic finite element model study of a lumbar motion segment L4-L5 was performed to predict the temporal shear response under various single and combined shear loads. Effects of nucleotomy and facetectomy as well as changes in the posture and facet gap distance were analyzed as well. Comparison of the predicted anterior displacement and stiffness response with available measurements indicates satisfactory agreement. Under shear loads up to 400 N, the model predicted an almost linear displacement response. With increasing shear load and/or compressive preload, the stiffening behavior becomes evident, primarily due to stretched collagen fibers and greater facet interactions. Removal of the facets markedly decreases the segmental stiffness in shear and thus highlights the importance of the facets in resisting shear force; 61-87% of the applied shear force is transmitted through the facets depending on the magnitude of the applied shear and compressive preload. Fluid exudation during the day as well as reduced facet gap distance and a more extended posture yielded higher facet joint forces. The shear resistance of the motion segment remains almost the same with time despite the transfer of load sharing from the disc to facets. Large forces on facet joints are computed especially under greater compression preloads, shear forces and extension rotations, as time progresses and with smaller gap distances. The disc contribution on the other hand increases under larger shear loads, smaller compression preloads, flexed postures, larger facet gap distances and at transient periods.

Effect of an orthosis on the loads acting on a vertebral body replacement.

BACKGROUND: The spinal load reduction by an orthosis is still a matter of debate. Some studies predicted a load reduction while others found no effect. The aim of this study was to measure the in vivo effect of the Lumbo TriStep brace and the hyperextension orthosis medi 3C on the spinal implant loads. METHODS: Telemeterized vertebral body replacements were implanted in 5 patients suffering from a severe fracture of the L1 or L3 vertebral body. The implant allows the measurement of 6 load components acting on it. For several activities during standing, sitting and walking, implant loads were measured in patients with and without an orthosis. FINDINGS: The average resultant force on the vertebral body for 26 activities was reduced by 9% with the Lumbo TriStep brace, and by 19% with the hyperextension orthosis. The force reduction is usually more pronounced for activities performed during sitting than it is for those performed while standing. However, considerable inter- and intra-individual variation was observed. In several cases, the measured implant forces were even higher when the patients were wearing an orthosis. INTERPRETATION: In some patients, for certain activities, an orthosis may reduce the force on a vertebral body replacement and thus on the anterior column of the spine. However, in other patients for the same activities, an orthosis may increase the force. The measurements do not allow a clear recommendation to wear an orthosis since the clinically relevant reduction of implant forces is unknown.