Mechanical Analysis of Notch-Free Pre-Bent Rods for Spinal Deformity Surgery.

STUDY DESIGN: Experimental study of spinal rod as per the American Society for Testing Materials (ASTM) F2193 methodology for static and dynamic four-point bending. OBJECTIVE: The hypotheses underlying this study were that the notch-free, curved rod would have a significantly higher ultimate load and fatigue strength compared with conventional notched curved rods. This study aimed to analyze the mechanical properties of notch-free curved rods compared with conventional notched rods. SUMMARY OF BACKGROUND DATA: The goal of instrumented spinal fusion in the management of spinal deformities is to realign the spine and maintain the correction and stability in order to obtain arthrodesis. Although rod curvature could play an important role, intraoperative contouring of the straight rod induces notches into the rod, leading to decreased fatigue strength. METHODS: Commercially produced titanium alloy (ϕ6.0 mm) and cobalt chromium alloy (ϕ5.5 mm) spinal rods were assessed by four-point bending tests in accordance with the ASTM F2193. RESULTS: Static four-point bending tests for the curved spinal rods showed that cobalt chromium alloy rods had significantly higher stiffness compared with titanium alloy rods. Notch-free cobalt chromium alloy rods had a significantly higher ultimate load than the conventional notched cobalt chromium alloy and titanium alloy rods. The dynamic four-point bending test showed that force/displacement at a minimum force at 2,500,000 cycles was larger in the notch-free cobalt chromium alloy rod than in the notched cobalt chromium alloy rod. CONCLUSION: The notch-free curved cobalt chromium alloy rod is likely to maintain its curvature after spinal deformity surgery with a decreased risk of breakage and could overcome the problems of the conventional notched rod such as breakage and spring-back. LEVEL OF EVIDENCE: N/A.

Corrosion of dental alloys in artificial saliva with Streptococcus mutans.

A comparative study of the corrosion resistance of CoCr and NiCr alloys in artificial saliva (AS) containing tryptic soy broth (Solution 1) and Streptococcus mutans (S. mutans) species (Solution 2) was performed by electrochemical methods, including open circuit potential measurements, impedance spectroscopy, and potentiodynamic polarization. The adherence of S. mutans to the NiCr and CoCr alloy surfaces immersed in Solution 2 for 24 h was verified by scanning electron microscopy, while the results of electrochemical impedance spectroscopy confirmed the importance of biofilm formation for the corrosion process. The R(QR) equivalent circuit was successfully used to fit the data obtained for the AS mixture without S. mutans, while the R(Q(R(QR))) circuit was found to be more suitable for describing the biofilm properties after treatment with the AS containing S. mutans species. In addition, a negative shift of the open circuit potential with immersion time was observed for all samples regardless of the solution type. Both alloys exhibited higher charge transfer resistance after treatment with Solution 2, and lower corrosion current densities were detected for all samples in the presence of S. mutans. The obtained results suggest that the biofilm formation observed after 24 h of exposure to S. mutans bacteria might enhance the corrosion resistance of the studied samples by creating physical barriers that prevented oxygen interactions with the metal surfaces.

Postoperative magnetic resonance imaging artifact with cobalt-chromium versus titanium spinal instrumentation: presented at the 2013 Joint Spine Section Meeting. Clinical article.

OBJECT: Cobalt-chromium alloy (CoCr) rods haves some preferred biomechanical properties over titanium rods for spinal fixation. The use of CoCr rods in spinal fusion is relatively new, and there is no study in the existing world literature assessing the artifact caused by these rods in patients undergoing postoperative MRI. The purpose of this study is to compare the amount of imaging artifact caused by these implants and to assess its impact on the visualization of neighboring neural structures. METHODS: This study investigated MR images in patients who underwent implantation of thoracolumbar instrumentation using 5.5-mm-diameter CoCr rods between November 2009 and March 2011 and images obtained in a comparison group of patients who had 5.5-mm titanium rods implanted during the same time period. Axial measurements of the artifact created by the rods between the screw heads were compared between the groups. Two blinded board-certified radiologists performed the measurements independently. They scored the visualization of the spinal canal using a subjective scoring system of 1-3, with 1 representing very good visualization and 2 and 3 representing reduced (good or suboptimal, respectively) visualization as a result of rod-related artifact. All measurements and scores were independently provided for T1-weighted and T2-weighted fast spin echo sequences (1.5-T magnet, 5-mm slice thickness). RESULTS: A total of 40 levels from the CoCr group (6 patients) and 30 levels from the titanium group (9 patients) were included in the analysis. Visualization of the canal at all levels was rated a score of 1 (very good) by both evaluators for both the CoCr and titanium groups. The average artifact on T1-weighted images measured 11.8 ± 1.8 mm for the CoCr group and 8.5 ± 1.2 mm for the titanium group (p < 0.01). The corresponding measurements on T2-weighted images were 11.0 ± 2.3 mm and 8.3 ± 1.7 mm (p < 0.01), respectively. In a mixed regression model, the mean artifact measurement for the CoCr group was, on average, 3.5 mm larger than for the control group. There was no significant difference between the measurements of the 2 evaluators (p = 0.99). CONCLUSIONS: The artifact caused by CoCr rods is approximately 3.5 mm larger than that caused by titanium rods on axial T1- and T2-weighted MRI. However, artifact from either CoCr or titanium was not found to interfere with the evaluation of the spinal canal and surrounding neural elements.

Would CoCr rods provide better correctional forces than stainless steel or titanium for rigid scoliosis curves?

STUDY DESIGN: Comparative in vitro, biomechanical study. OBJECTIVE: Compare the effect of rod curvature and material properties on rod flattening and correctional forces. SUMMARY OF BACKGROUND DATA: Traditional methods of correction for large progressive deformities involve 3-dimensional correction, performed with an attempt to reach a balanced correction in all planes, spinal instrumentation, and fusion. Increasing attention to the transverse plane correction has developed after the introduction of segmental pedicle screws into the treatment of idiopathic scoliosis. Approximation of the spine (pedicle screws or hooks) to the rods remains the heart of many deformity procedures. Therefore, it is crucial that the instrumentation used provide and maintain the initial correction of the spinal deformity while minimizing potential intraoperative failures. METHODS: Two experiments were performed using 80 rods made from 4 different materials namely: stainless steel (SS), titanium (Ti), cobalt chromium (CoCr), and ultrahigh strength stainless steel (UHSS). Half of the rods were contoured to 20 degrees, whereas the reaming contoured to 30 degrees. Half of the rods were approximated to a synthetic spine models to measure the flattening of the rods when approximated to highly rigid spine. The other half was used to measure the correctional forces produced by each rod type and curvature. RESULTS: For the 20-degree pre-bend rods, Ti was the best in maintaining its original shape followed by UHSS, SS, and CoCr of 90%, 77%, 62.5%, and 54.4%, respectively. The 30-degree pre-bend showed exactly a similar trend with 80.7% for Ti, 71% for UHSS, 54.6% for SS, and 48.1% for the CoCr rods. For 30-degree pre-bend CoCr and UHSS rods, the intraoperative reduction forces were almost 42% and 10% higher than the Ti and SS rods, respectively. The correctional force produced by the Ti 30-degree pre-bend rod was approximately 67% that of a CoCr and UHSS rods. CONCLUSIONS: CoCr and UHSS rods have the ability to produce the highest correction forces, however, both can plastically deform in a very rigid curves. Therefore, it is critical to have sense of the quality of the bone fixation as well as the curve flexibility when selecting for appropriate rod size material and contouring the rod to the desired shape.

Clinical evaluation of fixed partial dentures made in Sweden and China.

The aim of this study was to compare the quality of fixed partial dentures (FPDs) made in a Chinese dental laboratory with corresponding FPDs made in Swedish dental laboratories. Twenty-one patients were fitted with FPDs between March 2007 and December 2008. Single crowns and prostheses of up to seven units were made. All dentures, gold and CoCr alloys covered with ceramic, were produced in duplicate: one by a dental technician in China and the other by a dental technician in Sweden. The dentures were blind-tested with regard to marginal integrity, anatomic form and color, approximal and occlusal contacts, and time taken for adjustments. The composition of dentures was analyzed, and the material used, framework weight, compliance of the laboratories, and costs (material and labour) were recorded. There was no difference in the quality of marginal integrity, anatomic form, color, approximal and occlusal contacts, or in the time taken for adjustments. The bridge frameworks made in China were thinner and lighter (p<0.01) than those made in Sweden. Three FPDs from China showed elastic deformation when tested clinically and were considered too thin for clinical use. In 11 out of 14 orders from the Chinese laboratory, the gold alloy specified was not delivered and the cobalt-chromium alloy contained small amounts (0.19%) of nickel.The prostheses with gold-alloy frameworks from China cost 47% of those from Sweden (p<0.01) and those with cobalt/chromium frameworks 44% (p<0.01). In conclusion, the quality of the FPDs made in Sweden and China was comparable, with the exception of the dimension of the Chinese bridges, which in some cases was considered too weak. The gold alloy ordered from the Chinese laboratory was often not the alloy delivered and the CoCr alloy contained small amounts of nickel. FPDs from China cost less than half the price of those from Sweden.

Microhardness of Ni-Cr alloys under different casting conditions.

This study evaluated the microhardness of Ni-Cr alloys used in fixed prosthodontics after casting under different conditions. The casting conditions were: (1-flame/air torch) flame made of a gas/oxygen mixture and centrifugal casting machine in a non-controlled casting environment; (2-induction/argon) electromagnetic induction in an environment controlled with argon; (3-induction/vacuum) electromagnetic induction in a vacuum environment; (4-induction/air) electromagnetic induction in a non-controlled casting environment. The 3 alloys used were Ni-Cr-Mo-Ti, Ni-Cr-Mo-Be, and Ni-Cr-Mo-Nb. Four castings with 5 cylindrical, 15 mm-long specimens (diameter: 1.6 mm) in each casting ring were prepared. After casting, the specimens were embedded in resin and polished for Vickers microhardness (VH) measurements in a Shimadzu HMV-2 (1,000 g for 10 s). A total of 5 indentations were done for each ring, one in each specimen. The data was subjected to two-way ANOVA and Tukey's multiple comparison tests (alpha = 0.05). The VH values of Ni-Cr-Mo-Ti (422 +/- 7.8) were statistically higher (p < 0.05) than those of Ni-Cr-Mo-Nb (415 +/- 7.6). The lowest VH values were found for Ni-Cr-Mo-Be (359 +/- 10.7). The VH values obtained in the conditions induction/argon and induction/vacuum were similar (p > 0.05) and lower than the values obtained in the conditions induction/air and flame/air torch (p < 0.05). The VH values in the conditions induction/air and flame/air were similar (p > 0.05). The microhardness of the alloys is influenced by their composition and casting method. The hardness of the Ni-Cr alloys was higher when they were cast with the induction/air and flame/air torch methods.

Microhardness of Ni-Cr alloys under different casting conditions

Este estudo avaliou a microdureza de ligas de Ni-Cr usadas em prótese fixa fundidas sob diferentes condições. As condições de fundição foram: (1-maçarico) chama composta por uma mistura de gás/oxigênio e centrífuga sem o controle do ambiente de fundição; (2-indução/argônio) indução eletromagnética com o ambiente controlado com argônio; (3-indução/vácuo) indução eletromagnética com o ambiente sob vácuo; (4-indução/ar) indução eletromagnética sem o controle da atmosfera. Foram utilizadas três ligas: Ni-Cr-Mo-Ti, Ni-Cr-Mo-Be e Ni-Cr-Mo-Nb. Foram realizadas 4 fundições com 5 espécimes cilíndricos de 15 mm de comprimento (diâmetro de 1,6 mm). Depois das fundições os espécimes foram embutidos e polidos para as mensurações de microdureza Vickers (VH) em um Shimadzu HMV-2 (1.000 g por 10 s). Um total de 5 indentações foram feitas por anel, uma em cada espécime. Os dados de VH foram avaliados pelos testes de ANOVA e Tukey (a = 0,05) para contraste de média. A microdureza das ligas apresentou a seguinte ordem: Ni-Cr-Mo-Ti (422 ± 7,8) > Ni-Cr-Mo-Nb (415 ± 7,6) > Ni-Cr-Mo-Be (359 ± 10,7), sendo diferentes entre si. Os valores obtidos nas condições indução/argônio e indução/vácuo foram semelhantes entre si (p > 0,05) e menores que os obtidos nas condições indução/ar e maçarico, estes últimos semelhantes entre si (p > 0,05). A microdureza das ligas é dependente da composição da liga e do método de fundição. A dureza das ligas de Ni-Cr foi maior quando fundidas nas condições indução/ar e maçarico.

[Metallurgical differentiation of cobalt-chromium alloys for implants]. / Metallkundliche Differenzierung von Kobalt-Chrom-Legierungen für Implantate.

BACKGROUND: Cobalt Chromium alloys are used in cemented total hip or knee arthroplasty as well as in metal-on-metal bearings in total hip arthroplasty. An increasing number of publications report about (allergic) reactions to wear particles of Cobalt Chromium alloys. Reactions to nickel are more frequent in comparison to Cobalt or Chromium particles. It is well known that different kinds of Cobalt Chromium alloys contain different amounts of alloying elements; nevertheless. The aim of the current work was to compare the different Cobalt Chromium alloys according to ASTM F or ISO standards in respect to the different alloying elements. MATERIAL AND METHODS: Co28Cr6Mo casting alloys according to ASTM F 75 or ISO 5832-4 as well as forging alloy types according to ASTM F 799 and ISO 5832 such as Co20Cr15W10Ni, Co35Ni20Cr, Fe40Co20Cr10Ni, Co20Cr20Ni, and Co28Cr6Mo were analyzed in respect to their element content of Co, Cr, Ni, Mo, Fe, W, and Mn. RESULTS: In 1935 the Cobalt based alloy "Vitallium" Co30Cr5Mo basically used in the aircraft industry was introduced into medicine. The chemical composition of this alloy based on Cobalt showed 30 wt.% Chromium and 5 wt.% Molybdenum. The differentiation using alloy names showed no Nickel information in single alloy names. CONCLUSION: The information given about different alloys can lead to an unprecise evaluation of histopathological findings in respect to alloys or alloying constituents. Therefore, implant manufacturers should give the exact information about the alloys used and adhere to European law, Euronorm 93/42/EWG.

Treatment with removable partial dentures: a longitudinal study. Part I.

The aim of this study was to evaluate the effectiveness of an oral rehabilitation by removable partial denture (RPD). Between 1983 and 1994, 629 patients were provided with an RPD at the Dental School of the Université catholique de Louvain. All the RPDs were constructed with a cobalt-chromium framework. All the treatments were provided by dental students under the supervision of clinical instructors. At recall time (1998-2000), 269 patients could not be reached neither by telephone nor by mail and 27 had died. Consequently, 333 patients were called for clinical examination and 254 of these (76.3%) actually attended. For a total of 292 RPDs fitted for these 254 patients, 218 (74.7%) were still being worn at the time of the check-up. Seventy-four dentures were considered to be 'failures', either because they were replaced by another RPD or by a complete denture, or because they had actually never been worn. The statistical analysis (Mantel-Haenszel and Kaplan-Meier) shows that the number of failures is significantly higher at the lower jaw compared with the upper jaw. Most of the failures are attributable to RPDs with free-end saddles and, in particular, to class I mandibular dentures. The patients are wearing their denture(s) mostly continuously (63.6%) and award a high degree of satisfaction to their denture. In general, the results recorded may be considered as very satisfactory, all the more so as we have no regular recall procedures established at our school and as check-up asked for spontaneously by the patients in the course of the period of observation are most of the time occasional or non-existent.

Treatment with removable partial dentures: a longitudinal study. Part II.

The aim of this study was to evaluate the effectiveness of an oral rehabilitation by removable partial denture (RPD). Between 1983 and 1994, 629 patients were provided with an RPD at the Dental School of the Université catholique de Louvain. All the RPDs were constructed with a cobalt-chromium framework. All the treatments were provided by dental students under the supervision of clinical instructors. At recall time (1998-2000), 269 patients could not be reached neither by telephone nor by mail and 27 had died. Consequently, 333 patients were called for clinical examination and 254 of these (76.3%) actually attended. For a total of 292 RPDs checked 1893 persistent teeth were listed, with 804 serving as abutments; more than half (57.6%) of these were crowned, for which 51 debondings were recorded. For the period of observation we listed 79 abutments lost (37 at the upper jaw and 42 at the lower jaw), i.e. 9.8% of the total number of abutments. No relation could be established between the type of the abutments (natural or crowned teeth) and the losses observed (Test of Mantel-Haenszel: P=0.9496). In the upper jaw, the percentage of abutments lost was significantly higher in the presence of free-end edentulous areas as compared with bounded edentulous areas (Test of Mantel-Haenszel: P=0.0002); this difference does not appear for the lower jaws (P=0.9558). If we deduct the 25 abutments related with the 11 non-worn RPDs and the 79 abutments lost, no change becomes apparent for 92.2% of the maxillary abutments and for 85.8% of the mandibular abutments. For the 1089 other teeth, we observed the loss of 40 teeth and the appearance of caries or new fillings for 95 teeth. The fractures of cast clasps represent 3.4%.

Metal release from total hip articulations in vitro: substantial from CoCr/CoCr, negligible from CoCr/PE and alumina/PE.

We used a hip joint simulator to compare the metal release from CoCr/CoCr, CoCr/PE, and alumina/PE total hip articulations. The metal release was quantified by analyzing the Co, Cr, and Ni contents of the bovine serum lubricant used with atomic absorption spectroscopy. CoCr/CoCr articulations released substantial amounts of metal, whereas CoCr/PE was equal to the control, alumina/PE, in that metal release was negligible. The metal release was in accordance with the known clinical wear rates of CoCr/CoCr articulations. The largest dimensional changes occurred in polyethylene cups, the penetrations of CoCr heads to the polyethylene cups being twice that of the alumina head, which is consistent with clinical experience. The research on the wear behavior of different materials, aiming to find a prosthesis with negligible wear, needs to be continued. Due to the substantial metal release, the CoCr/CoCr articulation is hardly the final solution of the wear problem in total hip arthroplasty.

An analysis of the changes in the surfaces of metallic femoral components in hip prostheses. A study of 60 prostheses removed after 1-20 years.

A study of 60 femoral prosthetic components removed after 1-20 years allowed us to study the behaviour of the metallic surface in real life conditions. Changes were observed exclusively in cemented prostheses. They consisted of corrosion phenomena characteristic of the components of steel EN 58 J and 316 S, and wear phenomena secondary to mobilisation. The latter were observed in steel components as well as in those in Co-Cr alloy. The areas of corrosion in the steel prostheses were characteristically distributed, indicating a combination of causal factors, including an insufficient capacity of passivation of the metal and the particular situation of the cement-to-metal interface.