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http://dx.doi.org/10.3340/jkns.2021.0315

An Experimental Study on the Biomechanical Effectiveness of Bone Cement-Augmented Pedicle Screw Fixation with Various Types of Fenestrations  

Yoon, Sang Hoon (Department of Neurosurgery, Armed Forces Capital Hospital)
Lee, Sang Hyung (Department of Neurosurgery and Medical Device Development, Seoul National University College of Medicine)
Jahng, Tae-Ahn (Department of Neurosurgery, Seoul National University College of Medicine)
Publication Information
Journal of Korean Neurosurgical Society / v.65, no.6, 2022 , pp. 779-789 More about this Journal
Abstract
Objective : To analyze the effects of the number and shape of fenestrations on the mechanical strength of pedicle screws and the effects of bone cement augmentation (BCA) on the pull-out strength (POS) of screws used in conventional BCA. Methods : For the control group, a conventional screw was defined as C1, a screw with cannulated end-holes was defined as C2, a C2 screw with six pinholes was defined as C3, and the control group type was set. Among the experimental screws, T1 was designed using symmetrically placed thru-hole type fenestrations with an elliptical shape, while T2 was designed with half-moon (HM)-shaped asymmetrical fenestrations. T3 and T4 were designed with single HM-shaped fenestrations covering three pitches and five pitches, respectively. T5 and T6 were designed with 0.6-mm and 1-mm wider fenestrations than T3. BCA was performed by injecting 3 mL of commercial bone cement in the screw, and mechanical strength and POS tests were performed according to ASTM F1717 and ASTM F543 standards. Synthetic bone (model #1522-505) made of polyurethane foam was used as a model of osteoporotic bone, and radiographic examinations were performed using computed tomography and fluoroscopy. Results : In the fatigue test, at 75% ultimate load, fractures occurred 7781 and 9189 times; at 50%, they occurred 36122 and 82067 times; and at 25%, no fractures occurred. The mean ultimate load for each screw type was 219.1±52.39 N for T1, 234.74±15.9 N for T2, 220.70±59.23 N for T3, 216.45±32.4 N for T4, 181.55±54.78 N for T5, and 216.47±29.25 N for T6. In comparison with C1, T1, T2, T3, T4, and T6 showed significantly different ultimate load values (p<0.05). However, when the values for C2 and the fenestrated screws were evaluated with an unpaired t test, the ultimate load value of C2 significantly differed only from that of T2 (p=0.025). The ultimate load value of C3 differed significantly from those of T1 and T2 (C3 vs. T1 : p=0.048; C3 vs. T2 : p<0.001). Linear correlation analysis revealed a significant correlation between the fenestration area and the volume of bone cement (Pearson's correlation coefficient r=0.288, p=0.036). The bone cement volume and ultimate load significantly correlated with each other in linear correlation analysis (r=0.403, p=0.003). Conclusion : Fenestration yielded a superior ultimate load in comparison with standard BCA using a conventional screw. In T2 screws with asymmetrical two-way fenestrations showed the maximal increase in ultimate load. The fenestrated screws can be expected to show a stable position for the formation of the cement mass.
Keywords
Fenestration; Pedicle screw; Bone cement; Ultimate load; Pull-out strength;
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Times Cited By KSCI : 1  (Citation Analysis)
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1 Hancocks S : Sawbones no longer? Br Dent J 212 : 353, 2012   DOI
2 Hasegawa T, Inufusa A, Imai Y, Mikawa Y, Lim TH, An HS : Hydroxyapatite-coating of pedicle screws improves resistance against pull-out force in the osteoporotic canine lumbar spine model: a pilot study. Spine J 5 : 239-243, 2005   DOI
3 Hsieh MK, Liu MY, Chen JK, Tsai TT, Lai PL, Niu CC, et al. : Biomechanical study of the fixation stability of broken pedicle screws and subsequent strategies. PLoS One 14 : e0219189, 2019   DOI
4 Inceoglu S, Ehlert M, Akbay A, McLain RF : Axial cyclic behavior of the bone-screw interface. Med Eng Phys 28 : 888-893, 2006   DOI
5 Krag MH, Weaver DL, Beynnon BD, Haugh LD : Morphometry of the thoracic and lumbar spine related to transpedicular screw placement for surgical spinal fixation. Spine (Phila Pa 1976) 13 : 27-32, 1988   DOI
6 Krenn MH, Piotrowski WP, Penzkofer R, Augat P : Influence of thread design on pedicle screw fixation. Laboratory investigation. J Neurosurg Spine 9 : 90-95, 2008   DOI
7 La Barbera L, Galbusera F, Villa T, Costa F, Wilke HJ : ASTM F1717 standard for the preclinical evaluation of posterior spinal fixators: can we improve it? Proc Inst Mech Eng H 228 : 1014-1026, 2014   DOI
8 Leichtle CI, Lorenz A, Rothstock S, Happel J, Walter F, Shiozawa T, et al. : Pull-out strength of cemented solid versus fenestrated pedicle screws in osteoporotic vertebrae. Bone Joint Res 5 : 419-426, 2016   DOI
9 Liu D, Shi L, Lei W, Wei MQ, Qu B, Deng SL, et al. : Biomechanical comparison of expansive pedicle screw and polymethylmethacrylateaugmented pedicle screw in osteoporotic synthetic bone in primary implantation: an experimental study. Clin Spine Surg 29 : E351-E357, 2016   DOI
10 Cook SD, Barbera J, Rubi M, Salkeld SL, Whitecloud TS 3rd : Lumbosacral fixation using expandable pedicle screws. An alternative in reoperation and osteoporosis. Spine J 1 : 109-114, 2001   DOI
11 Costa F, Ortolina A, Galbusera F, Cardia A, Sala G, Ronchi F, et al. : Pedicle screw cement augmentation. A mechanical pullout study on different cement augmentation techniques. Med Eng Phys 38 : 181-186, 2016   DOI
12 Gaines RW Jr : The use of pedicle-screw internal fixation for the operative treatment of spinal disorders. J Bone Joint Surg Am 82 : 1458-1476, 2000   DOI
13 Goost H, Deborre C, Wirtz DC, Burger C, Prescher A, Folsch C, et al. : PMMA-augmentation of incompletely cannulated pedicle screws: a cadaver study to determine the benefits in the osteoporotic spine. Technol Health Care 22 : 607-615, 2014   DOI
14 Elder BD, Lo SF, Holmes C, Goodwin CR, Kosztowski TA, Lina IA, et al. : The biomechanics of pedicle screw augmentation with cement. Spine J 15 : 1432-1445, 2015   DOI
15 Frankel BM, D'Agostino S, Wang C : A biomechanical cadaveric analysis of polymethylmethacrylate-augmented pedicle screw fixation. J Neurosurg Spine 7 : 47-53, 2007   DOI
16 Galbusera F, Volkheimer D, Reitmaier S, Berger-Roscher N, Kienle A, Wilke HJ : Pedicle screw loosening: a clinically relevant complication? Eur Spine J 24 : 1005-1016, 2015   DOI
17 Gao M, Lei W, Wu Z, Liu D, Shi L : Biomechanical evaluation of fixation strength of conventional and expansive pedicle screws with or without calcium based cement augmentation. Clin Biomech (Bristol, Avon) 26 : 238-244, 2011   DOI
18 Glassman SD, Alegre GM : Adult spinal deformity in the osteoporotic spine: options and pitfalls. Instr Course Lect 52 : 579-588, 2003
19 Liu D, Wu ZX, Pan XM, Fu SC, Gao MX, Shi L, et al. : Biomechanical comparison of different techniques in primary spinal surgery in osteoporotic cadaveric lumbar vertebrae: expansive pedicle screw versus polymethylmethacrylate-augmented pedicle screw. Arch Orthop Trauma Surg 131 : 1227-1232, 2011   DOI
20 Matthews PG, Phan K, Rao PJ, Ball JR : Pedicle length and degree of slip in lumbosacral isthmic spondylolisthesis. Orthop Surg 7 : 108-111, 2015   DOI
21 Moon BJ, Cho BY, Choi EY, Zhang HY : Polymethylmethacrylateaugmented screw fixation for stabilization of the osteoporotic spine : a three-year follow-up of 37 patients. J Korean Neurosurg Soc 46 : 305-311, 2009   DOI
22 Ono A, Brown MD, Latta LL, Milne EL, Holmes DC : Triangulated pedicle screw construct technique and pull-out strength of conical and cylindrical screws. J Spinal Disord 14 : 323-329, 2001   DOI
23 Paxinos O, Tsitsopoulos PP, Zindrick MR, Voronov LI, Lorenz MA, Havey RM, et al. : Evaluation of pullout strength and failure mechanism of posterior instrumentation in normal and osteopenic thoracic vertebrae. J Neurosurg Spine 13 : 469-476, 2010   DOI
24 Pinera AR, Duran C, Lopez B, Saez I, Correia E, Alvarez L : Instrumented lumbar arthrodesis in elderly patients: prospective study using cannulated cemented pedicle screw instrumentation. Eur Spine J 20 Suppl 3(Suppl 3) : 408-414, 2011
25 Polly DW Jr, Orchowski JR, Ellenbogen RG : Revision pedicle screws. Bigger, longer shims--what is best? Spine (Phila Pa 1976) 23 : 1374-1379, 1998   DOI
26 Schulze M, Riesenbeck O, Vordemvenne T, Raschke MJ, Evers J, Hartensuer R, et al. : Complex biomechanical properties of nonaugmented and augmented pedicle screws in human vertebrae with reduced bone density. BMC Musculoskelet Disord 21 : 151, 2020   DOI
27 Wuisman PI, Van Dijk M, Staal H, Van Royen BJ : Augmentation of (pedicle) screws with calcium apatite cement in patients with severe progressive osteoporotic spinal deformities: an innovative technique. Eur Spine J 9 : 528-533, 2000   DOI
28 Rohmiller MT, Schwalm D, Glattes RC, Elalayli TG, Spengler DM : Evaluation of calcium sulfate paste for augmentation of lumbar pedicle screw pullout strength. Spine J 2 : 255-260, 2002   DOI
29 Yaman O, Demir T, Arslan AK, Iyidiker MA, Tolunay T, Camuscu N, et al. : The comparison of pullout strengths of various pedicle screw designs on synthetic foams and ovine vertebrae. Turk Neurosurg 25 : 532-238, 2015
30 Zindrick MR, Wiltse LL, Widell EH, Thomas JC, Holland WR, Field BT, et al. : A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res (203) : 99-112, 1986
31 Saadeh YS, Swong KN, Yee TJ, Strong MJ, Kashlan ON, Szerlip NJ, et al. : Effect of fenestrated pedicle screws with cement augmentation in osteoporotic patients undergoing spinal fusion. World Neurosurg 143 : e351-e361, 2020   DOI
32 Sarzier JS, Evans AJ, Cahill DW : Increased pedicle screw pullout strength with vertebroplasty augmentation in osteoporotic spines. J Neurosurg 96 (3 Suppl) : 309-312, 2002
33 Aydogan M, Ozturk C, Karatoprak O, Tezer M, Aksu N, Hamzaoglu A : The pedicle screw fixation with vertebroplasty augmentation in the surgical treatment of the severe osteoporotic spines. J Spinal Disord Tech 22 : 444-447, 2009   DOI
34 Becker S, Chavanne A, Spitaler R, Kropik K, Aigner N, Ogon M, et al. : Assessment of different screw augmentation techniques and screw designs in osteoporotic spines. Eur Spine J 17 : 1462-1469, 2008   DOI
35 Bianco RJ, Arnoux PJ, Wagnac E, Mac-Thiong JM, Aubin CE : Minimizing pedicle screw pullout risks: a detailed biomechanical analysis of screw design and placement. Clin Spine Surg 30 : E226-E232, 2017   DOI
36 Ayers MP, Clift SE, Gheduzzi S : Morsellised sawbones is an acceptable experimental substitute for the in vitro elastic and viscoelastic mechanical characterisation of morsellised cancellous bone undergoing impaction grafting. Med Eng Phys 36 : 26-31, 2014   DOI
37 Bullmann V, Schmoelz W, Richter M, Grathwohl C, Schulte TL : Revision of cannulated and perforated cement-augmented pedicle screws: a biomechanical study in human cadavers. Spine (Phila Pa 1976) 35 : E932-E939, 2010   DOI
38 Burval DJ, McLain RF, Milks R, Inceoglu S : Primary pedicle screw augmentation in osteoporotic lumbar vertebrae: biomechanical analysis of pedicle fixation strength. Spine (Phila Pa 1976) 32 : 1077-1083, 2007   DOI
39 Calvert KL, Trumble KP, Webster TJ, Kirkpatrick LA : Characterization of commercial rigid polyurethane foams used as bone analogs for implant testing. J Mater Sci Mater Med 21 : 1453-1461, 2010   DOI
40 Chang MC, Liu CL, Chen TH : Polymethylmethacrylate augmentation of pedicle screw for osteoporotic spinal surgery: a novel technique. Spine (Phila Pa 1976) 33 : E317-E324, 2008   DOI
41 Chao KH, Lai YS, Chen WC, Chang CM, McClean CJ, Fan CY, et al. : Biomechanical analysis of different types of pedicle screw augmentation: a cadaveric and synthetic bone sample study of instrumented vertebral specimens. Med Eng Phys 35 : 1506-1512, 2013   DOI
42 Charles YP, Pelletier H, Hydier P, Schuller S, Garnon J, Sauleau EA, et al. : Pullout characteristics of percutaneous pedicle screws with different cement augmentation methods in elderly spines: an in vitro biomechanical study. Orthop Traumatol Surg Res 101 : 369-374, 2015   DOI
43 Chang MC, Kao HC, Ying SH, Liu CL : Polymethylmethacrylate augmentation of cannulated pedicle screws for fixation in osteoporotic spines and comparison of its clinical results and biomechanical characteristics with the needle injection method. J Spinal Disord Tech 26 : 305-315, 2013   DOI
44 Chen LH, Tai CL, Lee DM, Lai PL, Lee YC, Niu CC, et al. : Pullout strength of pedicle screws with cement augmentation in severe osteoporosis: a comparative study between cannulated screws with cement injection and solid screws with cement pre-filling. BMC Musculoskelet Disord 12 : 33, 2011   DOI
45 Cho W, Wu C, Erkan S, Kang MM, Mehbod AA, Transfeldt EE : The effect on the pullout strength by the timing of pedicle screw insertion after calcium phosphate cement injection. J Spinal Disord Tech 24 : 116-120, 2011   DOI
46 Choma TJ, Pfeiffer FM, Swope RW, Hirner JP : Pedicle screw design and cement augmentation in osteoporotic vertebrae: effects of fenestrations and cement viscosity on fixation and extraction. Spine (Phila Pa 1976) 37 : E1628-E1632, 2012   DOI
47 Abshire BB, McLain RF, Valdevit A, Kambic HE : Characteristics of pullout failure in conical and cylindrical pedicle screws after full insertion and back-out. Spine J 1 : 408-414, 2001   DOI
48 Aldini NN, Fini M, Giavaresi G, Giardino R, Greggi T, Parisini P : Pedicular fixation in the osteoporotic spine: a pilot in vivo study on long-term ovariectomized sheep. J Orthop Res 20 : 1217-1224, 2002   DOI
49 Amendola L, Gasbarrini A, Fosco M, Simoes CE, Terzi S, De Iure F, et al. : Fenestrated pedicle screws for cement-augmented purchase in patients with bone softening: a review of 21 cases. J Orthop Traumatol 12 : 193-199, 2011   DOI