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Biomedical Engineering / Biomedizinische Technik

Editor-in-Chief: Dössel, Olaf

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Volume 57, Issue 6 (Dec 2012)

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Volume 57 (2012)

Correlation of pull-out strength of cement-augmented pedicle screws with CT-volumetric measurement of cement

Christian Fölsch
  • Department of Orthopaedics, University Hospital Marburg, Baldingerstrasse, 35033 Marburg, Germany
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/ Hans Goost
  • Department of Orthopaedics, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127 Bonn, Germany
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/ Jens Figiel
  • Department of Radiology, University Hospital Marburg, Baldingerstrasse, 35033 Marburg, Germany
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/ Jürgen R.J. Paletta
  • Department of Orthopaedics, University Hospital Marburg, Baldingerstrasse, 35033 Marburg, Germany
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/ Wolfgang Schultz
  • Department of Orthopaedics, University Hospital Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany
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/ Stefan Lakemeier
  • Corresponding author
  • Department of Orthopaedics, University Hospital Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany
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Published Online: 2012-11-09 | DOI: https://doi.org/10.1515/bmt-2012-0012

Abstract

Background: Cement augmentation of pedicle screws increases fixation strength in an osteoporotic spine. This study was designed to determine the cement distribution and the correlation between the pull-out strength of the augmented screw and the cement volume within polyurethane (PU) foam.

Methods: Twenty-eight cannulated pedicle screws (6×45 mm) (Peter Brehm, Erlangen, Germany) with four holes at the distal end of the screw were augmented with the acrylic Stabilit ER Bone Cement Vertebral Augmentation System (DFine Inc., San Jose, CA, USA) and implanted into open-cell rigid PU foam (Pacific Research Laboratories, Vashon Island, WA, USA) with a density of 0.12 g/cm3, resembling severe osteoporosis. Volumetric measurement of the cement with consideration of the distribution around the screws was done with multislice computed tomography scan (Somatom Definition, Siemens, Erlangen, Germany). Pull-out strength was tested with a servohydraulic system (MTS System Corporation, Eden Prairie, MN, USA), and nonaugmented screws served as control. Pearson’s correlation coefficient with significance level α=0.05 and one-way analysis of variance test were used.

Results: We found a high (r=0.88) and significant (p<0.01) correlation between the cement volume and the pull-out strength, which increased by more than 5-fold with a volume of 3 ml. The correlation appeared linear at least up to 4 ml cement volume and failure always occurred at the cement-bone interface. The cement distribution was symmetric and circular around the most proximal hole, with a distance of 14 mm from the tip, and nearly 90% of the cement was found 6 mm distal and cranial to it. The 95% confidence interval for the relative amount of cement was 37%–41% within 2 mm of the most proximal hole.

Conclusion: Compared with the control, a cement volume between 2.0 and 3.0 ml increased the pull-out strength significantly and is relevant for clinical purposes, whereas a volume of 0.5 ml did not. A cement volume beyond 3.0 ml should further increase the pull-out strength because the correlation was linear at least up to 4.0 ml, but the possibility of in vivo cement leakage with increasing volume has to be considered. Pressure-controlled cement application might be a tool to avoid this complication. The cement almost completely penetrated the most proximal perforation.

Keywords: cannulated pedicle screw; cement augmentation; cement volume; osteoporosis; pull-out strength

References

  • [1]

    Asnis SE, Ernberg JJ, Bostrom MP, et al. Cancellous bone screw thread design and holding power. J Orthop Trauma 1996; 10: 462–469.PubMedCrossrefGoogle Scholar

  • [2]

    Baroud G, Wu JZ, Bohner M, Sponagel S, Steffen T. How to determine the permeability for cement infiltration of osteoporotic cancellous bone. Med Eng Phys 2003; 25: 283–288.PubMedCrossrefGoogle Scholar

  • [3]

    Baroud G, Bohner M, Heini P, Steffen T. Injection biomechanics of bone cements used in vertebroplasty. Biomed Mater Eng 2004; 14: 487–504.PubMedGoogle Scholar

  • [4]

    Baroud G, Crookshank M, Bohner M. High-viscosity cement significantly enhances uniformity of cement filling in vertebroplasty: an experimental model and study on cement leakage. Spine (Phila Pa 1976) 2006; 31: 2562–2568.Google Scholar

  • [5]

    Baroud G, Martin PL, Cabana F. Ex vivo experiments of a new injection cannula for vertebroplasty. Spine (Phila Pa 1976) 2006; 31: 115–119.Google Scholar

  • [6]

    Becker S, Chavanne A, Spitaler R, et al. Assessment of different screw augmentation techniques and screw designs in osteoporotic spines. Eur Spine J 2008; 17: 1462–1469.CrossrefPubMedGoogle Scholar

  • [7]

    Belkoff SM, Mathis JM, Fenton DC, Scribner RM, Reiley ME, Talmadge K. An ex vivo biomechanical evaluation of an inflatable bone tamp used in the treatment of compression fracture. Spine (Phila Pa 1976) 2001; 26: 151–156.Google Scholar

  • [8]

    Belkoff SM, Mathis JM, Jasper LE, Deramond H. The biomechanics of vertebroplasty. The effect of cement volume on mechanical behavior. Spine (Phila Pa 1976) 2001; 26: 1537–1541.Google Scholar

  • [9]

    Berzins A, Shah B, Weinans H, Sumner DR. Nondestructive measurements of implant-bone interface shear modulus and effects of implant geometry in pull-out tests. J Biomed Mater Res 1997; 34: 337–340.CrossrefPubMedGoogle Scholar

  • [10]

    Blattert TR, Glasmacher S, Riesner HJ, Josten C. Revision characteristics of cement-augmented, cannulated-fenestrated pedicle screws in the osteoporotic vertebral body: a biomechanical in vitro investigation. Technical note. J Neurosurg Spine 2009; 11: 23–27.CrossrefGoogle Scholar

  • [11]

    Boucher HH. A method of spinal fusion. J Bone Joint Surg Br 1959; 41-B: 248–259.PubMedGoogle Scholar

  • [12]

    Brantley AG, Mayfield JK, Koeneman JB, Clark KR. The effects of pedicle screw fit. An in vitro study. Spine (Phila Pa 1976) 1994; 19: 1752–1758.Google Scholar

  • [13]

    Bullmann V, Liljenqvist UR, Rodl R, Schulte TL. Pedicle screw augmentation from a biomechanical perspective. Orthopade 2010; 39: 673–678.PubMedCrossrefGoogle Scholar

  • [14]

    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) 2010; 35: E932–E939.Google Scholar

  • [15]

    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) 2007; 32: 1077–1083.Google Scholar

  • [16]

    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 2010; 21: 1453–1461.CrossrefPubMedGoogle Scholar

  • [17]

    Chao CK, Hsu CC, Wang JL, Lin J. Increasing bending strength and pullout strength in conical pedicle screws: biomechanical tests and finite element analyses. J Spinal Disord Tech 2008; 21: 130–138.CrossrefPubMedGoogle Scholar

  • [18]

    Chapman JR, Harrington RM, Lee KM, Anderson PA, Tencer AF, Kowalski D. Factors affecting the pullout strength of cancellous bone screws. J Biomech Eng 1996; 118: 391–398.CrossrefPubMedGoogle Scholar

  • [19]

    Chen LH, Tai CL, Lai PL, et al. Pullout strength for cannulated pedicle screws with bone cement augmentation in severely osteoporotic bone: influences of radial hole and pilot hole tapping. Clin Biomech (Bristol, Avon) 2009; 24: 613–618.CrossrefGoogle Scholar

  • [20]

    Chen LH, Tai CL, Lee DM, 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 2011; 12: 33.PubMedCrossrefGoogle Scholar

  • [21]

    Ciarelli MJ, Goldstein SA, Kuhn JL, Cody DD, Brown MB. Evaluation of orthogonal mechanical properties and density of human trabecular bone from the major metaphyseal regions with materials testing and computed tomography. J Orthop Res 1991; 9: 674–682.CrossrefPubMedGoogle Scholar

  • [22]

    Frankel BM, D’Agostino S, Wang C. A biomechanical cadaveric analysis of polymethylmethacrylate-augmented pedicle screw fixation. J Neurosurg Spine 2007; 7: 47–53.CrossrefPubMedGoogle Scholar

  • [23]

    Gibson LJ. The mechanical behaviour of cancellous bone. J Biomech 1985; 18: 317–328.PubMedCrossrefGoogle Scholar

  • [24]

    Gisep A, Curtis R, Hanni M, Suhm N. Augmentation of implant purchase with bone cements: an in vitro study of injectability and dough distribution. J Biomed Mater Res B Appl Biomater 2006; 77: 114–119.CrossrefGoogle Scholar

  • [25]

    Goldstein SA, The mechanical properties of trabecular bone: dependence on anatomic location and function. J Biomech 1987; 20: 1055–1061.CrossrefPubMedGoogle Scholar

  • [26]

    Halvorson TL, Kelley LA, Thomas KA, Whitecloud TS 3rd, Cook SD, Effects of bone mineral density on pedicle screw fixation. Spine (Phila Pa 1976) 1994; 19: 2415–2420.Google Scholar

  • [27]

    Hashemi A, Bednar D, Ziada S, Pullout strength of pedicle screws augmented with particulate calcium phosphate: an experimental study. Spine J 2009; 9: 404–410.CrossrefPubMedGoogle Scholar

  • [28]

    Johnson AE, Keller TS. Mechanical properties of open-cell foam synthetic thoracic vertebrae. J Mater Sci Mater Med 2008; 19: 1317–1323.PubMedCrossrefGoogle Scholar

  • [29]

    Kafchitsas K, Geiger F, Rauschmann M, Schmidt S. Cement distribution in vertebroplasty pedicle screws with different designs. Orthopade 2010; 39: 679–686.PubMedCrossrefGoogle Scholar

  • [30]

    Keaveny TM, Pinilla TP, Crawford RP, Kopperdahl DL, Lou A. Systematic and random errors in compression testing of trabecular bone. J Orthop Res 1997; 15: 101–110.PubMedCrossrefGoogle Scholar

  • [31]

    Keller TS. Predicting the compressive mechanical behavior of bone. J Biomech 1994; 27: 1159–1168.CrossrefPubMedGoogle Scholar

  • [32]

    Kiner DW, Wybo CD, Sterba W, Yeni YN, Bartol SW, Vaidya R. Biomechanical analysis of different techniques in revision spinal instrumentation: larger diameter screws versus cement augmentation. Spine (Phila Pa 1976) 2008; 33: 2618–2622.Google Scholar

  • [33]

    Krenn MH, Piotrowski WP, Penzkofer R, Augat P. Influence of thread design on pedicle screw fixation. Laboratory investigation. J Neurosurg Spine 2008; 9: 90–95.CrossrefPubMedGoogle Scholar

  • [34]

    Li B, Aspden RM. Composition and mechanical properties of cancellous bone from the femoral head of patients with osteoporosis or osteoarthritis. J Bone Miner Res 1997; 12: 641–651.PubMedCrossrefGoogle Scholar

  • [35]

    Liebschner MA, Rosenberg WS, Keaveny TM. Effects of bone cement volume and distribution on vertebral stiffness after vertebroplasty. Spine (Phila Pa 1976) 2001; 26: 1547–1554.Google Scholar

  • [36]

    Lotz JC, Hu SS, Chiu DF, Yu M, Colliou O, Poser RD. Carbonated apatite cement augmentation of pedicle screw fixation in the lumbar spine. Spine (Phila Pa 1976) 1997; 22: 2716–2723.Google Scholar

  • [37]

    Molloy S, Mathis JM, Belkoff SM. The effect of vertebral body percentage fill on mechanical behavior during percutaneous vertebroplasty. Spine (Phila Pa 1976) 2003; 28: 1549–1554.Google Scholar

  • [38]

    Nazarian A, Stauber M, Zurakowski D, Snyder BD, Muller R. The interaction of microstructure and volume fraction in predicting failure in cancellous bone. Bone 2006; 39: 1196–1202.PubMedCrossrefGoogle Scholar

  • [39]

    Nicayenzi B, Shah S, Schemitsch EH, Bougherara H, Zdero R. The biomechanical effect of changes in cancellous bone density on synthetic femur behaviour. Proc Inst Mech Eng [H] 2011; 225: 1050–1060.Google Scholar

  • [40]

    Pare PE, Chappuis JL, Rampersaud R, et al. Biomechanical evaluation of a novel fenestrated pedicle screw augmented with bone cement in osteoporotic spines. Spine (Phila Pa 1976) 2011; 36: E1210–E1214.Google Scholar

  • [41]

    Patel PS, Shepherd DE, Hukins DW. Compressive properties of commercially available polyurethane foams as mechanical models for osteoporotic human cancellous bone. BMC Musculoskelet Disord 2008; 9: 137.CrossrefPubMedGoogle Scholar

  • [42]

    Ramaswamy R, Evans S, Kosashvili Y. Holding power of variable pitch screws in osteoporotic, osteopenic and normal bone: are all screws created equal? Injury 2010; 41: 179–183.CrossrefPubMedGoogle Scholar

  • [43]

    Renner SM, Lim TH, Kim WJ, Katolik L, An HS, Andersson GB. Augmentation of pedicle screw fixation strength using an injectable calcium phosphate cement as a function of injection timing and method. Spine (Phila Pa 1976) 2004; 29: E212–E216.Google Scholar

  • [44]

    Rice JC, Cowin SC, Bowman JA. On the dependence of the elasticity and strength of cancellous bone on apparent density. J Biomech 1988; 21: 155–168.CrossrefGoogle Scholar

  • [45]

    Rovinsky D, Haskell A, Liu Q, Paiement GD, Robinovitch S. Evaluation of a new method of small fragment fixation in a medial malleolus fracture model. J Orthop Trauma 2000; 14: 420–425.CrossrefGoogle Scholar

  • [46]

    Roy-Camille R, Saillant G, Mazel C. Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop Relat Res 1986; 203: 7–17.Google Scholar

  • [47]

    Sarzier JS, Evans AJ, Cahill DW. Increased pedicle screw pullout strength with vertebroplasty augmentation in osteoporotic spines. J Neurosurg 2002; 96: 309–312.PubMedGoogle Scholar

  • [48]

    Silva MJ, Gibson LJ. Modeling the mechanical behavior of vertebral trabecular bone: effects of age-related changes in microstructure. Bone 1997; 21: 191–199.PubMedCrossrefGoogle Scholar

  • [49]

    Soshi S, Shiba R, Kondo H, Murota K. An experimental study on transpedicular screw fixation in relation to osteoporosis of the lumbar spine. Spine (Phila Pa 1976) 1991; 16: 1335–1341.Google Scholar

  • [50]

    Stadelmann VA, Bretton E, Terrier A, Procter P, Pioletti DP. Calcium phosphate cement augmentation of cancellous bone screws can compensate for the absence of cortical fixation. J Biomech 2010; 43: 2869–2874.PubMedCrossrefGoogle Scholar

  • [51]

    Thompson MS, McCarthy ID, Lidgren L, Ryd L. Compressive and shear properties of commercially available polyurethane foams. J Biomech Eng 2003; 125: 732–734.PubMedCrossrefGoogle Scholar

  • [52]

    Waits C, Burton D, McIff T. Cement augmentation of pedicle screw fixation using novel cannulated cement insertion device. Spine (Phila Pa 1976) 2009; 34: E478–E483.Google Scholar

  • [53]

    Zindrick MR, Wiltse LL, Widell EH, et al. A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res 1986; 203: 99–112.PubMedGoogle Scholar

About the article

Corresponding author: Stefan Lakemeier, Department of Orthopedics, University Hospital Göttingen, Robert-Koch-Straße 40, D-37075 Göttingen, Germany, Phone: +49-5513-922775, Fax: +49-5513-95562


Received: 2012-04-03

Accepted: 2012-10-18

Published Online: 2012-11-09

Published in Print: 2012-12-01


Citation Information: Biomedizinische Technik/Biomedical Engineering, ISSN (Online) 1862-278X, ISSN (Print) 0013-5585, DOI: https://doi.org/10.1515/bmt-2012-0012.

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