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Biomedical subjects

Bryan W Cunningham

Publications and source records attributed to Bryan W Cunningham.

At least 19 recordsLinked to original sources

Soft tissue injury threshold during simulated whiplash: a biomechanical investigation.

STUDY DESIGN: A newly developed biofidelic whole cervical spine (WCS) model with muscle force replication (MFR) was subjected to whiplash simulations of varying intensity, and the resulting injuries were evaluated through changes in the intervertebral flexibility. OBJECTIVES: To identify the soft tissue injury threshold based on the peak T1 horizontal acceleration and the association between acceleration magnitude and injury severity resulting from simulated whiplash using the WCS + MFR model. SUMMARY OF BACKGROUND DATA: Whiplash has been simulated using mathematical models, whole cadavers, volunteers, and WCSs. The measurement of injury (difference between prewhiplash and postwhiplash flexibilities) is possible only using the WCS model. METHODS: Six WCS + MFR specimens (C0-T1) were incrementally rear-impacted at nominal T1 horizontal maximum accelerations of 3.5, 5, 6.5, and 8 g, and the changes in the intervertebral flexibility parameters of neutral zone and range of motion were determined. The injury threshold acceleration was the lowest T1 horizontal peak acceleration that caused a significant increase in the intervertebral flexibility. RESULTS: The first significant increase (P <0.01) of 39.8% occurred in the C5-C6 extension neutral zone following the 5 g acceleration. At higher accelerations, the injuries spread among the surrounding levels (C4-C5 to C7-T1). CONCLUSIONS: A rear-end collision is most likely to injure the lower cervical spine by intervertebral hyperextension at a peak T1 horizontal acceleration of 5 g and above. These results may aid in the design of injury prevention systems and more precise diagnoses of whiplash injuries.

Aged↗

Endoscopic instrumented posterolateral lumbar fusion with Healos and recombinant human growth/differentiation factor-5.

OBJECTIVE: The goal of this study was to use a minimally invasive endoscopic surgical technique in a sheep model to evaluate the efficacy of an osteoinductive growth factor, recombinant human growth/differentiation factor-5 (also designated MP52), and an osteoconductive matrix formulation (Healos; DePuy AcroMed, Inc., Mountain View, CA) for inducing and facilitating bone formation. METHODS: Twelve mature sheep underwent bilateral posterolateral lumbar fusion and pedicle screw fixation via a posterior endoscopic approach. Each sheep received two different types of graft material, autogenous iliac crest bone, or a bone graft substitute (MP52 with Healos), inserted into the right and left sides of the spine in an alternating fashion. Groups of four sheep were killed at 2, 4, and 6 months postoperatively for manual, radiographic, and histological evaluation. RESULTS: No neurological impairments, infections, or other complications were observed. After 2 months, partial fusion on both sides was observed, but radiographic evaluation showed greater bone growth on the side that received the bone graft substitute. Solid posterolateral fusion was observed in both autograft and bone graft substitute sites at 4 and 6 months, and autograft and Healos MP52 fusion sites were essentially the same at histological examination. There was no abnormal overgrowth of new bone from either of these two materials. CONCLUSION: Endoscopic posterolateral lumbar arthrodesis and instrumentation is feasible, safe, and effective in a sheep model. Healos is a useful bonding agent that mimics natural bone in posterolateral intertransverse fusion sites. Combined with MP52, it produced fusion comparable to that of autogenous bone graft. Minimally invasive techniques and bone graft substitutes could eliminate morbidity and increase the likelihood of successful fusion.

Animals↗

General principles of total disc replacement arthroplasty: seventeen cases in a nonhuman primate model.

STUDY DESIGN: To investigate the biomechanical, histochemical, and biologic ingrowth characteristics of two different lumbar disc prostheses-AcroFlex (DePuy-AcroMed) and the SB Charitè (DePuy-AcroMed)-for total disc replacement arthroplasty. METHODS: A total of 17 mature baboons (n = 17, Papio cynocephalus) underwent L5-L6 total disc replacement procedures. The AcroFlex device (n = 10 levels) consisted of sintered titanium beaded ingrowth surfaces, bound together by a hexene-based polyolefin rubber core. The SB Charitè (n = 7 levels) device prosthetic vertebral end plates were cobalt chrome, covered by two layers of thin titanium with an electrochemically bonded hydroxyapatite coating and an ultra-high molecular weight polyethylene core. RESULTS: Following 6-month survival periods, the range of motion of the SB Charitè and intact nonoperative controls under axial compression, flexion-extension, and lateral bending showed no statistical difference (P > 0.05). However, both exhibited greater range of motion compared to the AcroFlex treatments (P < 0.05). Plain film radiographic analysis showed no lucencies or loosening of any metallic prosthetic vertebral endplate. Gross histopathologic analysis of the AcroFlex and SB Charité prosthesis demonstrated excellent ingrowth at the level of the implant-bone interface, without evidence of fibrous tissue or synovium. Histochemical assays showed no local or systemic accumulation of particulate wear debris (titanium, ultra-high molecular weight polyethylene, or cobalt chrome) nor cytokines (TNF-alpha, PGE2, IL-1, IL-2, or IL-6). Porous ingrowth calculations showed the mean ingrowth (linear apposition) ranging from 47.9% +/- 9.12 for the SB Charitè device and 54.59% +/- 13.24 for the AcroFlex device. CONCLUSIONS: The porous ingrowth, percentage pore ingrowth coverage at the bone-metal interface was more favorable for total disc replacement compared to that reported for cementless total joint components in the appendicular skeleton (range 10-30%). The reason for the improved degree of porous ingrowth in total disc replacement prostheses is probably due to ligamentotaxis causing sustained compression across the metal-bone interface. This project serves as the first comprehensive in vivo investigation comparing two different types of unconstrained disc prostheses with alternate in-growth surfaces and establishes an excellent research model in the evaluation of lumbar total disc replacement arthroplasty.

Animals↗

Biomechanical evaluation of total disc replacement arthroplasty: an in vitro human cadaveric model.

STUDY DESIGN: This in vitro biomechanical study was undertaken to quantify the multidirectional intervertebral kinematics following total disc replacement arthroplasty compared to conventional stabilization techniques. OBJECTIVE: Using an in vitro human cadaveric model, the primary objective was to compare the multidirectional flexibility properties and map the center of intervertebral rotation of total disc arthroplasty versus conventional threaded fusion cages and cages augmented with transpedicular fixation for single-level spinal instrumentation. SUMMARY OF BACKGROUND DATA: The utilization of motion-preserving implants versus instrumentation systems, which stabilize the operative segments, necessitates improved understanding of their comparative biomechanical properties. METHODS: A total of eight human cadaveric lumbosacral spines (L2 to sacrum) were utilized in this investigation and biomechanically evaluated under the following L4-L5 reconstruction conditions: 1) intact spine; 2) SB Charitè disc prosthesis; 3) BAK cages; and 4) BAK cages + ISOLA pedicle screw/rod fixation (anteroposterior). The superior (L3-L4) and inferior (L5-S1) intervertebral levels remained uninstrumented to quantify adjacent level properties. Multidirectional flexibility included pure, unconstrained moments (+/-8 Nm) in axial rotation, flexion-extension, and lateral bending, with quantification of the operative and adjacent level range of motion and neutral zone, which were normalized to the intact spine condition. RESULTS: The SB Charitè prosthesis indicated an average percentage increase in axial rotation range of motion by 44% compared to the intact condition (P < 0.05), whereas the BAK and anteroposterior reconstructions decreased range of motion by 29% and 80%, respectively (P < 0.05). The SB Charitè was significantly different from BAK and combined anteroposterior reconstructions (P < 0.05). Flexion-extension indicated a minor increase in range of motion for the SB Charitè (3%) versus the intact disc (P > 0.05), whereas the BAK and anteroposterior stabilization groups resulted in significant decreases in range of motion (BAK = 57%, anteroposterior = 93%) (P < 0.05) when compared to the intact and SB Charitè conditions. Based on flexion-extension radiographs, the intervertebral centers of rotation were in the posterior one-third of the operative intervertebral disc only for the SB Charitè reconstruction and intact spine condition, with definitive evidence of physiologic intervertebral translation (intact 2.06 +/- 77 mm; SB III = 1.9 +/- 0.98 mm). CONCLUSIONS: Total disc arthroplasty serves as the next frontier in the surgical management of discogenic spinal pathology. The SB Charitè restored motion to the level of the intact segment in flexion-extension and lateral bending and increased motion in axial rotation. The anterior annular resection necessary for device implantation and unconstrained design of the prosthesis account for this change in rotation. The normal lumbar flexion-extension axis of rotation is an ellipse rather than a single point. Only disc replacement rather than pedicle instrumentation or BAK interbody instrumentation preserves the kinematic properties and normal mapping of segmental motion at the operative and adjacent intervertebral disc levels.

Arthroplasty, Replacement↗

Experimental design of total disk replacement-experience with a prospective randomized study of the SB Charitè.

STUDY DESIGN: Prospective randomized clinical trial. OBJECTIVES: To determine if a prospective randomized study of patients with symptomatic degenerative disc disease treated with disc arthroplasty could be safely completed. METHODS: Sixty patients with one-level discogenic pain confirmed by plain radiography, magnetic resonance imaging, and provocative discography for degenerative disc disease were randomized comparing 1/3 BAK anterior interbody fusion and 2/3 anterior SB Charitè artificial disc replacement. RESULTS: The mean age was 40.3 years (range 21-56 years). Nineteen cases were at L4-L5 and 41 cases were at L5-S1. Nineteen cases had BAK anterior interbody fusion and 41 cases were randomized as SB Charitè disc replacement. The length of surgery was mean 88.4 minutes (range 54-137 minutes) for both groups. The estimated blood loss was mean 289.5 cc (range 50-1800 cc). The length of hospital stay was a mean of 3.03 days (range 2 to 6 days). Oswestry Disability Index for the BAK control group was 45.9 +/- 10.4 before surgery and 23.5 +/- 17.2 at follow-up (P < 0.001). The corresponding ODI scores for the SB Charitè disc were 50.0 +/- 14.3 before surgery and 25.0 +/- 20.1 at a mean of 2 years' follow-up (P < 0.001). CONCLUSIONS: This is the first study that shows improvement of functional outcome measures in a prospective randomized design treating primarily mechanical back pain and achieving comparable successful results to lumbar spinal stenosis decompression.

Adult↗

Analysis of porous ingrowth in intervertebral disc prostheses: a nonhuman primate model.

STUDY DESIGN: A study was conducted to investigate the biomechanical, histochemical, and biologic ingrowth characteristics of the most widely used total disc prosthesis, the hydroxyapatite-coated SB Charité prosthesis. OBJECTIVE: To compare the porous ingrowth, linear apposition, or bony ingrowth in total disc replacement with published reports of porous ingrowth prostheses in the appendicular skeleton. METHODS: Seven mature baboons (Papio cynocephalus) underwent L5-L6 total disc replacement through an anterior transperitoneal approach. The SB Charité prosthetic vertebral endplates (n = 14) were cobalt-chrome covered by two layers of thin titanium with a hydroxyapatite coating, which was electrochemically bonded to the implant surface. RESULTS: At 6 months after surgery, the range of motion exhibited by the SB Charité and the nonoperative control subjects under axial compression, flexion-extension, and lateral bending showed no statistical difference (P > 0.05). Plain film radiographic analysis showed no lucencies or loosening of any prosthetic vertebral endplate. Gross histopathologic analysis of the hydroxyapatite-coated SB Charité prosthesis demonstrated excellent ingrowth at the level of the implant-bone interface, without evidence of fibrous tissue or synovium. Histochemical assays showed no accumulation of particulate wear debris (no titanium, ultrahigh molecular weight polyethylene, or cobalt-chrome) nor cytokines (tumor necrosis factor-alpha, prostaglandin E2, interleukin-1, -2, or -6). Total endplate area showed a mean ingrowth (volume fraction) of 47.9% +/- 9.12% and a total ingrowth range of 35.5% to 58.8%. CONCLUSIONS: The porous ingrowth (percentage of pore ingrowth coverage at the bone-metal interface) was more favorable for total disc replacement than for cementless total joint components in the appendicular skeleton (range, 10-30%). The reason for the improved degree of porous ingrowth in total disc replacement prostheses probably is that ligamentotaxis causes sustained compression across the metal-bone interface.

Animals↗

Classification of heterotopic ossification (HO) in artificial disk replacement.

There is currently no structured classification system to quantitate heterotopic bone formation after artificial disk replacement procedures. The purpose of this work was to develop a method of classifying heterotopic bone formation that is reliable between investigators with different levels of training and easy to remember with only five gradations of severity. One hundred one radiographs of clinical patients and 17 microradiographs from nonhuman primates having undergone various types of disk replacement were classified by seven independent reviewers. The kappa statistics were calculated for interobserver variation between the seven participants with various levels of spinal training and the intraobserver error based on two assessments made at least 2 months apart. The interobserver reliability correlation coefficient for seven raters calculated using the intraclass kappa correlation coefficient and the Kish rho was r = 0.9683 (P < 0.0001). The intraobserver reliability based on readings at two time intervals at a minimum of 2 months apart was r = 0.8949 (P = 0.01). This classification of heterotopic ossification, periannular calcification, and ectopic bone formation associated with total disk arthroplasty proved to be highly reliable and reproducible.

Animals↗

SB Charité disc replacement: report of 60 prospective randomized cases in a US center.

Sixty patients with one-level discogenic pain confirmed by plain radiography, magnetic resonance imaging, and provocative discography for degenerative disc disease were randomized: one-third BAK anterior interbody fusion and two-thirds anterior SB Charité artificial disc replacement. The mean age was 40.3 years (range 21-56 years). Nineteen cases were at L4-L5 and 41 cases were at L5-S1. Nineteen cases had BAK anterior interbody fusion and 41 cases were randomized as SB Charité disc replacement. The length of surgery was mean 88.4 minutes (range 54-137 minutes) for both groups. The estimated blood loss was mean 289.5 mL (range 50-1800 mL). The length of hospital stay was a mean of 3.03 days (range 2-6 days). Oswestry Disability Index scores for the SB Charité disc (aggregate study group) were 50.0 +/- 14.3 preoperatively and 25.0 +/- 20.1 at 1-3 years' follow-up (P < 0.001). This is the first study that shows improvement of functional outcome measures in a prospective randomized design with disc arthroplasty treating primarily mechanical back pain and achieving comparable successful results to lumbar fusion-interbody fusion cage and BMP or interbody autograft and pedicle screw instrumentation.

Adult↗

Biomechanical comparison of lumbosacral fixation techniques in a calf spine model.

STUDY DESIGN: biomechanical testing of the strength and stability of lumbosacral fixation constructs. OBJECTIVES: The purpose of this study was to quantify and compare the biomechanical properties of five different lumbosacral fixation constructs and determine the benefit of adding supplementary fixation to S1 screws. SUMMARY OF BACKGROUND DATA: Extension of long fusions to the sacrum remains a difficult clinical challenge. Only a limited number of biomechanical studies have evaluated the different fixation methods available, and none has included both nondestructive and load to failure testing of these fixation methods. METHODS: Six fresh-frozen calf spines were prepared and tested for each construct. The five constructs tested included the following: S1 screws alone, S1 screws and S2 proximally directed screws, S1 screws and S2 distally directed screws, S1 screws and intrasacral rods, and S1 screws and iliac screws. Nondestructive, multidirectional flexibility analyses included four loading methods followed by a destructive flexural load to failure. Lumbosacral peak range of motion (millimeters or degrees) and ultimate failure load (Nm) of the five reconstruction techniques were statistically compared using a one-way analysis of variance combined with a Student-Newman-Keuls post hoc test. RESULTS: S1 screw strain tested in flexion-extension was significantly reduced by the addition of any second point of distal fixation. There was no significant difference between any of the different sacral fixation constructs (P > 0.05). In axial compression, only the addition of iliac screws significantly reduced S1 screw strain. In destructive testing under flexion loading, only iliac screws statistically increased the load at failure (P = 0.005). CONCLUSION: This study demonstrates the effectiveness of adding a second fixation point distal to the S1 screws in reducing S1 screw strain. Iliac fixation is more effective than secondary sacral fixation points but may not be necessary in all clinical situations. Only iliac fixation effectively increased the load to failure under catastrophic loading conditions. Supplementary sacral fixation failed to significantly protect against catastrophic failure. These findings support the clinical observation that iliac fixation is least likely to fail in high-risk, long fusions. Whether testing range of motion, screw strain, or load to failure, no benefit could be demonstrated for intrasacral rod placement when compared with other supplementary sacral fixation techniques. Intrasacral rod placement was equal to a second sacral screw in reducing S1 screw strain during flexion-extension loading. It was not as effective as iliac fixation in reducing screw strain or preventing catastrophic failure. When choosing fixation methods in long fusions to the sacrum, this study supports the use of iliac fixation as the method least likely to loosen or pull out. A second point of sacral fixation also offers biomechanical advantages when compared with S1 fixation alone and may be an appropriate choice in less "high risk" fusions to the sacrum.

Animals↗

Biomechanical evaluation of lumbosacral reconstruction techniques for spondylolisthesis: an in vitro porcine model.

STUDY DESIGN: Biomechanical evaluation of lumbosacral fixation using a porcine model. OBJECTIVES: The primary objective of the current study was to quantify and compare the changes in lumbosacral range of motion produced by four different methods of surgical stabilization, as well as comparing the relative effects of the four constructs in destructive testing. SUMMARY OF BACKGROUND DATA: The lumbosacral junction continues to be a difficult region to obtain a successful spinal arthrodesis and is one of the primary regions for construct failure. METHODS: Twenty-four fresh-frozen porcine lumbosacral spines were used in this investigation. Following intact analysis, the specimens were radically destabilized at the lumbosacral junction and randomized into four treatment groups based on reconstruction: 1) L7-S1 pedicle screws alone (n = 6); 2) L7-S1 pedicle screws and interbody cage (titanium mesh) (n = 6); 3) L7-S1 pedicle screws and iliac screws (n = 6); and 4) L7-S1 pedicle/iliac screws and interbody cage (n = 6). Nondestructive, multidirectional flexibility analyses included four loading methods and fatigue component followed by a destructive flexural load to failure. Lumbosacral peak range of motion (millimeters or degrees) and ultimate failure load (Nm) of the four reconstruction techniques were statistically compared using a one-way analysis of variance combined with Fisher's PLSD. RESULTS: 1) Axial compression: There were no differences in lumbosacral flexibility among the four treatment groups (P > 0.05). 2) Axial rotation: Iliac screw constructs, with or without cages, decreased flexibility at the lumbosacral junction compared with pedicle screws alone (P < 0.05). However, interbody cage reconstructions did not significantly reduce motion. 3) Flexion-extension: Iliac screws with interbody cages reduced segmental motion about the lumbosacral junction, which was significantly different from the remaining treatments (P < 0.05). 4) Lateral bending: The iliac screw constructs afforded significantly less lumbosacral motion compared with bothpedicle screw constructs (with or without cages). With destructive testing, pullout for L7-S1 constructs occurred at the sacrum, whereas failure for the L7-S1/iliac screw, with and without cages, occurred at the proximal adjacent level. CONCLUSION: Iliac screw constructs reduced lumbosacral flexibility levels in three of four loading methods (axial rotation, flexion-extension, and lateral bending) compared with pedicle screw reconstructions. The addition of interbody cages decreased lumbosacral motion for the iliac screw treatments under flexion-extension loading and pedicle screw constructs under axial rotation but did not protect the sacral screws in destructive testing as the iliac screws did. Based on evaluation using an porcine model, both iliac screws and interbody cages effectively reduce the multidirectional flexibility properties of the lumbosacral junction; however, iliac screws are more restrictive of motion (at the lumbosacral joint) and protective of the S1 screws.

Animals↗

The effect of titanium particulate on development and maintenance of a posterolateral spinal arthrodesis: an in vivo rabbit model.

STUDY DESIGN: The current study was undertaken to determine if the presence of titanium wear particulate deleteriously influences early osseointegration of posterolateral bone graft or disrupts an established posterolateral fusion mass. OBJECTIVES: Using an in vivo animal model to evaluate the effect(s) of titanium wear particulate on a posterolateral spinal arthrodesis based on serologic, histologic, and immunocytochemical analyses. SUMMARY OF BACKGROUND DATA: The effect of unintended wear particulate resulting from micromotion between the interconnection mechanisms in spinal instrumentation remains a clinical concern. METHODS: Thirty-four New Zealand White rabbits were randomized into two groups based on postoperative time periods of 2 months (Group 1, n = 14) and 4 months (Group 2, n = 20). Group 1 underwent a posterolateral arthrodesis at L5-L6 using tricortical iliac autograft or tricortical iliac autograft + titanium particulate. Group 2 received iliac autograft at the initial surgery and were reoperated on after 8 weeks and treated with posterolateral arthrodesis exposure alone or titanium particulate. Postoperative analysis included serologic quantification of systemic cytokines. Postmortem microradiographic, immunocytochemical, and histopathologic assessment of the intertransverse fusion mass quantified the extent of osteolysis, local pro-inflammatory cytokines, osteoclasts, and inflammatory infiltrates. RESULTS: Serologic analysis of systemic cytokines indicated no significant differences in cytokine levels (P > 0.05) between the titanium or autograft treatments. Immunocytochemistry indicated increased levels of local cytokines (tumor necrosis factor-alpha) at the titanium-treated posterolateral arthrodesis sites at both time periods (P < 0.05). Osteoclast cell counts and regions of osteolytic resorption lacunas were higher in the titanium-treated versus autograft-alone groups (P < 0.05), and the extent of cellular apoptosis was markedly higher in the titanium-treated sites at both time intervals. Electron microscopy indicated definitive evidence of phagocytized titanium particles and foci of local, chronic, inflammatory changes in the titanium-treated sites. CONCLUSION: Titanium particulate debris introduced at the level of a spinal arthrodesis elicits a cytokine-mediated particulate-induced response favoring pro-inflammatory infiltrates, increased expression of intracellular tumor necrosis factor-alpha, increased osteoclastic activity, and cellular apoptosis. The presence of titanium particulate debris, secondary to motion between spinal implants, may serve as the impetus for late-onset inflammatory-infectious complications and long-term osteolysis of an established posterolateral fusion mass in the clinical setting.

Acid Phosphatase↗

Total disc replacement arthroplasty using the AcroFlex lumbar disc: a non-human primate model.

Using a non-human primate model, the current study was undertaken to investigate the efficacy of the AcroFlex lumbar disc as an intervertebral disc prosthesis, based on biomechanical, histopathologic and histomorphometric analyses. A total of 20 mature male baboons (Papio cynocephalus, mean weight 30 kg) were randomized into two equal groups based on post-operative time periods of 6 (n=10) and 12 months (n=10). Each animal underwent an anterior transperitoneal surgical approach to the lumbar spine, with intervertebral reconstructions performed at L3-L4 and L5-L6 using the following techniques: (1) tricortical iliac autograft and (2) AcroFlex lumbar disc. The two treatments were equally randomized between the non-contiguous operative lumbar levels. Post-mortem analysis included histopathologic assessment of the systemic reticuloendothelial tissues, multi-directional flexibility testing of the operative functional spinal units and quantitative histological analysis of trabecular bone coverage at the prosthesis endplates. Data were statistically compared using a one-way ANOVA with the Student-Newman-Keuls test. All animals survived the operative procedure and post-operative interval without significant intra- or peri-operative complications. Histopathologic analysis of the paraffin-embedded systemic reticuloendothelial tissues indicated no significant pathologic changes at the 6- or 12-month intervals. Plain film radiographic analysis showed no lucencies or loosening of any prosthetic vertebral endplate. Biomechanical testing of the 6-month autograft, reconstructions with AcroFlex lumbar disc and non-operative control (n=10) intact motion segments indicated no significant differences in peak range of motion (ROM) in axial compression. However, axial rotation produced significantly lower ROM for the autograft treatment compared to the intact and AcroFlex groups (P<0.05). The most significant differences in peak ROM were noted between all treatment groups under flexion/extension and lateral bending loading modalities (P<0.05). By 12 months, the intact condition indicated significantly more motion in all bending modes compared to the AcroFlex and autograft treatments, which were not statistically different from each other (P>0.05). Gross histopathologic analysis of the AcroFlex disc prosthesis demonstrated excellent ingrowth at the level of the implant-bone interface, without evidence of fibrous tissue or synovium. BioQuant histomorphometric analysis at the metal-bone interface (bone contact area/total endplate area) indicated the mean ingrowth was 54.59+/-13.24% at 6 months and 56.79+/-5.85% at 12 months. Radiographic analysis showed no lucencies or loosening of the AcroFlex vertebral endplate. Based on multi-directional flexibility testing, motion was preserved in axial rotation, but significantly diminished in the other bending modalities, particularly at the 12-month interval. This effect may be secondary to the limited surface area of device-vertebral endplate contact. Histomorphometric analysis of porous ingrowth coverage at the vertebral bone-metal interface was more favorable for total disc arthroplasty compared to historical reports of cementless femoral components. This project serves as the first comprehensive in vivo investigation into the AcroFlex disc prosthesis, and establishes an excellent research model in the evaluation of total disc replacement arthroplasty.

Animals↗

An in vitro human cadaveric study investigating the biomechanical properties of the thoracic spine.

STUDY DESIGN: An in vitro human cadaveric study comparing the effects of anterior and posterior sequential destabilization conditions on thoracic functional unit mechanics was studied. OBJECTIVES: To investigate the biomechanical properties of the human thoracic spine. SUMMARY OF BACKGROUND DATA: Few studies have addressed the mechanical role of the costovertebral joints under torsion in the stability of the human thoracic spine. METHODS: Sixteen functional spinal units with intact costovertebral joints were obtained from six human cadavers and randomized into two groups based on destabilization procedures: Group 1, anterior to posterior sequential resection; and Group 2, posterior to anterior sequential destabilization. Biomechanical testing was performed after each destabilization procedure, and the range of motion under maximum load was calculated. RESULTS: Group 1: Under flexion-extension, lateral bending, and axial rotation loading, discectomy increased the range of motion by 193%, 74%, and 111%, respectively. Moreover, subsequent right rib head resection further increased the range of motion by 81%, 84%, and 72%, respectively. Group 2: Under all loading conditions laminectomy + medial facetectomy resulted in a 22-30% increase in range of motion. Subsequent total facetectomy led to an additional 15-28% increase in range of motion. CONCLUSION: The rib head joints serve as stabilizing structures to the human thoracic spine in the sagittal, coronal, and transverse planes. In anterior scoliosis surgery additional rib head resection after discectomy may achieve greater curve and rib hump correction. The lateral portion of the facet joints plays an important role in providing spinal stability and should be preserved to minimize postoperative kyphotic deformity and segmental instability when performing decompressive wide laminectomy.

Aged↗

Microradiographic and histopathologic findings in a human cage explant after two-level corpectomy: a case report.

STUDY DESIGN: A case involving microradiographic and histopathologic analysis of an explanted human corpectomy mesh cage is reported. OBJECTIVE: To describe the clinical circumstance, the radiographic appearance, and the histopathologic assessment of a titanium mesh device explanted from a two-level corpectomy. SUMMARY OF BACKGROUND DATA: To the authors' knowledge, no published microradiographic or histopathologic reports have described a retrieved human corpectomy cage. METHODS: The explanted device was stained using Osteochrome Villanueva bone stain and underwent routine decalcified histologic processing and embedding in polymethylmethacrylate. Midsagittal sections were prepared and polished to 100 microm for histologic and microradiographic analysis. RESULTS: Microscopic analysis demonstrated normal-appearing lamellar and woven trabecular bone in close contact with the titanium implant interface. Further analysis of serial sections indicated that, on the average, 35% (range, 30-40%) of the inner device region contained trabecular bone. CONCLUSION: Osteosynthesis and bone remodeling can occur within titanium corpectomy cages. METHODS: This study involved one titanium mesh device (Harms cage), 20 mm in diameter and 45 mm long, explanted from a two-level corpectomy clinical case. This device was retrieved, processed, and analyzed after informed patient consent and approval from the authors' institutional review board.

Adult↗

Anterior BAK instrumentation and fusion: complete versus partial discectomy.

Beginning in January 1994, a prospective, clinical study was done comparing the effectiveness of complete anterior (Group 1) versus partial reamed channel discectomies (Group 2) in 100 consecutive patients who had anterior BAK instrumentation and fusion using autogenous iliac crest bone graft. At 2 or more years of followup, all patients in Group 1 who had complete operative disc removal achieved solid arthrodesis. There were no revision surgeries. However, in Group 2, there were seven patients who had a pseudarthrosis and an additional patient with early postoperative cage displacement, which resulted in eight patients in Group 2 requiring revision surgery. The differences in operative preparation of the disc space for BAK instrumentation surgery resulting in complications proved to be significant. The use of interbody titanium cages dramatically increases the biomechanical efficacy of anterior fusions. Original proponents of cages advocated removing a cylindrical channel of disc material using a drill. A prospective review of 100 patients who had complete versus partial discectomy revealed 14% of patients in Group 2 eventually had a pseudarthrosis develop.

Adult↗

The use of interbody cage devices for spinal deformity: a biomechanical perspective.

Spinal instrumentation has revolutionized the treatment of spinal deformities and offers a plethora of techniques and designs to surgically treat deformity conditions. The authors address the biomechanical properties afforded by various posterior and anterior spinal instrumentation mechanisms, with and without intervertebral reconstruction, and the principles associated with optimal reconstruction techniques. The integration of multiple strategies can improve anterior and posterior construct stiffness in the treatment of spinal deformities. Structural interbody support probably is the best method to minimize longitudinal rod and screw-bone interface strain. Moreover, anterior load-bearing structural grafts and interbody devices have been shown to increase construct stiffness, decrease the incidence posterior implant failure, permit the use of smaller diameter longitudinal rods, and may enhance the rate of successful spinal arthrodesis. From a biomechanical standpoint, treatment of medium to high-grade spondylolisthesis with stand-alone interbody or transvertebral cages, in the absence of supplemental posterior fixation, is contraindicated. Collectively, the included studies reinforce the principles of load sharing between the anterior and posterior spinal columns and affirm the biomechanical dominance of anterior column support in circumferential spinal arthrodesis.

Biomechanical Phenomena↗

Osseointegration of autograft versus osteogenic protein-1 in posterolateral spinal arthrodesis: emphasis on the comparative mechanisms of bone induction.

BACKGROUND CONTEXT: Recent studies have documented increased fusion success afforded by bone morphogenetic proteins versus autogenous graft for posterolateral spinal arthrodesis. PURPOSE: The current study was designed to investigate the time-course maturation processes of lumbar posterolateral arthrodeses performed with Osteogenic Protein-1 (Stryker Biotech, Inc., Hopkinton, MA, USA) (rhOP-1) versus "gold standard" autograft. STUDY DESIGN: The primary focus of this study was to compare the histologic mechanisms of posterolateral osseointegration produced by "hot topic" growth factors. METHODS: A total of 36 coonhounds were equally divided into one of four postoperative time periods of 4, 8, 12 and 24 weeks (nine animals per period). Posterolateral arthrodesis treatments included 1) autograft alone, 2) autograft plus rhOP-1, or 3) rhOP-1 alone. The treatments and animals were divided such that a value of n=6 was obtained for each treatment group per time period and no one animal received the same treatment at both operative sites. Functional spinal unit (FSU) fusion status was assessed using radiographic analysis, biomechanical testing and undecalcified histopathologic and histomorphometric analyses. RESULTS: Radiographic differences in fusion maturation between the treatment groups were evident as early as the 4-week time interval and continued through the 24-week time period. The Osteogenic Protein-1 treatments demonstrated an accelerated rate of radiographic fusion by 4 weeks, which plateaued after the 8-week time period (22% autograft, 88% autograft/rhOP-1 and 66% rhOP-1). In contradistinction, the so-called "gold standard" autograft alone treatments reached a maximum of 50% fusion by the 6-month interval. Biomechanical testing of the FSUs indicated lower flexion-extension and axial rotation range of motion levels for both rhOP-1 treatments versus autograft alone at the 8- and 12-week time periods, respectively (p<.05). Histomorphometric analysis yielded no difference in the posterolateral trabecular bone area (mm(2)) between the three treatments (p>.05), and histopathology indicated no significant histopathologic changes. The most distinctive finding in this study deals with the mechanisms of posterolateral ossification. Based on plain and polarized light microscopy, bone induction and development for the rhOP-1 treatments, with and without autograft, was the result of intramembranous ossification, whereas the process of osseointegration for autograft alone was endochondral bone formation. By the 24-week interval, no discernable differences in trabecular histomorphology were evident based on the different mechanisms of ossification. CONCLUSIONS: This serves as the first study to document the mechanisms of bone induction and fusion maturation between posterolateral arthrodeses treated with autograft versus rhOP-1. The histological data served to corroborate the radiographic and biomechanical findings, because the rhOP-1 treatments consistently demonstrated increased fusion rates and lower range of motion levels compared with the autograft group, particularly at the 8-week postoperative time period. The improvements in these fusion criteria for Osteogenic Protein-1 versus autograft were considered secondary to the differing mechanisms of bone induction. When implanted for posterolateral arthrodesis, rhOP-1 induces an intramembranous healing response, obviating the need for the cartilage intermediate phases found in endochondral bone development. The mechanism of increased speed and incidence of fusion using growth factors (rhOP-1) is delineated by this comprehensive study of preferential intramembranous ossification.

Animals↗