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Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

Postal Subscription Code 80-967

2018 Impact Factor: 1.847

Front. Med.    2019, Vol. 13 Issue (5) : 590-601    https://doi.org/10.1007/s11684-019-0710-z
RESEARCH ARTICLE
Effect of surgical factors on the augmentation of cement- injectable cannulated pedicle screw fixation by a novel calcium phosphate-based nanocomposite
Haolin Sun1,4, Chun Liu2, Shunlun Chen1, Yanjie Bai3, Huilin Yang2,4, Chunde Li1(), Lei Yang2,4,5()
1. Department of Orthopedics, Peking University First Hospital, Beijing 100034, China
2. Orthopedic Institute, Department of Orthopedics, First Affiliated Hospital, Soochow University, Suzhou 215006, China
3. School of Public Health, Medical College, Soochow University, Suzhou 215100, China
4. International Research Center for Translational Orthopedics, Suzhou 215006, China
5. School of Materials Science and Engineering, Hebei University of Technology, Tianjin 300130, China
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Abstract

Bone cement-augmented pedicle screw system demonstrates great efficacy in spinal disease treatments. However, the intrinsic drawbacks associated with clinically used polymethylmethacrylate (PMMA) cement demands for new bone cement formulations. On the basis of our previous studies, a novel injectable and biodegradable calcium phosphate-based nanocomposite (CPN) for the augmentation of pedicle screw fixation was systematically evaluated for its surgical feasibility and biomechanical performance by simulated and animal osteoporotic bone models, and the results were compared with those of clinical PMMA cement. ASTM-standard solid foam and open-cell foam models and decalcified sheep vertebra models were employed to evaluate the augmentation effects of CPN on bone tissue and on the cement-injected cannulated pedicle screws (CICPs) placed in osteoporotic bone. Surgical factors in CICPs application, such as injection force, tapping technique, screw diameter, and pedicle screw loosening scenarios, were studied in comparison with those in PMMA. When directly injected to the solid foam model, CPN revealed an identical augmentation effect to that of PMMA, as shown by the similar compressive strengths (0.73±0.04 MPa for CPN group vs. 0.79±0.02 MPa for PMMA group). The average injection force of CPN at approximately 40–50 N was higher than that of PMMA at approximately 20 N. Although both values are acceptable to surgeons, CPN revealed a more consistent injection force pattern than did PMMA. The dispersing and anti-pullout ability of CPN were not affected by the surgical factors of tapping technique and screw diameter. The axial pullout strength of CPN evaluated by the decalcified sheep vertebra model revealed a similar augmentation level as that of PMMA (1351.6±324.2 N for CPN vs. 1459.7±304.4 N for PMMA). The promising results of CPN clearly suggest its potential for replacing PMMA in CICPs augmentation application and the benefits of further study and development for clinical uses.

Keywords bone cement      pedicle screw      degenerative spinal diseases      calcium phosphate      injectable     
Corresponding Author(s): Chunde Li,Lei Yang   
Just Accepted Date: 01 August 2019   Online First Date: 23 September 2019    Issue Date: 14 October 2019
 Cite this article:   
Haolin Sun,Chun Liu,Shunlun Chen, et al. Effect of surgical factors on the augmentation of cement- injectable cannulated pedicle screw fixation by a novel calcium phosphate-based nanocomposite[J]. Front. Med., 2019, 13(5): 590-601.
 URL:  
https://academic.hep.com.cn/fmd/EN/10.1007/s11684-019-0710-z
https://academic.hep.com.cn/fmd/EN/Y2019/V13/I5/590
Fig.1  Augmentation effects of bone cements evaluated by solid foam model. (A) Cylindrical solid foam model (D= 30 mm, H= 19.8 mm) with a spherical cavity (D= 16 mm); (B) X-ray radiographs of the solid foam blocks injected with different bone cement; (C) setup of uniaxial compression tests; (D) sawbones–cement complexes after uniaxial compression tests; (E) typical stress–strain curves; and (F) averaged compressive strength of the cement-augmented solid foam blocks. Data are represented as mean±standard deviation (***P<0.001).
Fig.2  Injection force measurement of bone cement. (A) Setup of injection force tests on a mechanical testing machine; (B and C) representative load–displacement curves of injection when different volumes of CPN and PMMA were injected, respectively; and (D) comparison of the injection force between CPN and PMMA in the open-cell foam models for different injected volumes. Data are represented as mean±standard deviation (**P<0.01, ***P<0.001).
Fig.3  Effect of L/S ratio of CPN on screw augmentation performance. (A) X-ray radiograph of cement-augmented screw in open-cell sawbones foam, setup of axial pullout test, and photo of the screw–cement complexes after axial pullout test; (B) typical load–displacement curves of pullout tests for the different L/S ratios of CPN; and (C) average axial pullout strength of CPN-augmented pedicle screws. Data are represented as mean±standard deviation (*P<0.05, **P<0.01, ***P<0.001).
Fig.4  Effect of different volumes of bone cement on the augmentation of pedicle screws. (A) X-ray radiographs of the different volumes of bone cement-augmented pedicle screws in the open-cell foam model; (B) 3-D reconstruction of CT scans viewed horizontally and vertically; (C and D) horizontal and vertical projection areas of bone cement, respectively; (E) dispersing volumes of CPN and PMMA; and (F) statistical results of the axial pullout strengths of cement-augmented pedicle screws. Data are represented as mean±standard deviation (*P<0.05, **P<0.01, ***P<0.001).
Fig.5  Tapping technique for screw placement. (A) X-ray radiographs of the augmentation of CICPs in the open-cell foam model, where screws were inserted using the same-size tapping (6.5 mm in diameter), one-size-under tapping (5.5 mm in diameter), or no-tapping technique (as control); (B and C) horizontal and vertical projection areas of bone cements, respectively; (D) dispersing volumes of CPN and PMMA; and (E) statistical results of the axial pullout strengths of cement-augmented pedicle screws. Data are represented as mean±standard deviation (**P<0.01, ***P<0.001).
Fig.6  CICPs with different diameters were augmented with bone cements. (A) X-ray radiographs of CICPs with different diameters were augmented with bone cements; (B and C) horizontal and vertical projection areas of bone cement, respectively; (D) dispersing volumes of CPN and PMMA; and (E) statistical results of the axial pullout strengths of cement-augmented pedicle screws. Data are represented as mean±standard deviation (**P<0.01, ***P<0.001).
Fig.7  Pedicle screw loosening scenario. (A) X-ray radiographs of the augmentation of CICPs in the open-cell foam model, where screws were inserted into a loosening model and a no-loosening model (as control); (B and C) horizontal and vertical projection areas of bone cement, respectively; (D) dispersing volumes of CPN and PMMA; and (E) statistical results of the axial pullout strengths of cement-augmented pedicle screws. Data are represented as mean±standard deviation (***P<0.001).
Fig.8  Augmentation effect of cements evaluated by decalcified sheep vertebra model. (A) Representative micro-CT images of vertebral bodies in decalcification at different time periods; (B) comparison of bone mineral density before and after decalcification; (C) setup of axial pullout tests for the augmented CICPs; (D) the photographs of the screw–cement complex before and after the axial pullout tests; and (E) average pullout strengths of cement-augmented pedicle screws in decalcified sheep vertebra. Data are represented as mean±standard deviation (***P<0.001).
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