In vitro and in vivo mechanical properties of human ulnar and median nerves.

Peripheral nerves are often subjected to mechanical stretching, which in excess results in various degrees of impairment of their function. An understanding of the biomechanical behavior of peripheral nerves is important to the prevention of nerve injury during surgical manipulation. Here, in vitro mechanical properties and viscoelastic behavior of human ulnar/median nerves were measured with a tensile tester. In vivo stress and deformation of an ulnar nerve was also examined in continuity during a surgical procedure. Finite element models were developed to determine in vitro and in vivo viscoelastic parameters of the nerves. The results show that in vitro mechanical properties of fresh ulnar nerve are different from those measured in vivo. Several factors that are possibly attributed to the difference were analyzed. The in situ strain of the nerves is one of the major factors that must be considered to obtain accurate strain-stress relationship in the in vivo measurement.

Cumulative multiple freeze-thaw cycles and testing does not affect subsequent within-day variation in intervertebral flexibility of human cadaveric lumbosacral spine.

STUDY DESIGN: An in vitro biomechanical study on 3-dimensional flexibility of human lumbosacral motion segments after multiple freeze-thaw cycles and cumulative testing. OBJECTIVE: To determine the significance of multiple freeze-thaw cycles and extended testing duration on between-day and within-day variations in motion segment flexibility. SUMMARY OF BACKGROUND DATA: Previous studies have found no significant effect of single freeze-thaw cycle on creep behavior of human spinal motion segments. Up to 3 freeze-thaw cycles were found to not affect flexibility of porcine spines and viscoelastic properties of human tendons, but more than 5 freeze-thaw cycles resulted in declined structural properties of human tendons. METHODS: Three lumbosacral motion segments were subjected to repeated flexibility tests to determine both the effects of within-day ambient exposure and between-day multiple freeze-thaw cycles on range of motion (ROM) and neutral zone (NZ). Repeated measures analysis of variance was carried out to evaluate within-day and between-day effects at α = .05. RESULTS: Significant between-day effects were found for intervertebral ROM and NZ in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) (all P < 0.001). Post hoc analysis indicated that significant differences from test day 1 become apparent after 4 freeze-thaw cycles with cumulative testing. There were no within-day variations from repeated testing on intervertebral FE ROM (P = 0.10), LB ROM (P = 0.36), AR ROM (P = 0.46), FE NZ (P = 0.83), LB NZ (P = 0.42), and AR NZ (P = 0.72). CONCLUSION: The flexibility of the human cadaveric lumbosacral motion segments between test days was significantly affected after repeated freeze-thaw and cumulative testing cycles. Multiple freeze-thaw cycles and cumulative testing, however, does not affect flexibility data for tests carried out within a single test day.

Local autograft retrieval from a cervical vertebral body: biomechanical consequences.

OBJECT: To avoid the cost of bone graft substitutes and the morbidity of iliac crest bone graft retrieval, locally harvested vertebral body bone has been used to fill interbody cages. When marginal hypertrophic osteophytes are used, there is little impact on the adjacent vertebrae, but when cancellous bone is removed from the central part of the vertebral body, it is not clear how significantly this procedure weakens the vertebra. The objective of this study was to investigate the immediate mechanical response of the cervical spine after removing bone from the central vertebral body. METHODS: Fourteen cervical functional spinal units (FSUs) (mean age 73.3 years, range 63-90 years) were used. For each FSU, bone mineral density (BMD) was determined using lateral-view dual-energy x-ray absorptiometry studies. The FSUs were assigned to 1 of 2 groups (test group or control group) with an equal distribution of BMD. All specimens received a cage placed into the cleaned disc space. The specimens from the test group had a 5-mm-diameter bone plug removed from the vertebral bodies superior and inferior to the cage-fitted disc. The specimens were loaded in flexion-compression until failure via an eccentric compressive force at 0.25 mm/second. RESULTS: The yield compression strength was 1149 ± 523 N for the test group and 1647 ± 962 N for the control group (p = 0.25). The ultimate compression strength was 1699 ± 498 N for the test group and 2450 N ± 835 N for the control group (p = 0.06). Force at 4 mm displacement was 1064 N for the test group and 1574 N for the control group (p = 0.15). Displacement at yield compression strength was 4.4 mm for the test group and 4.2 mm for the control group (p = 0.78). There was no significant intergroup difference for any of the studied parameters. CONCLUSIONS: There does not appear to be a significant early biomechanical weakening of adjacent vertebrae caused by aforementioned technique of local bone harvest.

Oblique lumbar interbody fixation: a biomechanical study in human spines.

STUDY DESIGN: In vitro spine biomechanics. OBJECTIVE: To determine the biomechanical properties of oblique lumbar interbody fixation (OLIF) in human cadaveric spines. SUMMARY OF BACKGROUND DATA: OLIF has been used for stabilization of degenerative spondylolisthesis at the lumbosacral junction. Biomechanical properties and mode of failure of OLIF as a standalone device for motion segments without sagittal deformity has not yet been investigated. We hypothesize that the biomechanical properties of OLIF will be comparable with the contemporary standard of pedicle screw (PS) fixation. METHOD: Randomly matched motion segments from L1 to L5 were allocated into 2 groups: (A) OLIF (group 1, n=5) or (B) PS (group 2, n=5). The intact and instrumented motion segments with and without anterior interbody graft were first tested under a combination of 200N axial compression and 5 Nm bending moments in flexion-extension and in lateral bending. Range of motion (ROM) and neutral zone were determined and compared between intact, OLIF and PS. A final load to failure test was carried out for each motion segment in either flexion or extension. RESULT: OLIF resulted in reduction of flexion-extension ROM to 36%±14% of intact whereas PS resulted in reduction to 27%±22% of intact. The reduction of lateral bending ROM were 32%±13% and 32%±24% of intact with OLIF and PS. There were no significant difference in ROM between OLIF and PS (P=0.39). The mean failure loads with OLIF and PS in flexion were 1284 and 1158N, and in extension were 1879 and 1934N, respectively. Failure occurred at the ventral screw bone interface without pedicle fracture. CONCLUSIONS: These results indicate that stiffness and load to failure of the OLIF is comparable with PS fixation. OLIF failure occurred ventrally through the anterior cortical rim without concomitant pedicle fracture.

The effect of tibial tuberosity realignment procedures on the patellofemoral pressure distribution.

PURPOSE: The study was performed to characterize the influence of tibial tuberosity realignment on the pressure applied to cartilage on the patella in the intact condition and with lesions on the lateral and medial facets. METHODS: Ten knees were loaded in vitro through the quadriceps (586 N) and hamstrings (200 N) at 40°, 60°, and 80° of flexion while measuring patellofemoral contact pressures with a pressure sensor. The tibial tuberosity was positioned 5 mm lateral of the normal position to represent lateral malalignment, 5 mm medial of the normal position to represent tuberosity medialization, and 10 mm anterior of the medial position to represent tuberosity anteromedialization. The knees were tested with intact cartilage, with a 12-mm-diameter lesion created within the lateral patellar cartilage, and with the lateral lesion repaired with silicone combined with a medial lesion. A repeated measures ANOVA and post hoc tests were used to identify significant (P < 0.05) differences in the maximum lateral and medial pressure between the tuberosity positions. RESULTS: Tuberosity medialization and anteromedialization significantly decreased the maximum lateral pressure by approximately 15% at 60° and 80° for intact cartilage and cartilage with a lateral lesion. Tuberosity medialization significantly increased the maximum medial pressure for intact cartilage at 80°, but the maximum medial pressure did not exceed the maximum lateral pressure for any testing condition. CONCLUSIONS: The results indicate that medializing the tibial tuberosity by 10 mm reduces the pressure applied to lateral patellar cartilage for intact cartilage and cartilage with lateral lesions, but does not overload medial cartilage.

The difference in spine specimen dual-energy X-ray absorptiometry bone mineral density between in situ and in vitro scans.

BACKGROUND CONTEXT: Human cadaveric specimens are commonly used to evaluate bone-implant interface strength in osteoporotic spine fixation. Dual-energy X-ray absorptiometry (DXA) scans are usually carried out on explanted spine specimens to measure bone mineral density (BMD) before in vitro biomechanical studies are carried out. PURPOSE: The purposes of this study were to verify and quantify the difference in DXA BMD between unexplanted (in situ) and explanted (in vitro) scans and to develop and validate a correction factor (CF) between in vitro and in situ DXA BMD. STUDY DESIGN: This is a retrospective analysis of past DXA scans of explanted specimens and a repeated measure scan rescan study of in situ and in vitro spine specimens. METHODS: Dual-energy X-ray absorptiometry scans were previously carried out on 106 male and 83 female lumbar specimens. Using multiple regressions, the correlation functions between Z score, BMD, and age were determined for male and female groups. The CF was developed based on difference in BMD between mean in vitro and population data. Next, in situ DXA scans were carried out on the lumbar spine of four full human cadavers, and subsequently, in vitro scans were repeated after explantation. The CF was applied to these in vitro scan data and the resulting corrected BMD compared with in situ scan values. RESULTS: The specimens had significantly lower Z score than population mean. The mean Z score was -0.7+/-1.4 (p<.001) for male and -0.3+/-1.3 (p=.03) for female specimens. The difference between in situ and in vitro scans was quantified to be 0.06 g/cm(2) for male specimens and to be a function of age (6.80 Age(-0.5)-3.76 Age(-0.365)) for female specimens. In vitro BMD was 96+/-11% of in situ BMD and was significantly different (p=.04). Corrected BMD after application of CF was 97+/-11% of in situ BMD and was not significantly different (p=.13). CONCLUSIONS: In vitro BMD scan on explanted specimens measured lower DXA values than in situ BMD scans on full cadavers. A CF when used resulted in more accurate measure of the in situ BMD.

The effect of cement augmentation and extension of posterior instrumentation on stabilization and adjacent level effects in the elderly spine.

STUDY DESIGN: An in vitro cadaveric study comparing different implant fixation techniques using a repeated measures design. OBJECTIVE: To compare the effects of cement augmentation of pedicle screws and extension of posterior fixation on (i) 3-dimensional stabilization, and (ii) adjacent level effects in the aging spine. SUMMARY OF BACKGROUND DATA: Device loosening and adjacent level effects are concerns in implant fixation in the elderly spine. Extension of posterior fixation and cement augmentation of pedicle screws have not been previously compared with respect to stabilization and adjacent level effects. METHODS: Twelve T9 to L3 cadaveric specimens were tested in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) with applied pure moments of +/-5 Nm. A T11 corpectomy was reconstructed with a vertebral body replacement device and T10 to T12 posterior instrumentation. Further stabilization was provided by posterior rod extension to L1 (flexible or rigid rods) and/or cement augmentation of T12 and L1 screws. The effects of cement augmentation and posterior rod extension on intersegmental motion were compared using the hybrid flexibility-stiffness protocol. Two-way repeated measures ANOVA and SNK post hoc tests (99% significance level) were used. RESULTS: Range of motion at the corpectomy T10 to T12 levels significantly decreased after cement augmentation (AR 43%, LB 71%, FE 68%), and posterior rod extension (rigid rods: AR 26%, LB 64%, FE 57%) (flexible rods: AR 16%, LB 53%, FE 39%). Posterior rod extension significantly reduced range of motion at the rod extension level. Motion at the distal noninstrumented L1 to L2 level was increased significantly by posterior rod extension and cement augmentation. There were however, smaller magnitudes of increase in motion across L1 to L2 level with flexible rod and cement augmentation (AR 12%, LB 45%, FE 31%). CONCLUSION: Cement augmentation of pedicle screws resulted in the most stable vertebral reconstruction, whereas flexible rod extension minimized changes in range of motion at both adjacent rod extension and distal noninstrumented levels.

Cement augmentation of vertebral screws enhances the interface strength between interbody device and vertebral body.

STUDY DESIGN: An in vitro cadaveric study comparing cage-vertebra interface strengths for 3 different screw-cement configurations. OBJECTIVES: To determine the effects of cement augmentation of pedicle screws on cage-vertebra interface failure properties for 2 interbody device shapes (elliptical or cloverleaf); and to compare between pedicle and anterior vertebral body screws with cement augmentation. SUMMARY OF BACKGROUND DATA: Pedicle or anterior screw fixation is commonly used with interbody device fixation. Cement has recently been shown to augment screw fixation in the osteoporotic spine by improving the screw-bone interface strength. The effect of cement augmentation of pedicle or anterior screws on cage-vertebra interface properties has not been previously studied or compared. METHODS: An elliptical or a cloverleaf-shaped indentor covering 40% of the endplate was axially compressed against the superior endplate of 48 thoracolumbar vertebrae. Each vertebra had polymethylmethacrylate cement augmentation of 1) anterior screws, 2) pedicle screws, or 3) pedicle screws without cement. Compressive load was applied through a mechanism that allowed unconstrained rotation of the indentors. RESULTS: Cement augmentation of pedicle screws resulted in significantly higher failure loads (54%) and failure strength (69%) for both shaped indentors when compared with uncemented pedicle screws. There was no significant difference in failure load and failure strength between pedicle and anterior screws with cement augmentation. Indentor shape was not a significant factor on failure load or failure strength. CONCLUSIONS: Cage-vertebra interface properties were improved when cement was used to augment vertebral and pedicle screws. Cement augmentation of pedicle or anterior screws may reduce interbody device subsidence.

Wrist impact velocities are smaller in forward falls than backward falls from standing.

The wrist is a common fracture site for both young and older adults. The purpose of this study was to compare wrist kinematics in backward and forward falls with different fall protective responses. We carried out within-subject comparison of impact velocities and maximum velocities during descent of the distal radius among three different fall configurations: (a) backward falls with knees flexed, (b) backward falls with knees extended and (c) forward falls with knees flexed. We also examined the effect of fall configuration on fall durations, elbow flexion, trunk flexion and forearm angles at impact. Forward falls resulted in smaller impact velocities of the distal radius, longer fall duration, longer braking duration, greater elbow flexion and more horizontal landing position of the forearm compared to backward falls. The distal radius impact velocity during forward falls (1.33 m/s) was significantly lower than in backward falls, and among the backward falls the impact velocity of the flexed knee strategy (2.01 m/s) was significantly lower than the extended knee strategy (2.27 m/s). These impact velocities were significantly reduced from the maximum velocities observed during descent (forward falls=3.57 m/s, backward falls with knee flexed=3.16 m/s, backward falls with knees extended=3.52 m/s). We conclude that (1) smaller impact velocities of the wrists in forward falls could imply a lower fracture risk compared to backward falls, and (2) fall protective responses reduced wrist impact velocities in all fall directions.

The effect of interbody cage positioning on lumbosacral vertebral endplate failure in compression.

STUDY DESIGN: A biomechanical investigation using a human cadaver, multisegmental lumbosacral spine model. OBJECTIVES: To determine if 2 small, posterolaterally positioned titanium mesh interbody cages would provide superior construct strength and stiffness in compression compared to central cage placement. In addition, determine construct stiffness with interbody cages as opposed to an intact spine and assess the effect of bone mineral density (BMD). SUMMARY OF BACKGROUND DATA: Previous work has shown that the posterolateral corners of the lumbosacral endplates are stronger than the anterior and central regions. Information to suggest appropriate interbody cage positioning to avoid subsidence into adjacent vertebrae would be valuable for spine surgeons and implant designers. METHODS: A total of 27 functional spinal units from L3 to S1 were dual x-ray absorptiometry scanned for BMD, instrumented with pedicle screw systems, and tested to failure in compression with titanium mesh interbody cages placed in 1 of 3 positions: 2 small posterolateral, 2 small central, or 1 large central. Analysis of covariance was conducted to compare failure load and stiffness across the different cage configurations. Repeated measures analysis of variance was used to analyze stiffness between functional spinal units with intact disc, discectomy, or interbody cages. Failure load was correlated against BMD. RESULTS: Of the 3 placement patterns, 2 small titanium mesh cages in the posterolateral corners had 20% higher failure loads, although the difference was not significant (P = 0.20). Stiffness in compression for the 3 cage positions was not significantly different (P = 0.82). All intact discs with posterior instrumentation were significantly stiffer than any of the cage patterns (P = 0.0001). BMD of the vertebrae significantly correlated with failure loads (P = 0.007). CONCLUSIONS: The placement of 2 small interbody cages posterolaterally tended to result in higher failure loads than central cage placement, although the results were not statistically significant. It is noteworthy that cage placement in any position resulted in a less stiff construct in compression than with an intact disc.

Interbody device shape and size are important to strengthen the vertebra-implant interface.

STUDY DESIGN: An in vitro cadaveric study to compare compressive failure load, strength, and stiffness of the implant-vertebra interface. OBJECTIVES: To determine the effect of cage shape (kidney, cloverleaf, or oval) and cage surface area on endplate failure strength and secondly to determine the extent and pattern of trabecular failure adjacent to an interbody device. SUMMARY OF BACKGROUND DATA: Recent studies indicate that the posterolateral and peripheral regions of the endplate are stronger than the central. Current implants are not designed to take advantage of these stronger regions of the endplate. The zone of trabecular failure that results from interbody device subsidence has not been reported extensively in the literature. METHODS: Uniaxial compression testing with unrestricted rotation was carried out on the superior endplates of 48 thoracolumbar (T9-L2) vertebrae with 1 of 3 shaped indentors covering 20% or 40% of the endplate area. Failure load, failure strength, and stiffness were compared. Quantitative computed tomography scans were carried out before and following indentation tests to identify areas of trabecular densification that indicate localized failure. RESULTS: The cloverleaf-shaped indentors resulted in significantly higher (P < 0.001) failure loads (by >45%), strength (>49%), and construct stiffness (>35%) for both the 20% and 40% cross-sectional area sizes. Trabecular bone failure occurred in a semielliptical zone underlying the interbody devices, leaving the endplate and underlying cancellous bone intact. CONCLUSIONS: The cloverleaf-shaped indentor displayed an improved strength and stiffness profile when compared to oval or kidney-shaped indentors of similar surface areas.

Pedicle screw motion in the osteoporotic spine after augmentation with laminar hooks, sublaminar wires, or calcium phosphate cement: a comparative analysis.

STUDY DESIGN: A biomechanical study addressing the motion of pedicle screws in a human cadaveric, osteoporotic spine model. OBJECTIVES: To compare the fixation of pedicle screws in an osteoporotic spine model after augmentation with laminar hooks, sublaminar wires, or calcium phosphate cement and to determine the kinematic patterns of these screws. SUMMARY OF BACKGROUND DATA: Numerous techniques exist for improving the quality of fixation within the osteoporotic spine, including supplementing the construct with laminar hooks, sublaminar wires, or calcium phosphate cement. Direct comparisons of these practices, however, are lacking. METHODS.: Twenty-four cadaveric lumbar vertebrae were instrumented with a pedicle screw and rod construct augmented with laminar hooks, sublaminar wires, or calcium phosphate cement. The screws were tested cyclically with physiologic loads. Rigid body motions of the screws were measured using an optoelectronic camera system, and the motion at the screw tip and at the screw head were calculated. Screw motions were compared using nonparametric paired statistical analysis. RESULTS: Between augmentation groups, there were no significant differences in the magnitude of motion at the screw head and at the screw tip. After calcium phosphate cement supplementation, screw motion was predominantly rotational in nature, whereas rigid body translation of the screw was more common with sublaminar wires or laminar hooks. CONCLUSIONS: The three augmentation techniques were similar in their ability to enhance the rigidity of fixation of the pedicle screws. Differences did exist, however, in the patterns of pedicle screw motion, with the calcium phosphate cement augmentation resulting in less rigid body translation than the other two techniques.