Application of the cortical bone trajectory technique in posterior lumbar fixation

The cortical bone trajectory(CBT) is a novel technique in lumbar fixation and fusion.The unique caudocephalad and medial-lateral screw trajectories endow it with excellent screw purchase for vertebral fixation via a minimally invasive method.The combined use of CBT screws with transforaminal or posterior lumbar interbody fusion can treat a variety of lumbar diseases,including spondylolisthesis or stenosis,and can also be used as a remedy for revision surgery when the pedicle screw fails.CBT has obvious advantages in terms of surgical trauma,postoperative recovery,prevention and treatment of adjacent vertebral disease,and the surgical treatment of obese and osteoporosis patients.However,the concept of CBT internal fixation technology appeared relatively recently;consequently,there are few relevant clinical studies,and the long-term clinical efficacy and related complications have not been reported.Therefore,large sample and prospective studies are needed to further reveal the long-term complications and fusion rate.As a supplement to the traditional pedicle trajectory fixation technique,the CBT technique is a good choice for the treatment of lumbar diseases with accurate screw placement and strict indications and is thus deserving of clinical recommendation.

Experimental Investigation of Material Removal in Elliptical Vibration Cutting of Cortical Bone

To benefit tissue removal and postoperative rehabilitation,increased efficiency and accuracy and reduced operating force are strongly required in the osteotomy.A novel elliptical vibration cutting(EVC)has been introduced for bone cutting compared with conventional cutting(CC)in this paper.With the assistance of high-speed microscope imaging and the dynamometer,the material removals of cortical bone and their cutting forces from two cutting regimes were recorded and analysed comprehensively,which clearly demonstrated the chip morphology improvement and the average cutting force reduction in the EVC process.It also revealed that the elliptical vibration of the cutting tool could promote fracture propagation along the shear direction.These new findings will be of important theoretical and practical values to apply the innovative EVC process to the surgical procedures of the osteotomy.

Cortical bone trajectory screws in the treatment of lumbar degenerative disc disease in patients with osteoporosis

Lumbar degenerative disc disease(DDD)in the elderly population remains a global health problem,especially in patients with osteoporosis.Osteoporosis in the elderly can cause failure of internal fixation.Cortical bone trajectory(CBT)is an effective,safe and minimally invasive technique for the treatment of lumbar DDD in patients with osteoporosis.In this review,we analyzed the anatomy,biomechanics,and advantages of the CBT technique in lumbar DDD and revision surgery.Additionally,the clinical trials and case reports,indications,advancements and limitations of this technique were further discussed and reviewed.Finally,we concluded that the CBT technique can be a practical,effective and safe alternative to traditional pedicle screw fixation,especially in DDD patients with osteoporosis.

A mathematical model of cortical bone remodeling at cellular level under mechanical stimulus

A bone cell population dynamics model for cor- tical bone remodeling under mechanical stimulus is devel- oped in this paper. The external experiments extracted from the literature which have not been used in the creation of the model are used to test the validity of the model. Not only can the model compare reasonably well with these ex- perimental results such as the increase percentage of final values of bone mineral content （BMC） and bone fracture en- ergy （BFE） among different loading schemes （which proves the validity of the model）, but also predict the realtime devel- opment pattern of BMC and BFE, as well as the dynamics of osteoblasts （OBA）, osteoclasts （OCA）, nitric oxide （NO） and prostaglandin E2 （PGE2） for each loading scheme, which can hardly be monitored through experiment. In conclusion, the model is the first of its kind that is able to provide an in- sight into the quantitative mechanism of bone remodeling at cellular level by which bone cells are activated by mechan- ical stimulus in order to start resorption/formation of bone mass. More importantly, this model has laid a solid foun- dation based on which future work such as systemic control theory analysis of bone remodeling under mechanical stimu- lus can be investigated. The to-be identified control mecha- nism will help to develop effective drugs and combined non- pharmacological therapies to combat bone loss pathologies. Also this deeper understanding of how mechanical forces quantitatively interact with skeletal tissue is essential for the generation of bone tissue for tissue replacement purposes in tissue engineering.

Measurement of Cortical Bone Thickness in Adults by Cone-beam Computerized Tomography for Orthodontic Miniscrews Placement

The purpose of this study was to investigate the cortical bone thickness of the inter-dental area of both jaws for orthodontic miniscrew placement. The cone-beam computerized tomography images of 32 non-orthodontic adults with normal occlusion were taken to measure the cortical bone thick- ness in both.jaws. One-way analysis of variance （ANOVA） was used to analyze the differences in cortical bone thickness. Buccal cortical bone in the mandible was thicker than that in the maxilla. In the maxilla, cortical bone thickness was thicker in the buccal side than in the palatal side. Buccal cortical bone thickness in the mandible was thickest at the site distal to the first molar, and in the maxilla it was thickest at the site mesial to the first molar, while in the palatal side of maxilla it was thickest at the site mesial to the second premolar. The changing pattern of cortical bone thickness varies at different sites. In the buccal side of maxilla, the thinnest cortical bone thickness was lbund to be at 4 mm level from the alveolar crest, while the thickest was at 10 mm level （except for the site mesial to the first premolar）. The buccal cortical bone thickness at the sites mesial or distal to the first molar in the mandible and palatal cortical bone thickness of maxilla tended to increase with increasing distance from the alveolar bone.

In vivo evidence of IGF-I–estrogen crosstalk in mediating the cortical bone response to mechanical strain

Although insulin-like growth factor-I （IGF-I） and estrogen signaling pathways have been shown to be involved in mediating the bone anabolic response to mechanical loading, it is not known whether these two signaling pathways crosstalk with each other in producing a skeletal response to mechanical loading. To test this, at 5 weeks of age, partial ovariectomy （pOVX） or a sham operation was performed on heterozygous IGF-I conditional knockout （H IGF-I KO） and control mice generated using a Cre-loxP approach. At 10 weeks of age, a 10 N axial load was applied on the right tibia of these mice for a period of 2 weeks and the left tibia was used as an internal non-non-loaded control. At the cortical site, partial estrogen loss reduced total volumetric bone mineral density （BMD） by 5% in control pOVX mice （P=0.05, one-way ANOVA）, but not in the H IGF-I KO pOVX mice. At the trabecular site, bone volume/total volume （BV/TV） was reduced by 5%-6% in both control pOVX （P〈0.05） and H IGF-I KO pOVX （P=0.05） mice. Two weeks of mechanical loading caused a 7 %-8% and an 11%-13% （P〈0.05 vs. non-loaded bones） increase in cortical BMD and cortical thickness （Ct.Th）, respectively, in the control sham, control pOVX and H IGF-I KO sham groups. By contrast, the magnitude of cortical BMD （4%, P=0.13） and Ct.Th （6%, P〈0.05） responses were reduced by 50% in the H IGF-I KO pOVX mice compared to the other three groups. The interaction between genotype and estrogen deficiency on the mechanical loading-induced cortical bone response was significant （P〈0.05） by two-way ANOVA. Two weeks of axial loading caused similar increases in trabecular BV/TV （13%-17%） and thickness （17%-23%） in all four groups of mice. In conclusion, partial loss of both estrogen and IGF-I significantly reduced cortical but not the trabecular bone response to mechanical loading, providing in vivo evidence of the above crosstalk in mediating the bone response to loading.

Cortical bone trajectory fixation in cemented vertebrae in lumbar degenerative disease:A case report

BACKGROUND Percutaneous vertebroplasty(PVP)has been widely used in osteoporotic vertebral compression fracture(OVCF).Following surgery,the bone cement would be positioned permanently.However,in some cases of lumbar degenerative disease,the cemented vertebrae needs to be fixed after decompression and fusion procedure.It is difficult to implant traditional pedicle screws into the cemented vertebrae because of the bone cement filling.At present,the main treatment strategy is to skip the cemented vertebra and conduct a long segment fixation.This article presents a cortical bone trajectory(CBT)fixation technique for cemented vertebrae.CASE SUMMARY PVP involving the L3 and L4 was performed in an 82-year-old man due to OVCF.During the surgery,bone cement leakage occurred,resulting in compression of the root of the right L3 nerve.We performed a partial facetectomy to retrieve the leaked bone cement and to relieve the patient’s neurological symptoms.After 3 mo,the patient developed lumbar disc herniation in L3/4,potentially due to instability caused by the previous surgery.Therefore,it was necessary to perform intervertebral fusion and fixation.It was difficult to implant traditional trajectory pedicle screws in L3 and L4 because of the bone cement filling.Hence,we implanted CBT screws in the L3 and L4 vertebrae.As a result,the patient’s symptoms resolved and he reported satisfaction with the surgery at follow-up after 8 mo.CONCLUSION It is feasible to utilize CBT in cemented vertebrae for the treatment of lumbar degenerative disease.

Lumbar pedicle cortical bone trajectory screw

Objective The purpose of this study was to demonstrate the lumbar pedicle cortical bone trajectory （CBT） screw fixation technique,a new fixation technique for lumbar surgery.Data sources The data analyzed in this review are mainly from articles reported in PubMed published from 1994 to 2014.Study selection Original articles and critical reviews relevant to CBT technique and lumbar pedicle fixation were selected.Results CBT technique was firstly introduced as a new fixation method for lumbar pedicle surgery in 2009.The concepts,morphometric study,biomechanical characteristics and clinical applications of CBT technique were reviewed.The insertional point of CBT screw is located at the lateral point of the pars interarticularis,and its trajectory follows a caudocephalad path sagittally and a laterally directed path in the transverse plane.CBT technique can be used for posterior fixation during lumbar fusion procedures.This technique is a minimally invasive surgery,which affords better biomechanical stability,fixation strength and surgical safety.Therefore,CBT technique has the greatest benefit in lumbar pedicle surgery for patients with osteoporosis and obesity.Conclusion CBT technique is a better alternative option of lumbar pedicle fixation,especially for patients with osteoporosis and obesity.

A cortical bone milling force model based on orthogonal cutting distribution method

In orthopedic surgery,the bone milling force has attracted attention owing to its significant influence on bone cracks and the breaking of tools.It is necessary to build a milling force model to improve the process of bone milling.This paper proposes a cortical bone milling force model based on the orthogonal cutting distribution method(OCDM),explaining the effect of anisotropic bone materials on milling force.According to the model,the bone milling force could be represented by the equivalent effect of a transient cutting force in a rotating period,and the transient milling force could be calculated by the transient milling force coefficients,cutting thickness,and cutting width.Based on the OCDM,the change in transient cutting force coefficients during slotting can be described by using a quadratic polynomial.Subsequently,the force model is updated for robotic bone milling,considering the low stiffness of the robot arm.Next,an experimental platform for robotic bone milling is built to simulate the milling process in clinical operation,and the machining signal is employed to calculate the milling force.Finally,according to the experimental result,the rationality of the force model is verified by the contrast between the measured and predicted forces.The milling force model can satisfy the accuracy requirement for predicting the milling force in the different processing directions,and it could promote the development of force control in orthopedic surgery.

Comparative Study on Inorganic Composition and Crystallographic Properties of Cortical and Cancellous Bone

Objective To comparatively investigate the inorganic composition and crystallographic properties of cortical and cancellous bone via thermal treatment under 700 ℃. Methods Thermogravimetric measurement, infrared spectrometer, X-ray diffraction, chemical analysis and X-ray photo-electron spectrometer were used to test the physical and chemical properties of cortical and cancellous bone at room temperature 250 ℃, 450 ℃, and 650 ℃, respectively. Results The process of heat treatment induced an extension in the a-lattice parameter and changes of the c-lattice parameter, and an increase in the crystallinity reflecting lattice rearrangement after release of lattice carbonate and possible lattice water. The mineral content in cortical and cancellous bone was 73.2wt% and 71.5wt%, respectively. For cortical bone, the weight loss was 6.7% at the temperature from 60 ℃ to 250℃, 17.4% from 250 ℃ to 450 ℃, and 2.7% from 450 ℃ to 700 ℃. While the weight loss for the cancellous bone was 5.8%, 19.9%, and 2.8 % at each temperature range, the Ca/P ratio of cortical bone was 1.69 which is higher than the 1.67 of stoichiometric HA due to the B-type CO32- substitution in apatite lattice. The CaJP ratio of cancellous bone was lower than 1.67, suggesting the presence of more calcium deficient apatite. Conclusion The collagen fibers of cortical bone were arrayed more orderly than those of cancellous bone, while their mineralized fibers ollkded similar. The minerals in both cortical and cancellous bone are composed of poorly crystallized nano-size apatite crystals with lattice carbonate and possible lattice water. The process of heat treatment induces a change of the lattice parameter, resulting in lattice rearrangement after the release of lattice carbonate and lattice water and causing an increase in crystal size and crystallinity. This finding is helpful for future biomaterial design, preparation and application.

EFFECT OF INTERNAL FIXATION PLATES ON MICROCIRCULATION IN UNDER-PLATE CORTICAL BONES MICROANGIOGRAPHY AND SCANNING ELECTRONMICROSCOPY

To elucidate the effect of the internal fixation plates on the local bone blood sapply, we used microangiography and scanning electron microscopy to observe the morphological changes of microcirculation in the cortical bones obtained from intact rabbit tibiae on which plates of two different stiffness had been fixed for comparison. The results indicated that both rigid stainless steel plate and less rigid methyl methacrylate plate could induce the bone microcirculation under the plate to undergo a process from early depression to late reactive recruitment. The features of the microcircuiation recruitment such as vascular number, arrangement and dilatation varied with plates of different stiffness and were more obvious in the cortex fixed by rigid stainless steel plate.

Quantitative Histological Study on Changes of the Cortical Bones after Internal Fixation with Plates of Different Rigidity

In an effect to explore the potemtial role of bone microcirculation causing plate-induced reginal osteoporosis

Fatigue behavior of cortical bone:a review

Fatigue is a common cause of bone failure.As the main load-bearing tissue,cortical bone carries a considerable share of load in the whole bone.Under cyclic loading condition,microdamage may generates and accumulates in cortical bone,which further triggers the fracture of bone.It is crucial to explore the fatigue properties of cortical bone and the influential factors for both clinical diagnosis and establishment of models that can predict fatigue failure of human cortical bone.In this review,the fatigue behavior of cortical bone was investigated.Through the complex hierarchical structure and self-repairing process,the risk of catastrophic fracture is reduced.Based on these understandings,the multiple influential factors of cortical bone fatigue properties were analyzed,which were considered to be a combination of internal and external factors.The internal factors include material properties of bone composition(i.e.,mineral,organic material,and water)and bone structure.External factors refer to loading condition such as frequency,amplitude and direction of load.Besides,age,disease,radiation exposure and other factors affect the fatigue behavior of bone by altering one or more factors mentioned above.

Cortical Bone Model with a Microcrack under Tensile Loading

The fracture mechanics of cortical bone has received much attention in biomedical engineering.It is a fundamental question how the material constants and the geometric parameters of the cortical bone affect the fracture behavior of the cortical bone.In this work,the plane problem for cortical bone with a microcrack located in the interstitial tissue under tensile loading was considered.Using the solution for the continuously distributed edge dislocations as Green ’ s functions,the problem was formulated as singular integral equations with Cauchy kernels.The numerical results suggest that a soft osteon promotes microcrack propagation,while a stiff osteon repels it,but the interaction effect between the microcrack and the osteon is limited near the osteon.This study not only sheds light on the fracture mechanics behavior of cortical bone but also offers inspiration for the design of bioinspired materials in biomedical engineering.

Characteristics of Rat Lumbar Vertebral Body Bone Mineral Density and Differential Segmental Responses to Sex Hormone Deficiency:a Clinical Multidetector Computed Tomography Study

Objective To investigate sex hormone deficiency related osteoporosis and efficacy of different therapies. Methods Orchiectomized and ovariectomized rat models are used to investigate sex hormone deficiency related osteoporosis and efficacy of different therapies. A rat vertebral body can be longitudinally divided into central portion, which contain more trabecular bone, and para-endplate portions which contain more compact bone. In matured male and female Wistar and Sprague-Dawley rat lumbar spines, we investigated baseline bone mineral density （BMD） characteristics and the differential segmental responses in bone loss within the lumbar vertebral body post gonadal surgery with clinical multidetector computed tomography. Results Para-endplate sections had a higher BMD than central sections. The cephalad para-endplate sections had a higher BMD than the caudad para-endplate sections. Eight weeks after gonadal removal, there was more bone loss in central sections than para-endplate sections. The relative difference of bone loss between para-endplate and central sections was more apparent in male rats than in female rats. There was more bone loss in caudad sections than cephalad sections; this lead to a further increase of BMD difference between caudad para-endplate sections and cephalad para-endplate sections post gonadal surgery. Conclusion The approach described in this study provided a consistent way to study BMD change within predominantly compact bone portion and trabecular bone portion of the vertebral body.

Multitrack and multianchor point screw technique combined with the Wiltse approach for lesion debridement for lumbar tuberculosis

BACKGROUND The incidence of lumbar tuberculosis is high worldwide,and effective treatment is a continuing problem.AIM To study the safety and efficacy of the multitrack and multianchor point screw technique combined with the contralateral Wiltse approach for lesion debridement to treat lumbar tuberculosis.METHODS The C-reactive protein(CRP)level,erythrocyte sedimentation rate(ESR),visual analogue scale(VAS)score,oswestry disability index(ODI)and American Spinal Injury Association(ASIA)grade were recorded and analysed pre-and postoperatively.RESULTS The CRP level and ESR returned to normal,and the VAS score and ODI were decreased at 3 mo postoperatively,with significant differences compared with the preoperative values(P<0.01).Neurological dysfunction was relieved,and the ASIA grade increased,with no adverse events.CONCLUSION The multitrack,multianchor point screw fixation technique combined with the contralateral Wiltse approach for debridement is an effective and safe method for the treatment of lumbar tuberculosis.

Two-Year Outcomes of Midline lumbar Fusion Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Treatment of L4-L5 Degenerative Disease

Objective We aimed to compare the clinical and radiological outcomes of midline lumbar fusion(MIDLF)versus minimally invasive transforaminal lumbar interbody fusion(MI-TLIF)in patients with degenerative spondylolisthesis and/or stenosis in L4-L5 two years after surgery.Methods Consecutively treated patients with lumbar pathology who underwent MIDLF(n=16)and a historical control group who underwent MI-TLIF(n=34)were included.Clinical symptoms were evaluated using Oswestry Disability Index(ODI),the 36-Item Short-Form Health Survey,and visual analog scale(VAS)scores before surgery and 3,6,12,and 24 months after surgery.Results The mean operative time and hematocrit(HCT,Day 1)were significantly shorter and lower in MIDLF cases(174 min vs.229 min,P<0.001;0.34 vs.0.36,P=0.037).The MI-TLIF group showed better improvement than the MIDLF group in ODI and VAS back and leg pain at 3 months postoperatively.VAS leg pain was higher in MIDLF than in MI-TLIF cases at 6 months.At 24 months follow-up,VAS back pain was higher in MI-TLIF than in MIDLF cases(P=0.018).Conclusion MIDLF is comparable to MI-TLIF at L4-5 in clinical outcomes and fusion rates,and the results verified the meaningful advantage of using MIDLF for the elderly with osteoporosis.

Chromium Content in the Human Hip Joint Tissues

Objective Chromium has many important functions in the human body. For the osseous tissue, its role has not been clearly defined. This study was aimed at determining chromium content in hip joint tissues. Methods A total of 91 hip joint samples were taken in this study, including 66 from females and 25 from males. The sample tissues were separated according to their anatomical parts. The chromium content was determined by the AAS method. The statistical analysis was performed with U Mann-Whitney＇s non-parametric test, P〈0.05. Results The overall chromium content in tissues of the hip joint in the study subjects was as follows： 5.73 μg/g in the articular cartilage, 5.33 μ/g in the cortical bone, 27.86 μ/g in the cancellous bone, 5.95 μg/8 in the fragment of the cancellous bone from the intertrochanteric region, and 2.28 μ/g in the joint capsule. The chromium contents were observed in 2 group patients, it was 7.04 μ/g in people with osteoarthritis and 22.59 μ/g in people with fractures. Conclusion The observed chromium content was highest in the cancellous bone and the lowest in the joint capsule. Chromium content was significantly different between the people with hip joint osteoarthritis and the people with femoral neck fractures.

Radiological and clinical outcomes of midline lumbar fusion on sagittal lumbar-pelvic parameters for degenerative lumbar diseases

BACKGROUND Improving the sagittal lumbar-pelvic parameters after fusion surgery is important for improving clinical outcomes.The impact of midline lumbar fusion(MIDLF)on sagittal lumbar-pelvic alignment for the management of degenerative lumbar diseases is still unknown.AIM To analyze the effects of short-segment MIDLF and minimally invasive transforaminal lumbar interbody fusion(MIS-TLIF)on sagittal lumbar-pelvic parameters.METHODS We retrospectively analyzed 63 patients with degenerative lumbar diseases who underwent single-segment MIDLF or MIS-TLIF.The imaging data of patients were collected before surgery and at the final follow-up.The radiological sagittal parameters included the lumbar lordosis(LL),lower LL,L4 slope(L4S),L5 slope(L5S),L5 incidence(L5I),L1 axis and S1 distance(LASD),pelvic incidence(PI),pelvic tilt(PT),sacral slope(SS),and PI-LL mismatch(PI-LL).Additionally,the clinical outcomes,including lower back and leg pain visual analog scale(VAS)and Oswestry disability index(ODI)scores,were also analyzed.RESULTS In both groups,LL and Lower LL significantly increased,while L5I and LASD significantly decreased at the final follow-up compared to that recorded prior to operation(P<0.05).In the MIDLF group,L4S significantly decreased compared to that recorded prior to operation(P<0.05),while the mean SS significantly increased and the PT significantly decreased compared to that recorded prior to operation(P<0.05).In the MIS-TLIF group,SS slightly increased and the mean PT value decreased compared to that recorded prior to operation,but without a statistically significant difference(P>0.05).However,the PI-LL in both groups was significantly reduced compared to that recorded prior to operation(P<0.05).There was no significant difference in the sagittal lumbar-pelvic parameters between the two groups prior to operation and at the final follow-up(P>0.05).In addition,the change in sagittal lumbar-pelvic parameters did not differ significantly,except forΔLASD within the two groups(P>0.05).The mean lower back and leg pain VAS and ODI scores in both groups were significantly improved three months after surgery and at the final follow-up.Though the mean ODI score in the MIDLF group three months after surgery was slightly higher than that in the MIS-TLIF group,there was no significant difference between the two groups at the final follow-up.CONCLUSION Short-segment MIDLF and MIS-TLIF can equally improve sagittal lumbar parameters such as LL,Lower LL,L5I,and LASD in the treatment of lumbar degenerative diseases.However,MIDLF had a larger impact on pelvic parameters than MIS-TLIF.

Comparison of Concentrations of Lead and Cadmium in Various Parts of The Femur Head in Patients after Arthroplasty of The Hip Joint in Northwest Poland

Abstract Objective To determine the concentrations of lead （Pb） and cadmium （Cd） in three kinds of materials （cartilage, cortical bone, and cancellous bone） of the femur head obtained from patients in the process of operation. Methods Concentrations of Pb and Cd were determined in selected parts of the femur head of 30 patients after total hip arthroplasty, using ICP-AES （atomic absorption spectrophotometry）. Results Pb contained the highest concentration in cortical bone, while Cd did so in cancellous bone. There were statistically significant differences in the concentrations of both elements between the cartilage and cortical bone, and also differences in the concentration of Pb between the cartilage and cancellous bone. There were no significant differences in the concentrations of Pb or Cd between cortical and cancellous bone. Conclusion Comparative studies on toxic metals should take into account both analogous bones and their fragments, as even if they come from the same kind of bones （e.g. femur head）, clear differences exist in concentrations of heavy metals related to the sampling site and type of tissue （cartilage, cortical bone, and cancellous bone）.