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A 20-Year Review of Biomechanical Experimental Studies on Spine Implants Used for Percutaneous Surgical Repair of Vertebral Compression Fractures. BIOMED RESEARCH INTERNATIONAL 2022; 2022:6015067. [PMID: 36187502 PMCID: PMC9519286 DOI: 10.1155/2022/6015067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/07/2022] [Indexed: 12/02/2022]
Abstract
A vertebral compression fracture (VCF) is an injury to a vertebra of the spine affecting the cortical walls and/or middle cancellous section. The most common risk factor for a VCF is osteoporosis, thus predisposing the elderly and postmenopausal women to this injury. Clinical consequences include loss of vertebral height, kyphotic deformity, altered stance, back pain, reduced mobility, reduced abdominal space, and reduced thoracic space, as well as early mortality. To restore vertebral mechanical stability, overall spine function, and patient quality of life, the original percutaneous surgical intervention has been vertebroplasty, whereby bone cement is injected into the affected vertebra. Because vertebroplasty cannot fully restore vertebral height, newer surgical techniques have been developed, such as kyphoplasty, stents, jacks, coils, and cubes. But, relatively few studies have experimentally assessed the biomechanical performance of these newer procedures. This article reviews over 20 years of scientific literature that has experimentally evaluated the biomechanics of percutaneous VCF repair methods. Specifically, this article describes the basic operating principles of the repair methods, the study protocols used to experimentally assess their biomechanical performance, and the actual biomechanical data measured, as well as giving a number of recommendations for future research directions.
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Day GA, Jones AC, Wilcox RK. Optimizing computational methods of modeling vertebroplasty in experimentally augmented human lumbar vertebrae. JOR Spine 2020; 3:e1077. [PMID: 32211589 PMCID: PMC7084049 DOI: 10.1002/jsp2.1077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/22/2019] [Accepted: 12/25/2019] [Indexed: 11/09/2022] Open
Abstract
Vertebroplasty has been widely used for the treatment of osteoporotic compression fractures but the efficacy of the technique has been questioned by the outcomes of randomized clinical trials. Finite-element (FE) models allow an investigation into the structural and geometric variation that affect the response to augmentation. However, current specimen-specific FE models are limited due to their poor reproduction of cement augmentation behavior. The aims of this study were to develop new methods of modeling the vertebral body in both a nonaugmented and augmented state. Experimental tests were conducted using human lumbar spine vertebral specimens. These tests included micro-computed tomography imaging, mechanical testing, augmentation with cement, reimaging, and retesting. Specimen-specific FE models of the vertebrae were made comparing different approaches to capturing the bone material properties and to modeling the cement augmentation region. These methods significantly improved the modeling accuracy of nonaugmented vertebrae. Methods that used the registration of multiple images (pre- and post-augmentation) of a vertebra achieved good agreement between augmented models and their experimental counterparts in terms of predictions of stiffness. Such models allow for further investigation into how vertebral variation influences the mechanical outcomes of vertebroplasty.
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Affiliation(s)
- Gavin A. Day
- Institute of Medical and Biological Engineering, Mechanical EngineeringUniversity of LeedsLeedsUK
| | - Alison C. Jones
- Institute of Medical and Biological Engineering, Mechanical EngineeringUniversity of LeedsLeedsUK
| | - Ruth K. Wilcox
- Institute of Medical and Biological Engineering, Mechanical EngineeringUniversity of LeedsLeedsUK
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Santana Artiles ME, Venetsanos DT. Numerical investigation of the effect of bone cement porosity on osteoporotic femoral augmentation. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2018; 34:e2989. [PMID: 29603673 DOI: 10.1002/cnm.2989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/19/2018] [Accepted: 03/24/2018] [Indexed: 06/08/2023]
Abstract
Femoroplasty is the injection of bone cement into the proximal femur, enhances the bone load capacity, and is typically applied to osteoporotic femora. To minimize the required injected volume of bone cement and maximize the load capacity enhancement, an optimization problem must be solved, where the modulus of elasticity of the augmented bone is a key element. This paper, through the numerical investigation of a fall on the greater trochanter of an osteoporotic femur, compares different ways to calculate this modulus and introduces an approach, based on the concept of bone cement porosity, which provides results statistically similar to those obtained with other considerations. Based on this approach, the present paper quantifies the correlation between degree of osteoporosis and optimum volume of bone cement. It concludes with an exhaustive search that reveals the effect of the bone cement porosity on the optimum volume of PMMA, for various combinations of the frontal and transverse angles of the fall on the greater trochanter.
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Affiliation(s)
- María E Santana Artiles
- School of Engineering, Faculty of Science, Engineering and Computing, Kingston University, Friars Ave., Roehampton Vale Campus, SW15 3DW, London, UK
| | - Demetrios T Venetsanos
- School of Mechanical, Aerospace and Automotive Engineering, Faculty of Engineering, Environment & Computing, Coventry University, Gulson Road, CV1 2JH, Coventry, UK
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JAMSHIDI NIMA, FARADONBEH SEYEDAREFHOSSEINI. A REVIEW ON BIOMECHANICAL ASPECTS OF VERTEBROPLASTY AND KYPHOPLASTY USING FINITE ELEMENT MODELING-BASED METHODS. J MECH MED BIOL 2018. [DOI: 10.1142/s021951941750107x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The vertebroplasty (VP) and kyphoplasty (KP) are two minimally invasive surgeries using cement augmentation to treat the osteoporotic vertebrae in elderlies in order to relieve pain and prevent the continuation of microfractures. Biomechanists have always tried to assess the mechanical behavior of vertebrae after cement augmentation by using both the experimental and theoretical methods such as finite element modeling (FEM). In this study, 31 related articles using FEM in analyzing the VP and KP have been reviewed. This study included two main categories of spinal load distribution and tension in vertebrae after the VP and KP operations. This could be obtained by conducting FEM on the whole spine or other sectors of it such as intervertebral disc (IVD) or end plates (EPs). This study also referred to articles predicting the probability of adjacent fractures following VP and KP. The most common software employed in FEM was ABAQUS, applied for static and dynamic loads’ analyses. It was found that most of the reviewed articles adopted reverse engineering techniques by converting 2D computed tomography (CT) scan images into 3D reconstructed models. The material properties were generally taken from the literature. In more than 80% of studies, the model geometry was based on CT data of the spine. Almost 45% of the studies have attempted to compare the simulated vertebra after augmentation with experimental results taken from the literature (5% of the reviewed articles) or their own experimental tests (40% of the reviewed articles).
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Affiliation(s)
- NIMA JAMSHIDI
- Department of Biomedical Engineering, Faculty of Engineering, University of Isfahan, Isfahan, Iran
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Zapata-Cornelio FY, Day GA, Coe RH, Sikora SNF, Wijayathunga VN, Tarsuslugil SM, Mengoni M, Wilcox RK. Methodology to Produce Specimen-Specific Models of Vertebrae: Application to Different Species. Ann Biomed Eng 2017; 45:2451-2460. [PMID: 28744839 PMCID: PMC5622177 DOI: 10.1007/s10439-017-1883-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/07/2017] [Indexed: 11/23/2022]
Abstract
Image-based continuum-level finite element models have been used for bones to evaluate fracture risk and the biomechanical effects of diseases and therapies, capturing both the geometry and tissue mechanical properties. Although models of vertebrae of various species have been developed, an inter-species comparison has not yet been investigated. The purpose of this study was to derive species-specific modelling methods and compare the accuracy of image-based finite element models of vertebrae across species. Vertebral specimens were harvested from porcine (N = 12), ovine (N = 13) and bovine (N = 14) spines. The specimens were experimentally loaded to failure and apparent stiffness values were derived. Image-based finite element models were generated reproducing the experimental protocol. A linear relationship between the element grayscale and elastic modulus was calibrated for each species matching in vitro and in silico stiffness values, and validated on independent sets of models. The accuracy of these relationships were compared across species. Experimental stiffness values were significantly different across species and specimen-specific models required species-specific linear relationship between image grayscale and elastic modulus. A good agreement between in vitro and in silico values was achieved for all species, reinforcing the generality of the developed methodology.
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Affiliation(s)
- Fernando Y Zapata-Cornelio
- School of Mechanical Engineering, Institute of Medical and Biological Engineering, University of Leeds, Leeds, LS2 9JT, UK.
| | - Gavin A Day
- School of Mechanical Engineering, Institute of Medical and Biological Engineering, University of Leeds, Leeds, LS2 9JT, UK
| | - Ruth H Coe
- School of Mechanical Engineering, Institute of Medical and Biological Engineering, University of Leeds, Leeds, LS2 9JT, UK
| | - Sebastien N F Sikora
- School of Mechanical Engineering, Institute of Medical and Biological Engineering, University of Leeds, Leeds, LS2 9JT, UK
| | - Vithanage N Wijayathunga
- School of Mechanical Engineering, Institute of Medical and Biological Engineering, University of Leeds, Leeds, LS2 9JT, UK
| | - Sami M Tarsuslugil
- School of Mechanical Engineering, Institute of Medical and Biological Engineering, University of Leeds, Leeds, LS2 9JT, UK
| | - Marlène Mengoni
- School of Mechanical Engineering, Institute of Medical and Biological Engineering, University of Leeds, Leeds, LS2 9JT, UK
| | - Ruth K Wilcox
- School of Mechanical Engineering, Institute of Medical and Biological Engineering, University of Leeds, Leeds, LS2 9JT, UK
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Varga P, Inzana JA, Schwiedrzik J, Zysset PK, Gueorguiev B, Blauth M, Windolf M. New approaches for cement-based prophylactic augmentation of the osteoporotic proximal femur provide enhanced reinforcement as predicted by non-linear finite element simulations. Clin Biomech (Bristol, Avon) 2017; 44:7-13. [PMID: 28282569 DOI: 10.1016/j.clinbiomech.2017.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 02/27/2017] [Accepted: 03/01/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND High incidence and increased mortality related to secondary, contralateral proximal femoral fractures may justify invasive prophylactic augmentation that reinforces the osteoporotic proximal femur to reduce fracture risk. Bone cement-based approaches (femoroplasty) may deliver the required strengthening effect; however, the significant variation in the results of previous studies calls for a systematic analysis and optimization of this method. Our hypothesis was that efficient generalized augmentation strategies can be identified via computational optimization. METHODS This study investigated, by means of finite element analysis, the effect of cement location and volume on the biomechanical properties of fifteen proximal femora in sideways fall. Novel cement cloud locations were developed using the principles of bone remodeling and compared to the "single central" location that was previously reported to be optimal. FINDINGS The new augmentation strategies provided significantly greater biomechanical benefits compared to the "single central" cement location. Augmenting with approximately 12ml of cement in the newly identified location achieved increases of 11% in stiffness, 64% in yield force, 156% in yield energy and 59% in maximum force, on average, compared to the non-augmented state. The weaker bones experienced a greater biomechanical benefit from augmentation than stronger bones. The effect of cement volume on the biomechanical properties was approximately linear. Results of the "single central" model showed good agreement with previous experimental studies. INTERPRETATION These findings indicate enhanced potential of cement-based prophylactic augmentation using the newly developed cementing strategy. Future studies should determine the required level of strengthening and confirm these numerical results experimentally.
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Affiliation(s)
| | | | - Jakob Schwiedrzik
- Institute of Surgical Technology and Biomechanics, University of Bern, Switzerland
| | - Philippe K Zysset
- Institute of Surgical Technology and Biomechanics, University of Bern, Switzerland
| | | | - Michael Blauth
- Department for Trauma Surgery, Medical University Innsbruck, Austria
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Zysset P, Pahr D, Engelke K, Genant HK, McClung MR, Kendler DL, Recknor C, Kinzl M, Schwiedrzik J, Museyko O, Wang A, Libanati C. Comparison of proximal femur and vertebral body strength improvements in the FREEDOM trial using an alternative finite element methodology. Bone 2015; 81:122-130. [PMID: 26141837 DOI: 10.1016/j.bone.2015.06.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 06/23/2015] [Accepted: 06/29/2015] [Indexed: 01/15/2023]
Abstract
Denosumab reduced the incidence of new fractures in postmenopausal women with osteoporosis by 68% at the spine and 40% at the hip over 36 months compared with placebo in the FREEDOM study. This efficacy was supported by improvements from baseline in vertebral (18.2%) strength in axial compression and femoral (8.6%) strength in sideways fall configuration at 36 months, estimated in Newtons by an established voxel-based finite element (FE) methodology. Since FE analyses rely on the choice of meshes, material properties, and boundary conditions, the aim of this study was to independently confirm and compare the effects of denosumab on vertebral and femoral strength during the FREEDOM trial using an alternative smooth FE methodology. Unlike the previous FE study, effects on femoral strength in physiological stance configuration were also examined. QCT data for the proximal femur and two lumbar vertebrae were analyzed by smooth FE methodology at baseline, 12, 24, and 36 months for 51 treated (denosumab) and 47 control (placebo) subjects. QCT images were segmented and converted into smooth FE models to compute bone strength. L1 and L2 vertebral bodies were virtually loaded in axial compression and the proximal femora in both fall and stance configurations. Denosumab increased vertebral body strength by 10.8%, 14.0%, and 17.4% from baseline at 12, 24, and 36 months, respectively (p<0.0001). Denosumab also increased femoral strength in the fall configuration by 4.3%, 5.1%, and 7.2% from baseline at 12, 24, and 36 months, respectively (p<0.0001). Similar improvements were observed in the stance configuration with increases of 4.2%, 5.2%, and 5.2% from baseline (p≤0.0007). Differences between the increasing strengths with denosumab and the decreasing strengths with placebo were significant starting at 12 months (vertebral and femoral fall) or 24 months (femoral stance). Using an alternative smooth FE methodology, we confirmed the significant improvements in vertebral body and proximal femur strength previously observed with denosumab. Estimated increases in strength with denosumab and decreases with placebo were highly consistent between both FE techniques.
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Affiliation(s)
| | - Dieter Pahr
- Vienna University of Technology, Vienna, Austria
| | - Klaus Engelke
- University of Erlangen, Erlangen, Germany and Synarc Germany, Hamburg, Germany
| | | | | | | | | | | | | | - Oleg Museyko
- University of Erlangen-Nuremberg, Erlangen-Nuremberg, Germany
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Badilatti SD, Kuhn GA, Ferguson SJ, Müller R. Computational modelling of bone augmentation in the spine. J Orthop Translat 2015; 3:185-196. [PMID: 30035057 PMCID: PMC5986996 DOI: 10.1016/j.jot.2015.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 08/31/2015] [Accepted: 09/10/2015] [Indexed: 11/19/2022] Open
Abstract
Computational models are gaining importance not only for basic science, but also for the analysis of clinical interventions and to support clinicians prior to intervention. Vertebroplasty has been used to stabilise compression fractures in the spine for years, yet there are still diverging ideas on the ideal deposition location, volume, and augmentation material. In particular, little is known about the long-term effects of the intervention on the surrounding biological tissue. This review aims to investigate computational efforts made in the field of vertebroplasty, from the augmentation procedure to strength prediction and long-term in silico bone biology in augmented human vertebrae. While there is ample work on simulating the augmentation procedure and strength prediction, simulations predicting long-term effects are lacking. Recent developments in bone remodelling simulations have the potential to show adaptation to cement augmentation and, thus, close this gap.
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Affiliation(s)
| | - Gisela A Kuhn
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | | | - Ralph Müller
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
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Imai K. Computed tomography-based finite element analysis to assess fracture risk and osteoporosis treatment. World J Exp Med 2015; 5:182-187. [PMID: 26309819 PMCID: PMC4543812 DOI: 10.5493/wjem.v5.i3.182] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 11/23/2014] [Accepted: 05/08/2015] [Indexed: 02/06/2023] Open
Abstract
Finite element analysis (FEA) is a computer technique of structural stress analysis and developed in engineering mechanics. FEA has developed to investigate structural behavior of human bones over the past 40 years. When the faster computers have acquired, better FEA, using 3-dimensional computed tomography (CT) has been developed. This CT-based finite element analysis (CT/FEA) has provided clinicians with useful data. In this review, the mechanism of CT/FEA, validation studies of CT/FEA to evaluate accuracy and reliability in human bones, and clinical application studies to assess fracture risk and effects of osteoporosis medication are overviewed.
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