Potential risks of using cement-augmented screws for spinal fusion in patients with low bone quality

BACKGROUND CONTEXT

Dramatic increases in the average life expectancy have led to increases in the variety of degenerative changes and deformities observed in the aging spine. The elderly population can present challenges for spine surgeons, not only because of increased comorbidities, but also because of the quality of their bones. Pedicle screws are the implants used most commonly in spinal surgery for fixation, but their efficacy depends directly on bone quality. Although polymethyl methacrylate (PMMA)-augmented screws represent an alternative for patients with osteoporotic vertebrae, their use has raised some concerns because of the possible association between cement leakages (CLs) and other morbidities.

PURPOSE

To analyze potential complications related to the use of cement-augmented screws for spinal fusion and to investigate the effectiveness of using these screws in the treatment of patients with low bone quality.

STUDY DESIGN

A retrospective single-center study.

PATIENT SAMPLE

This study included 313 consecutive patients who underwent spinal fusion using a total of 1,780 cement-augmented screws.

METHODS AND OUTCOME MEASURES

We analyzed potential complications related to the use of cement-augmented screws, including CL, vascular injury, infection, screw extraction problems, revision surgery, and instrument failure. There are no financial conflicts of interest to report.

RESULTS

A total of 1,043 vertebrae were instrumented. Cement leakage was observed in 650 vertebrae (62.3%). There were no major clinical complications related to CL, but two patients (0.6%) had radicular pain related to CL at the S1 foramina. Of the 13 patients (4.1%) who developed deep infections requiring surgical debridement, two with chronic infections had possible spondylitis that required instrument removal. All patients responded well to antibiotic therapy. Revision surgery was performed in 56 patients (17.9%), most of whom had long construction. A total of 180 screws were removed as a result of revision. There were no problems with screw extraction.

CONCLUSIONS

These results demonstrate the efficacy and safety of cement-augmented screws for the treatment of patients with low bone mineral density.

Effect of the calcium to phosphorus ratio on the setting properties of calcium phosphate bone cements

α-Tricalcium phosphate (α-TCP) has become the main reactant of most experimental and commercial ceramic bone cements. It has calcium-to-phosphorus (Ca/P) ratio of 1.50. The present study expands and reports on the microstructures and mechanical properties of calcium phosphate (CP) cements containing sintered monolithic reactants obtained in the interval 1.29 < Ca/P < 1.77. The study focuses on their cement setting and hardening properties as well as on their microstructure and crystal phase evolution. The results showed that: (a) CP-cements made with reactants with Ca/P ratio other than 1.50 have longer setting and lower hardening properties; (b) CP-cements reactivity was clearly affected by the Ca/P ratio of the starting reactant; (c) reactants with Ca/P < 1.50 were composed of several phases, calcium pyrophosphate and α- and β-TCP. Similarly, reactants with Ca/P > 1.50 were composed of α-TCP, tetracalcium phosphate and hydroxyapatite; (d) only the reactant with Ca/P = 1.50 was monophasic and was made of α-TCP, which transformed during the setting into calcium deficient hydroxyapatite; (e) CP-cements developed different crystal microstructures with specific features depending on the Ca/P ratio of the starting reactant.

Ultrasound monitoring of the setting of calcium-based bone cements

In this study, the setting of calcium-sulphate (CS) and -phosphate (CP) based bone cements (BCs) was monitored by ultrasound. The objective was to link acoustic and material properties of ceramic-based BCs from the early stages of the cement curing process. The powder phase of the CS-cement consisted of CS hemihydrate; the CP-cement was a mixture of alpha-tricalcium phosphate, CS dihydrate and hydroxyapatite. For the CS-cement, the acoustic impedance z (c)(t), the speed of sound c (c)(t) and the density ρ(c)(t) were measured at the interval of liquid-to-powder ratios LPRs from 0.20 to 3.00 ml/g. For the CP-cement, the acoustic characteristics obtained were the z (c)(t) and the reflection coefficient R (p,c)(t), and the LPRs ranged from 0.30 to 0.40 ml/g. The resulting acoustic properties indicated that CP- and CS-cements exhibited distinctly different curing behaviour; while CS-cement expanded, CP-cement shrank with time.

Injectable iron-modified apatitic bone cement intended for kyphoplasty: cytocompatibility study

In this study, the cytocompatibility of human ephitelial (HEp-2) cells cultured on new injectable iron-modified calcium phosphate cements (IM-CPCs) has been investigated in terms of cell adhesion, cell proliferation, and morphology. Quantitative MTT-assay and scanning electron microscopy (SEM) showed that cell adhesion and viability were not affected with culturing time by iron concentration in a dose-dependent manner. SEM-cell morphology showed that HEp-2 cells, seeded on IM-CPCs, were able to adhere, spread, and attain normal morphology. These results showed that the new injectable IM-CPCs have cytocompatible features of interest to the intended kyphophasty application, for the treatment of osteoporotic vertebral compression fractures.

Does mixing affect the setting of injectable bone cement? An ultrasound study

Experimental calcium sulphate bone cement has been tested by ultrasounds to characterise its progressive setting through the evolution of several acoustic properties. The acoustic impedance z(t), the density rho (t) and the speed of sound c(t) versus the curing time have been monitored during the viscous-to-solid transition of the cement as a function of different mixing conditions. Injectability tests were also performed and the results have been related to the acoustic properties measured previously. It has been observed that further mixing after cement's constituency, and before the initial setting time of the cement, drastically affects both the characteristic setting times and the injectability of the cement.

High-strength apatitic cement by modification with superplasticizers

This study reports on a novel method to improve the strength of apatitic bone cements. The liquid phase of Biocement-H was modified with commercial superplasticizers. The results showed that small additions, i.e. 0.5 vol%, in the aqueous liquid phase improved the maximum compressive strength of Biocement-H (35 MPa) by 71%, i.e. 60 MPa. Moreover, the addition of high amounts of superplasticizers, i.e. 50 vol.%, allowed for a significant reduction of the liquid-to-powder ratio from 0.32 to 0.256 mL/g, without affecting the maximum strength and/or the workability of the cement. These results open up new ways to develop injectable and high-strength apatitic bone cements for load-bearing applications.