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Pull-out strength of patient-specific template-guided vs. free-hand fluoroscopically controlled thoracolumbar pedicle screws: a biomechanical analysis of a randomized cadaveric study

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Abstract

Purpose

To assess the pull-out strength of thoracolumbar pedicle screws implanted via either a patient-specific template-guided or conventional free-hand fluoroscopically controlled technique in a randomized cadaveric study, and to evaluate the influence of local vertebral bone density, quantified by Hounsfield units (HU), on pedicle screw pull-out strength.

Methods

Thoracolumbar pedicles of three spine cadavers were instrumented using either a free-hand fluoroscopically controlled or a patient-specific template-guided technique. Preoperative bone density was quantified by HU measured on CT. Pedicle perforation was evaluated on postoperative CT scans by an independent and blinded radiologist. After dissected vertebrae were embedded in aluminum fixation devices, pull-out testing was initiated with a preload of 50 N and a constant displacement rate of 0.5 mm/s. Subgroup analyses were performed excluding pedicle screws with a pedicle breach (n = 47).

Results

Pull-out strength was significantly different with 549 ± 278 and 441 ± 289 N in the template-guided (n = 50) versus fluoroscopically controlled (n = 48) subgroups (p = 0.031), respectively. Subgroup analysis limited to screws with an intrapedicular trajectory revealed a tendency toward a higher pull-out strength in the template-guided (n = 30) versus fluoroscopically controlled screws (n = 21) with 587 ± 309 and 454 ± 269 N (p = 0.118), respectively. There was a trend toward a higher pull-out strength (709 ± 418 versus 420 ± 149 N) in vertebrae with a bone density of (>171 HU) versus (<133 HU), respectively (p = 0.061).

Conclusions

There was a significantly higher pull-out strength of thoracolumbar pedicle screws when inserted via a patient-specific template-guided versus conventional free-hand fluoroscopically controlled technique, potentially associated with screw trajectory.

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Acknowledgements

The authors would like to thank Ioannis Spyrou and Tobias Götschi for their support during biomechanical testing.

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Authors and Affiliations

  1. Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland

    A. Aichmair, M. Moser, M. R. Bauer, E. Bachmann, J. G. Snedeker, M. Betz & M. Farshad

  2. Switzerland Laboratory for Orthopaedic Biomechanics, Swiss Federal Institute of Technology in Zurich (ETHZ), Zurich, Switzerland

    E. Bachmann & J. G. Snedeker

Authors
  1. A. Aichmair
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  2. M. Moser
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  3. M. R. Bauer
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  4. E. Bachmann
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  5. J. G. Snedeker
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  6. M. Betz
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  7. M. Farshad
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Correspondence to A. Aichmair.

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This study was conducted in accordance with Swiss and international law requirements. Ethical board’s approval was obtained from the Ethical Committee of Northwestern and Central Switzerland (ID: EKNZ BASEC 2016-00204).

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Aichmair, A., Moser, M., Bauer, M.R. et al. Pull-out strength of patient-specific template-guided vs. free-hand fluoroscopically controlled thoracolumbar pedicle screws: a biomechanical analysis of a randomized cadaveric study. Eur Spine J 26, 2865–2872 (2017). https://doi.org/10.1007/s00586-017-5025-7

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  • DOI: https://doi.org/10.1007/s00586-017-5025-7

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