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Does the cement stiffness affect fatigue fracture strength of vertebrae after cement augmentation in osteoporotic patients?

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Abstract

Purpose

Normal progression of osteoporosis or the rigid reinforcement of the fractured vertebral body with polymethyl methacrylate (PMMA) cement is being discussed as a cause for adjacent-level fractures after vertebroplasty. The purpose of this study was to investigate whether augmentation with low stiffness cement can decrease the risk of adjacent-level fractures in low-quality bone.

Methods

Eighteen female osteoporotic lumbar specimens (L1–L5) were harvested and divided into three groups according to bone mineral density: (I) native; (II) PMMA; (III) modified PMMA (lower stiffness). For the PMMA and modified PMMA groups, a compression fracture was first mechanically induced in L3, and then the fracture received vertebroplasty treatment. The cement stiffness reduction of the modified PMMA group was achieved via an addition of 8 mL of serum to the typical PMMA base. All specimens were exposed to cyclic loading (4 Hz) and a stepwise increasing applied peak force. Cement stiffness was tested according to ISO 5833.

Results

A 51 % decrease in cement stiffness was achieved in the modified PMMA group (954 ± 141 vs. 1,937 ± 478 MPa, p < 0.001). Fatigue fracture force (the force level during cyclic loading at which the deformation experienced a sudden increase; FFF) was significantly affected by bone quality (r 2 = 0.39, p = 0.006) and by the initial fracture force (the force necessary to create the initial fracture in L3 prior to augmentation; r 2 = 0.82, p < 0.001). Using initial fracture force as a covariate, the FFF of the modified PMMA group (1,764 ± 49 N) was significantly higher than in the PMMA group (1,544 ± 55 N; p = 0.03).

Conclusions

A possible method to reduce adjacent-level fractures after vertebroplasty in patients with reduced bone quality could be the use of a lower modulus cement. Therefore, mixing cement with biocompatible fluids could prove useful to tailor cement properties in the operating theater.

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Notes

  1. FFF for the modified PMMA group was also significantly higher than the PMMA group when the FFF was normalized with the initial fracture force (FFF/IFF) rather than using the IFF as a covariate (p = 0.03). To account for differences of individual specimen geometry, an ANCOVA analysis comparing the change in apparent fatigue strength (FFF/endplate area) adjusted for apparent initial strength (IFF/endplate area) was performed. In accordance with the FFF analysis, the modified PMMA fatigue strength (1.30 ± 0.041 MPa, n = 6) was also significantly higher than in the PMMA group (1.07 ± 0.045 MPa, n = 5, F(1,8) = 11.99, η 2 = 0.60, p = 0.009, Fig. 5).

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Acknowledgments

Funding from the state of Hamburg and the Marie Curie ITN project SpineFX is kindly acknowledged. The authors would also like to thank Synthes GmbH for providing the cement.

Conflict of interest

Prof. Dr. Andreas Boger was formerly a Senior Project Scientist at Synthes GmbH until September 2011. No other authors have any declarations.

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Authors and Affiliations

  1. Department of Trauma-, Hand- and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany

    Jan Philipp Kolb, Johannes M. Rueger & Wolfgang Lehmann

  2. Institute for Biomechanics, TUHH Hamburg University of Technology, Denickestrasse 15, 21073, Hamburg, Germany

    Rebecca A. Kueny, Michael M. Morlock & Gerd Huber

  3. Department of Legal Medicine, University Medical Center Hamburg Eppendorf, Butenfeld 34, 22529, Hamburg, Germany

    Klaus Püschel

  4. Ansbach University of Applied Science, Residenzstraße 8, 91522, Ansbach, Germany

    Andreas Boger

Authors
  1. Jan Philipp Kolb
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  2. Rebecca A. Kueny
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  3. Klaus Püschel
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  4. Andreas Boger
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  5. Johannes M. Rueger
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  7. Gerd Huber
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  8. Wolfgang Lehmann
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Corresponding author

Correspondence to Wolfgang Lehmann.

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Kolb, J.P., Kueny, R.A., Püschel, K. et al. Does the cement stiffness affect fatigue fracture strength of vertebrae after cement augmentation in osteoporotic patients?. Eur Spine J 22, 1650–1656 (2013). https://doi.org/10.1007/s00586-013-2809-2

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  • DOI: https://doi.org/10.1007/s00586-013-2809-2

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