Skip to main content

Cement augmentation of odontoid peg fractures: the effect of cement volume and distribution on construct stiffness

We’re sorry, something doesn't seem to be working properly.

Please try refreshing the page. If that doesn't work, please contact support so we can address the problem.



The cement augmentation of a conventional anterior screw fixation in type II odontoid process fractures for elderly patients significantly increased stiffness and load to failure under anterior–posterior load in comparison with non-augmented fixation. The amount and quality of bone cement are usually taken ad hoc in clinical practise. In this study, we wanted to clarify the role of bone cement amount and its quality to the stiffness of odontoid and vertebrae body junction.


Finite-element method was used to achieve different scenarios of cement augmentation. For all models, an initial stiffness was calculated. Model (1) the intact vertebrae were virtually potted into a polymethylmethacrylate base via the posterior vertebral arches. A V-shaped punch was used for loading the odontoid in an anterior–posterior direction. (2) The odontoid fracture type IIa (Anderson–D’Alonzo classification) was achieved by virtual transverse osteotomy. Anterior screw fixation was virtually performed by putting self-drilling titanium alloy 3.5 mm diameter anterior cannulated lag screw with a 12 mm thread into the inspected vertebrae. A V-shaped punch was used for loading the odontoid in an anterior–posterior direction. The vertebrae body was assumed to be non-cemented and cemented with different volume.


The mean cement volume was lowest for body base filling with 0.47 ± 0.03 ml. The standard body filling corresponds to 0.95 ± 0.15 ml. The largest volume corresponds to 1.62 ± 0.12 ml in the presence of cement leakage. The initial stiffness of the intact C2 vertebrae was taken as the reference value. The mean initial stiffness for non-porous cement (E = 3000 MPa) increased linearly (R2 = 0.98). The lowest stiffness (123.3 ± 5.8 N/mm) was measured in the intact C2 vertebrae. However, the highest stiffness (165.2 ± 5.2 N/mm) was measured when cement leakage out of the odontoid peg occurred. The mean initial stiffness of the base-only cemented group was 147.2 ± 8.4 N/mm compared with 157.9 ± 6.6 N/mm for the base and body cemented group. This difference was statistically significant (p < 0.0061). The mean initial stiffness for porous cement (E = 500 MPa) remains constant. Therefore, there is no difference between cemented and non-cemented junction. This difference was not statistically significant (p < 0.18).


The present study showed that the low porous cement was able to significantly influence the stiffness of the augmented odontoid screw fixation in vitro, although further in vivo clinical studies should be undertaken. Our results suggest that only a small amount of non-porous cement is needed to restore stiffness at least to its pre-fracture level and this can be achieved with the injection of 0.7–1.2 ml of cement.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8


  1. Hide IG, Gangi A (2004) Percutaneous vertebroplasty: history, technique and current perspectives. Clin Radiol 59(6):461–467

    Article  CAS  Google Scholar 

  2. Liebschner MA, Rosenberg WS, Keaveny TM (2001) Effects of bone cement volume and distribution on vertebral stiffness after vertebroplasty. Spine (Phila Pa 1976) 26(14):1547–1554

    Article  CAS  Google Scholar 

  3. Kohlhof H, Seidel U, Hoppe S, Keel MJ, Benneker LM (2013) Cement-augmented anterior screw fixation of Type II odontoid fractures in elderly patients with osteoporosis. Spine J 13(12):1858–1863

    Article  Google Scholar 

  4. Waschke A, Berger-Roscher N, Kielstein H, Ewald C, Kalff R, Wilke HJ (2015) Cement augmented anterior odontoid screw fixation is biomechanically advantageous in osteoporotic patients with Anderson Type II fractures. J Spinal Disord Tech 28(3):E126–E132

    Article  Google Scholar 

  5. Schmidt R, Cakir B, Mattes T, Wegener M, Puhl W, Richter M (2005) Cement leakage during vertebroplasty: an underestimated problem? Eur Spine J 14(5):466–473

    Article  CAS  Google Scholar 

  6. Hulme PA, Krebs J, Ferguson SJ, Berlemann U (2006) Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine (Phila Pa 1976) 31(17):1983–2001

    Article  Google Scholar 

  7. Zhan Y, Jiang J, Liao H, Tan H, Yang K (2017) Risk factors for cement leakage after vertebroplasty or kyphoplasty: a meta-analysis of published evidence. World Neurosurg 101:633–642

    Article  Google Scholar 

  8. Nieuwenhuijse MJ, Van Erkel AR, Dijkstra PD (2011) Cement leakage in percutaneous vertebroplasty for osteoporotic vertebral compression fractures: identification of risk factors. Spine J 11(9):839–848

    Article  Google Scholar 

  9. Sun HB, Jing XS, Liu YZ, Qi M, Wang XK, Hai Y (2018) The optimal volume fraction in percutaneous vertebroplasty evaluated by pain relief, cement dispersion, and cement leakage: a prospective cohort study of 130 patients with painful osteoporotic vertebral compression fracture in the thoracolumbar vertebra. World Neurosurg 114:e677–e688

    Article  Google Scholar 

  10. Yang EZ, Xu JG, Huang GZ, Xiao WZ, Liu XK, Zeng BF et al (2016) Percutaneous vertebroplasty versus conservative treatment in aged patients with acute osteoporotic vertebral compression fractures: a prospective randomized controlled clinical study. Spine (Phila Pa 1976) 41(8):653–660

    Article  Google Scholar 

  11. Berlemann U, Ferguson SJ, Nolte LP, Heini PF (2002) Adjacent vertebral failure after vertebroplasty. A biomechanical investigation. J Bone Joint Surg Br 84(5):748–752

    Article  CAS  Google Scholar 

  12. Boszczyk B (2010) Volume matters: a review of procedural details of two randomised controlled vertebroplasty trials of 2009. Eur Spine J 19(11):1837–1840

    Article  Google Scholar 

  13. Rehousek P, Jenner E, Holton J, Czyz M, Capek L, Henys P et al (2018) Biomechanical comparison of cemented versus non-cemented anterior screw fixation in type II odontoid fractures in the elderly: a cadaveric study. Spine J 18(10):1888–1895

    Article  Google Scholar 

  14. Goel VK, Nyman E (2016) Computational modeling and finite element analysis. Spine (Phila Pa 1976) 41(Suppl 7):S6–S7

    Article  Google Scholar 

  15. Rohlmann A, Burra NK, Zander T, Bergmann G (2007) Comparison of the effects of bilateral posterior dynamic and rigid fixation devices on the loads in the lumbar spine: a finite element analysis. Eur Spine J 16(8):1223–1231

    Article  Google Scholar 

  16. Morgan EF, Bayraktar HH, Keaveny TM (2003) Trabecular bone modulus-density relationships depend on anatomic site. J Biomech 36(7):897–904

    Article  Google Scholar 

  17. Pauchard Y, Fitze T, Browarnik D, Eskandari A, Enns-Bray W, Pálsson H, Sigurdsson S, Ferguson Stephen J, Harris Tamara B, Gudnason V, Helgason B (2016) Interactive graph-cut segmentation for fast creation of finite element models from clinical CT data for hip fracture prediction. Comput Methods Biomech Biomed Eng 19(16):1693–1703

    Article  Google Scholar 

  18. Yushkevich PA, Piven J, Hazlett HC, Smith RG, Ho S, Gee JC et al (2006) User-guided 3D active contour segmentation of anatomical structures: significantly improved efficiency and reliability. Neuroimage 31(3):1116–1128

    Article  Google Scholar 

  19. Pal D, Sell P, Grevitt M (2011) Type II odontoid fractures in the elderly: an evidence-based narrative review of management. Eur Spine J 20(2):195–204

    Article  CAS  Google Scholar 

  20. Löhrer L, Raschke MJ, Thiesen D, Hartensuer R, Surke C, Ochman S et al (2012) Current concepts in the treatment of Anderson type II odontoid fractures in the elderly in Germany, Austria and Switzerland. Injury 43(4):462–469

    Article  Google Scholar 

  21. Daniels AH, Magee W, Badra M, Bay B, Hettwer W, Hart RA (2012) Preliminary biomechanical proof of concept for a hybrid locking plate/variable pitch screw construct for anterior fixation of type II odontoid fractures. Spine (Phila Pa 1976) 37(19):E1159–E1164

    Article  Google Scholar 

  22. Belkoff SM, Mathis JM, Jasper LE, Deramond H (2001) The biomechanics of vertebroplasty. The effect of cement volume on mechanical behavior. Spine (Phila Pa 1976) 26(14):1537–1541

    Article  CAS  Google Scholar 

  23. Luo J, Daines L, Charalambous A, Adams MA, Annesley-Williams DJ, Dolan P (2009) Vertebroplasty: only small cement volumes are required to normalize stress distributions on the vertebral bodies. Spine (Phila Pa 1976) 34(26):2865–2873

    Article  Google Scholar 

  24. Lador R, Dreiangel N, Ben-Galim PJ, Hipp JA (2010) A pictorial classification atlas of cement extravasation with vertebral augmentation. Spine J 10(12):1118–1127

    Article  Google Scholar 

  25. Belkoff SM, Molloy S (2003) Temperature measurement during polymerization of polymethylmethacrylate cement used for vertebroplasty. Spine (Phila Pa 1976) 28(14):1555–1559

    Google Scholar 

  26. Teo JCM, Teoh SH (2012) Permeability study of vertebral cancellous bone using micro- computational fluid dynamics. Comput Methods Biomech Biomed Eng 15:417–423

    Article  Google Scholar 

  27. Kurutza M, Vargab P, Jakab G (2019) Prophylactic vertebroplasty versus kyphoplasty in osteoporosis: A comprehensive biomechanical matched-pair study by in vitro compressive testing. Med Eng Phys 65:45–46

    Google Scholar 

Download references


This work was supported by the Charles University Grant Agency (GAUK) no. 816016.


The manuscript has not previously been published in print or electronic form and is not under consideration by another publication.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Petr Henys.

Ethics declarations

Conflict of interest

Authors declare that there is no ethical problem or conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PPTX 17105 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Capek, L., Rehousek, P., Henys, P. et al. Cement augmentation of odontoid peg fractures: the effect of cement volume and distribution on construct stiffness. Eur Spine J 29, 977–985 (2020).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Fracture
  • Spine
  • Finite element
  • Bone cement
  • Odontoid