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Biomechanical Analysis of Acute Proximal Junctional Failure After Surgical Instrumentation of Adult Spinal Deformity: The Impact of Proximal Implant Type, Osteotomy Procedures, and Lumbar Lordosis Restoration

  • Biomechanics and Basic science
  • Published:
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Abstract

Study design

Computer biomechanical simulations to analyze risk factors of proximal junctional failure (PJF) following adult scoliosis instrumentation.

Objective

To evaluate the biomechanical effects on the proximal junctional spine of the proximal implant type, tissue dissection, and lumbar lordosis (LL) restoration.

Summary of Background Data

PJF is a severe proximal junctional complication following adult spinal instrumentation requiring revision surgery. Potential risk factors have been reported in the literature, but knowledge on their biomechanics is still lacking to address the issues.

Methods

A patient-specific multibody and finite-element hybrid modeling technique was developed for a 54-year-old patient having undergone instrumented spinal fusion for multilevel stenosis resulting in PJF. Based on the actual surgery, 30 instrumentation scenarios were derived and simulated by changing the implant type at the upper instrumented vertebra (UIV), varying the extent of proximal osteotomy and the degree of LL creation. Five functional loads were simulated, and stresses and strains were analyzed for each of the 30 tested scenarios.

Results

There was 80% more trabecular bone with stress greater than 0.5 MPa in the UIV with screws compared to hooks. Hooks allowed 96% more mobility of the proximal instrumented functional unit compared to screws. The bilateral complete facetectomy along with posterior ligaments dissection caused a significant increase of the range of motion of the functional unit above the UIV. LL creation increased the flexion moment applied on the proximal vertebra from 7.5 to 17.5 Nm, which generated damage at the bone-screw interface that affected the screw purchase.

Conclusion

Using hooks at UIV and reducing posterior proximal spinal element dissection lowered stress levels in the proximal junctional spinal segment and thus reduced the biomechanical risks of PJF. LL restoration was associated with increased stress levels in postoperative functional upper body flexion.

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Author information

Authors and Affiliations

  1. Department of Mechanical Engineering, Polytechnique Montréal, P.O. Box 6079, Downtown Station, Montreal, Quebec, H3C 3A7, Canada

    Leo Fradet PhD, Xiaoyu Wang PhD & Carl-Eric Aubin PhD, PEng

  2. Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, Quebec, H3T 1C5, Canada

    Leo Fradet PhD, Xiaoyu Wang PhD & Carl-Eric Aubin PhD, PEng

  3. iLab-Spine (International Laboratory–Spine Imaging and Biomechanics), Montreal, Canada and Marseille, France

    Leo Fradet PhD & Carl-Eric Aubin PhD, PEng

  4. Sonoran Spine Center, 1255 W. Rio Salado Parkway, Tempe, AZ, 85281, USA

    Dennis Crandall MD

Authors
  1. Leo Fradet PhD
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  2. Xiaoyu Wang PhD
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  3. Dennis Crandall MD
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  4. Carl-Eric Aubin PhD, PEng
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Corresponding author

Correspondence to Carl-Eric Aubin PhD, PEng.

Additional information

Author disclosures: LF (none), XW (none), DC (other from Medtronic, other from SpineWave, other from Orthosensor, outside the submitted work), CEA (grants from Medtronic, during the conduct of the study; grants from Natural Sciences and Engineering Research Council of Canada, outside the submitted work; and Canada Research Chair in Orthopedic Engineering [research grant]—through the University, to support academic research; Natural Sciences and Engineering Research Council of Canada [Discovery grant]—through the University, to support academic research).

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Fradet, L., Wang, X., Crandall, D. et al. Biomechanical Analysis of Acute Proximal Junctional Failure After Surgical Instrumentation of Adult Spinal Deformity: The Impact of Proximal Implant Type, Osteotomy Procedures, and Lumbar Lordosis Restoration. Spine Deform 6, 483–491 (2018). https://doi.org/10.1016/j.jspd.2018.02.007

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  • DOI: https://doi.org/10.1016/j.jspd.2018.02.007

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