1.
A level-1 pilot study to evaluate of ultraporous beta-tricalcium phosphate as a graft extender in the posterior correction of adolescent idiopathic scoliosis.
Lerner, T, Bullmann, V, Schulte, TL, Schneider, M, Liljenqvist, U
European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2009;(2):170-9
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Abstract
The objective of this study is to compare the clinical and radiographic results of ultraporous beta-tricalcium phosphate (beta-TCP) versus autogenous iliac crest bone graft (ICBG), through prospective randomized pilot study (EBM-Level 1), as graft extenders in scoliosis surgery. In the posterior correction of scoliosis, local bone resected as part of the procedure is used as the base bone graft material. Supplemental grafting from the iliac crest is considered the gold-standard in posterior spinal fusion. However, autograft is not available in unlimited quantities, and bone harvesting is a source of significant morbidity. Ultraporous beta-TCP might be a substitute for ICBG in these patients and thus eliminate donor site morbidity. A total of 40 patients with adolescent idiopathic scoliosis (AIS) were randomized into two treatment groups and underwent corrective posterior instrumentation. In 20 patients, ICBG harvesting was performed whereas the other half received beta-TCP (VITOSS) to augment the local bone graft. If thoracoplasty was performed, the resected rib bone was added in both groups. Patients were observed clinically and radiographically for a minimum of 20 months postoperatively, with a mean follow-up of 4 years. Overall pain and pain specific to the back and donor site were assessed using a visual analog scale (VAS). As a result, both groups were comparable with respect to the age at the time of surgery, gender ratio, preoperative deformity, and hence length of instrumentation. There was no significant difference in blood loss and operative time. In nine patients of the beta-TCP group and eight patients of the ICBG group, thoracoplasty was performed resulting in a rib graft of on average 7.9 g in both groups. Average curve correction was 61.7% in the beta-TCP group and 61.2% in the ICBG group at hospital discharge (P=0.313) and 57.2 and 54.3%, respectively, at follow-up (P=0.109). Loss of curve correction amounted on average 2.6 degrees in the beta-TCP group and 4.2 degrees in the comparison group (P=0.033). In the ICBG group, four patients still reported donor site pain of on average 2/10 on the VAS at last follow-up. One patient in the beta-TCP group was diagnosed with a pseudarthrosis at the caudal end of the instrumentation. Revision surgery demonstrated solid bone formation directly above the pseudarthrosis with no histological evidence of beta-TCP in the biopsy taken. In conclusion, the use of beta-TCP instead of ICBG as extenders of local bone graft yielded equivalent results in the posterior correction of AIS. The promising early results of this pilot study support that beta-TCP appears to be an effective bone substitute in scoliosis surgery avoiding harvesting of pelvic bone and the associated morbidity.
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New Insight in Loss of Gut Barrier during Major Non-Abdominal Surgery.
Derikx, JP, van Waardenburg, DA, Thuijls, G, Willigers, HM, Koenraads, M, van Bijnen, AA, Heineman, E, Poeze, M, Ambergen, T, van Ooij, A, et al
PloS one. 2008;(12):e3954
Abstract
BACKGROUND Gut barrier loss has been implicated as a critical event in the occurrence of postoperative complications. We aimed to study the development of gut barrier loss in patients undergoing major non-abdominal surgery. METHODOLOGY/PRINCIPAL FINDINGS Twenty consecutive children undergoing spinal fusion surgery were included. This kind of surgery is characterized by long operation time, significant blood loss, prolonged systemic hypotension, without directly leading to compromise of the intestines by intestinal manipulation or use of extracorporeal circulation. Blood was collected preoperatively, every two hours during surgery and 2, 4, 15 and 24 hours postoperatively. Gut mucosal barrier was assessed by plasma markers for enterocyte damage (I-FABP, I-BABP) and urinary presence of tight junction protein claudin-3. Intestinal mucosal perfusion was measured by gastric tonometry (P(r)CO2, P(r-a)CO2-gap). Plasma concentration of I-FABP, I-BABP and urinary expression of claudin-3 increased rapidly and significantly after the onset of surgery in most children. Postoperatively, all markers decreased promptly towards baseline values together with normalisation of MAP. Plasma levels of I-FABP, I-BABP were significantly negatively correlated with MAP at (1/2) hour before blood sampling (-0.726 (p<0.001), -0.483 (P<0.001), respectively). Furthermore, circulating I-FABP correlated with gastric mucosal P(r)CO2, P(r-a)CO2-gap measured at the same time points (0.553 (p = 0.040), 0.585 (p = 0.028), respectively). CONCLUSIONS/SIGNIFICANCE This study shows the development of gut barrier loss in children undergoing major non-abdominal surgery, which is related to preceding hypotension and mesenterial hypoperfusion. These data shed new light on the potential role of peroperative circulatory perturbation and intestinal barrier loss.
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An implantable strain measurement system designed to detect spine fusion: preliminary results from a biomechanical in vivo study.
Szivek, JA, Roberto, RF, Slack, JM, Majeed, BS
Spine. 2002;(5):487-97
Abstract
STUDY DESIGN The strain distribution on the thoracic vertebrae during anteroposterior bending and torsion was examined for use with an implantable strain gauge system and miniature radio transmitter, which also were evaluated. OBJECTIVES To identify strain gauge placement sites by testing cadaver spines in vivo, and to evaluate an implantable gauge bonding technique and subminiature radio transmitter for accurate strain monitoring. SUMMARY OF BACKGROUND DATA Fusion is determined currently through the use of radiographic techniques. Discrepancies exist between radiographic evidence and more direct measurements of fusion such as operative exploration4,5,12 and biomechanical or histologic measurements.12,15 To facilitate the return of patients to full unrestricted activity, it would be useful to develop a technique for accurate in vivo determination of fusion. METHODS Three cadaver spines were tested during anteroposterior bending and torsional loading in the control, instrumented, and instrumented plus polymethylmethacrylate states. The spines were instrumented with an ISOLA(R) (Acromed Corporation, Cleveland, Ohio) construct, and a simulated fusion was achieved through the application of polymethylmethacrylate. Strain gauges were attached in uniaxial, biaxial, and rosette configurations. The principal strains were calculated. Calcium phosphate ceramic-coated gauges were implanted in patients and recovered after up to 15 months in vivo. A radio transmitter was developed and tested for use in patients. RESULTS The largest and most consistent strain changes after simulated fusion were recorded during torsional loading on the laminae of a vertebra directly underneath a hook. Calcium phosphate ceramic-coated strain gauges showed excellent bone bonding to the lamina when fusion occurred. Radio telemetry accurately tracked strain magnitudes and strain rates expected in patients. CONCLUSIONS The consistency obtained in torsional loading indicates that this type of loading will provide the most useful data from patients in vivo. Excellent bonebonding and accurate strain transmission using a long-term strain measurement system and miniature radio transmitter indicate that strains collected from patients with this system will be accurate.