Vertebral compression fractures rank among the most frequent injuries to the musculoskeletal system, with more than 1 million fractures per annum worldwide. The past decade has seen a considerable increase in the utilisation of surgical procedures such as balloon kyphoplasty to treat these injuries. While many kyphoplasty studies have examined the risk of damage to adjacent vertebra after treatment, recent case reports have also emerged to indicate the potential for the treated vertebra itself to re-collapse after surgery. The following study presents a combined experimental and computational study of balloon kyphoplasty which aims to establish a methodology capable of evaluating these cases of vertebral re-collapse. Results from both the experimental tests and computational models showed significant increases in strength and stiffness after treatment, by factors ranging from 1.44 to 1.93, respectively. Fatigue tests on treated specimens showed a 37% drop in the rate of stiffness loss compared to the untreated baseline case. Further analysis of the computational models concluded that inhibited PMMA interdigitation at the interface during kyphoplasty could reverse improvements in strength and stiffness that could otherwise be gained by the treatment.
GozVErricoTJWeinrebJH, et al. Vertebroplasty and kyphoplasty: national outcomes and trends in utilization from 2005 through 2010. Spine J2013; 15(5): 959–965.
2.
Hacein-BeyL.Current and emerging treatment strategies for vertebral compression fractures. Orthop Res Rev2012; 4: 65–75.
3.
FrankelBMMonroeTWangC.Percutaneous vertebral augmentation: an elevation in adjacent-level fracture risk in kyphoplasty as compared with vertebroplasty. Spine J2007; 7(5): 575–582.
4.
FribourgDTangCSraP, et al. Incidence of subsequent vertebral fracture after kyphoplasty. Spine (Phila. Pa. 1976)2004; 29(20): 2270–2276.
5.
MeyerCvan GaalenKLeschingerT, et al. Kyphoplasty of osteoporotic fractured vertebrae: a finite element analysis about two types of cement. Biomed Res Int2019; 2019: 9232813.
6.
ZhaoWTQinDPZhangXG, et al. Biomechanical effects of different vertebral heights after augmentation of osteoporotic vertebral compression fracture: A three-dimensional finite element analysis. J Orthop Surg Res2018; 13(1): 1–10.
7.
IJLeeLam ChoiAYieM-Y, et al. CT evaluation of local leakage of bone cement after percutaneous kyphoplasty and vertebroplasty. Acta Radiol2010; 51(6): 649–654.
8.
PflugmacherRSchroederR-JKlostermannCK.Incidence of adjacent vertebral fractures in patients treated with balloon kyphoplasty: two years’ prospective follow-up. Acta Radiol2006; 47(8): 830–840.
9.
TogawaDBauerTWLiebermanIH, et al. Histologic evaluation of human vertebral bodies after vertebral augmentation with polymethyl methacrylate. Spine (Phila. Pa. 1976). 2003; 28(14): 1521–1527.
10.
PurcellPTyndykMMcEvoyF, et al. A parametric finite element analysis of the compacted bone-cement interface following balloon kyphoplasty. Proc Inst Mech Eng H. 2014; 228(1): 89–97.
11.
PurcellPTyndykMMcEvoyF, et al. Stress distribution at the bone-cement interface changes during kyphoplasty rehabilitation. IEEE Comput Soc2013; Biomedical: 65–66.
12.
KrügerAOberkircherLKratzM, et al. Cement interdigitation and bone-cement interface after augmenting fractured vertebrae: a cadaveric study. Int J Spine Surg2012; 6: 115–123.
13.
DaltonBEKohmACMillerLE, et al. Radiofrequency-targeted vertebral augmentation versus traditional balloon kyphoplasty: radiographic and morphologic outcomes of an ex vivo biomechanical pilot study. Clin Interv Aging2012; 7: 525–531.
14.
Leslie-MazwiTDeenHG.Repeated fracture of a vertebral body after treatment with balloon kyphoplasty: case illustration. J Neurosurg Spine. 2006; 4(3): 270.
15.
OhbaTEbataSClintonD, et al. Instability of treated vertebrae after balloon kyphoplasty causing paraparesis in osteoporotic vertebral compression fracture: a report of two cases. Eur Spine J2012; 22: S341–S345.
16.
LiXLouXLinX, et al. Refracture of osteoporotic vertebral body concurrent with cement fragmentation at the previously treated vertebral level after balloon kyphoplasty: a case report. Osteoporos Int2014; 25(5): 1647–1650, 2014.
17.
MuellerMDaniels-WredenhagenMBeschL, et al. Postoperative aseptic osteonecrosis in a case of kyphoplasty. Eur Spine J2009; 18(Suppl 2): 213–216.
18.
KimKHSKuhSUParkJY, et al. What is the importance of ‘halo’ phenomenon around bone cement following vertebral augmentation for osteoporotic compression fracture?Osteoporos Int2012; 23(10): 2559–2565.
19.
LuoJBertramWSangarD, et al. Is kyphoplasty better than vertebroplasty in restoring normal mechanical function to an injured spine?Bone2010; 46(4): 1050–1057.
20.
KimY-YRhyuK-W.Recompression of vertebral body after balloon kyphoplasty for osteoporotic vertebral compression fracture. Eur Spine J2010; 19(11): 1907–1912.
21.
Dong-HoonYChoKHChungYS, et al. Effect of vertebroplasty with bone filler device and comparison with balloon kyphoplasty. Eur Spine J2014; 23: 2718–2725.
22.
MoonE-SKimH-SParkJ-O, et al. The incidence of new vertebral compression fractures in women after kyphoplasty and factors involved. Yonsei Med J2007; 48(4): 645–652.
23.
TatsumiRLChingACByrdGD, et al. Predictors and prevalence of patients undergoing additional kyphoplasty procedures after an initial kyphoplasty procedure. Spine J2010; 10(11): 979–986.
24.
KimMJLindseyDPHannibalM, et al. Vertebroplasty versus kyphoplasty: biomechanical behavior under repetitive loading conditions. Spine (Phila. Pa. 1976). 2006; 31(18): 2079–2084.
25.
WilkeH-JMehnertUClaesLE, et al. Biomechanical evaluation of vertebroplasty and kyphoplasty with polymethyl methacrylate or calcium phosphate cement under cyclic loading. Spine (Phila. Pa. 1976). 2006; 31(25): 2934–2941.
26.
WangJ-LChiangC-KKuoY-W, et al. Mechanism of fractures of adjacent and augmented vertebrae following simulated vertebroplasty. J Biomech2012; 45(8): 1372–1378.
27.
TsouknidasASavvakisSAsaniotisY, et al. The effect of kyphoplasty parameters on the dynamic load transfer within the lumbar spine considering the response of a bio-realistic spine segment. Clin Biomech (Bristol, Avon), 2013; 28(9–10): 949–955.
28.
VillarragaLMCriptonPABellezzaAJ, et al. Stress levels in bones and bone cement in the thoracolumbar spine afer kyphoplasty. Finite element study. Orthopade2004; 33(1): 48–55.
29.
DabirrahmaniDDBeckerSHoggM, et al. Mechanical variables affecting balloon kyphoplasty outcome - a finite element study. Comput Methods Biomech Biomed Engin2012; 15: 211–220.
30.
BettenJ.Generalization of nonlinear material laws found in experiments to multi-axial states of stress. Eur J Mech A Solids1989; 8: 325–339.
31.
KosmopoulosVKellerTS.Finite element modeling of trabecular bone damage. Comput Methods Biomech Biomed Eng2003; 6: 209–216.
32.
KosmopoulosVSchizasCKellerTS.Modeling the onset and propagation of trabecular bone microdamage during low-cycle fatigue. J Biomech2008; 41(3): 515–522.
PurcellPMcEvoyFTiernanS, et al. An experimentally validated computational study of changes in static and fatigue properties following balloon kyphoplasty. In: 8th world congress of biomechanics, 2018. Dublin, Ireland.
37.
PurcellPTiernanSMcEvoyF, et al. Strong similarities in the creep and damage behaviour of a synthetic bone model compared to Human trabecular bone under compressive cyclic loading. J Mech Behav Biomed Mater2015; 48: 51–59.
38.
GómezSVladMDLópezJ, et al. Characterization and three-dimensional reconstruction of synthetic bone model foams. Mater Sci Eng C Mater Biol Appl2013; 33(6): 3329–3335.
DendorferSMaierHJTaylorD, et al. Anisotropy of the fatigue behaviour of cancellous bone. J Biomech2008; 41(3): 636–641.
41.
RaceAMannKAEdidinAA. Mechanics of bone/PMMA composite structures: an in vitro study of human vertebrae. J Biomech2007; 40(5): 1002–1010.
42.
WilkeH-JNeefPCaimiM, et al. New in-vivo measurements of pressures in the intervertebral disc in daily life. Spine (Phila. Pa. 1976). 1999; 24(8): 755–762.
43.
LochmüllerE.-M.PöschlKWürstlinL, et al. Does thoracic or lumbar spine bone architecture predict vertebral failure strength more accurately than density?Osteoporos Int2008; 19(4): 537–545.
44.
HaddockSMYehOCMummaneniPV, et al. Similarity in the fatigue behavior of trabecular bone across site and species. J Biomech2004; 37(2): 181–187.
45.
RapillardLCharleboisMZyssetPK.Compressive fatigue behavior of human vertebral trabecular bone. J Biomech2006; 39(11): 2133–2139.
46.
WallbridgeNDowsonD.The walking activity of patients with artificial hip joints. Eng Med1982; 11: 95–96.
47.
SchneiderCARasbandWSEliceiriKW.NIH Image to ImageJ: 25 years of image analysis. Nat Methods2012;9(7):671–675.
48.
KosmopoulosVKellerTS.Predicting trabecular bone microdamage initiation and accumulation using a non-linear perfect damage model. Med Eng Phys2008; 30(6): 725–732.
49.
PurcellPTyndykMMcEvoyF, et al. A multiscale finite element analysis of balloon kyphoplasty to investigate the risk of bone-cement separation in vivo. Int J Spine Surg2021; 15: 302–314.
50.
LambersFMBoumanARRimnacCM, et al. Microdamage caused by fatigue loading in human cancellous bone: relationship to reductions in bone biomechanical performance. PLoS One2013; 8(12): 1–9.
51.
BelkoffSMMathisJMFentonDC, et al. An ex vivo biomechanical evaluation of an inflatable bone tamp used in the treatment of compression fracture. Spine (Phila. Pa. 1976)2001; 26(2): 151–156.
52.
ChenBLiYXieD, et al. Comparison of unipedicular and bipedicular kyphoplasty on he stiffness and biomechanical balance of compression fractured vertebrae. Eur Spine J2011; 20(8): 1272–1280.
53.
WilsonDRMyersERMathisJM, et al. Effect of augmentation on the mechanics of vertebral wedge fractures. Spine (Phila. Pa. 1976)2000; 25(2): 158–165.
54.
KayanjaMMTogawaDLiebermanIH.Biomechanical changes after the augmentation of experimental osteoporotic vertebral compression fractures in the cadaveric thoracic spine. Spine J2005; 5(1): 55–63.
55.
TomitaSMolloySJasperLE, et al. Biomechanical comparison of kyphoplasty with different bone cements. Spine (Phila. Pa. 1976)2004; 29(11): 1203–1207.
56.
TomitaSKinAMasayaY, et al. Biomechanical evaluation of kyphoplasty and vertebroplasty with calcium phosphate cement in a simulated osteoporotic compression fracture. J Orthop Sci2003; 8: 192–197.
57.
BerlemannUFergusonSJNolteLP, et al. Adjacent vertebral failure after vertebroplasty. A biomechanical investigation. J Bone Jt Surg Br2002; 84(5): 748–752.
58.
MooreTLAO’BrienFJGibsonLJ. Creep does not contribute to fatigue in bovine trabecular bone. J Biomech Eng2004; 126(3): 321.
59.
DiamondTHClarkWAKumarSV.Histomorphometric analysis of fracture healing cascade in acute osteoporotic vertebral body fractures. Bone2007; 40(3): 775–780.
60.
J.VanderoostJaecquesSVNVan der PerreG, et al. Fast and accurate specimen-specific simulation of trabecular bone elastic modulus using novel beam-shell finite element models. J Biomech2011; 44(8): 1566–1572.
61.
Almhdie-ImjabberAHambliRTouvierJ, et al. Mechanical assessment of trabecular bone stiffness using hybrid skeleton and finite element analysis. Comput Methods Biomech Biomed Eng Imaging Vis2014; 2015: 1–8.
