Class of 2012 Abstract / Specific Aims: To evaluate surgery, infectious disease, and nephrology consult documentation of antimicrobial content in bone cement within 30 days post-surgery; evaluate documentation of antimicrobial cement content by pharmacists in pharmacokinetic drug level evaluations within 6 months post-surgery; assess frequency and severity of adverse drug events associated with antimicrobials in bone cement. Methods: Retrospective chart review, which utilized a data collection form to evaluate the dose and type of antimicrobial agents prescribed, median and range antimicrobial doses per 40 grams of cement, documentation rates of antimicrobial content in clinical notes and incidence of potential adverse drug effects. Subjects were identified based on an ICD-9 code and their electronic medical records were accessed. Main Results: The sample size was 24 patients. The surgery notes had the highest rates of documentation with 96% naming the drug and 75% included the dose. The rates were the same in the infectious diseases consults and pharmacy pharmacokinetics notes with the drug name at 27% and the dose at 9%. No nephrology consult notes mentioned antimicrobials contained in the cement. Renal dysfunction (sCr≥2) developed in 13% of patients within 30 days and 25% of patients within 100 days. Approximately 17% of patients with renal dysfunction had the antimicrobial-laden cement removed. Conclusions: A variety of antimicrobial agents were embedded in bone cement at various concentrations and documentation from multiple sources was inconsistent. Likewise, adverse events associated with antimicrobial containing bone cement are not consistent.

Multiwall carbon nanotubes (MWNTs) have extraordinary mechanical and thermal transport properties. They significantly improve the static and dynamic mechanical properties of acrylic orthopaedic bone cement when added to the dry cement polymer powder. Understanding the role MWNTs play on bone cement polymerization temperatures will lead to improved mechanical integrity of the cement-bone interface in joint arthroplasties. It was determined through thermal testing that MWNTs increased the polymerization time of the methylmethacrylate by 45-460% and decreased the peak exothermic temperature of bone cement with and without antibiotics. The flow of heat produced during polymerizing cement was reduced 25-85% with the addition of MWNTs to the cement powder. This decreases the probability of thermal necrosis and “hot” spots caused by high exothermic polymerization temperatures that can destroy the bone adjacent to the cement. These high temperatures also affect the potency and range of antibiotics used in arthroplasty. Isothermal and elution studies determined that MWNTs altered the heat flow and amount of antibiotic release from bone cement during polymerization. Antibiotic elution from bone cement containing MWNTs could match the elution seen in pure cement. The alteration of the flow of heat from bone cement leads to new options for heat-labile antibiotics in total joint arthroplasty.

Bone cement surgery is a new technique widely used in medical field nowadays. In this thesis I analyze 48 bone cement types using their content of 20 elements. My goal is to ?find a method to classify new found bone cement sample into these 48 categories. Here I will use multinomial logistic regression method to see whether it works or not. Due to the lack of observations, I generate enough data by adding white noise in proper scales to the original data again and again, and then I get a data set of over 100 times as many points as the original one. Then I use purposeful variable selection method to pick the covariates I need, rather than stepwise selection. There are 15 covariates left after the selection, and then I use my new data set to fit such a multinomial logistic regression model. The model doesn't perform that good in goodness of ?fit test, but the result is still acceptable, and the diagnostic statistics also indicate a good performance. Combined with clinical experience and prior conditions, this model is helpful in this classification case.

No description available.

Suture or bone anchors are used to reattach a tendon or ligament after it has been torn away from the bone. Anchors provide secure attachments to bone during trauma or reconstructive surgery, holding the ligament or tendon in place and potentially allowing greater mobility during recovery. Computer modelling techniques are used to investigate both established bone anchor technology, such as threaded implants, and emerging technologies such as cement augmentation or sonic-fusion. Sonic fusion is an ultrasound-assisted anchoring method which has recently been introduced in low load maxillofacial applications, and is expected to be used in other low load applications such as hallux valgus alignment procedures and suture attachment. Threaded anchors were examined using two Finite Element (FE) models of human cancellous bone, representing both “normal” and “weaker” bone. Simulation and analysis revealed the critical nature of modelling the microstructure of bone. Changing the direction of loading in the model leads to significant changes in the response of the construct, and this cannot be represented in continuum models, or in physical models using artificial cancellous bone. Rapid prototyping (RP) using 3d printing was used for validation of the FE models. While this method has previously been implemented to create physical bone models, testing an assembly model and comparing it to FE results for inclined loading had not been attempted. RP models were created of the threaded anchor in both “normal” and “weaker” bone, and a sonic fusion model in the normal bone was also created. These models were then subjected to mechanical testing. Results produced from the simulation correlated with the physical results. The importance of a cortical layer was re-confirmed. At the apparent densities simulated, engagement with the cortical layer increases pull-out force dramatically. Engaging the anchor even with a thin cortical layer can produce a significant improvement to pull-out strength. Novel sonic fusion FE models were created from a CT scan of animal bone, and the geometry for both the sonic-fusion pin and bone were taken from the CT scan. Computer generated geometry was used to build pin concepts of varying shapes. It was shown that if good engagement is made with bone, as in the case of all of the concepts created, then sonic fusion can produce a good holding power - comparable with that of a threaded anchor. The results showed that sonic-fusion requires less drill penetration into the bone, meaning less of the inherent bone structure is removed – vital for patients with poor bone quality. Bone cement models were investigated. Bone augmentation models were created, and the addition of cement demonstrated an improvement in anchor holding power. The research showed that there are benefits to using FEA as a tool to evaluate the mechanical aspects of cement distribution. The results proved the hypothesis that augmentation will likely increase the holding power of anchor, and its distribution will affect pull-out significantly. This work has created a method for modelling and evaluating both established and novel bone anchor technology in CT bone geometry, a procedure which could be expanded to other bone implants. It has been validated using the innovative approach of rapid prototyping.

Implants such as intramedullary nails or cancellous screws are used to mechanically stabilize fractures in bone. They provide reinforcement to the bone if they find good purchase in cancellous bone. Not all implants hold enough loads for mechanical stability and pull-out or cut-out may happen in some cases. This is linked to the interface between the bone and the implant. Computer modelling techniques are used to investigate both the effects of cut-out in a femur model, and the pull-out forces of cancellous bone screws. The bone geometry was based on CT scanned cancellous bone and converted using Mimics® software. The finite element models were produced in ANSYS®. Simple bone models were used to examine a fractured femur under standard gait loading. These models were continuum models and idealised the screw to bone interface in order to ease computational demand. The models were used to investigate the ideal positions of intramedullary devices lag screws on an anterior-posterior view of the implant location. In accordance with literature, an inferior-central or central-central position was the best position of the lag screw, while a superior-anterior or inferior-anterior position was adverse. The introduction of multi-scale modelling in order to investigate cut-out with a discrete bone model was not achieved. Discrete cancellous bone models were used to examine some of the cancellous screw characteristics, including pitch, inner diameter and proximal half angle, while a cancellous screw was also studied using a model of cancellous bone with a range of bone densities. The calculated reaction force for a pull-out of 0.2mm shows the influence of some parameters. Change in the proximal half angle increased the stiffness and strength by about 15% in line with the experimental findings of others, while apparent density changes of 2.5% increased the forces threefold. A significant reduction in reaction force was observed when a particular screw geometry in lower apparent density bone was modelled and rotated through 180° on a plane. Examination of the geometry of the bone/screw interface shows that in certain positions there is very little cancellous bone to support the implant. This will lead to low strength and is very difficult to predict. The same models were used to examine the effect of increasing bone stiffness adjacent to the implant and the use of a cement layer to augment the screw model. The increasing stiffness concluded that an increase in pull-out stiffness can be achieved, even in low quality bone, while the cement augmentation showed a significant increase in pull-out strength, though it was idealised as bonded to the bone and screw.

No description available.

Sacral insufficiency fractures are an under-diagnosed source of acute lower back pain. A polymethylmethacrylate (PMMA) cement injection procedure called sacroplasty has recently been utilized as a treatment for sacral insufficiency fractures. It is believed that injection of cement reduces fracture micromotion, thus relieving pain. In this study, finite element models were used to examine the mechanical effects of sacroplasty. Finite element models were constructed from CT images of cadavers on which sacroplasties were performed. The images were used to create the mesh geometry, and to apply non-homogeneous material properties to the models. Models were created with homogeneous and non-homogeneous material properties, normal and osteoporotic bone, and with and without cement. The results indicate that the sacrum has a 3D multi-axial state of strain. While compressive strains were the largest, tensile and shear strains were significant as well. It was found that a homogeneous model can account for around 80% of the variation in strain seen in a non-homogeneous model. Thus, while homogeneous models provide a reasonable estimate of strains, non-homogeneous material properties have a significant effect in modeling bone. A reduction in bone density simulating osteoporosis increased strains nearly linearly, even with non-homogeneous material properties. Thus, the non-homogeneity was modeled similarly in both density cases. Cement in the sacrum reduced strains 40-60% locally around the cement. However, overall model stiffness only increased 1-4%. This indicates that the effects of sacroplasty are primarily local. / Master of Science

O cimento ósseo, utilizado para a fixação de componentes protéticos nas cirurgias de substituição articular, mais resistente às forças de compressão do que às forças de tração, tem suas propriedades mecânicas alteradas por vários fatores entre esses a formulação comercial e o método de preparação empregado. É o objetivo deste trabalho avaliar comparativamente as propriedades mecânicas à compressão de duas formulações comerciais de cimento ósseo preparadas manualmente e a vácuo, segundo as instruções do fabricante. Um conjunto de moldagem confeccionado em aço inoxidável permitiu preparar 48 corpos de prova para cada grupo experimental, totalizando 192 corpos de prova, que foram testados na Máquina Universal de Ensaios, tendo as especificações baseadas nas normas ISO 5833 e ASTM F451-86. A elaboração do diagrama tensão x deformação de cada grupo experimental analisou as propriedades mecânicas do cimento ósseo quanto ao módulo de elasticidade, tensão e deformação no limite de proporcionalidade, entre grupos de mesma formulação comercial e entre os grupos com mesmo método de mistura. Analisados estatisticamente pelo método de Variança de Kruskal-Wallis (p ≤0,001) e pelo método de Dunn's (p ≤0,05). Quanto ao módulo de elasticidade, o grupo 2M foi o que apresentou maior módulo, 1563 MPa, valor estatisticamente significante (p ≤ 0,05) em relação aos grupos 1M, 1V e 2V. Para a tensão no limite de proporcionalidade os grupos 1M (39,40 MPa) e 2V (39,65 MPa) foram os maiores valores de tensão no limite de proporcionalidade, não havendo diferença estatisticamente significante entre eles, mas essas diferenças foram significativas quando comparadas aos grupos 1V e 2M. A deformação no limite de proporcionalidade de maior valor percentual foi para o grupo 1M, 3,36%, sendo esta diferença estatisticamente significante quando comparado ao grupo 2M. Os testes de resistência à compressão do cimento nacionalizado e importado, preparados manualmente e a vácuo, mostraram não haver diferença importante entre os dois tipos de cimento ósseo, nem entre as duas formas de misturá-los. / The bone cement used for the fixation of the prosthetic components in the surgeries of joint replacement, more resistant to the compression than to the traction, has its mechanical properties altered by several factors among those the commercial formulation and preparation employee's method. It is the objective of this work to evaluate the mechanical properties to the compression of the two commercial formulas of bone cement manually prepared and using vacuum, according to the manufacturer's instructions. A molding set was made in stainless steel and it allowed for the preparation of 48 bodies of proof for each experimental group, adding up to 192 proof bodies total which were tested in the Universal Rehearsal Machine, with the specifications based on the ISO 5833 and the ASTM F451-86 regulations. The elaboration of the diagram "tension vs. deformation" of each of the experimental group analyzed the mechanical properties of the bone cement in relation to the elasticity module, tension and deformation on the proportional limit among the groups with the same commercial formula and among the groups with the same mixture method. Analyzed statistically, by Kruskal-Wallis's method of the variation (p ≤0.001) and by the Dunn’s method (p ≤0.05). Regarding the elasticity, the group 2M was the one with the highest module, 1563 MPa, a statistically significant value (p ≤0.05) in relation to the groups 1M, 1V and 2V to the tension at the limit of the proportionality, there is no significant differences among them, but these differences were relevant when compared to groups 1V and 2M. The deformation at the limit of the proportionality of the highest percentage was to group 1M, 3.36%, being this the relevant statistical difference when compared to group 2M. The resistance tests to the compression of the national and international cement prepared manually and by vacuum show that there is no important difference between the two kind of bone cement, and neither between the two ways of mixing them.

Introdução: O tratamento dos tumores ósseos benignos é frequentemente realizado por abordagem intralesional com curetagem do tumor e preenchimento da falha óssea com substâncias biológicas ou sintéticas. Entre as biológicas estão os vários tipos de enxertos e o maior representante das sintéticas é o cimento ósseo ou polimetilmetacrilato (PMMA). O uso do cimento ósseo compacto pode apresentar problemas devido à necrose térmica, ao afrouxamento asséptico, à incapacidade de remodelação e à elasticidade inadequada em relação ao osso normal. O desenvolvimento de um cimento ósseo esponjoso que atenda a estas demandas mecânicas e biológicas e que seja de fácil manipulação no ambiente cirúrgico tem estimulado alguns pesquisadores. Basicamente, é possível formar poros no interior do cimento por mistura de substâncias hidrossolúveis ou por reação química produtora de gás. Objetivo: Desenvolver e caracterizar fisicamente e mecanicamente um cimento ósseo com poros intercomunicantes de aspecto estrutural esponjoso. Material e métodos: A produção de cimento esponjoso foi realizada misturando-se o PMMA com bicarbonato de sódio e ácido cítrico. Foram confeccionados 90 corpos de prova com 40 mm de altura por 20 mm de diâmetro distribuídos em 6 grupos (n=15): G1 formado por cimento esponjoso em que antes da polimerização do cimento foram adicionados bicarbonato de sódio e ácido cítrico na proporção de 10% em relação ao componente sólido do cimento (polímero); G2 - cimento esponjoso na proporção de 20%; G3 - cimento esponjoso na proporção de 30%; G4 - cimento ósseo de PMMA compacto; G5 - formado por cimento de poliuretana de mamona (Bioósteo®) na proporção de 20%; G6 formado de corpos de prova cilíndricos de osso esponjoso extraído com trefina de côndilos tibiais proximais de bovinos. A qualidade do cimento esponjoso foi avaliada por macroscopia, cálculo de densidade, imersão em azul de metileno, tomografia computadorizada, microscopia eletrônica de varredura e ensaio mecânico de compressão. Resultados: A melhor forma de produção de cimento esponjoso foi pela mistura de PMMA e componentes efervescentes. O teste da imersão em azul de metileno mostrou que os G2 e G3 apresentaram melhor intercomunicabilidade. As análises com o microscópio eletrônico de varredura (MEV) mostraram uma ampla variação no tamanho e distribuição dos poros que medem de 50m a 3mm. Em relação aos ensaios mecânicos não houve diferenças significativas entres os grupos de cimento esponjoso G1, G2 e G3. Estes grupos apresentaram valores pouco inferiores aos do grupo G6 de osso esponjoso bovino. O grupo G4 (PMMA compacto) apresentou valores extremamente altos quando comparado ao osso esponjoso bovino e ao cimento esponjoso. O grupo G5 de cimento ósseo de mamona não atingiu os valores aceitáveis de resistência mecânica. Conclusão: Foi possível desenvolver um cimento esponjoso à base de polimetilmetacrilato pela mistura com os aditivos efervescentes, bicarbonato de sódio e ácido cítrico, que apresenta características físicas e mecânicas desejadas como substituto ósseo esponjoso nas curetagens para tratamento de tumores ósseos benignos. O cimento de mamona esponjoso na forma testada mostrou-se inadequado para os fins pretendidos. / Introduction: Benign bone tumors are usually treated by intralesional curettage. The bone defect may be filled with synthetic or biological substitutes. Polymetylmethacrylate (PMMA) is the most popular synthetic substitute and the solid form is associated to thermal necrosis, aseptic loosening, bone remodeling prevention and distinct elasticity. Research of porous cement that solves these drawbacks and can be molded intraoperatively has encouraged many authors. For surgical purposes, porosity can be achieved by mixing hydrosoluble substances or by gas-foaming reactions. Objective: Development and physical and mechanical characterization of a bone cement with interconnecting pores and cancellous bone like structural aspect. Methods: Porous cement was produced by adding the effervescent components sodium bicarbonate and citric acid to PMMA. Six groups of fifteen cylindrical samples (40 mm height, 20 mm diameter) were compared. G1, G2 and G3 groups consisted of porous cement specimens of PMMA with 10%, 20% and 30% of effervescent components respectively. G4 consisted of solid PMMA cement specimens. G5 group consisted of porous ricinic polyurethane cement (Bioósteo®) with 20% effervescent components specimens. The control group G6 consisted of bovine cancellous bone samples. The porous cements were characterized in terms of porosity, density, pore interconnectivity and compressive strength. Macroscopic evaluation and measuring, methylene blue immersion, Scanning Electron Microscopy (SEM), mechanical testing and a special computed tomography reading software were employed for these evaluations. Results: The pilot study showed that adding effervescent components to PMMA was the best solution for porous cement production. The methylene blue immersion test showed that G2 and G3 groups had better pore interconnection. Scanning electron microscopy (SEM) showed a wide variation in pore size, from 50m to 3mm, and pore distribution. No significant differences between G1, G2 and G3porous cement groups were found regarding to mechanical strength and Young Modulus. Cancellous bovine bone, G6, was slightly stronger and less elastic than these groups. This property is potentially beneficial considering osteointegration as a consequence of Wolfs law. Solid PMMA is extremely strength and inelastic. These properties do not match with cancellous bone. The porous ricinic polyurethane cement (Bioósteo®) is unacceptably weak. Conclusion: Porous cement was developed by adding effervescent components, sodium bicarbonate and citric acid, to polymethylmetacrylate. Physical and mechanical properties are very similar to cancellous bone. Further investigations to evaluate its bone substitute potential should be encouraged. The porous ricinic polyurethane cement (Bioósteo®) is inadequate these purpose.