title: In vitro stability of FRA spacers with integrated crossed screws for anterior lumbar interbody fusion.
abstract: METHODS
  Mechanical testing of human lumbar functional spine units was carried out after instrumenting the disc space with femoral ring allografts (FRAs) with and without integrated crossed anterior screws applied into the adjacent bodies.
  
  
  OBJECTIVE
  To assess the stability of FRA construct with and without the integrated crossed anterior screws and to compare that with the intact specimen.
  
  
  BACKGROUND
  Most modern methods of achieving anterior lumbar intervertebral fusion rely on the use of interbody spacers to restore and maintain intervertebral height, overall alignment, and stability while facilitating arthrodesis. The FRAs have the advantage of biologic compatibility but may not have enough stability when used as stand-alone devices. FRA spacers alone are less stiff in torsion and extension compared with other instrumented constructs. Increased motion could lead to higher failure rates because of graft migration and pseudarthrosis. This makes the use of supplementary anterior or posterior fixation necessary. The current authors hypothesized that the addition of anterior integrated crossed screws applied through the FRA spacer into the adjacent vertebral bodies would increase the stability of the FRA spacer in extension and torsion in the absence of further posterior instrumentation.
  
  
  METHODS
  Seven fresh-frozen human cadaveric lumbar spine functional spine units were tested applying cantilever bending moments in flexion, lateral bending, torsion, and extension. The specimens were tested in the following sequence: intact, with FRA spacer alone and with FRA spacer and integrated crossed screws. The stiffness of each construct was then compared with the intact specimen. Specimens with obvious deformity on radiographs or dual-energy radiograph absorptiometry t score values <-1.2 were excluded.
  
  
  RESULTS
  The addition of the integrated crossed metal screw system improved the stiffness of the construct by 53% over the intact (P = 0.02) and by 31% over the FRA alone in extension (P = 0.01), whereas it improved the stiffness by 40% over the intact (P = 0.03) and by 18% over the FRA alone in torsion (P = 0.21). The crossed screw system did not improve the stiffness compared with intact in either flexion or lateral bending modes.
  
  
  CONCLUSIONS
  Although there is a trend toward improved stability of the FRA spacers in torsion with the addition of the metal screws, this is not statistically significant. The integrated crossed anterior metal screw system significantly improves the stability of the FRA spacers in extension when used for anterior lumbar interbody fusion.
authors.affiliation: Department of Spine Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
authors.forename: Ranjith R
authors.initials: RR
authors.lastname: Kuzhupilly
authors.forename: Isador H
authors.initials: IH
authors.lastname: Lieberman
authors.forename: Robert F
authors.initials: RF
authors.lastname: McLain
authors.forename: Antonio
authors.initials: A
authors.lastname: Valdevit
authors.forename: Helen
authors.initials: H
authors.lastname: Kambic
authors.forename: Bradford J
authors.initials: BJ
authors.lastname: Richmond
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001696:Biomechanical Phenomena; D001863:Bone Screws / Q000592:standards / Q000706:statistics & numerical data; D002102:Cadaver; D004548:Elasticity; D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery*; D008875:Middle Aged; D019736:Prostheses and Implants / Q000592:standards* / Q000706:statistics & numerical data*; D013123:Spinal Fusion / Q000295:instrumentation* / Q000379:methods*; D013314:Stress, Mechanical; D014102:Torsion Abnormality