A biomechanical investigation of dual growing rods used for fusionless scoliosis correction

Background The use of dual growing rods is a fusionless surgical approach to the treatment of early onset scoliosis (EOS), which aims of harness potential growth in order to correct spinal deformity. The purpose of this study was to compare the in-vitro biomechanical response of two different dual rod designs under axial rotation loading. Methods Six porcine spines were dissected into seven level thoracolumbar multi-segmental units. Each specimen was mounted and tested in a biaxial Instron machine, undergoing nondestructive left/right axial rotation to peak moments of 4Nm at a constant rotation rate of 8deg.s-1. A motion tracking system (Optotrak) measured 3D displacements of individual vertebrae. Each spine was tested in an un-instrumented state first and then with appropriately sized semi-constrained growing rods and ‘rigid’ rods in alternating sequence. Range of motion, neutral zone size and stiffness were calculated from the moment-rotation curves and intervertebral ranges of motion were calculated from Optotrak data. Findings Irrespective of test sequence, rigid rods showed significantly reduction of total rotation across all instrumented levels (with increased stiffness) whilst semi-constrained rods exhibited similar rotation behavior to the un-instrumented (P<0.05). An 11% and 8% increase in stiffness for left and right axial rotation respectively and 15% reduction in total range of motion was recorded with dual rigid rods compared with semi-constrained rods. Interpretation Based on these findings, the semi-constrained growing rods do not increase axial rotation stiffness compared with un-instrumented spines. This is thought to provide a more physiological environment for the growing spine compared to dual rigid rod constructs.

A biomechanical analysis of growing rods used in the management of early onset scoliosis (EOS)

The use of dual growing rods is a fusionless surgical approach to the treatment of early onset scoliosis (EOS) which aims to harness potential growth in order to correct spinal deformity. This study compared through in-vitro experiments the biomechanical response of two different rod designs under axial rotation loading. The study showed that a new design of telescoping growing rod preserved the rotational flexibility of the spine in comparison with rigid rods indicating them to be a more physiological way to improve the spinal deformity.

A biomechanical analysis of growing rods used in the management of early onset scoliosis

INTRODUCTION Managing spinal deformities in young children is challenging, particularly early onset scoliosis (EOS). Surgical intervention is often required if EOS has been unresponsive to conservative treatment particularly with rapidly progressive curves. An emerging treatment option for EOS is fusionless scoliosis surgery. Similar to bracing, this surgical option potentially harnesses growth, motion and function of the spine along with correcting spinal deformity. Dual growing rods are one such fusionless treatment, which aims to modulate growth of the vertebrae. The aim of this study was to ascertain the extent to which semiconstrained growing rods (Medtronic, Sofamor, Danek, Memphis, TN) with a telescopic sleeve component, reduce rotational constraint on the spine compared with standard "constrained / rigid" rods and hence potentially provide a more physiological mechanical environment for the growing spine. METHODS Six 40-60kg English Large White porcine spines served as a model for the paediatric human spine. Each spine was dissected into a 7 level thoracolumbar multi-segment unit (MSU), removing all non-ligamentous soft tissues and leaving 3cm of ribs either side. Pure nondestructive axial rotation moments of ±4Nm at a constant rotation rate of 8deg.s-1 were applied to the mounted MSU spines using a biaxial Instron testing machine. Displacement of each vertebral level was captured using a 3D motion tracking system (Optotrak 3020, Northern Digital Inc, Waterloo, ON). Each spine was tested in an un-instrumented state first and then with appropriately sized semi-constrained growing rods and rigid rods in alternating sequence. The rods were secured by multi-axial pedicle screws (Medtronic CD Horizon) at levels 2 and 6 of the construct. The range of motion (ROM), neutral zone (NZ) size and stiffness (Nm.deg-1) were calculated from the Instron load-displacement data and intervertebral ROM was calculated through a MATLAB algorithm from Optotrak data. RESULTS Irrespective of the order of testing, rigid rods significantly reduced the total ROM compared with semi-constrained rods (p<0.05) with in a significantly stiffer spine for both left and right axial rotation (p<0.05). Analysing the intervertebral motion within the instrumented levels 2-6, rigid rods showed reduced ROM compared with semi-constrained growing rods and compared with un-instrumented motion segments. CONCLUSION Semi-constrained growing rods maintain similar stiffness in axial rotation to un-instrumented spines, while dual rigid rods significantly reduce axial rotation. Clinically the effect of semi-constrained growing rods as observed in this study is that they would be expected to allow growth via the telescopic rod components while maintaining the axial flexibility of the spine, which may reduce occurrence of the crankshaft phenomenon.

A biomechanical analysis of growing rods used in the management of early onset scoliosis

INTRODUCTION Managing spinal deformities in young children is challenging, particularly early-onset scoliosis (EOS). Any progressive spinal deformity particularly in early life presents significant health risks for the child and a challenge for the treating surgeon. Surgical intervention is often required if EOS has been unresponsive to conservative treatment particularly with rapidly progressive curves. An emerging treatment option particularly for EOS is fusionless scoliosis surgery. Similar to bracing this surgical option potentially harnesses growth, motion and function of the spine along with correcting spinal deformity. Dual growing rods is one such fusionless treatment, which aims to modulate growth of the vertebrae. The aim of this study was to ascertain the extent to which semi-constrained growing rods (Medtronic, Memphis, TN) with a telescopic sleeve component, reduce rotational constraint on the spine compared with standard rigid rods and hence potentially provide a more physiological mechanical environment for the growing spine. METHODS Six 40-60kg English Large White porcine spines served as a model for the paediatric human spine. Each spine was dissected into 7 level thoracolumbar multi-segment unit (MSU) spines, removing all non-ligamentous soft tissues. Appropriately sized semi-constrained growing rods and rigid rods were secured by multi-axial screws (Medtronic) prior to testing in alternating sequences for each spine. Pure nondestructive moments of +/4Nm at a constant rotation rate of 8deg/s was applied to the mounted MSU spines. Displacement of each level was captured using an Optotrak (Northern Digital Inc, Waterloo, ON). The range of motion (ROM), neutral zone (NZ) size and stiffness (Nm/deg) were calculated from the Instron load-displacement data and intervertebral ROM was calculated through a MATLAB algorithm from Optotrak data. RESULTS Irrespective of sequence order rigid rods significantly reduced the total ROM (deg) than compared to semi-constrained rods (p<0.05) and resulted in a significantly stiffer (Nm/deg) spine for both left and right axial rotation testing (p<0.05). Analysing the intervertebral motion within the instrumented levels, rigid rods showed reduced ROM (Deg) than compared to semi-constrained growing rods and the un-instrumented (UN-IN) test sequences. CONCLUSION The semi-constrained growing rods maintained rotation similar to UN-IN spines while the rigid rods showed significantly reduced axial rotation across all instrumented levels. Clinically the effect of semi-constrained growing rods evaluated in this study is that they will allow growth via the telescopic rod components while maintaining the axial rotation ability of the spine, which may also reduce the occurrence of the crankshaft phenomenon.

Percutaneous insertion of Dual Growth Rods using a new mobile bearing implant

Growth rods are commonly used for the treatment of scoliosis in the immature spine. Many variations have been proposed but breakage of implants is a common problem. Growth rod insertion commonly involves large exposures at initial insertion followed by multiple smaller procedures for lengthening. We present our early experiences using a percutaneous technique of insertion of a new titanium mobile bearing implant (Medtronic Inc). The implant allows some rotatory motion in the middle of the construct thus reducing construct stresses and thus possibly reducing rod breakage risk. Based on this small initial series with 12 months follow-up, percutaneous insertion of growth rods using the new implant is a safe and reliable technique although the infection rate in our sample was of note. This may be related to the titanium wear and inflammation seen in the soft tissues at time of operation and visualised on histology. No implants have required removal due to infection, and all infections were treated with debridement at next lengthening and suppressive antibiotics. Propionibacterium is one of the commonest infections seen with spinal implants and sometimes does not respond to simple antibiotic suppression. The technique allows preservation of the soft tissues until definitive fusion is needed and may lead to a decrease in hospital stay. The implant is low profile and seems to offer advantages over other systems on the market. Further follow up is needed to look at longer term outcomes with this new implant type.

Growing rod analysis for the fusionless correction of early onset scoliosis (EOS)

Managing spinal deformities in young children is challenging, particularly early onset scoliosis (EOS). Surgical intervention is often required if EOS has been unresponsive to conservative treatment particularly with rapidly progressive curves. An emerging treatment option for EOS is fusionless scoliosis surgery. Similar to bracing, this surgical option potentially harnesses growth, motion and function of the spine along with correcting spinal deformity. Dual growing rods are one such fusionless treatment, which aims to modulate growth of the vertebrae. The aim of this study was to ascertain the extent to which semi-constrained growing rods (Medtronic Sofamor Danek Memphis, TN, USA) with a telescopic sleeve component, reduce rotational constraint on the spine compared with standard rigid rods and hence potentially provide a more physiological mechanical environment for the growing spine. This study found that semi-constrained growing rods would be expected to allow growth via the telescopic rod components while maintaining the axial flexibility of the spine and the improved capacity for final correction.

Paediatric spinal deformity research at the Mater Children's Hospital, Brisbane, Australia.

The Paediatric Spine Research group was formed in 2002 to perform high quality research into the prevention and management of spinal deformity, with an emphasis on scoliosis. The group has successfully built collaborative bridges between the scientific and research expertise at QUT, and the clinical skills and experience of the spinal orthopaedic surgeons at the Mater Children’s Hospital in Brisbane. Clinical and biomechanical research is now possible as a result of the development of detailed databases of patients who have innovative and unique surgical interventions for spinal deformity such as thoracoscopic scoliosis correction, thoracoscopic staple insertion for juvenile idiopathic scoliosis and minimally invasive growing rods. The Mater in Brisbane provides these unique datasets of spinal deformity surgery patients, whose procedures are not being performed anywhere else in the Southern Hemisphere. The most detailed is a database of thoracoscopic scoliosis correction surgery which now contains 180 patients with electronic collections of X-Rays, photographs and patient questionnaires. With ethics approval, a subset of these patients has had CT scans, and a further subset have had MRI scans with and without a compressive load to simulate the erect standing position. This database has to date contributed to 17 international refereed journal papers, a further 7 journal papers either under review or in final preparation, 53 national conference presentations and 35 international conference presentations. Major findings from selected journal publications will be presented. It is anticipated that as the surgical databases grow they will continue to provide invaluable clinical data which will feed into clinically relevant projects driven by both medical and engineering researchers whose findings will benefit spinal deformity patients and scientific knowledge worldwide.

Metamorphosis of human lumbar vertebrae induced by VEPTR growth modulation and stress shielding

INTRODUCTION Distraction-based spinal growth modulation by growing rods or vertical expandable prosthetic titanium ribs (VEPTRs) is the mainstay of instrumented operative strategies to correct early onset spinal deformities. In order to objectify the benefits, it has become common sense to measure the gain in spine height by assessing T1-S1 distance on anteroposterior (AP) radiographs. However, by ignoring growth changes on vertebral levels and by limiting measurement to one plane, valuable data is missed regarding the three-dimensional (3D) effects of growth modulation. This information might be interesting when it comes to final fusion or, even more so, when the protective growing implants are removed and the spine re-exposed to physiologic forces at the end of growth. METHODS The goal of this retrospective radiographic study was to assess the growth modulating impact of year-long, distraction-based VEPTR treatment on the morphology of single vertebral bodies. We digitally measured lumbar vertebral body height (VBH) and upper endplate depth (VBD) at the time of the index procedure and at follow-up in nine patients with rib-to-ileum constructs (G1) spanning an anatomically normal lumbar spine. Nine patients with congenital thoracic scoliosis and VEPTR rib-to-rib constructs, but uninstrumented lumbar spines, served as controls (G2). All had undergone more than eight half-yearly VEPTR expansions. A Wilcoxon signed-rank test was used for statistical comparison of initial and follow-up VBH, VBD and height/depth (H/D) ratio (significance level 0.05). RESULTS The average age was 7.1 years (G1) and 5.2 year (G2, p > 0.05) at initial surgery; the average overall follow-up time was 5.5 years (p = 1). In both groups, VBH increased significantly without a significant intergroup difference. Group 1 did not show significant growth in depth, whereas VBD increased significantly in the control group. As a consequence, the H/D ratio increased significantly in group 1 whereas it remained unchanged in group 2. The growth rate for height in mm/year was 1.4 (group 1) and 1.1 (group 2, p = 0.45), and for depth, it was -0.3 and 1.1 (p < 0.05), respectively. CONCLUSIONS VEPTR growth modulating treatment alters the geometry of vertebral bodies by increasing the H/D ratio. We hypothesize that the implant-related deprivation from axial loads (stress-shielding) impairs anteroposterior growth. The biomechanical consequence of such slender vertebrae when exposed to unprotected loads in case of definitive VEPTR removal at the end of growth is uncertain.

Wavelength/Time orthogonal codes with FEC offer dual advantage

To meet the growing demands of the high data rate applications, suitable asynchronous schemes such as Fiber-Optic Code Division Multiple Access (FO-CDMA) are required in the last mile. FO-CDMA scheme offers potential benefits and at the same time it faces many challenges. Wavelength/Time (W/T) 2-D codes for use in FO-CDMA, can be classified mainly into two types: 1) hybrid codes and 2) matrix codes, to reduce the 'time' like property, have been proposed. W/T single-pulse-per-row (SPR) are energy efficient codes as this family of codes have autocorrelation sidelobes of '0', which is unique to this family and the important feature of the W/T multiple-pulses-per-row (MPR) codes is that the aspect ratio can be varied by trade off between wavelength and temporal lengths. These W/T codes have improved cardinality and spectral efficiency over other W/T codes and at the same time have lowest crosscorrelation values. In this paper, we analyze the performances of the FO-CDMA networks using W/T SPR codes and W/T MPR codes, with and without forward error correction (FEC) coding and show that with FEC there is dual advantage of error correction and reduced spread sequence length.

High-strain composites and dual-matrix composite structures

Most space applications require deployable structures due to the limiting size of current launch vehicles. Specifically, payloads in nanosatellites such as CubeSats require very high compaction ratios due to the very limited space available in this typo of platform. Strain-energy-storing deployable structures can be suitable for these applications, but the curvature to which these structures can be folded is limited to the elastic range. Thanks to fiber microbuckling, high-strain composite materials can be folded into much higher curvatures without showing significant damage, which makes them suitable for very high compaction deployable structure applications. However, in applications that require carrying loads in compression, fiber microbuckling also dominates the strength of the material. A good understanding of the strength in compression of high-strain composites is then needed to determine how suitable they are for this type of application.

The goal of this thesis is to investigate, experimentally and numerically, the microbuckling in compression of high-strain composites. Particularly, the behavior in compression of unidirectional carbon fiber reinforced silicone rods (CFRS) is studied. Experimental testing of the compression failure of CFRS rods showed a higher strength in compression than the strength estimated by analytical models, which is unusual in standard polymer composites. This effect, first discovered in the present research, was attributed to the variation in random carbon fiber angles respect to the nominal direction. This is an important effect, as it implies that microbuckling strength might be increased by controlling the fiber angles. With a higher microbuckling strength, high-strain materials could carry loads in compression without reaching microbuckling and therefore be suitable for several space applications.

A finite element model was developed to predict the homogenized stiffness of the CFRS, and the homogenization results were used in another finite element model that simulated a homogenized rod under axial compression. A statistical representation of the fiber angles was implemented in the model. The presence of fiber angles increased the longitudinal shear stiffness of the material, resulting in a higher strength in compression. The simulations showed a large increase of the strength in compression for lower values of the standard deviation of the fiber angle, and a slight decrease of strength in compression for lower values of the mean fiber angle. The strength observed in the experiments was achieved with the minimum local angle standard deviation observed in the CFRS rods, whereas the shear stiffness measured in torsion tests was achieved with the overall fiber angle distribution observed in the CFRS rods.

High strain composites exhibit good bending capabilities, but they tend to be soft out-of-plane. To achieve a higher out-of-plane stiffness, the concept of dual-matrix composites is introduced. Dual-matrix composites are foldable composites which are soft in the crease regions and stiff elsewhere. Previous attempts to fabricate continuous dual-matrix fiber composite shells had limited performance due to excessive resin flow and matrix mixing. An alternative method, presented in this thesis uses UV-cure silicone and fiberglass to avoid these problems. Preliminary experiments on the effect of folding on the out-of-plane stiffness are presented. An application to a conical log-periodic antenna for CubeSats is proposed, using origami-inspired stowing schemes, that allow a conical dual-matrix composite shell to reach very high compaction ratios.

Coherent Control of High Harmonic Generation via Dual-Gas Multijet Arrays

High harmonic generation (HHG) is a central driver of the rapidly growing field of ultrafast science. We present a novel quasiphase-matching (QPM) concept with a dual-gas multijet target leading, for the first time, to remarkable phase control between multiple HHG sources (> 2) within the Rayleigh range. The alternating jet structure with driving and matching zones shows perfect coherent buildup for up to six QPM periods. Although not in the focus of the proof-of-principle studies presented here, we achieved competitive conversion efficiencies already in this early stage of development.

Studies on the dual in Mycenaean, in the Homeric poetry and in the Attic Theatre of the 5th century — morphological, dialectal and stylistical variations

The present dissertation focuses on the dual number in Ancient Greek in a diachronical lapse stretching from the Mycenaean age to the Attic Drama and Comedy of the 5th century BC. In the first chapter morphological issues are addressed, chiefly in a comparative perspective. The Indo European evidence on the dual is hence gathered in order to sketch patterns of grammaticalisation and paradigmatisation of specific grams, growing increasingly functional within the Greek domain. In the second chapter syntactical problems are tackled. After a survey of scholarly literature on the Greek dual, we engage in a functional and typological approach, in order to disentangle some biased assessments on the dual, namely its alleged lack of regularity and intermittent agreement. Some recent frameworks in General Linguistics provide useful grounds for casting new light on the subject. Internal Reconstruction, for instance, supports the facultativity of the dual in each and every stage of its development; Typology and the Animacy Hierarcy add precious cross linguistical insight on the behaviour of the dual toward agreement. Glaring differences also arise as to the adoption — or avoidance — of the dual by different authors. Idiolectal varieties prove in fact conditioned by stylistical and register necessity. By means of a comparison among Epics, Tragedy and Comedy it is possible to enhance differences in the evaluation of the dual, which led sometimes to forms of ‘censure’ — thus triggering the onset of competing strategies to express duality. The last two chapters delve into the tantalising variety of the Homeric evidence, first of all in an account of the notorious issue of the Embassy of Iliad IX, and last in a commentary of all significant Homeric duals — mostly represented by archaisms, formulae, and ad hoc coinages.

Coping with eldercare [microform] : a growing challenge in the workplace : hearing before a subcommittee of the Committee on Government Operations, House of Representatives, One Hundredth Congress, second session, October 28, 1988.

CIS Microfiche Accession Numbers: CIS 89 H401-23

A theoretical analysis of eyewitness identification: Dual -process theory, signal detection theory and eyewitness confidence

Given the growing number of wrongful convictions involving faulty eyewitness evidence and the strong reliance by jurors on eyewitness testimony, researchers have sought to develop safeguards to decrease erroneous identifications. While decades of eyewitness research have led to numerous recommendations for the collection of eyewitness evidence, less is known regarding the psychological processes that govern identification responses. The purpose of the current research was to expand the theoretical knowledge of eyewitness identification decisions by exploring two separate memory theories: signal detection theory and dual-process theory. This was accomplished by examining both system and estimator variables in the context of a novel lineup recognition paradigm. Both theories were also examined in conjunction with confidence to determine whether it might add significantly to the understanding of eyewitness memory. ^ In two separate experiments, both an encoding and a retrieval-based manipulation were chosen to examine the application of theory to eyewitness identification decisions. Dual-process estimates were measured through the use of remember-know judgments (Gardiner & Richardson-Klavehn, 2000). In Experiment 1, the effects of divided attention and lineup presentation format (simultaneous vs. sequential) were examined. In Experiment 2, perceptual distance and lineup response deadline were examined. Overall, the results indicated that discrimination and remember judgments (recollection) were generally affected by variations in encoding quality and response criterion and know judgments (familiarity) were generally affected by variations in retrieval options. Specifically, as encoding quality improved, discrimination ability and judgments of recollection increased; and as the retrieval task became more difficult there was a shift toward lenient choosing and more reliance on familiarity. ^ The application of signal detection theory and dual-process theory in the current experiments produced predictable results on both system and estimator variables. These theories were also compared to measures of general confidence, calibration, and diagnosticity. The application of the additional confidence measures in conjunction with signal detection theory and dual-process theory gave a more in-depth explanation than either theory alone. Therefore, the general conclusion is that eyewitness identifications can be understood in a more complete manor by applying theory and examining confidence. Future directions and policy implications are discussed. ^

Site controlled red-yellow-green light emitting InGaN quantum discs on nano-tipped GaN rods

We report a method of growing site controlled InGaN multiple quantum discs (QDs) at uniform wafer scale on coalescence free ultra-high density (>80%) nanorod templates by metal organic chemical vapour deposition (MOCVD). The dislocation and coalescence free nature of the GaN space filling nanorod arrays eliminates the well-known emission problems seen in InGaN based visible light sources that these types of crystallographic defects cause. Correlative scanning transmission electron microscopy (STEM), energy-dispersive X-ray (EDX) mapping and cathodoluminescence (CL) hyperspectral imaging illustrates the controlled site selection of the red, yellow and green (RYG) emission at these nano tips. This article reveals that the nanorod tips' broad emission in the RYG visible range is in fact achieved by manipulating the InGaN QD's confinement dimensions, rather than significantly increasing the In%. This article details the easily controlled method of manipulating the QDs dimensions producing high crystal quality InGaN without complicated growth conditions needed for strain relaxation and alloy compositional changes seen for bulk planar GaN templates.