The importance of loading the periphery of the vertebral endplate

Commercial fusion cages typically provide support in the central region of the endplate, failing to utilize the increased compressive strength around the periphery. This study demonstrates the increase in compressive strength that can be achieved if the bony periphery of the endplate is loaded.

Sixteen cadaveric lumbar vertebrae (L1-L5) were randomly divided into two even groups. A different commercial mass produced implant (MPI) was allocated to each group: (I) a Polyether-ether-ketone (PEEK) anterior lumber inter-body fusion (ALIF) MPI; and (II) a titanium ALIF MPI. Uniaxial compression at a displacement rate of 0.5 mm/sec was applied to all vertebrae during two phases: (I) with the allocated MPI situated in the central region of the endplate; (II) with an aluminum plate, designed to load the bony periphery of the endplate. The failure load and mode of failure was recorded.

From phase 1 to phase 2, the failure load increased from 1.1±0.4 to 2.9±1.4 kN for group 1; and from 1.3±1.0 to 3.0±1.9 kN for group 2. The increase in strength from phase 1 to phase 2 was statistically significant for each group (group 1: P<0.01, group 2: P<0.05, paired t-test). There was no significant difference between the groups in either phase (P>0.05, t-test). The mode of failure in phase 1 was the implant being forced through the endplate for both groups. In phase 2, the mode of failure was either a fracture of the epiphyseal rim or buckling of the side wall of the vertebral body.

Loading the periphery of the vertebral endplate achieved significant increase in compressive load capacity compared to loading the central region of the endplate. Clinically, this implies that patient-specific implants which load the periphery of the vertebral endplate could decrease the incidence of subsidence and improve surgical outcomes.