Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Symposium: Biomechanics of Bone Healing 11 articles


The Effects of Loading on Cancellous Bone in the Rabbit

Marjolein C. H. van der Meulen PhD, Xu Yang MD, Timothy G. Morgan PhD, Mathias P. G. Bostrom MD Mechanical stimuli are critical to the growth, maintenance, and repair of the skeleton. The adaptation of bone to mechanical forces has primarily been studied in cortical bone. As a result, the mechanisms of bone adaptation to mechanical forces are not well-understood in cancellous bone. Clinically, however, diseases such as osteoporosis primarily affect cancellous tissue and mechanical solutions could counteract cancellous bone loss. We previously developed an in vivo model in the rabbit to study cancellous functional adaptation by applying well-controlled mechanical loads to cancellous sites. In the rabbit, in vivo loading of the lateral aspect of the distal femoral condyle simulated the in vivo bone-implant environment and enhanced bone mass. Using animal-specific computational models and further in vivo experiments we demonstrate here that the number of loading cycles and loading duration modulate the cancellous response by increasing bone volume fraction and thickening trabeculae to reduce the strains experienced in the bone tissue with loading and stiffen the tissue in the loading direction.

Type of Hip Fracture Determines Load Share in Intramedullary Osteosynthesis

Sebastian Eberle MS, Claus Gerber MS, Geert Oldenburg MS, Sven Hungerer MD, Peter Augat PhD The choice of the appropriate implant continues to be critical for fixation of unstable hip fractures. Therefore, the goal of this study was to develop a numerical model to investigate the mechanical performance of hip fracture osteosynthesis. We hypothesized that decreasing fracture stability results in increasing load share of the implant and therefore higher stress within the implant. We also investigated the relationship of interfragmentary movement to the fracture stability. A finite element model was developed for a cephalomedullary nail within a synthetic femur and simulated a pertrochanteric fracture, a lateral neck fracture, and a subtrochanteric fracture. The femur was loaded with a hip force and was constrained physiologically. The FE model was validated by mechanical experiments. All three fractures resulted in similar values for stiffness (462–528 N/mm). The subtrochanteric fracture resulted in the highest local stress (665 MPa), and the pertrochanteric fracture resulted in a lower stress (621 MPa) with even lower values for the lateral neck fracture (480 MPa). Thus, intramedullary implants can stabilize unstable hip fractures with almost the same amount of stiffness as seen in stable fractures, but they have to bear a higher load share, resulting in higher stresses in the implant.

Measurement of the Mechanical Properties of Bone: A Recent History

John Currey DPhil Much progress has been made in the last 50 years in our understanding of bone’s mechanical properties, and the reasons it has these properties and not others. The question is to what extent these advances have arisen from an increase in the techniques available for the study of bone, and how much stems from an increased understanding of the basic processes involved. Although considerable enlightenment has come from the transfer of ideas from the physical sciences, in particular materials science, the author argues that most increases have come from the vastly increased power and resolution of the observational and mechanical techniques available. Even so, the remarkably hierarchical nature of bone’s structure makes it an almost uniquely difficult material to understand properly, and much remains to be done to marry explanations at the macro-, micro- and nanolevels to obtain a full understanding of bone mechanics.

Parecoxib and Indomethacin Delay Early Fracture Healing: A Study in Rats

Sigbjorn Dimmen MD, Lars Nordsletten MD, PhD, Jan Erik Madsen MD, PhD Nonsteroidal antiinflammatory drugs (NSAIDs) are used to reduce inflammatory response and pain. These drugs have been reported to impair bone metabolism. Parecoxib, a specific COX-2 inhibitor, exerts an inhibitory effect on the mineralization of fracture callus after a tibial fracture in rats. Decreased bone mineral density (BMD) at a fracture site may indicate impairment of early healing, casting doubt on the safety of using COX-2 inhibitors during the early treatment of diaphyseal fractures. Forty-two female Wistar rats were randomly allocated to three groups. They were given parecoxib, indomethacin, or saline intraperitoneally for 7 days after being subjected to a closed tibial fracture stabilized with an intramedullary nail. Two and 3 weeks after surgery, the bone density at the fracture site was measured using dual energy xray absorptiometry (DEXA). Three weeks after the operation the rats were euthanized and the healing fractures were mechanically tested in three-point cantilever bending. Parecoxib decreased BMD at the fracture site for 3 weeks after fracture, indomethacin for 2 weeks. Both parecoxib and indomethacin reduced the ultimate bending moment and the bending stiffness of the healing fractures after 3 weeks. These results suggest COX inhibitors should be avoided in the early phase after fractures.

Quantification of Fracture Healing from Radiographs Using the Maximum Callus Index

S. J. Eastaugh-Waring MB, ChB, FRCS, C. C. Joslin MB, ChB, FRCS, J. R. W. Hardy MD, FRCS, J. L. Cunningham PhD Callus formation and growth are an essential part of secondary fracture healing. Callus growth can be observed radiographically and measured using the “Callus Index,” which is defined as the maximum diameter of the callus divided by the diameter of the bone. We compared three groups of patients with tibial fractures treated by external fixation, intramedullary nailing, and casting to assess the validity of using serial measurements of callus index as a measure of fracture healing. When callus index was plotted against time for each patient, the point at which the fracture began to remodel, indicated by the highest point of the curve, was observed as a consistent feature regardless of fixation method. This occurred on average at 2½ weeks after plaster cast removal (14 weeks post injury), 5 weeks after external fixator removal (22 weeks post injury), and 27 weeks post injury for the intramedullary nailed fractures. Because remodeling only occurs once the fracture is stable, a peak in callus index is a reliable sign that the fracture has united. Serial measurements of callus index would therefore appear to offer a simple method of quantifying secondary fracture healing regardless of the treatment method used.,[object Object]

Ability and Limitation of Radiographic Assessment of Fracture Healing in Rats

Yoshinobu Watanabe MD, PhD, Yu Nishizawa MD, Nobuyuki Takenaka MD, PhD, Makoto Kobayashi MD, PhD, Takashi Matsushita MD, DMsc [object Object]

Monitoring the Mechanical Properties of Healing Bone

L. E. Claes PhD, J. L. Cunningham PhD Fracture healing is normally assessed through an interpretation of radiographs, clinical evaluation, including pain on weight bearing, and a manual assessment of the mobility of the fracture. These assessments are subjective and their accuracy in determining when a fracture has healed has been questioned. Viewed in mechanical terms, fracture healing represents a steady increase in strength and stiffness of a broken bone and it is only when these values are sufficiently high to support unrestricted weight bearing that a fracture can be said to be healed. Information on the rate of increase of the mechanical properties of a healing bone is therefore valuable in determining both the rate at which a fracture will heal and in helping to define an objective and measurable endpoint of healing. A number of techniques have been developed to quantify bone healing in mechanical terms and these are described and discussed in detail. Clinical studies, in which measurements of fracture stiffness have been used to identify a quantifiable end point of healing, compare different treatment methods, predictably determine whether a fracture will heal, and identify factors which most influence healing, are reviewed and discussed.

Trabecular Bone Mechanical Properties in Patients with Fragility Fractures

Jaclynn M. Kreider MS, Steven A. Goldstein PhD Fragility fractures are generally associated with substantial loss in trabecular bone mass and alterations in structural anisotropy. Despite the high correlations between measures of trabecular mass and mechanical properties, significant overlap in density measures exists between individuals with osteoporosis and those who do not fracture. The purpose of this paper is to provide an analysis of trabecular properties associated with fragility fractures. While accurate measures of bone mass and 3-D orientation have been demonstrated to explain 80% to 90% of the variance in mechanical behavior, clinical and experimental experience suggests the unexplained proportion of variance may be a key determinant in separating high- and low-risk patients. Using a hierarchical perspective, we demonstrate the potential contributions of structural and tissue morphology, material properties, and chemical composition to the apparent mechanical properties of trabecular bone. The results suggest that the propensity for an individual to remodel or adapt to habitual damaging or nondamaging loads may distinguish them in terms of risk for failure.