Effects of culture conditions on the mechanical and biological properties of engineered cartilage constructed with collagen hybrid scaffold and human mesenchymal stem cells.

Mesenchymal stem cells (MSCs) has been used as one of the new cell sources in osteochondral tissue engineering. It has been well known that control of their differentiation into chondrocytes plays a key role in developing engineered cartilages. Therefore, this study aims to develop a fundamental protocol to control the differentiation and proliferation of MSCs to construct an engineered cartilage. We compared the effects of three different culture conditions on cell proliferation, extracellular matrix formation and the mechanical response of engineered cartilage constructed using a collagen-based hybrid scaffold and human MSCs. The experimental results clearly showed that the combined culture condition of the chondrogenic differentiation culture and the chondrocyte growth culture exhibited statistically significant cell proliferation, ECM formation and stiffness responses as compared to the other two combinations. It is thus concluded that the combination of the differentiation culture with the subsequent growth culture is recommended as the culture condition for chondrogenic tissue engineering using hMSCs.

Adhesion, proliferation and differentiation of human mesenchymal stem cell on chitosan/collagen composite scaffold.

In vitro tissue engineering requires a progenitor cell source and a porous scaffold providing three dimensional (3D) supports for growth and differentiation to attain tissue architectures. This research focused on fabrication and characterization of 3D porous scaffolds using chitosan (CS), collagen (CG) and chitosan-collagen (CS-CG) composite to investigate their influence on human mesenchymal stem cell (hMSC) adhesion, proliferation and differentiation. Material dependent variations in porous morphology and mechanical behavior of the fabricated CS, CG and CS-CG scaffold showed significant impact on hMSC adhesion, proliferation and differentiation. The maximum hMSC adhesion and proliferation was reported on CS-CG scaffold among all fabricated scaffold groups. Interconnectivity of pores structure in CS-CG scaffold was considered as preferable attribute for such enhanced growth and distribution throughout the scaffold. Besides, CS scaffold with well interconnected pores showed poor adhesion and proliferation because of inadequate adhesion motifs. In case of CG scaffold, optimum growth and distribution of hMSC occurs only at the surface because of the absence of interconnectivity in their pore structures. Likewise, osteogenic differentiation of hMSC occurs most preferably in CS-CG composite scaffold among all scaffold groups. Such enhanced hMSC proliferation and differentiation in CS-CG scaffold significantly influenced on mechanical behavior of scaffold which is essential for in vivo application of a bone tissue implant. Thus CS-CG composite scaffold holds promise to be a suitable platform for in vitro engineering of bone tissue implant.

Development and characterization of hybrid tubular structure of PLCL porous scaffold with hMSCs/ECs cell sheet.

Tissue engineering offers an alternate approach to providing vascular graft with potential to grow similar with native tissue by seeding autologous cells into biodegradable scaffold. In this study, we developed a combining technique by layering a sheet of cells onto a porous tubular scaffold. The cell sheet prepared from co-culturing human mesenchymal stem cells (hMSCs) and endothelial cells (ECs) were able to infiltrate through porous structure of the tubular poly (lactide-co-caprolactone) (PLCL) scaffold and further proliferated on luminal wall within a week of culture. Moreover, the co-culture cell sheet within the tubular scaffold has demonstrated a faster proliferation rate than the monoculture cell sheet composed of MSCs only. We also found that the co-culture cell sheet expressed a strong angiogenic marker, including vascular endothelial growth factor (VEGF) and its receptor (VEGFR), as compared with the monoculture cell sheet within 2 weeks of culture, indicating that the co-culture system could induce differentiation into endothelial cell lineage. This combined technique would provide cellularization and maturation of vascular construct in relatively short period with a strong expression of angiogenic properties.

Tissue Reaction to a Novel Bone Substitute Material Fabricated With Biodegradable Polymer-Calcium Phosphate Nanoparticle Composite.

PURPOSE: The aim of this study was to evaluate the effectiveness of a novel bone substitute material fabricated using a biodegradable polymer-calcium phosphate nanoparticle composite. METHODS: Porous structured poly-L-lactic acid (PLLA) and hydroxyapatite (HA) nanoparticle composite, which was fabricated using solid-liquid phase separation and freeze-drying methods, was grafted into bone defects created in rat calvarium or tibia. Rats were killed 4 weeks after surgery, and histological analyses were performed to evaluate new bone formation. RESULTS: Scanning electron microscopic observation showed the interconnecting pores within the material and the pore diameter was approximately 100 to 300 µm. HA nanoparticles were observed to be embedded into the PLLA beams. In the calvarial implantation model, abundant blood vessels and fibroblastic cells were observed penetrating into pores, and in the tibia model, newly formed bone was present around and within the composite. CONCLUSIONS: The PLLA-HA nanoparticle composite bone substitute developed in this study showed biocompatibility, elasticity, and operability and thus has potential as a novel bone substitute.

Neck fracture of femoral stems with a sharp slot at the neck: biomechanical analysis.

BACKGROUND: Fracture of the femoral stem in total hip arthroplasty (THA) is a rare complication. We have encountered 2 cases of neck fractures of the femoral stem occurring 9 and 12 years after THA. Morphological and biomechanical analysis were performed to investigate the mechanism of these fractures. METHOD: A titanium alloy femoral stem having a slot with sharp corners (R = 0.2 mm) at the neck had been implanted in both cases. Fracture surfaces were examined by use of scanning electron microscopy (SEM). Stress concentration was simulated by using a finite element method (FEM) to compare slots with sharp (R = 0.2 mm) and smooth (R = 2 mm) corners. RESULTS: Study of the retrieved stems revealed that neck fractures had occurred at the distal end of the slot in both cases. SEM revealed numerous fine fissures extending from the anterolateral edge, striations on the middle of the fracture surface, and dimples on the posteromedial surface, suggesting that the fractures had occurred from the anterolateral aspect toward the posteromedial aspect because of metallic fatigue. FEM analysis showed that mechanical stress was concentrated at the distal and anterolateral corners of the slot. Under 3500-N loading force, the stress at the sharp corner was 556 MPa, which was approximately twofold that at the smooth corner and exceeded the fatigue strength of titanium alloy. CONCLUSION: These findings showed that the sharp corner of slot increased stress concentrations at the anterolateral aspect and led to the neck fractures.

Modulation of extracellular conditions prevents the multilayering of the simple epithelium.

Simple epitheliums in normal glandular systems are regulated not to stratify even though the constituent cells proliferate and will rise from the epithelium. Since epithelial cells have the potential to establish cell-cell adhesions, the avoidance of stratification must be related to the intracellular signal cascades and the extracellular conditions. The contributions of the former are becoming clarified, but the influence of the latter is poorly understood. In the present study, we examined whether the frequency of cell-on-cell adhesion, which mimics the early stage of multilayering, is dependent on the type of the extracellular scaffold protein. Wild-type epithelial cells were cultured on E-cadherin-Fc (a cell-cell adhesion protein) or collagen (an extracellular matrix protein), and then, green fluorescent protein (GFP)-positive cells were seeded onto these wild-type cells. We observed that the cell-on-cell adhesion (adhesion of the GFP-positive cell to the wild-type cells) was more frequent in the E-cadherin-Fc treatment than the collagen treatment. The cell-on-cell adhesions that were observed in the E-cadherin treatment were transient and decreased in frequency to that of the collagen treatment after the 12 h of cell culture. We observed the disappearance of E-cadherin-Fc but not collagen during cell culture. These results suggest that transient multilayering in simple epithelium is possible, depending on the types of extracellular scaffold protein, and they imply that cells can modify the extracellular conditions to meet normal cellular conditions.

The effect of malrotation of tibial component of total knee arthroplasty on tibial insert during high flexion using a finite element analysis.

One of the most common errors of total knee arthroplasty procedure is a malrotation of tibial component. The stress on tibial insert is closely related to polyethylene failure. The objective of this study is to analyze the effect of malrotation of tibial component for the stress on tibial insert during high flexion using a finite element analysis. We used Stryker NRG PS for analysis. Three different initial conditions of tibial component including normal, 15° internal malrotation, and 15° external malrotation were analyzed. The tibial insert made from ultra-high-molecular-weight polyethylene was assumed to be elastic-plastic while femoral and tibial metal components were assumed to be rigid. Four nonlinear springs attached to tibial component represented soft tissues around the knee. Vertical load was applied to femoral component which rotated from 0° to 135° while horizontal load along the anterior posterior axis was applied to tibial component during flexion. Maximum equivalent stresses on the surface were analyzed. Internal malrotation caused the highest stress which arose up to 160% of normal position. External malrotation also caused higher stress. Implanting prosthesis in correct position is important for reducing the risk of abnormal wear and failure.

Dynamic finite element analysis of mobile bearing type knee prosthesis under deep flexional motion.

The primary objective of this study is to distinguish between mobile bearing and fixed bearing posterior stabilized knee prostheses in the mechanics performance using the finite element simulation. Quantifying the relative mechanics attributes and survivorship between the mobile bearing and the fixed bearing prosthesis remains in investigation among researchers. In the present study, 3-dimensional computational model of a clinically used mobile bearing PS type knee prosthesis was utilized to develop a finite element and dynamic simulation model. Combination of displacement and force driven knee motion was adapted to simulate a flexion motion from 0° to 135° with neutral, 10°, and 20° internal tibial rotation to represent deep knee bending. Introduction of the secondary moving articulation in the mobile bearing knee prosthesis has been found to maintain relatively low shear stress during deep knee motion with tibial rotation.

Proximal cementation of a collarless polished tapered hip stem: biomechanical analysis using a validated finite element model.

Total hip replacement (THR) with cemented stem is a common procedure for patients with hip osteoarthritis. When primary THR fails, removal of the cement is problematic and poses challenges during revision surgeries. The possibility of proximal partial cementing of the hip stem was explored to mitigate the problem. 3D finite element analysis was performed to investigate the feasibility of reduced cement length for effective implant fixation and load transmission. Three levels of cement reduction (40 mm, 80 mm, and 100 mm) in the femoral stem were evaluated. All models were assigned loadings of peak forces acting on the femur during walking and stair climbing. The experimental and predicted max/min principal bone strains were fitted into regression models and showed good correlations. FE results indicated stress increment in the femoral bone, stem, and cement due to cement reduction. A notable increase of bone stress was observed with large cement reduction of 80-100 mm, particularly in Gruen zones 3 and 5 during walking and Gruen zones 3 and 6 during stair climbing. The increase of cement stresses could be limited to 11% with a cement reduction of 40 mm. The findings suggested that a 40-mm cement reduction in hip stem fixation was desirable to avoid unwanted complications after cemented THR.

Adjacent vertebral fractures in the lumbar and thoracic spine after balloon kyphoplasty: A finite element analysis.

The purpose of the present study was to mechanically verify after vertebral augmentation (AVA) scores using a finite element method (FEM) with accurate material constants of balloon kyphoplasty (BKP) cement. Representative cases with AVA scores of 1 (case 1), 3 (case 2), and 5 (case 3) among patients with vertebral body fractures who underwent BKP were analyzed. A FEM model consisting of 5 vertebral bodies was created, including the injured vertebral body in each case. The amount of displacement for each load (up to 4000 N) between the upper and lower vertebral bodies of each model was measured. Young modulus of the BKP cement was calculated from actual measurements using the EZ-Test EZ-S (Shimadzu Corporation, Kyoto, Japan). In all cases, the number of shell elements (209,296-299,876), solid elements (1913,029-2417,671), and nodes (387,848-487,756) were similar, indicating that FEM modeling was comparable among the cases. Young modulus of BKP cement, calculated using EZ-Test EZ-S, was 572 MPa. Fractures were detected by compressive forces of 3300 N (upper) and 3300 N (lower), 3000 N (upper) and 3100 N (lower), and 1200 N (upper) and 1200 N (lower) in cases 1, 2, and 3, respectively. The AVA scoring system was mechanically verified using the accurate material constants of BKP cement. A multicenter survey and external validation are therefore required for the clinical implementation of the AVA score.

Analysis for Predictors of Failure of Orthodontic Mini-implant Using Patient-Specific Finite Element Models.

In this study, we analyzed the clinical factors and mechanical parameters for predicting orthodontic mini-implant (OMI) failure in the mandible, which has different properties from the maxilla. A patient-specific finite element analysis was applied to 32 OMIs (6 failures and 26 successes) implanted between the mandibular second premolars and first molars used for anchorage. The peak stress and strain parameters were calculated for each sample. A logistic regression of the failure (vs. success) of OMIs on the mechanical parameters in the models was conducted. In addition, the influence of clinical factors on the mechanical parameters considered to be related to OMI failure was examined by a regression analysis. The mechanical parameter which best predicts OMI failure in the mandible was found to be a minimum principal strain of between 0.5 to 1.0 mm from the OMI surface (R2 = 0.8033). The results indicate the patient's bone density, distance between the OMIs and adjacent root, and vertical implantation angle of the OMIs are potential clinical predictors of OMI failure in the mandible.

Mechanical evaluation of revision surgery for femoral shaft nonunion initially treated with intramedullary nailing: Exchange nailing versus augmentation plating.

INTRODUCTION: Exchange nailing (EN) or augmentation plating (AP) has been employed to treat nonunions after intramedullary nailing for femoral shaft fractures. Although instability is a factor in hypertrophic nonunion, mechanical evaluations have been limited because the contribution of the callus to fracture site stability varies with healing. Our previous study illustrated the potential for evaluation using a finite element analysis (FEA) that incorporates callus material properties. This study aimed to mechanically evaluate revision surgery for nonunions using FEA. MATERIALS AND METHODS: A quantitative computed tomography-based FEA was performed on virtual revision models of a patient with suspected nonunion after intramedullary nailing. In addition to the initial nailing model (IN) with an 11-mm diameter (D) and 360-mm length (L), four EN models with D12mm (EN1), D13mm (EN2), D12mm-L400mm (EN3), and D13mm-L400mm (EN4) nails and three AP models with 5- (AP1), 6- (AP2), and 7-hole (AP3) plates were created. As with bone, callus was assigned inhomogeneous material properties derived from density based on an empirical formula. The hip joint reaction force and muscle forces at maximum load during the gait cycle were applied. The volume ratio of the callus at the fracture site with a tensile failure risk of ≥1 (tensile failure ratio) and bone fragment movement were evaluated. RESULTS: The tensile failure ratio was 11.6 % (IN), 10.1 % (EN1), 6.3 % (EN2), 10.9 % (EN3), 6.2 % (EN4), 6.4 % (AP1), 7.2 % (AP2), and 7.7 % (AP3), respectively. The bone fragment movement showed an opening on the lateral side with the initial intramedullary nailing. However, both revision surgeries reduced the opening, leading to compression except in the EN1 model. The proximal bone fragments were internally rotated relative to the distal fragments, and the rotational instability was more suppressed in models with lower tensile failure ratio. CONCLUSIONS: For EN, the increase in diameter, not length, is important to suppress instability. AP reduces instability, comparable to a 2 mm increase in nail diameter, and screw fixation closer to the fracture site reduces instability. This study suggest that AP is mechanically equivalent to EN and could be an option for revision surgery for femoral shaft nonunions.

Osteoconductivity and neurotoxicity of silver-containing hydroxyapatite coating cage for spinal interbody fusion in rats.

Background: The use of spinal instrumentation is an established risk factor for postoperative infection. To address this problem, we prepared silver-containing hydroxyapatite coating, consisting of highly osteoconductive hydroxyapatite interfused with silver. The technology has been adopted for total hip arthroplasty. Silver-containing hydroxyapatite coating has been reported to have good biocompatibility and low toxicity. However, no studies about applying this coating in spinal surgery have addressed the osteoconductivity and direct neurotoxicity to the spinal cord of silver-containing hydroxyapatite cages in spinal interbody fusion. Aim: In this study, we evaluated the osteoconductivity and neurotoxicity of silver-containing hydroxyapatite-coated implants in rats. Materials & Methods: Titanium (non-coated, hydroxyapatite-coated, and silver-containing hydroxyapatite-coated) interbody cages were inserted into the spine for anterior lumbar fusion. At 8 weeks postoperatively, micro-computed tomography and histology were performed to evaluate the osteoconductivity of the cage. Inclined plane test and toe pinch test were performed postoperatively to assess neurotoxicity. Results: Micro-computed tomography data indicated no significant difference in bone volume/total volume among the three groups. Histologically, the hydroxyapatite-coated and silver-containing hydroxyapatite-coated groups showed significantly higher bone contact rate than that of the titanium group. In contrast, there was no significant difference in bone formation rate among the three groups. Data of inclined plane and toe pinch test showed no significant loss of motor and sensory function in the three groups. Furthermore, there was no degeneration, necrosis, or accumulation of silver in the spinal cord on histology. Conclusions: This study suggests that silver-hydroxyapatite-coated interbody cages produce good osteoconductivity and are not associated with direct neurotoxicity.

Biomechanical evaluation of porous bioactive ceramics after implantation: micro CT-based three-dimensional finite element analysis.

Hydroxyapatite ceramics have been widely investigated for bone regeneration due to their high biocompatibility. However, few studies focus on their mechanical characteristics after implantation. In this study, the finite element (FE) method was used to evaluate the mechanical properties of a fully interconnected porous hydroxyapatite (IPHA) over time of implantation. Based on the micro-CT images obtained from the experiments dealing with IPHA implanted into rabbit femoral condyles, three-dimensional FE models of IPHA (1, 5, 12, 24, and 48 weeks after implantation) were developed. FE analysis indicated that the elastic modulus gradually increased from 1 week and reached the peak value at 24 weeks, and then it kept at high level until 48 weeks postoperatively. In addition, as a local biomechanical response, strain energy density became to distribute evenly over time after the implantation. Results confirmed that the mechanical properties of IPHA are strongly correlated to bone ingrowth. The efficiency of the proposed numerical approach was validated in combination with experimental studies, and the feasibility of applying this approach to study such implanted porous bioceramics was proved.

Determination of representative dimension parameter values of Korean knee joints for knee joint implant design.

Knee joint implants developed by western companies have been imported to Korea and used for Korean patients. However, many clinical problems occur in knee joints of Korean patients after total knee joint replacement owing to the geometric mismatch between the western implants and Korean knee joint structures. To solve these problems, a method to determine the representative dimension parameter values of Korean knee joints is introduced to aid in the design of knee joint implants appropriate for Korean patients. Measurements of the dimension parameters of 88 male Korean knee joint subjects were carried out. The distribution of the subjects versus each measured parameter value was investigated. The measured dimension parameter values of each parameter were grouped by suitable intervals called the "size group," and average values of the size groups were calculated. The knee joint subjects were grouped as the "patient group" based on "size group numbers" of each parameter. From the iterative calculations to decrease the errors between the average dimension parameter values of each "patient group" and the dimension parameter values of the subjects, the average dimension parameter values that give less than the error criterion were determined to be the representative dimension parameter values for designing knee joint implants for Korean patients.

Evaluation of bone healing process after intramedullary nailing for femoral shaft fracture by quantitative computed tomography-based finite element analysis.

BACKGROUND: There is no proven method for quantitative evaluation of bone healing progress or decision to remove the nail after intramedullary nailing for femoral shaft fractures. Finite element analysis has become commonly utilized in bone analysis, but it may also be used to evaluate callus. The goal of this study was to use quantitative CT-based finite element analysis to assess the bone healing process and predict bone strength with the nail removed. METHODS: Quantitative CT-based finite element analysis was conducted on CT images from patients who had intramedullary nailing after a femoral shaft fracture at 6, 12, and 15 months postoperatively. The failure risk of the callus was evaluated with maximal load throughout the gait cycle. The tensile failure ratio was calculated using the volume ratio of the callus element with a tensile failure risk ≥100%. A virtual model with the nail removed was built for bone strength study, and the strength was calculated using the displacement-load curve. FINDINGS: The tensile failure ratio reduced with time, reaching 11.6%, 2.6%, and 0.5% at 6, 12, and 15 months postoperatively, respectively, consistent with bone healing inferred from imaging results. At 15 months, the bone strength at nail removal grew to 212, 2670, and 3385 N, surpassing the healthy side's 2766 N. INTERPRETATION: Quantitative CT-based finite element analysis enables mechanical assessment during the bone healing process and is expected to be applied to the selection of revision surgery. It is also applicable to the nail removal decision.

Development and characterization of reinforced poly(L-lactide) scaffolds for bone tissue engineering.

Novel reinforced poly(L-lactic acid) (PLLA) scaffolds such as solid shell, porous shell, one beam and two beam reinforced scaffolds were developed to improve the mechanical properties of a standard PLLA scaffold. Experimental results clearly indicated that the compressive mechanical properties such as the strength and the modulus are effectively improved by introducing the reinforcement structures. A linear elastic model consisting of three phases, that is, the reinforcement, the porous matrix and the boundary layer was also introduced in order to predict the compressive moduli of the reinforced scaffolds. The comparative study clearly showed that the simple theoretical model can reasonably predict the moduli of the scaffolds with three phase structures. The failure mechanism of the solid shell and the porous shell reinforced scaffolds under compression were found to be buckling of the solid shell and localized buckling of the struts constructing the pores in the porous shell, respectively. For the beam reinforced scaffolds, on the contrary, the primary failure mechanism was understood to be micro-cracking within the beams and the subsequent formation of the main-crack due to the coalescence of the micro-racks. The biological study was exhibited that osteoblast-like cells, MC3T3-E1, were well adhered and proliferated on the surfaces of the scaffolds after 12 days culturing.

Prediction of Bone Mineral Density (BMD) Adaptation in Pelvis-Femur Model with Hip Arthroplasties.

The prediction of bone remodeling behaviour is a challenging factor in encouraging the long-term stability of hip arthroplasties. The presence of femoral components modifies the biomechanical environment of the bone and alters the bone growth process. Issues of bone loss and gait instability on both limbs are associated with the remodeling process. In this study, finite element analysis with an adaptive bone remodeling algorithm was used to predict the changes in bone mineral density following total hip and resurfacing hip arthroplasty. A three-dimensional model of the pelvis-femur was constructed from computed tomography (CT-based) images of a 79-year-old female patient with hip osteoarthritis. The prosthesis stem of the total hip arthroplasty was modelled with a titanium alloy material, while the femoral head had alumina properties. Meanwhile, resurfacing of the hip implant was completed with a cobalt-chromium material. Contact between the components and bone was designed to be perfectly bonded at the interface. Results indicate that the bone mineral density was modified over five years on all models, including hip osteoarthritis. The changes of BMD were predicted as being high between year zero and year one, especially in the proximal region. Changes were observed to be minimal in the following years. The bone remodeling process was also predicted for the non-operated femur. However, the adaptation was lower compared to the operated limbs. The reduction in bone mineral density suggested the bone loss phenomenon after a few years.

Improvement of Mechanical Strength of Tissue Engineering Scaffold Due to the Temperature Control of Polymer Blend Solution.

Polymeric scaffolds made of PCL/PLCL (ratio 1:3, respectively) blends have been developed by using the Thermally Induced Phase Separation (TIPS) process. A new additional technique has been introduced in this study by applying pre-heat treatment to the blend solution before the TIPS process. The main objective of this study is to evaluate the influence of the pre-heat treatment on mechanical properties. The mechanical evaluation showed that the mechanical strength of the scaffolds (including tensile strength, elastic modulus, and strain) improved as the temperature of the polymer blend solution increased. The effects on the microstructure features were also observed, such as increasing strut size and differences in phase separation morphology. Those microstructure changes due to temperature control contributed to the increasing of mechanical strength. The in vitro cell study showed that the PCL/PLCL blend scaffold exhibited better cytocompatibility than the neat PCL scaffold, indicated by a higher proliferation at 4 and 7 days in culture. This study highlighted that the improvement of the mechanical strength of polymer blends scaffolds can be achieved using a very versatile way by controlling the temperature of the polymer blend solution before the TIPS process.

Risk assessment of vertebral compressive fracture using bone mass index and strength predicted by computed tomography image based finite element analysis.

BACKGROUND: A main purpose of osteoporosis diagnosis is to evaluate the bone fracture risk. Some bone mass indices evaluated using bone mineral density has been utilized clinically to assess the degree of osteoporosis. On the other hand, Computed tomography image based finite element analysis has been developed to evaluate bone strength of vertebral bodies. The strength of a vertebra is defined as the load at the onset of compressive fracture. The objective of this study was therefore to propose a new feasible method to combine the advantages of the two osteoporotic indices such as the bone mass index and the bone strength. METHODS: Three-dimensional finite element models of 246 vertebral bodies from 88 patients were constructed using the computed tomography images. Finite element analysis was then conducted to evaluate their strength values. The Pearson's correlation analysis was also conducted between the vertebral strength and bone mass indices. FINDINGS: It was found that relatively weak positive correlations existed between the strength and the bone mass indices. A new assessment method was then proposed by combining the strength and the bone mass index. "high risk zone" corresponding to low strength with normal bone mass was found from the assessment method. INTERPRETATION: Singe bone mass index cannot predict the fracture risk with high standard. The results of fracture risk assessment conducted by the new method clearly indicated the necessity and effectiveness to take both the strength and the bone mass index into account.