The effect of cortex thickness on intact femur biomechanics: a comparison of finite element analysis with synthetic femurs.

Biomechanical studies on femur fracture fixation with orthopaedic implants are numerous in the literature. However, few studies have compared the mechanical stability of these repair constructs in osteoporotic versus normal bone. The present aim was to examine how changes in cortical wall thickness of intact femurs affect biomechanical characteristics. A three-dimensional, linear, isotropic finite element (FE) model of an intact femur was developed in order to predict the effect of bicortical wall thickness, t, relative to the femur's mid-diaphyseal outer diameter, D, over a cortex thickness ratio range of 0 < or = t/D < or = 1. The FE model was subjected to loads to obtain axial, lateral, and torsional stiffness. Ten commercially available synthetic femurs were then used to mimic 'osteoporotic' bone with t/D = 0.33, while ten synthetic left femurs were used to simulate 'normal' bone with t/D = 0.66. Axial, lateral, and torsional stiffness were measured for all femurs. There was excellent agreement between FE analysis and experimental stiffness data for all loading modes with an aggregate average percentage difference of 8 per cent. The FE results for mechanical stiffness versus cortical thickness ratio (0 < or = t/D < or = 1) demonstrated exponential trends with the following stiffness ranges: axial stiffness (0 to 2343 N/mm), lateral stiffness (0 to 62 N/mm), and torsional stiffness (0 to 198 N/mm). This is the first study to characterize mechanical stiffness over a wide range of cortical thickness values. These results may have some clinical implications with respect to appropriately differentiating between older and younger human long bones from a mechanical standpoint.

The biomechanics of the T2 femoral nailing system: a comparison of synthetic femurs withfinite element analysis.

Intramedullary nails are commonly used to repair femoral fractures. Fractures in normal healthy bone often occur in the young during motor vehicle accidents. Although clinically beneficial, bone refracture and implant failure persist. Large variations in human femur quality and geometry have motivated recent experimental use of synthetic femurs that mimic human tissue and the development of increasingly sophisticated theoretical models. Four synthetic femurs were fitted with a T2 femoral nailing system (Stryker, Mahwah, New Jersey, USA). The femurs were not fractured in order to simulate post-operative perfect union. Six configurations were created: retrograde nail with standard locking (RS), retrograde nail with advanced locking 'off' (RA-off), retrograde nail with advanced locking 'on' (RA-on), antegrade nail with standard locking (AS), antegrade nail with advanced locking 'off' (AA-off), and antegrade nail with advanced locking 'on' (AA-on). Strain gauges were placed on the medial side of femurs. A 580 N axial load was applied, and the stiffness was measured. Strains were recorded and compared with results from a three-dimensional finite element (FE) model. Experimental axial stiffnesses for RA-off (771.3 N/mm) and RA-on (681.7 N/mm) were similar to intact human cadaveric femurs from previous literature (757 + 264 N/mm). Conversely, experimental axial stiffnesses for AS (1168.8N/mm), AA-off (1135.3N/mm), AA-on (1152.1 N/mm), and RS (1294.0 N/mm) were similar to intact synthetic femurs from previous literature (1290 +/- 30 N/mm). There was better agreement between experimental and FE analysis strains for RS (average percentage difference, 11.6 per cent), RA-on (average percentage difference, 11.1 per cent), AA-off (average percentage difference, 13.4 per cent), and AA-on (average percentage difference, 16.0 per cent), than for RA-off (average percentage difference, 33.5 per cent) and AS (average percentage difference, 32.6 per cent). FE analysis was more predictive of strains in the proximal and middle sections of the femur-nail construct than the distal. The results mimicked post-operative clinical stability at low static axial loads once fracture healing begins to occur.

Evaluating the critical strain energy release rate of bioactive glass coatings on Ti6Al4V substrates after degradation.

It has been reported that the adhesion of bioactive glass coatings to Ti6Al4V reduces after degradation, however, this effect has not been quantified. This paper uses bilayer double cantilever (DCB) specimens to determine GIC and GIIC, the critical mode I and mode II strain energy release rates, respectively, of bioactive coating/Ti6Al4V substrate systems degraded to different extents. Three borate-based bioactive glass coatings with increasing amounts of incorporated SrO (0, 15 and 25mol%) were enamelled onto Ti6Al4V substrates and then immersed in de-ionized water for 2, 6 and 24h. The weight loss of each glass composition was measured and it was found that the dissolution rate significantly decreased with increasing SrO content. The extent of dissolution was consistent with the hypothesis that the compressive residual stress tends to reduce the dissolution rate of bioactive glasses. After drying, the bilayer DCB specimens were created and subjected to nearly mode I and mode II fracture tests. The toughest coating/substrate system (one composed of the glass containing 25mol% SrO) lost 80% and 85% of its GIC and GIIC, respectively, in less than 24h of degradation. The drop in GIC and GIIC occurred even more rapidly for other coating/substrate systems. Therefore, degradation of borate bioactive glass coatings is inversely related to their fracture toughness when coated onto Ti6A4V substrates. Finally, roughening the substrate was found to be inconsequential in increasing the toughness of the system as the fracture toughness was limited by the cohesive toughness of the glass itself.

Computational fluid dynamics modeling of insertion and advancement of a reamer into the intramedullary canal of a long bone.

The effect of reaming velocity on the pressure distribution within the bone was investigated numerically by solving the full three-dimensional momentum equations together with the continuity equation using the finite element technique. Viscosity was also varied to obtain a pressure envelope. It was found that all the experimental data follow the same trends as the envelopes predicted by the finite element model. It was clear that an increase in either the implant insertion rate or the viscosity resulted in an increase in pressure in the intramedullary canal.

Osteochondral defect repair using a novel tissue engineering approach: sheep model study.

Porous calcium polyphosphate (CPP) constructs of desired density were formed by sintering CPP powders. Articular cartilage was formed on these constructs in cell culture over an 8-week period with the resulting cartilage layer forming on the CPP surface and within the near surface pores thereby mechanically anchoring the cartilage to the CPP. The biphasic constructs so formed were implanted in sheep femoral condyle sites and left for short-term periods (3 to 4 months) or longer periods (9 months). Implant fixation within the condyle sites was achieved through bone ingrowth into the inferior CPP pores. The properties and characteristics of the as-in vitro-formed, short- and long-term implanted tissues were compared. The results indicated that such implants might be useful for repair of small subchondral defects.

Quantifying the mode II critical strain energy release rate of borate bioactive glass coatings on Ti6Al4V substrates.

Bioactive glasses have been used as coatings for biomedical implants because they can be formulated to promote osseointegration, antibacterial behavior, bone formation, and tissue healing through the incorporation and subsequent release of certain ions. However, shear loading on coated implants has been reported to cause the delamination and loosening of such coatings. This work uses a recently developed fracture mechanics testing methodology to quantify the critical strain energy release rate under nearly pure mode II conditions, GIIC, of a series of borate-based glass coating/Ti6Al4V alloy substrate systems. Incorporating increasing amounts of SrCO3 in the glass composition was found to increase the GIIC almost twofold, from 25.3 to 46.9J/m2. The magnitude and distribution of residual stresses in the coating were quantified, and it was found that the residual stresses in all cases distributed uniformly over the cross section of the coating. The crack was driven towards, but not into, the glass/Ti6Al4V substrate interface due to the shear loading. This implied that the interface had a higher fracture toughness than the coating itself.

Long-term functional outcomes and knee alignment of computer-assisted navigated total knee arthroplasty.

INTRODUCTION: This retrospective study examined the relationship between the mechanical axis throughout a functional arc of motion and functional outcome scores in patients undergoing computer-assisted navigation-based total knee arthroplasty (CAN-TKA) at 6-year follow-up. MATERIALS AND METHODS: The Stryker eNact Precision Knee Navigation System was utilized to obtain pre- and postoperative alignment measurements throughout the functional arc of motion. Patients were contacted via telephone and asked to complete the Short Form-12 and Western Ontario and McMaster Universities, which have been demonstrated to be reliable, valid, and sensitive assessment tools in this patient population. Statistical analysis was performed to determine the correlation between arc alignment and patient-reported functional outcome measures. RESULTS: A total of 47 patients at a mean of 76.1 (±6.3)-month follow-up and mean age of 65.9 (±7.9) years were surveyed. No correlation was found between the postoperative alignment or degree of intraoperative correction and the functional outcome scores. In a planned subgroup analysis of patients with a mean functional arc alignment greater than 3° from neutral, mean intraoperative degree of correction correlated with decreasing physical function (Spearman's ρ = 0.772, p = 0.04) and mean postoperative arc alignment positively correlated with increasing stiffness (ρ = 0.798, p = 0.03). CONCLUSION: This study suggests that patients undergoing CAN-TKA with mean functional arc range of motion greater than 3° may be at increased risk for suboptimal patient-reported functional outcomes. This study also illustrates the ability of CAN-TKA to measure the varus or valgus alignment of the knee throughout the entire range of motion.

Repair of osteochondral defects with biphasic cartilage-calcium polyphosphate constructs in a sheep model.

There has been interest in developing novel biological treatments to repair focal cartilage defects. We have developed a method of forming biphasic constructs ("osteochondral"-type plug) in vitro consisting of cartilaginous tissue, formed on and anchored to the intended articulation surface of a porous ceramic substrate. The purpose of this study was to evaluate the biochemical and biomechanical properties and morphology of in vitro-formed biphasic constructs 3 and 9 months after implantation into 4mm diameter full thickness osteochondral defects in the trochlear groove of sheep stifles. The implants withstood loading in vivo up to 9 months with evidence of fusion to adjacent native cartilage and fixation by bone ingrowth into the ceramic substrate. The cartilage layer was eroded from those implants that were proud to the joint surface. Control implants (ceramic only) had fibrous tissue on the articulating surface after implantation for 3-4 months. Neither the cellularity nor proteoglycan content of the implanted cartilage, when it remained, changed significantly between 3 and 9 months and the collagen content increased slightly. The elastic equilibrium modulus of the cartilage improved with time with the greatest improvement (10-fold) occurring early during the first 3-4 months after implantation. This study suggests that biphasic constructs may be suitable to repair joint defects as the implants were maintained up to 9 months in sheep. Importantly the mechanical properties of the implanted cartilage improved significantly after implantation suggesting that cartilage can mature in vivo after implantation. The results indicate that further study of this treatment approach is warranted to attempt to overcome the technical surgical difficulties identified in this study.

Outcome of revision hip arthroplasty in patients with a previous total hip replacement for developmental dysplasia of the hip.

Our aim was to determine if the height of the cup, lateralisation or the abduction angle correlated with functional outcome or survivorship in revision total hip replacement in patients with a previous diagnosis of developmental dysplasia of the hip. A retrospective investigation of 51 patients (63 hips) who had undergone revision total hip replacement was performed. The mean duration of follow-up was 119 months. Forty-one patients (52 hips) were available for both determination of functional outcome and survivorship analysis. Ten patients (11 hips) were only available for survivorship analysis. The height of the cup was found to have a statistically significant correlation with functional outcome and a high hip centre correlated with a worse outcome score. Patients with a hip centre of less than 3.5 cm above the anatomical level had a statistically better survivorship of the cup than those with centres higher than this. Restoration of the height of the centre of the hip to as near the anatomical position as possible improved functional outcome and survivorship of the cup.

Familial arteriovenous malformations in siblings.

BACKGROUND: Familial arteriovenous malformations (AVMs) of the brain are rare. We present two sisters with the same parents who harbored AVMs that were successfully treated. METHODS: The elder sister presented with a unilateral migrainous type of headache overlying the right parietal area. The younger one suffered from exercise-induced headaches. Both were neurologically intact. Magnetic resonance imaging scans of the brain and cerebral angiography delineated the lesions. Both sisters underwent endovascular embolization followed by surgical resection. RESULTS: Postoperatively, aside from a left inferior quadrantanopsia in the elder sister, both were neurologically intact. CONCLUSIONS: We report the rare occurrence of familial AVMs in two siblings and review the literature of 14 reports. No genetic predisposition was found.

Finite element analysis of a femoral retrograde intramedullary nail subject to gait loading.

Intramedullary nails are routinely used in the treatment of fractures of the femur. While their effectiveness has been demonstrated clinically, a number of complications, including bone refracture and implant failure, persist. This paper presents novel three-dimensional finite element (FE) models, at four stages of gait, of: (i) a realistic femur analogue known as third generation composite bone, and (ii) a system consisting of an intramedullary nail implanted in the femur of (i). A comparison of experimentally measured strains on the surface of the femur with those predicted by the FE model revealed good agreement. The models were then used to identify implant/bone load sharing patterns, and areas of stress concentration in both the intramedullary nail and the bone, when statically locked by one or two screws at either end. The results of this study can be used to guide future implant design and surgical procedure.

The biomechanics of human femurs in axial and torsional loading: comparison of finite element analysis, human cadaveric femurs, and synthetic femurs.

To assess the performance of femoral orthopedic implants, they are often attached to cadaveric femurs, and biomechanical testing is performed. To identify areas of high stress, stress shielding, and to facilitate implant redesign, these tests are often accompanied by finite element (FE) models of the bone/implant system. However, cadaveric bone suffers from wide specimen to specimen variability both in terms of bone geometry and mechanical properties, making it virtually impossible for experimental results to be reproduced. An alternative approach is to utilize synthetic femurs of standardized geometry, having material behavior approximating that of human bone, but with very small specimen to specimen variability. This approach allows for repeatable experimental results and a standard geometry for use in accompanying FE models. While the synthetic bones appear to be of appropriate geometry to simulate bone mechanical behavior, it has not, however, been established what bone quality they most resemble, i.e., osteoporotic or osteopenic versus healthy bone. Furthermore, it is also of interest to determine whether FE models of synthetic bones, with appropriate adjustments in input material properties or geometric size, could be used to simulate the mechanical behavior of a wider range of bone quality and size. To shed light on these questions, the axial and torsional stiffness of cadaveric femurs were compared to those measured on synthetic femurs. A FE model, previously validated by the authors to represent the geometry of a synthetic femur, was then used with a range of input material properties and change in geometric size, to establish whether cadaveric results could be simulated. Axial and torsional stiffnesses and rigidities were measured for 25 human cadaveric femurs (simulating poor bone stock) and three synthetic "third generation composite" femurs (3GCF) (simulating normal healthy bone stock) in the midstance orientation. The measured results were compared, under identical loading conditions, to those predicted by a previously validated three-dimensional finite element model of the 3GCF at a variety of Young's modulus values. A smaller FE model of the 3GCF was also created to examine the effects of a simple change in bone size. The 3GCF was found to be significantly stiffer (2.3 times in torsional loading, 1.7 times in axial loading) than the presently utilized cadaveric samples. Nevertheless, the FE model was able to successfully simulate both the behavior of the 3GCF, and a wide range of cadaveric bone data scatter by an appropriate adjustment of Young's modulus or geometric size. The synthetic femur had a significantly higher stiffness than the cadaveric bone samples. The finite element model provided a good estimate of upper and lower bounds for the axial and torsional stiffness of human femurs because it was effective at reproducing the geometric properties of a femur. Cadaveric bone experiments can be used to calibrate FE models' input material properties so that bones of varying quality can be simulated.

Recombination, mutation, or constitutive expression at a Gm locus and familial hypergammaglobulinemia.

In a hypercholesterolemic Lebanese family, an uncommon Gm haplotype carrying an unexpected C gamma 1 gene was inherited by only one of 10 siblings. A new recombination during the maternal or paternal meiosis could explain its formation. According to this hypothesis, our data would be informative for the linkage relationship between the gamma-cistrons and the alpha 2-cistron. The latter might be located near the N-terminal side of the gamma-cistron linkage group, and the sequence of genes would be alpha 2, gamma 4, gamma 3, and gamma 1. A mutation could also effect the change from G1m(17) (codons AAA and AAG) TO G1m(3) (codons AGA and AGG). Another alternative is to postulate a constitutive expression of a C gamma 1 structural gene which, normally, would not be expressed. The uncommon derepression could be the consequence of uncommon cellular response to environmental, pathological or metabolic perturbation of a regulatory mechanism.