Angle-stable interlocking nailing in a canine critical-sized femoral defect model for bone regeneration studies: In pursuit of the principle of the 3R's.

Introduction: Critical-sized long bone defects represent a major therapeutic challenge and current treatment strategies are not without complication. Tissue engineering holds much promise for these debilitating injuries; however, these strategies often fail to successfully translate from rodent studies to the clinical setting. The dog represents a strong model for translational orthopedic studies, however such studies should be optimized in pursuit of the Principle of the 3R's of animal research (replace, reduce, refine). The objective of this study was to refine a canine critical-sized femoral defect model using an angle-stable interlocking nail (AS-ILN) and reduce total animal numbers by performing imaging, biomechanics, and histology on the same cohort of dogs. Methods: Six skeletally mature hounds underwent a 4 cm mid-diaphyseal femoral ostectomy followed by stabilization with an AS-ILN. Dogs were assigned to autograft (n = 3) or negative control (n = 3) treatment groups. At 6, 12, and 18 weeks, healing was quantified by ordinal radiographic scoring and quantified CT. After euthanasia, femurs from the autograft group were mechanically evaluated using an established torsional loading protocol. Femurs were subsequently assessed histologically. Results: Surgery was performed without complication and the AS-ILN provided appropriate fixation for the duration of the study. Dogs assigned to the autograft group achieved radiographic union by 12 weeks, whereas the negative control group experienced non-union. At 18 weeks, median bone and soft tissue callus volume were 9,001 mm3 (range: 4,939-10,061) for the autograft group and 3,469 mm3 (range: 3,085-3,854) for the negative control group. Median torsional stiffness for the operated, autograft treatment group was 0.19 Nm/° (range: 0.19-1.67) and torque at failure was 12.0 Nm (range: 1.7-14.0). Histologically, callus formation and associated endochondral ossification were identified in the autograft treatment group, whereas fibrovascular tissue occupied the critical-sized defect in negative controls. Conclusion: In a canine critical-sized defect model, the AS-ILN and described outcome measures allowed refinement and reduction consistent with the Principle of the 3R's of ethical animal research. This model is well-suited for future canine translational bone tissue engineering studies.

A Morphological Study of the Meniscus, Cartilage and Subchondral Bone Following Closed-Joint Traumatic Impact to the Knee.

Post-traumatic osteoarthritis (PTOA) is a debilitating disease that is a result of a breakdown of knee joint tissues following traumatic impact. The interplay of how these tissues influence each other has received little attention because of complex interactions. This study was designed to correlate the degeneration of the menisci, cartilage and subchondral bone following an acute traumatic event that resulted in anterior cruciate ligament (ACL) and medial meniscus tears. We used a well-defined impact injury animal model that ruptures the ACL and tears the menisci. Subsequently, the knee joints underwent ACL reconstruction and morphological analyses were performed on the menisci, cartilage and subchondral bone at 1-, 3- and 6-months following injury. The results showed that the morphological scores of the medial and lateral menisci worsened with time, as did the tibial plateau and femoral condyle articular cartilage scores. The medial meniscus was significantly correlated to the medial tibial subchondral bone at 1 month (p = 0.01), and to the medial tibial cartilage at 3 months (p = 0.04). There was only one significant correlation in the lateral hemijoint, i.e., the lateral tibial cartilage to the lateral tibial subchondral bone at 6 months (p = 0.05). These data may suggest that, following trauma, the observed medial meniscal damage should be treated acutely by means other than a full or partial meniscectomy, since that procedure may have been the primary cause of degenerative changes in the underlying cartilage and subchondral bone. In addition to potentially treating meniscal damage differently, improvements could be made in optimizing treatment of acute knee trauma.

Effect of bending direction on the mechanical behaviour of 3.5 mm String-of-Pearls and Limited Contact Dynamic Compression Plate constructs.

OBJECTIVE: To compare the bending properties of String-of-Pearls® (SOP) and Limited Contact Dynamic Compression Plate® (LC-DCP) constructs in orthogonal bending directions. METHODS: 3.5 mm SOP and LC-DCP plates were fixed to a bone model simulating a comminuted tibial fracture. Specimens were non-destructively tested in both mediolateral and craniocaudal bending for 10 cycles. Bending stiffness and total angular deformation were compared using parametric analyses (p <0.05). RESULTS: For both constructs, stiffness was significantly less when bending moments were applied against the thickness of the plates (mediolateral bending) than against the width (craniocaudal bending). When compared to the mediolateral plane, bending constructs in the craniocaudal plane resulted in a 49% (SOP group) and 370% (LC-DCP group) increase in stiffness (p <0.001). Mediolateral bending stiffness was significantly greater in the SOP than the LC-DCP constructs. Conversely, in craniocaudal bending, SOP constructs stiffness was significantly less than that of the LC-DCP constructs. The differences between the two constructs in total angular deformation had an identical pattern of significance. CLINICAL SIGNIFICANCE: This study found that SOP showed less variability between the orthogonal bending directions than LC-DCP in a comminuted fracture model, and also described the bi-planar bending behaviour of both constructs. Although not exhibiting identical bending properties in both planes, SOP constructs had a more homogenous bending behaviour in orthogonal loading directions. The difference between the SOP with a circular cross sectional shape compared to the rectangular shape of standard plates is probably responsible for this difference.

Minimally displaced tibial tuberosity avulsion fracture in nine skeletally immature large breed dogs.

OBJECTIVE: The objective of this study was to describe the clinical and radiographic features, as well as the treatment and outcome of minimally displaced tibial-tuberosity-avulsion-fractures (MDTTAF). MATERIALS AND METHODS: Signalment, history, diagnostics, therapy, and outcome were recorded. Follow-up was documented as re-examination, radiographic assessment or telephone conversation. RESULTS: Nine large breed dogs that were presented with lameness originating from the proximal tibia were included. All showed signs of pain when pressure was applied to the tibial tuberosity. There was no stifle instability or intra-articular disease. The main feature on mediolateral radiographs was a widened tibial-tuberosity-physis with reactive new bone and loss of edge definition of the epiphyseal and metaphyseal margins. Non-surgical treatment was chosen in eight dogs, and surgery in one dog. Radiographic follow-up showed progressive closure of the tibial-tuberosity-physis and healing. Clinical signs resolved at a median of 28 days (range: 14-120). DISCUSSION: Minimally displaced tibial-tuberosity-avulsion-fractures should be a differential diagnosis in skeletally immature large breed dogs older than nine months of age with signs of subtle pelvic-limb lameness, and signs of proximal tibial pain, but no evidence of stifle joint disease. Thorough clinical examination and critical review of bilateral radiographs are important to diagnose MDTTAF. The outcome in these cases suggests that the prognosis for MDTTAF is excellent. Age and size of the affected dogs in this study differ from an earlier publication that illustrated more severely displaced tibial tuberosity avulsion fractures, occurring mainly in terriers around five months of age.

In vitro mechanical evaluation of a limited contact dynamic compression plate and hybrid carpal arthrodesis plate for canine pancarpal arthrodesis.

OBJECTIVE: To compare the mechanical properties of pancarpal arthrodesis (PCA) constructs stabilized at 20° of extension using either a 3.5 mm limited contact dynamic compression plate (LC-DCP) or a 3.5/2.7 mm hybrid plate (HP). METHODS: Seven forelimb pairs were used from dogs of similar size. All soft tissues were removed except for supporting structures of the carpus and proximal metacarpal region. All plates were accurately bent to 20°, and then instrumented with two, 350Ω strain gauges applied at the level of the bend. Constructs were embedded in epoxy moulds then mounted onto a servo-hydraulic testing machine. Specimens were loaded for 10 cycles at 100N, 200N and 300N. Tenth cycle construct compliance (CC), maximum angular deformation (MAD), and peak plate strain (PPS) were compared using two-factor analysis of variance (ANOVA) and Student-Newman-Keuls post-hoc tests (p <0.05). RESULTS: Regardless of load, CC was 29% to 33% smaller in the HP than the LC-DCP group (p <0.03). In each group, the CC significantly increased with increasing loads (p <0.02). Mean MAD was 19% to 22% less in HP than LC-DCP constructs, with significant differences seen at 200N and 300N loads. In both groups, MAD was significantly greater with increasing loads (p <0.02). In addition, PPS was 37% to 43% smaller for HP than LC-DCP. CLINICAL SIGNIFICANCE: The mechanical advantages of the HP over the LC-DCP make it a viable alternative for PCA. Smaller CC, MAD and PSS of the HP may reduce the risk of implant failure and postoperative morbidity following PCA.

Bone transport osteogenesis for treatment of canine osteomyelitis. A report of two cases.

Bone transport osteogenesis, as described by Ilizarov, has been used to resolve segmental bone defects in both human and veterinary patients. These defects are created when a large osseous tumour, sequestrum, or non-union fracture is resected. This report documents two cases in which the principle of bone transport osteogenesis was applied by utilising the Ilizarov technique to bridge large osseous defects resulting from debridement of an infected nonunion fracture (case 1) and debridement of a sequestrum (case 2). Defects were treated by transporting either a complete or a hemi-circumferential bone segment. Both cases had resolution of osteomyelitis, satisfactory fracture union, and functional usage of the limb 39 weeks and 15 weeks post-surgery, respectively. Although manageable complications were encountered during the treatment of these cases, the long-term clinical outcome was eventually favorable. The authors believe that bone transport osteogenesis offers a valid restorative option in the treatment of bone defects resulting from extensive debridement and seque- strectomy.

Effect of bending direction on the mechanical behaviour of interlocking nail systems.

OBJECTIVES: To compare the mechanical properties of various interlocking nail constructs in medio-lateral (ML) and cranio-caudal (CC) bending. METHODS: Synthetic bone models simulating a severely comminuted tibial fracture were treated with either screwed or bolted, 6 or 8 mm standard interlocking nails (ILN), or an angle-stable ILN (AS-ILN), after which they were then sequentially tested in ML and CC bending. Construct compliance, maximum angular deformation (MaxDef) and slack were statistically compared (p<0.05). RESULTS: The compliance of all constructs was significantly greater in CC than in ML bending. However, due to the presence of a greater slack in the ML plane, standard ILN constructs sustained significantly more deformation in that plane. Maximum deformation of the novel AS-ILN constructs was the smallest of all constructs and consistently occurred without slack regardless of bending direction. CLINICAL SIGNIFICANCE: This study suggested that standard ILN construct overall deformation and acute instability (slack) may be more critical in ML than in CC bending. Conversely, the small MaxDef and the absence of slack in both bending planes seen in novel angle-stable AS-ILN may provide optimal construct stability and in turn may be more conducive to bone healing.

Does Osgood-Schlatter disease exist in the dog?

Osgood-Schlatter disease (OSD) is a condition affecting human adolescents in which there is partial separation of bone fragments from the tibial tuberosity at the site of insertion of the patellar ligament to the tibial tuberosity. Tensile trauma seems to be the most likely aetiology. Clinical signs in people consist of swelling and pain at the proximal part of the tibial tuberosity and around the distal end of patellar ligament. Radiographs frequently show small ossicles at the patellar ligament insertion. Conservative treatment is usually curative. The term OSD has also been used for the canine patient. However, radiographs of these patients typically show an enlarged radiolucent line at the apophyseal plate of the tibial tuberosity. This finding is consistent with a mild avulsion fracture of the canine tibial tuberosity. Based on the radiographic differences between the two species, it seems more appropriate to use the term OSD only for people. The purpose of this paper is to review the literature on OSD in people and the reports of injuries to the proximal tibial tuberosity in dogs. In addition, a new classification system for tibial tuberosity avulsion injuries in the immature dog is proposed, with an algorithm for management of this injury.

Photoelastic stress analysis of strain patterns in equine hooves after four-point trimming.

OBJECTIVE: To evaluate changes in strain patterns in normal equine hooves following 4-point trimming, using photoelastic stress analysis. SAMPLE POPULATION: 15 equine front limbs with normal hoof configuration. PROCEDURE: Limbs were disarticulated at the carpometacarpal joint. Weight-bearing surfaces of each hoof were trimmed level to ensure 100% ground contact. Hoof walls were coated with a custom-made strain-sensitive plastic, and limbs were loaded to a third of body weight. Using a polariscope, strain distribution, magnitudes, and directions were evaluated in level hooves as well as before and after standardized 4-point trimming. Repeated-measures ANOVA was used to compare strain magnitudes and directions before and after trimming. RESULTS: In leveled specimens, strain fields were symmetrically distributed above the heels and at quarter-toe junctions along a line between the middle and distal thirds of the hoof wall. After 4-point trimming, strain epicenters localized above the contact points, whereas strain magnitudes significantly increased by approximately 50%. Decreasing contact area by 50% resulted in an additional significant increase (32%) in strain magnitude. Trimming did not have a significant effect on strain orientations. CONCLUSION AND CLINICAL RELEVANCE: This study documents that 4-point trimming results in strain concentration above the hoof contact points and that strain magnitude is dependent on contact area.

Effect of tibial plateau leveling on cranial and caudal tibial thrusts in canine cranial cruciate-deficient stifles: an in vitro experimental study.

OBJECTIVES: To investigate the effect of tibial plateau leveling (TPL) on tibial subluxation and tibial axial rotation; to determine the minimal tibial plateau rotation (MinTPR) angle that provides stifle stability; and to evaluate caudal cruciate ligament (CaCL) strain following tibial plateau rotation in cranial cruciate ligament (CrCL)-deficient stifles. ANIMALS: Fifteen canine cadaver hind limbs. METHODS: Tibial subluxation was measured from lateral radiographs in intact, loaded stifles and after sequential CrCL transection, MinTPR, TPL, and CaCL transection. The MinTPR angle was determined using a custom-made hinge plate and compared with the TPL angle. Tibial axial rotation was evaluated in CrCL-deficient stifles before and after TPL. Finally, CaCL strain was recorded in intact, loaded stifles, and following MinTPR, TPL, and tibial plateau over-rotation (MaxTPR) using a force probe. RESULTS: Cranial tibial subluxation in CrCL-deficient stifles was eliminated with TPL. Tibial plateau rotation, however, induced caudal tibial subluxation, which significantly increased from MinTPR to TPL before and after CaCL transection. The MinTPR angle was 6.5 degrees +/- 0.9 degrees less than the TPL angle (P <.05). Tibial internal rotation decreased significantly after TPL in CrCL-deficient stifles. Finally, CaCL strain increased with increasing tibial plateau rotation. CONCLUSIONS: This study suggests that, during stance phase, TPL transforms cranial tibial thrust into caudal tibial thrust, thereby stabilizing the stifle in the cranio-caudal plane via the constraint of the CaCL. The increase in CaCL stress, which results from tibial plateau rotation, could predispose the CaCL to fatigue failure and therefore would caution against tibial plateau over-rotation.

Tissue-engineered rotator cuff tendon using porcine small intestine submucosa. Histologic and mechanical evaluation in dogs.

To determine its efficacy in stimulating the regeneration of a rotator cuff tendon, an implant of 10-ply porcine small intestinal submucosa was used to replace a completely resected infraspinatus tendon in 21 adult mongrel dogs. The contralateral infraspinatus tendon was elevated and then reattached to the greater tubercle with sutures to mimic conventional repair (sham operation). Mechanical evaluations were performed at 0, 3, and 6 months (five specimens at each time period). Histologic comparisons were made at 3 and 6 months (three specimens). At both times, the gross appearance, histologic continuity, and failure mode of the constructs mimicked those of sham-operated and native infraspinatus tendons, thus suggesting host tissue ingrowth and implant remodeling with solid integration of the regenerated tissue to muscular and bony interfaces. Tissue ingrowth occurred without histologic evidence of foreign body or immune-mediated reactions or adhesions to peripheral tissues. Sham operations simulated tendon mobilization and reimplantation procedures routinely performed to treat chronic rotator cuff tendon injuries. Although the ultimate strength of small intestinal submucosa-regenerated tendons was significantly less than that of native infraspinatus tendons (P < 0.001), it was similar to that of reimplanted tendons at 3 (P > 0.05) and 6 months (P > 0.05).

The effect of varied electrical current densities on lumbar spinal fusions in dogs.

BACKGROUND CONTEXT: The use of electrical stimulation has been shown to increase the rate of successful spinal fusions. It is possible that increasing the current density of these stimulators may increase the speed and success rate of these fusions. PURPOSE: This study evaluated the effects of varied current densities on the speed and success rate of spinal fusion in dogs. STUDY DESIGN/SETTING: Three different current densities (0.83 microA/cm, 4 microA/cm and 10 microA/cm) were used to stimulate spinal fusions in a canine model over a 12-week period. OUTCOME MEASURES: Radiographic and histologic assessments were used to determine the degree of facet fusions at each time period. METHODS: Fifteen dogs underwent spinal facet fusion bilaterally at the level of L1-2 and L4-5. Each fusion site was electrically stimulated using one of three current densities. At 6, 9 and 12 weeks, the specimens were evaluated using high-resolution radiography and routine histology. The fusion masses were graded and then statistically evaluated. RESULTS: The results demonstrate a dose response of fusion mass scores to increasing current density. The highest current density (10 microA/cm) demonstrated a statistically higher fusion scores than the lowest currently density (0.83 microA/cm) at 6 weeks and statistically greater than both the middle (4 microA/cm) and lowest (0.83 microA/cm) current densities at 9 weeks. No differences were noted at 12 weeks, because all groups showed complete fusion. CONCLUSIONS: This controlled study suggests that speed of fusion may be further improved by increasing the current density of the electrical stimulation.

The effect of an exogenous fibrin clot on the regeneration of the triangular fibrocartilage complex: an in vivo experimental study in dogs.

The effect of an exogenous fibrin clot on the regeneration of the triangular fibrocartilage complex (TFCC) was examined in a dog model. In 12 mature dogs, bilateral TFCC resection was performed. The resulting defect was packed with an exogenous fibrin clot (experimental) while the contralateral side was left empty (control). Tissue regeneration was evaluated grossly and histologically at 6, 12, and 26 weeks. At each time period, the regenerated tissue in the fibrin clot-filled defect appeared more mature and more congruent with the adjacent cartilaginous surfaces than did the control (empty) defect. At 26 weeks, the clot regenerated tissue had the histological appearance of a normal TFCC with a homogeneous fibrocartilaginous matrix, regularly oriented collagen fibers, and normal integration with the adjacent support structures of the joint. The results of this study indicate that an exogenous fibrin clot could be used to promote a fibrocartilaginous repair tissue for a resected TFCC. Such therapy could be used in the arthroscopic treatment of TFCC injury and resection in an effort to improve postoperative outcome.

A method for determination of equine hoof strain patterns using photoelasticity: an in vitro study.

During impact, equine hooves undergo viscoelastic deformations which may result in potentially harmful strains. Previous hoof strain studies using strain gauges have been inconclusive due to arbitrary gauge placement. Photoelastic stress analysis (PSA) is a full-field technique which visually displays strains over entire loaded surfaces. This in vitro study identifies normal hoof strain patterns using PSA. Custom-made photoelastic plastic sheets were applied to the hoof surface. The hooves were axially loaded (225 kg) under level and varus/valgus conditions. Strain patterns were video-recorded through a polariscope. Strains were concentrated between middle and distal thirds of the hoof wall regardless of the loading conditions. This strain distribution appears to result from the differential expansion of the hoof wall under load. Increasing load resulted in higher strains and asymmetric loading resulted in an ipsilateral increase in strain magnitudes without altering strain locations. This study shows that PSA is a reliable method with which to evaluate hoof strains in vitro and is sensitive enough to reflect subtle load-related strain alterations.

Use of small intestinal submucosal implants for regeneration of large fascial defects: an experimental study in dogs.

A single layer of porcine small intestinal submucosa (SIS) was sutured into a 5 x 5 cm window created in the fascia lata of ten adult mongrel dogs in order to determine the efficacy of this material in promoting tissue regeneration of large fascial defects. A similar defect in the contralateral limb was left empty and served as a negative control. Tissue regeneration was examined grossly and histologically at 6 and 12 weeks. By 6 weeks, marked fibroplasia and angiogenesis had occurred throughout the SIS scaffold. The regenerated tissue was well organized and showed good integration with the adjacent fascia while the control specimens were filled with loose areolar connective tissue. At 12 weeks the experimental defects were filled with a regenerated tissue that grossly and histologically resembled normal fascia. There was no evidence of adhesions to the underlying musculature. Conversely, the tissue that filled the control defects remained disorganized and was markedly thinner than the adjacent fascia. The results of this study suggest that SIS is capable of supporting tissue regeneration in large fascial defects. The ability of this material to induce regeneration of a substantial area of tissue grossly and histologically similar to normal fascia and without adhesions to the underlying musculature makes its application in reconstructive surgery appear promising.

The effect of triple pelvic osteotomy on the articular contact area of the hip joint in dysplastic dogs: an in vitro experimental study.

OBJECTIVE: To investigate the effect of triple pelvic osteotomy (TPO) on articular contact area and acetabular coverage of dysplastic hip joints in dogs. STUDY DESIGN: Articular contact area and femoral head coverage by the acetabulum were computed in vitro in normal and dysplastic canine hips. The effect of TPO on articular contact and coverage was then analyzed in the dysplastic hips. Sample Population-Five normal and six dysplastic canine cadaver specimens. METHODS: Contact area and coverage of loaded hips were computed using serial computed tomography scan images before and after TPO. Three angles of acetabular ventroversion (AVV) were studied (20 degrees, 30 degrees, and 40 degrees). Using a custom-designed hinge plate, angles of spontaneous hip reduction in dysplastic hips were compared with previously recorded angles of reduction determined by the Ortolani test. RESULTS: Contact area significantly increased from 0 degrees to 30 degrees of AVV, then remained virtually unchanged. Coverage significantly increased from 0 degrees to 20 degrees of AVV. Both contact and coverage of normal hips were similar, yet significantly smaller than those of dysplastic hips once reduction had occurred. The experimental angles of reduction were significantly smaller and poorly correlated with the angles of reduction determined by the Ortolani test. Although coverage continued to increase with AVV, the actual joint contact area did not significantly vary after relocation of the femoral head. CONCLUSIONS: This study suggests that increasing AVV beyond 20 degrees does not significantly improve the beneficial effects of TPO and therefore should be carefully weighed against increased risks of postoperative complications associated with large angles of AVV.

Cancellous bone grafting of large osteochondral defects: an experimental study in dogs.

Autogenous cancellous bone was evaluated as a material to repair large osteochondral defects in 20 adult mongrel dogs. In one knee, the bone graft was used to fill an osteochondral cylindrical defect (10 mm diameter x 10 mm deep) created in the femoral trochlea. A similar lesion was created in the contralateral knee but was left untreated for spontaneous healing. Four animals were killed at each of five periods (2, 4, 8, 12, and 24 weeks), and the healing response of the defects was evaluated by gross anatomic inspection, plain film radiography, high-resolution radiography, and histology. The results of this study suggest that the use of a cancellous bone graft accelerates the repair of large osteochondral defects and produces more uniform filling of the defect than the ungrafted control. The reparative surface of the grafted lesions also differed from that of controls, having uniform coverage with histochemical-positive staining fibrocartilage at 8 weeks, a finding not observed in any control defect through the length of this study, 24 weeks.

The intraosseous blood supply of the canine radius: implications for healing of distal fractures in small dogs.

The intraosseous vascular anatomy of the radius was studied in 12 pairs of canine cadaver limbs. Six pairs of specimens were obtained from small-breed dogs (less than 6 kg) and six pairs were obtained from large-breed dogs (18 to 30 kg). All specimens were studied after arterial injection with India ink. Samples were fixed, frozen, then sectioned and processed using a modified Spalteholz technique. In all specimens, the intraosseous blood supply arose from the nutrient artery with its associated branches and the metaphyseal arteries. In small-breed dogs, there was decreased vascular density at the distal diaphyseal-metaphyseal junction compared with large-breed dogs. The reduced vascularity corresponded to the region associated with a poor prognosis for fracture healing in small-breed dogs. This regional association suggests that a decreased vascular supply in the distal radius may contribute to a higher frequency of delayed union and nonunion in smaller dogs.

The effect of triple pelvic osteotomy on hip force in dysplastic dogs: a theoretical analysis.

The effect of a triple pelvic osteotomy (TPO) procedure on the forces acting about the hip joint was examined in five dysplastic canine hips using a previously described theoretical analysis. Hip reaction force (Fh) and its angle of application (theta h) were calculated from radiographic measurements made before and after TPO procedures which sequentially increased acetabular ventroversion from 0 degree to 20 degrees, 30 degrees, and 40 degrees. The results of the in vitro study showed that Fh decreased with increasing acetabular ventroversion reaching an asymptotic value between 30 degrees and 40 degrees. The decrease in Fh corresponded to an increase in theta h toward the vertical, with statistical significance found in both Fh and theta h between 0 degree and 20 degrees. The changes observed in Fh and theta h after TPO were attributed to the medialization of the femoral head resulting from the reduction of the subluxated head. The results of this study suggest that the noted reduction in the magnitude of the forces acting on the hip joint may act in concert with increased coverage of the femoral head to effect the beneficial clinical results observed with the TPO procedure.