Microbiome-induced Increases and Decreases in Bone Tissue Strength can be Initiated After Skeletal Maturity.

Recent studies in mice have indicated that the gut microbiome can regulate bone tissue strength. However, prior work involved modifications to the gut microbiome in growing animals and it is unclear if the same changes in the microbiome, applied later in life, would change matrix strength. Here we changed the composition of the gut microbiome before and/or after skeletal maturity (16 weeks of age) using oral antibiotics (ampicillin + neomycin). Male and female mice (n=143 total, n=12-17/group/sex) were allocated into five study groups:1) Unaltered, 2) Continuous (dosing 4-24 weeks of age), 3) Delayed (dosing only 16-24 weeks of age), 4) Initial (dosing 4-16 weeks of age, suspended at 16 weeks), and 5) Reconstituted (dosing from 4-16 weeks following by fecal microbiota transplant from Unaltered donors). Animals were euthanized at 24 weeks of age. In males, bone matrix strength in the femur was 25-35% less than expected from geometry in mice from the Continuous (p= 0.001), Delayed (p= 0.005), and Initial (p=0.040) groups as compared to Unaltered. Reconstitution of the gut microbiota, however, led to a bone matrix strength similar to Unaltered animals (p=0.929). In females, microbiome-induced changes in bone matrix strength followed the same trend as males but were not significantly different, demonstrating sex-related differences in the response of bone matrix to the gut microbiota. Minor differences in chemical composition of bone matrix were observed (Raman spectroscopy). Our findings indicate that microbiome-induced impairment of bone matrix in males can be initiated and/or reversed after skeletal maturity. The portion of the femoral cortical bone formed after skeletal maturity (16 weeks) is small; however, this suggests that microbiome-induced changes in bone matrix occur without osteoblast/osteoclast turnover using an, as of yet unidentified mechanism. These findings add to evidence that the mechanical properties of bone matrix can be altered in the adult skeleton.

Skeletal effects of plyometric exercise and metformin in ovariectomized rats.

Estrogen deficiency causes bone loss and skeletal muscle dysfunction, and attenuates the musculoskeletal effects of exercise. The anti-diabetic drug metformin has been suggested to promote beneficial skeletal effects. To explore whether metformin can improve musculoskeletal training response during estrogen deficiency, we investigated the skeletal effects of plyometric exercise and metformin, in an ovarectomized (OVX) rat model of osteoporosis. Female Sprague Dawley rats, 12 weeks of age, rats were allocated to a sham-operated group (Sham), and four OVX groups; metformin (OVX-Met), exercise (OVX-Ex), combined metformin and exercise (OVX-MetEx) and a control group (OVX-Ctr), n = 12/group. Dual X-ray absorptiometry, micro computed tomography, fracture toughness testing, histomorphometry and plasma analyses were performed to explore skeletal effects. All intervention groups exhibited a higher gain in femoral bone mineral density (BMD) than OVX-Ctr (p < .01). The combined intervention also resulted in a higher gain in femoral and spine BMD compared to OVX-Met (p < .01). Both exercise groups displayed improved microarchitecture, including both cortical and trabecular parameters (p < .05). This was most evident in the OVX-MetEx group where several indices were at sham level or superior to OVX-Ctr (p < .05). The OVX-MetEx group also exhibited an enhanced toughening effect compared to the other OVX groups (p < .05). The beneficial skeletal effects seemed to be mediated by inhibition of bone resorption and stimulation of bone formation. The training response (i.e. jumping height) was also greater in the metformin treated rats compared to OVX-Ex (p < .01), indicating a performance-enhancing effect of metformin. Both exercise groups displayed higher lean mass than OVX-Ctr (p < .05). In conclusion, the combination of plyometric exercise and metformin improved trabecular microarchitecture and bone material properties relative to OVX controls. However, no additive effect of the combined intervention was observed compared to exercise alone.

Bone toughening through stress-induced non-collagenous protein denaturation.

Bone toughness emerges from the interaction of several multiscale toughening mechanisms. Recently, the formation of nanoscale dilatational bands and hence the accumulation of submicron diffuse damage were suggested as an important energy dissipation processes in bone. However, a detailed mechanistic understanding of the effect of this submicron toughening mechanism across multiple scales is lacking. Here, we propose a new three-dimensional ultrastructure volume element model showing the formation of nanoscale dilatational bands based on stress-induced non-collagenous protein denaturation and quantify the total energy released through this mechanism in the vicinity of a propagating crack. Under tensile deformation, large hydrostatic stress develops at the nanoscale as a result of local confinement. This tensile hydrostatic stress supports the denaturation of non-collagenous proteins at organic-inorganic interfaces, which leads to energy dissipation. Our model provides new fundamental understanding of the mechanism of dilatational bands formation and its contribution to bone toughness.

Eigenstrain Toughening in Presence of Elastic Heterogeneity with Application to Bone.

Transformation toughening has been used in commercial products for several decades in order to increase the toughness of brittle materials. Composites made from an elastic matrix and elastic-plastic inclusions similarly exhibit increased toughness and R-curve behavior due to the residual stress induced in the wake of the crack tip by the unloaded, plastically deforming fillers. These two mechanisms, in which the eigenstrains in the wake of a major crack lead to toughening, belong to the same class. In this study, we investigate the effect of the elastic heterogeneity of the matrix on such toughening mechanisms and observe that increasing the elastic heterogeneity amplifies the effect. The analysis is relevant for bone, which is a highly heterogeneous hierarchical material, in which localized plastic deformation has been recently shown to occur at dilatational bands. Understanding toughening in bone is a subject of current interest in the context of age-related fragility. The heterogeneity-enhanced eigenstrain toughening effect is of interest for a broad range of engineering applications.

Assessment of collagen quality associated with non-enzymatic cross-links in human bone using Fourier-transform infrared imaging.

Aging and many disease conditions, most notably diabetes, are associated with the accumulation of non-enzymatic cross-links in the bone matrix. The non-enzymatic cross-links, also known as advanced glycation end products (AGEs), occur at the collagen tissue level, where they are associated with reduced plasticity and increased fracture risk. In this study, Fourier-transform infrared (FTIR) imaging was used to detect spectroscopic changes associated with the formation of non-enzymatic cross-links in human bone collagen. Here, the non-enzymatic cross-link profile was investigated in one cohort with an in vitro ribose treatment as well as another cohort with an in vivo bisphosphonate treatment. With FTIR imaging, the two-dimensional (2D) spatial distribution of collagen quality associated with non-enzymatic cross-links was measured through the area ratio of the 1678/1692cm-1 subbands within the amide I peak, termed the non-enzymatic crosslink-ratio (NE-xLR). The NE-xLR increased by 35% in the ribation treatment group in comparison to controls (p<0.005), with interstitial bone tissue being more susceptible to the formation of non-enzymatic cross-links. Ultra high-performance liquid chromatography, fluorescence microscopy, and fluorometric assay confirm a correlation between the non-enzymatic cross-link content and the NE-xLR ratio in the control and ribated groups. High resolution FTIR imaging of the 2D bone microstructure revealed enhanced accumulation of non-enzymatic cross-links in bone regions with higher tissue age (i.e., interstitial bone). This non-enzymatic cross-link ratio (NE-xLR) enables researchers to study not only the overall content of AGEs in the bone but also its spatial distribution, which varies with skeletal aging and diabetes mellitus and provides an additional measure of bone's propensity to fracture.

Differences in non-enzymatic glycation and collagen cross-links between human cortical and cancellous bone.

UNLABELLED: It is important to establish the relationship between pentosidine and advanced glycation endproducts (AGEs) in bone. We found the relationship between pentosidine and AGEs and their magnitude of accumulation were dependent on bone's surface-to-volume ratio. Results illustrate the importance of measuring pentosidine and AGEs separately in cancellous and cortical bone. INTRODUCTION: Accumulation of collagen cross-links (AGEs) produced by non-enzymatic glycation deteriorates bone's mechanical properties and fracture resistance. Although a single AGE, pentosidine, is commonly used as a representative marker, it is unclear whether it quantitatively reflects total fluorescent AGEs in bone. The goal of this study was to establish the relationship between pentosidine and total AGEs in cancellous and cortical bone. METHODS: Pentosidine and total AGEs were quantified in 170 human bone samples. Total fluorescent AGEs were measured in 28 additional cancellous and cortical bone specimens of the same apparent volume that were incubated in control or in vitro glycation solutions. Correlations between pentosidine and total AGEs and differences between cortical and cancellous groups were determined. RESULTS: Pentosidine was correlated with total AGEs in cancellous bone (r = 0.53, p < 0.0001) and weakly correlated in cortical bone (r = 0.23, p < 0.05). There was more pentosidine (p < 0.01) and total AGEs (p < 0.001) in cancellous than in cortical bone. The in vitro glycation substudy showed that cancellous bone accumulated more AGEs than cortical bone (p < 0.05). CONCLUSION: The relationship between pentosidine and total AGEs and their magnitude of accumulation differed in cancellous and cortical bone of the same apparent volume, and were dependent on the surface-to-volume ratios of each sample. It is important to consider the bone types as two separate entities, and it is crucial to quantify total AGEs in addition to pentosidine to allow for more comprehensive analysis of the effects of non-enzymatic glycation in bone.

Local strain and damage mapping in single trabeculae during three-point bending tests.

The use of bone mineral density as a surrogate to diagnose bone fracture risk in individuals is of limited value. However, there is growing evidence that information on trabecular microarchitecture can improve the assessment of fracture risk. One current strategy is to exploit finite element analysis (FEA) applied to 3D image data of several mm-sized trabecular bone structures obtained from non-invasive imaging modalities for the prediction of apparent mechanical properties. However, there is a lack of FE damage models, based on solid experimental facts, which are needed to validate such approaches and to provide criteria marking elastic-plastic deformation transitions as well as microdamage initiation and accumulation. In this communication, we present a strategy that could elegantly lead to future damage models for FEA: direct measurements of local strains involved in microdamage initiation and plastic deformation in single trabeculae. We use digital image correlation to link stress whitening in bone, reported to be correlated to microdamage, to quantitative local strain values. Our results show that the whitening zones, i.e. damage formation, in the presented loading case of a three-point bending test correlate best with areas of elevated tensile strains oriented parallel to the long axis of the samples. The average local strains along this axis were determined to be (1.6±0.9)% at whitening onset and (12±4)% just prior to failure. Overall, our data suggest that damage initiation in trabecular bone is asymmetric in tension and compression, with failure originating and propagating over a large range of tensile strains.

The relative contributions of non-enzymatic glycation and cortical porosity on the fracture toughness of aging bone.

The risk of fracture increases with age due to the decline of bone mass and bone quality. One of the age-related changes in bone quality occurs through the formation and accumulation of advanced glycation end-products (AGEs) due to non-enzymatic glycation (NEG). However as a number of other changes including increased porosity occur with age and affect bone fragility, the relative contribution of AGEs on the fracture resistance of aging bone is unknown. Using a high-resolution nonlinear finite element model that incorporate cohesive elements and micro-computed tomography-based 3d meshes, we investigated the contribution of AGEs and cortical porosity on the fracture toughness of human bone. The results show that NEG caused a 52% reduction in propagation fracture toughness (R-curve slope). The combined effects of porosity and AGEs resulted in an 88% reduction in propagation toughness. These findings are consistent with previous experimental results. The model captured the age-related changes in the R-curve toughening by incorporating bone quantity and bone quality changes, and these simulations demonstrate the ability of the cohesive models to account for the irreversible dynamic crack growth processes affected by the changes in post-yield material behavior. By decoupling the matrix-level effects due to NEG and intracortical porosity, we are able to directly determine the effects of NEG on fracture toughness. The outcome of this study suggests that it may be important to include the age-related changes in the material level properties by using finite element analysis towards the prediction of fracture risk.

Non-enzymatic glycation alters microdamage formation in human cancellous bone.

INTRODUCTION: The accumulation of advanced glycation end-products (AGEs) in bone has been suggested to adversely affect the fracture resistance of bone with aging, diabetes, and pharmacological treatments. The formation of AGEs increases crosslinking in the organic matrix of bone but it is unknown how elevated levels of AGEs affect the mechanisms of fracture resistance such as microdamage formation. METHODS: Human tibial cancellous bone cores were subjected to non-enzymatic glycation (NEG) by in vitro ribosylation and were mechanically loaded to pre- (0.6%) and post- (1.1%) yield apparent level strains. Loaded specimens were stained with lead-uranyl acetate and subjected to microCT-based 3D quantification and characterization of microdamage as either diffuse damage and linear microcracks. Damaged volume per bone volume (DV/BV) and damaged surface per damaged volume (DS/DV) ratios were used to quantify the volume and morphology of the detected microdamage, respectively. RESULTS: In vitro ribosylation increased the microdamage morphology parameter (DS/DV) under both pre- (p<0.05; +51%) and post-yield loading (p<0.001; +38%), indicating that the alteration of bone matrix by NEG caused the formation of crack-like microdamage morphologies. Under post-yield loading, the NEG-mediated increase in DS/DV was coupled with the reductions in microdamage formation (DV/BV; p<0.001) and toughness (p<0.001). DISCUSSION: Using a novel microCT technique to characterize and quantify microdamage, this study shows that the accumulation of AGEs in the bone matrix significantly alters the quantity and morphology of microdamage production and results in reduced fracture resistance.

Translational aspects of bone quality--vertebral fractures, cortical shell, microdamage and glycation: a tribute to Pierre D. Delmas.

Among vertebral deformities, the prevalence of wedge fractures is about twice that of endplate (biconcave) deformities, both of which are greater than that of crush deformities. The anterior cortex is, therefore, a site of interest for understanding mechanisms of vertebral fracture. Despite its importance to vertebral mechanics, there are limited data describing the role of cortical shell, microdamage, and bone matrix parameters in vertebral fragility. This review of literature emphasizes the translational aspects of bone quality and demonstrates that a greater understanding of bone fractures will be gained through bone quality parameters related to both cortical and cancellous compartments as well as from microdamage and bone matrix parameters. In the context of vertebral fractures, measures of cortical shell and bone matrix parameters related to the organic matrix (advanced glycation products and alpha/beta CTX ratio) are independent of BMD measurements and can therefore provide an additional estimate of fracture risk in older patients.

Changes in non-enzymatic glycation and its association with altered mechanical properties following 1-year treatment with risedronate or alendronate.

SUMMARY: One year of high-dose bisphosphonate (BPs) therapy in dogs allowed the increased accumulation of advanced glycation end-products (AGEs) and reduced postyield work-to-fracture of the cortical bone matrix. The increased accumulation of AGEs in these tissues may help explain altered bone matrix quality due to the administration of BPs in animal models INTRODUCTION: Non-enzymatic glycation (NEG) is a posttranslational modification of the organic matrix that results in the formation of advanced glycation end-products (AGEs). In bone, the accumulation of AGEs play an important role in determining fracture resistance, and elevated levels of AGEs have been shown to adversely affect the bone's propensity to brittle fracture. It was thus hypothesized that the suppression of tissue turnover in cortical bone due to the administration of bisphosphonates would cause increased accumulation of AGEs and result in a more brittle bone matrix. METHODS: Using a canine animal model (n = 12), we administered daily doses of a saline vehicle (VEH), alendronate (ALN 0.20, 1.00 mg/kg) or risedronate (RIS 0.10, 0.50 mg/kg). After a 1-year treatment, the mechanical properties, intracortical bone turnover, and the degree of nonenzymatic cross-linking of the organic matrix were measured from the tibial cortical bone tissue of these animals. RESULTS: There was a significant accumulation of AGEs at high treatment doses (+49 to + 86%; p < 0.001), but not at doses equivalent to those used for the treatment of postmenopausal osteoporosis, compared to vehicle. Likewise, postyield work-to-fracture of the tissue was significantly reduced at these high doses (-28% to -51%; p < 0.001) compared to VEH. AGE accumulation inversely correlated with postyield work-to-fracture (r (2) = 0.45; p < 0.001), suggesting that increased AGEs may contribute to a more brittle bone matrix. CONCLUSION: High doses of bisphosphonates result in the accumulation of AGEs and a reduction in energy absorption of cortical bone. The increased accumulation of AGEs in these tissues may help explain altered bone matrix quality due to the administration of BPs in animal models.

A non-invasive in vitro technique for the three-dimensional quantification of microdamage in trabecular bone.

An accurate analysis and quantification of microdamage is critical to understand how microdamage affects the mechanics and biology of bone fragility. In this study we demonstrate the development and validation of a novel in vitro micro-computed tomography (microCT) method that employs lead-uranyl acetate as a radio-opaque contrast agent for automated quantification of microdamage in trabecular bone. Human trabecular bone cores were extracted from the femoral neck, scanned via microCT, loaded in unconfined compression to a range of apparent strains (0.5% to 2.25%), stained in lead-uranyl acetate, and subsequently re-scanned via microCT. An investigation of the regions containing microdamage using the backscatter mode of a scanning electron microscope (BSEM) showed that the lead-uranyl sulfide complex was an effective contrast agent for microdamage in bone. Damaged volume fraction (DV/BV), as determined by microCT, increased exponentially with respect to applied strains and proportionately to mechanically determined modulus reduction (p<0.001). Furthermore, the formation of microdamage was observed to occur before any apparent stiffness loss, suggesting that the localized tissue yielding occurs prior to the structural yielding of trabecular bone. This non-invasive in vitro technique for the detection of microdamage using microCT may serve as a valuable complement to existing morphometric analyses of bone.

Effects of non-enzymatic glycation on cancellous bone fragility.

Post-translational modifications of collagen, such as non-enzymatic glycation (NEG), occur through the presence of extracellular sugars and cause the formation of advanced glycation end-products (AGEs). While AGEs have been shown to accumulate in a variety of collagenous human tissues and alter the tissues' functional behavior, the role of AGEs in modifying the mechanical properties of cancellous bone is not well understood. In this study, an in vitro ribosylation model was used to examine the effect of NEG on the mechanical behavior of cancellous bone. Cancellous bone cores and individual trabeculae were harvested from the femoral heads of eight fresh human cadavers and paired for ribosylation and control treatments. The cores were subjected to either unconfined compression tests or were demineralized and subjected to stress relaxation tests. The trabeculae were loaded to fracture in four-point bending. In vitro NEG significantly reduced the energy dissipation characteristics of the organic matrix as well as the post-yield properties including the stiffness loss of the individual trabeculae (p<0.05) and the damage fraction of cancellous bone (p<0.001). AGEs in cancellous bone cores from both treatment groups correlated with damage fraction (r(2)=0.36, p<0.05) and post-yield strain energy (r(2)=0.21, p<0.05); and with energy dissipation characteristics of the organic matrix (r(2)=0.35, p<0.05). In the control group, AGEs content increased up to six-fold with age (r(2)=0.95, p<0.008). This study shows that cancellous bone is susceptible to NEG that increases its propensity to fracture. Moreover, despite tissue turnover, cancellous bone may be susceptible to an age-related accumulation of AGEs.

Susceptibility of aging human bone to mixed-mode fracture increases bone fragility.

Since bone-mass-based measurements have demonstrated limited success in predicting age-related increase in fracture incidence, recent emphasis has been placed on quantification of bone quality. Specifically, material parameters such as strength, stiffness, and toughness have been quantified to characterize bone quality through mechanical testing. This study is the first one to report multiaxial failure characteristics of bone (quality) by conducting fatigue tests on human cortical bone specimens under physiologically relevant loading involving simultaneous application of axial and torsional loading to produce previously reported in vivo shear/normal stress ratios. Our results show that, compared to uniaxial tests, multiaxial fatigue tests show up to a 20-fold reduction in the fatigue life of human cortical bone. More significantly, the susceptibility of mixed-mode failure increases bone fragility in aging human bone. Furthermore, since the magnitude of mixed-mode loading varies with physiological activities, results of this study also suggest that a reduction in the activities involving significant mixed-mode loading may lower the overall fracture incidence among older individuals.

Damage mechanisms and failure modes of cortical bone under components of physiological loading.

Fatigue damage development in cortical bone was investigated in vitro under different mechanical components of physiological loading including tension, compression, and torsion. During each test, stress and strain data were collected continuously to monitor and statistically determine the occurrence of the primary, secondary, and tertiary stages associated with fatigue and/or creep failure of bone. The resultant microdamage and failure modes were identified by histological and fractographic analysis, respectively. The tensile group demonstrated Mode I cracking and the three classic stages of fatigue and creep suggesting a low crack initiation threshold, steady crack propagation and final failure by coalescence of microcracks. In contrast, the compressive group displayed Mode II cracking and a two-stage fatigue behavior with limited creep suggesting a high crack initiation threshold followed by a sudden fracture. The torsion group also displayed a two-stage fatigue profile but demonstrated extensive damage from mixed mode (Modes II and III) microcracking and predominant time-dependent damage. Thus, fatigue behavior of bone was found to be uniquely related to the individual mechanical components of physiological loading and the latter determined the specific damage mechanisms associated with fatigue fracture.

Age-dependent fatigue behaviour of human cortical bone.

Despite a general understanding that bone quality contributes to skeletal fragility, very little information exits on the age-dependent fatigue behavior of human bone. In this study four-point bending fatigue tests were conducted on aging bone in conjunction with the analysis of stiffness loss and preliminary investigation of nanoindentation based measurements of local tissue stiffness and histological evaluation of resultant tensile and compressive damage to identify the damage mechanism responsible for the increase in age-related bone fragility. The results obtained show that there is an exponential decrease in fatigue life with age, and old bone exhibits different modulus degradation profiles than young bone. In addition, this study provides preliminary evidence indicating that during fatigue loading, younger bone formed diffuse damage, lost local tissue stiffness on the tensile side. Older bone, in contrast, formed linear microcracks lost local tissue stiffness on the compressive side. Thus, the propensity of aging human bone to form more linear microcracks than diffuse damage may be a significant contributor to bone quality, and age related fragility in bone.

Effects of damage morphology on cortical bone fragility.

Despite a general understanding that bone microdamage has distinct strain dependent morphologies, very little information exists on how different damage morphologies develop and participate in bone fracture. In this study, cortical bone beams were subjected to the primary or tertiary phases of bending fatigue followed by either post-hoc fracture toughness tests or microdamage analysis to determine the sequence in which linear microcracks and diffuse damage form during bending fatigue and how they affect the propensity of bone to fracture. The results demonstrate that, following the primary phase, linear microcracks and diffuse damage are formed on the compressive and tensile sides, respectively (p<0.05). Furthermore, this mode of damage formation results in a greater toughness loss if a fracture crack initiates from the tensile side rather than the compressive side (p<0.05). Continued loading of bone specimens to the tertiary phase, however, leads to further accumulation of damage only on the compressive side (p<0.05), and this mode of damage formation results in a further toughness loss if a fracture crack initiates from the compressive side rather than the tensile side (p<0.05). Thus, cortical bone compartmentalizes the damage morphologies in different regions and the sequence of damage production in different phases of cyclic loading to dissipate energy and resist a catastrophic fracture.

Influence of phase angle between axial and torsional loadings on fatigue fractures of bone.

Fatigue fractures of cortical bone involve combined axial-torsional loading yet it is unknown how the relationship between axial and torsional loadings affects the fatigue behavior of bone. In this study the effect of superimposing in-phase and out-of-phase torsional on axial loading on the fatigue behavior of bone was investigated by conducting in vitro tests involving 0 degrees and 90 degrees phase shift between cyclic torsional and axial loadings. Results obtained indicate that fatigue life, patterns of moduli loss, microcracking and modes of fractures are dependent on the phase angle between axial and torsional loadings. Specimens subjected to in-phase torsional on axial loading demonstrated greater mixed mode interaction, underwent proportionate stiffness losses in tension, compression, and torsion, and consequently had a shorter fatigue life. In contrast, specimens subjected to out-of-phase loading regime displayed a smaller contribution of mixed mode failure, underwent a disproportionately large stiffness loss in torsion, and had a longer fatigue life. Furthermore, increase in phase angle provided additional planes on which damage was diffused delaying the final failure. Change in phase angle, seen in vivo during a number of physiological activities including walking, running and sprinting, will therefore affect fatigue behavior and contribute to pathogenesis of fatigue fractures.

Experimental validation of a microcracking-based toughening mechanism for cortical bone.

It has been proposed that cortical bone derives its toughness by forming microcracks during the process of crack propagation (J. Biomech. 30 (1997) 763; J. Biomech. 33 (2000) 1169). The purpose of this study was to experimentally validate the previously proposed microcrack-based toughening mechanism in cortical bone. Crack initiation and propagation tests were conducted on cortical bone compact tension specimens obtained from the antlers of red deer. For these tests, the main fracture crack was either propagated to a predetermined crack length or was stopped immediately after initiating from the notch. The microcracks produced in both groups of specimens were counted in the same surface area of interest around and below the notch, and crack growth resistance and crack propagation velocity were analyzed. There were more microcracks in the surface area of interest in the propagation than in initiation specimens showing that the formation of microcracks continued after the initiation of a fracture crack. Crack growth resistance increased with crack extension, and crack propagation velocity vs. crack extension curves demonstrated the characteristic jump increase and decrease pattern associated with the formation of microcracks. The scanning electron micrographs of crack initiation and propagation displayed the formation of a frontal process zone and a wake, respectively. These results support the microcrack-based toughening mechanism in cortical bone. Bone toughness is, therefore, determined by its ability to form microcracks during fracture.