The role of vibration and drainage in femoral impaction bone grafting.

Vibration is commonly used in civil engineering applications to efficiently compact aggregates. This study examined the effect of vibration and drainage on bone graft compaction and cement penetration in an in vitro femoral impaction bone grafting model with the use of 3-dimensional micro-computed tomographic imaging. Three regions were analyzed. In the middle and proximal femoral regions, there was a significant increase in the proportion of bone grafts with a reciprocal reduction in water and air in the vibration-assisted group (P < .01) as compared with the control group, suggesting tighter graft compaction. Cement volume was also significantly reduced in the middle region in the vibration-assisted group. No difference was observed in the distal region. This study demonstrates the value of vibration and drainage in bone graft compaction, with implications therein for clinical application and outcome.

Adult mesenchymal stem cells and impaction grafting: a new clinical paradigm shift.

The demographic challenges of an increasingly aging population emphasize the need for innovative approaches to skeletal reconstruction to augment and repair skeletal tissue lost as a consequence of implant loosening, trauma, degeneration or in situations involving revision surgery requiring bone stock. These clinical imperatives to augment skeletal tissue loss have brought mesenchymal stem cells to the fore in combination with the emerging discipline of tissue engineering. To date, impaction bone grafting for revision hip surgery is a recognized technique to reconstitute bone utilizing morselized allograft to provide a good mechanical scaffold, although with little osteoinductive biological potential. This review details laboratory and clinical examples of a paradigm shift in the application of mesenchymal stem cells with allograft to produce a living composite using the principles of tissue engineering. This step change creates a composite that offers a biological and mechanical advantage over the current gold standard of allograft alone. This translation of tissue engineering concepts into clinical practice offers enormous input into the field of bone regeneration and has implications for translation and future change in skeletal orthopedic practice in an increasingly aging population.

Bone remodelling inside a cemented resurfaced femoral head.

BACKGROUND: Although the short-term performance of modern resurfacing hip arthroplasty is impressive, the long-term performance is still unknown. It is hypothesised that bone remodelling and the resulting changes in stress/strain distribution within the resurfaced femur influence the risk of fixation failure. METHOD: Three-dimensional finite element models and adaptive bone remodelling algorithms have been used to predict long-term changes in bone density following cemented femoral head resurfacing. Applied loading conditions include normal walking and stair climbing. The remodelling simulation was validated by comparing the results of an analysis of a proximal femur implanted with a Charnley femoral component with known clinical data in terms of bone density adaptations. FINDINGS: Resurfacing caused a reduction of strain of 20-70% in the bone underlying the implant as compared to the intact femur, immediately post operative. Elevated strains, ranging between 0.50 and 0.80% strain, were generated post-operatively around the proximal femoral neck regions, indicating a potential risk of neck fracture. However, this strain concentration was considerably reduced after bone remodelling. After remodelling, bone resorption of 60-90% was observed in the bone underlying the implant. Reduction in bone density of 5-47% occurred in the lateral femoral head. Bone apposition was observed in the proximal-medial cortex, around the inferior edge of the implant. Hardly any changes in bone density occurred in the distal neck or the femoral diaphysis. INTERPRETATION: Although resurfacing has produced encouraging clinical results, bone remodelling within the femoral head might be a concern for long-term fixation. Regions of strain concentration at the head-neck junction, which may increase the initial risk of femoral neck fracture, are reduced with bone remodelling. In order to reduce this risk of femoral neck fracture, patients should avoid activities which induce high loading of the hip during the early rehabilitation period after surgery.

The effects of interfacial conditions and stem length on potential failure mechanisms in the uncemented resurfaced femur.

It is hypothesized that changes in stem length and implant-bone interfacial conditions would affect the mechanical environment within the uncemented resurfaced femur, thereby influencing potential short- and long-term failure mechanisms. This study is aimed at investigating the influence of changes in implant-bone interfacial conditions and stem length on eventual failure, using 3D FE models integrated with bone remodeling simulations. Musculoskeletal forces corresponding to normal walking and stair climbing were used as applied loading conditions. Sliding micromotions of 26-72 microm at the implant-bone interfaces for both the stem designs suggest bone ingrowth on the coated surface of the implant was likely. The initial risk of femoral neck fracture was less for the uncemented designs as compared to the cemented designs, irrespective of interfacial conditions and variation in stem length. For the uncemented variety, shortening the stem length provided only slight advantages (5%) with regard to strain shielding and bone remodeling. However, bone resorption was considerably higher when fully bonded interfaces were simulated. It may, therefore, be concluded that cementless fixation seems to be a viable alternative to cemented fixation, provided sufficient initial fixation and secondary stability through bone ingrowth into the coated surface of the implant can be achieved.

Design considerations for ceramic resurfaced femoral head: effect of interface characteristics on failure mechanisms.

Ceramic hip resurfacing may offer improved wear resistance compared to metallic components. The study is aimed at investigating the effects of stiffer ceramic components on the stress/strain-related failure mechanisms in the resurfaced femur, using three-dimensional finite element models of intact and resurfaced femurs with varying stem­bone interface conditions. Tensile stresses in the cement varied between 1 and 5 MPa. Postoperatively, 20­85% strain shielding was observed inside the resurfaced head. The variability in stem­bone interface condition strongly influenced the stresses and strains generated within the resurfaced femoral head. For full stem­bone contact, high tensile (151­158 MPa) stresses were generated at the cup­stem junction, indicating risk of fracture. Moreover, there was risk of femoral neck fracture due to elevated bone strains (0.60­0.80% strain) in the proximal femoral neck region. Stresses in the ceramic component are reduced if a frictionless gap condition exists at the stem­bone interface. High stresses, coupled with increased strain shielding in the ceramic resurfaced femur, appear to be major concerns regarding its use as an alternative material.

Influence of the change in stem length on the load transfer and bone remodelling for a cemented resurfaced femur.

The effect of a short-stem femoral resurfacing component on load transfer and potential failure mechanisms has rarely been studied. The stem length has been reduced by approximately 50% as compared to the current long-stem design. Using 3-D FE models of natural and resurfaced femurs, the study is aimed at investigating the influence of a short-stem resurfacing component on load transfer and bone remodelling. Applied loading conditions include normal walking and stair climbing. The mechanical role of the stem along with implant-cement and stem-bone contact conditions was observed to be crucial. Shortening the stem length to half of the current length (long-stem) led to several favourable effects, even though the stress distributions in the implant and the cement were similar in both the cases. The short-stem implant led not only to a more physiological stress distribution but also to bone apposition (increase of 20-70% bone density) in the superior resurfaced head, when the stem-bone contact prevailed. This also led to a reduction in strain concentration in the cancellous bone around the femoral neck-component junction. The normalised peak strain in this region was lower for the short-stem design as compared to that of the long-stem one, thereby reducing the initial risk of neck fracture. The effect of strain shielding (50-75% reduction) was restricted to a small bone volume underlying the cement, which was approximately half of that of the long-stem design. Consequently, bone resorption was considerably less for the short-stem design. The short-stem design offers better prospects than the long-stem resurfacing component.

Strain and micromotion in intact and resurfaced composite femurs: experimental and numerical investigations.

Understanding the load transfer within a resurfaced femur is necessary to determine the influence of mechanical factors on potential failure mechanisms such as early femoral neck fractures and stress shielding. In this study, an attempt has been made to measure the stem-bone micromotion and implant cup-bone relative displacements (along medial-lateral and anterior-posterior direction), in addition to surface strains at different locations and orientations on the proximal femur and to compare these measurements with those predicted by equivalent FE models. The loading and the support conditions of the experiment were closely replicated in the FE models. A new experimental set-up has been developed, with specially designed fixtures and load application mechanism, which can effectively impose bending and deflection of the tested femurs, almost in any direction. High correlation coefficient (0.92-0.95), low standard error of the estimate (170-379 muepsilon) and low percentage error in regression slope (12.8-17.5%), suggested good agreement between the numerical and measured strains. The effect of strain shielding was observed in two (out of eight) strain gauges located on the posterior side. A pronounced strain increase occurred in strain gauges located on the anterior head and neck regions after implantation. Experimentally measured stem-bone micromotion and implant cup-bone relative displacements (0-13.7 microm) were small and similar in trends predicted by the FE models (0-25 microm). Despite quantitative deviations in the measured and numerical results, it appears that the FE model can be used as a valid predictor of the actual strain and stem-bone micromotion.

Biological and mechanical enhancement of impacted allograft seeded with human bone marrow stromal cells: potential clinical role in impaction bone grafting.

With the demographics of an aging population the incidence of revision surgery is rapidly increasing. Clinical imperatives to augment skeletal tissue loss have brought mesenchymal stem cells to the fore in combination with the emerging discipline of tissue engineering. Impaction bone grafting for revision hip surgery is a recognized technique to reconstitute bone, the success of which relies on a combination of mechanical and biological factors. The use of morsellized allograft is currently the accepted clinical standard providing a good mechanical scaffold with little osteoinductive biological potential. We propose that applying the principles of a tissue engineering paradigm, the combination of human bone marrow stromal cells (hBMSCs) with allograft to produce a living composite, offers a biological and mechanical advantage over the current gold standard of allograft alone. This study demonstrates that hBMSCs combined with allograft can withstand the forces equivalent to a standard femoral impaction and continue to differentiate and proliferate along the bony lineage. In addition, the living composite provides a biomechanical advantage, with increased interparticulate cohesion and shear strength when compared with allograft alone.

Taking tissue-engineering principles into theater: augmentation of impacted allograft with human bone marrow stromal cells.

Human bone marrow contains bone progenitor cells that arise from multipotent mesenchymal stem cells. Seeding bone progenitor cells onto a scaffold can produce a 3D living composite with significant mechanical and biological potential. This article details laboratory and clinical findings from two clinical cases, where different proximal femoral conditions were treated using impacted allograft augmented with marrow-derived autogenous progenitor cells. Autologous bone marrow was seeded onto highly washed morselized allograft and impacted. Samples of the impacted graft were also taken for ex vivo analysis. Both patients made an uncomplicated clinical recovery. Imaging confirmed defect filling with encouraging initial graft incorporation. Histochemical and alkaline phosphatase staining demonstrated that a live composite graft with osteogenic activity had been introduced into the defects. These studies demonstrate that marrow-derived cells can adhere to highly washed morselized allograft, survive the impaction process and proliferate with an osteoblastic phenotype, thus creating a living composite.

A new bleeding model of the human acetabulum and a pilot comparison of 2 different cement pressurizers.

In this cadaver study, we compared 2 different acetabular cement pressurizers (Exeter and Bernoski type) in paired human acetabula with simulated intraosseous bleeding. Pressure transducers were used to record intra-acetabular pressures during pressurization. Anteroposterior radiographs of the entire specimens were taken. Subsequently, standardized 3-mm-thick sections were cut through the acetabula, which were then microradiographed to evaluate cement penetration. Adequate pressurization was obtained with either pressurizer. The peak and sustained pressures obtained with the Exeter pressurizer (peak, 80 kPa; sustained, 38 kPa) tended to be higher than the pressures obtained with the Bernoski pressurizer (73 kPa; 24 kPa; P > 0.05). Accordingly, a tendency toward improved cement penetration into cancellous bone was found using the Exeter pressurizer (P >.05).