Differentiation of the bone-tissue remodeling response to axial and torsional loading in the turkey ulna

Molecular pathways mediating mechanical signaling in bone

Bone tissue has the capacity to adapt to its functional environment such that its morphology is "optimized" for the mechanical demand. The adaptive nature of the skeleton poses an interesting set of biological questions (e.g., how does bone sense mechanical signals, what cells are the sensing system, what are the mechanical signals that drive the system, what receptors are responsible for transducing the mechanical signal, what are the molecular responses to the mechanical stimuli). Studies of the characteristics of the mechanical environment at the cellular level, the forces that bone cells recognize, and the integrated cellular responses are providing new information at an accelerating speed. This review first considers the mechanical factors that are generated by loading in the skeleton, including strain, stress and pressure. Mechanosensitive cells placed to recognize these forces in the skeleton, osteoblasts, osteoclasts, osteocytes and cells of the vasculature are reviewed. The identity of the mechanoreceptor(s) is approached, with consideration of ion channels, integrins, connexins, the lipid membrane including caveolar and non-caveolar lipid rafts and the possibility that altering cell shape at the membrane or cytoskeleton alters integral signaling protein associations. The distal intracellular signaling systems on-line after the mechanoreceptor is activated are reviewed, including those emanating from G-proteins (e.g., intracellular calcium shifts), MAPKs, and nitric oxide. The ability to harness mechanical signals to improve bone health through devices and exercise is broached. Increased appreciation of the importance of the mechanical environment in regulating and determining the structural efficacy of the skeleton makes this an exciting time for further exploration of this area.

Phylogenetic Signal in Bone Microstructure of Sauropsids

In spite of the fact that the potential usefulness of bone histology in systematics has been discussed for over one and a half centuries, the presence of a phylogenetic signal in the variation of histological characters has rarely been assessed. A quantitative assessment of phylogenetic signal in bone histological characters could provide a justification for performing optimizations of these traits onto independently generated phylogenetic trees (as has been done in recent years). Here we present an investigation on the quantification of the phylogenetic signal in the following bone histological, microanatomical, and morphological traits in a sample of femora of 35 species of sauropsids: vascular density, vascular orientation, index of Haversian remodeling, cortical thickness, and cross-sectional area (bone size). For this purpose, we use two methods, regressions on distance matrices tested for significance using permutations (a Mantel test) and random tree length distribution. Within sauropsids, these bone microstructural traits have an optimal systematic value in archosaurs. In this taxon, a Mantel test shows that the phylogeny explains 81.8% of the variation of bone size and 86.2% of the variation of cortical thickness. In contrast, a Mantel test suggests that the phylogenetic signal in histological traits is weak: although the phylogeny explains 18.7% of the variation of vascular density in archosaurs, the phylogenetic signal is not significant either for vascular orientation or for the index of Haversian remodeling. However, Mantel tests seem to underestimate the proportion of variance of the dependent character explained by the phylogeny, as suggested by a PVR (phylogenetic eigenvector) analysis. We also deal with some complementary questions. First, we evaluate the functional dependence of bone vascular density on bone size by using phylogenetically independent contrasts. Second, we perform a variation partitioning analysis and show that the phylogenetic signal in bone vascular density is not a by-product of phylogentic signal in bone size. Finally, we analyze the evolution of cortical thickness in diapsids by using an optimization by squared change parsimony and discuss the functional significance of this character in terms of decreased buoyancy in crocodiles and mass saving in birds. These results are placed in the framework of the constructional morphology model, according to which the variation of a character in a clade has a historical (phylogenetic) component, a functional (adaptive) component, and a structural (architectural) component.

Hibernating bears as a model for preventing disuse osteoporosis

The hibernating bear is an excellent model for disuse osteoporosis in humans because it is a naturally occurring large animal model. Furthermore, bears and humans have similar lower limb skeletal morphology, and bears walk plantigrade like humans. Black bears (Ursus americanus) may not develop disuse osteoporosis during long periods of disuse (i.e. hibernation) because they maintain osteoblastic bone formation during hibernation. As a consequence, bone volume, mineral content, porosity, and strength are not adversely affected by annual periods of disuse. In fact, cortical bone bending strength has been shown to increase with age in hibernating black bears without a significant change in porosity. Other animals require remobilization periods 2-3 times longer than the immobilization period to recover the bone lost during disuse. Our findings support the hypothesis that black bears, which hibernate for as long as 5-7 months annually, have evolved biological mechanisms to mitigate the adverse effects of disuse on bone porosity and strength.

Complications encountered while using thin-wire-hybrid-external fixation modular frames for fracture fixation. A retrospective clinical analysis and possible support for "Damage Control Orthopaedic Surgery"

One hundred ninety eight adult patients who had sustained long bone fractures were treated by external fixation from admission to bone healing and consolidation. Of these, 135 had sustained high-energy injuries, 39 of them had suffered multi-system injuries. Superficial pin track infection was the most common complication, occurring predominantly in pins located in the femur, upper tibia and upper humerus. There were no cases of deep infection or osteomyelitis. One patient with a femoral shaft fracture developed a DVT although he was on preventive low molecular weight heparin, i.e. sc Clexane 40 mg daily. There were no cases of PE or ARDS. External fixation systems are a minimal invasive surgical modality, which allow three-dimensional fracture fixation after closed or minimal open reduction. They require a good command of surgical anatomy, but provide an optimal preservation of the fracture's soft tissue envelope, the critical biological factor for new bone formation and fracture healing. Recent publications have suggested that in the critically ill patient, minimally invasive fracture fixation surgery may prevent the perpetuation of a reactive, life threatening inflammatory reaction (the "second hit") which may induce the development of multiple organ dysfunction (MODS).

Comparative evaluation of implant designs: influence of diameter, length, and taper on strains in the alveolar crest

OBJECTIVES

Our aim was to analyze and compare systematically the relative and interactive effects of implant diameter, length, and taper on calculated crestal bone strains.

MATERIAL AND METHODS

Three-dimensional finite-element models were created of a 20-mm premolar section of the mandible with a single endosseous implant embedded in high- or low-density cancellous bone. Oblique (200-N vertical and 40-N horizontal) occlusal loading was applied. Cortical and cancellous bone were modeled as transversely isotropic and linearly elastic. Perfect bonding was assumed at all interfaces. A two-level factorial statistical design was used to determine the main and interactive effects of four implant design variables on maximum shear strains in the crestal alveolar bone: diameter, length of tapered segment, length of untapered segment, and taper. Implant diameter ranged from 3.5 to 6 mm, total implant length from 5.75 to 23.5 mm, and taper from 0 to 14 degrees , resulting in 16 implant designs.

RESULTS

Increasing implant diameter resulted in as much as a 3.5-fold reduction in crestal strain, increasing length caused as much as a 1.65-fold reduction, whereas taper increased crestal strain, especially in narrow and short implants, where it increased 1.65-fold. Diameter, length, and taper have to be considered together because of their interactive effects on crestal bone strain.

CONCLUSION

If the objective is to minimize peri-implant strain in the crestal alveolar bone, a wide and relatively long, untapered implant appears to be the most favorable choice. Narrow, short implants with taper in the crestal region should be avoided, especially in low-density bone.

Torsional resistance as a principal component of the structural design of long bones: comparative multivariate evidence in birds

Here we study the occurrence of torsion-resisting morphological and histological features (thin bone walls, circular shaft cross-section, oblique collagen fibers, and laminar tissue arrangement) in a sample of 168 long bones from wings and legs of 22 bird species. These structural parameters were measured in mid diaphyseal undemineralized cross-sections and analyzed using uni-, bi-, and multivariate (principal components analysis) data analysis techniques. We found that the four variables are significantly and positively correlated, and that covariation between variables accounts for as much as 58% of the total variation. These results suggest that torsion is a main determinant of the macro- and microstructural design of long bones in birds. Humerus, ulna, and femur generally possess torsion-resisting features, while other bones (radius, carpometacarpus, tibiotarsus, tarsometatarsus, and foot phalanx) rather show bending/axial load-resisting structural properties. These results are congruent with in vivo strain data from the literature, which reported high torsional loading in humerus and ulna during flapping flight, but also in the subhorizontal avian femur during terrestrial locomotion. The precise function of the laminar tissue spatial arrangement, the role of pneumatization, and the influence of flight mode are discussed.

Osteocytic expression of constitutive NO synthase isoforms in the femoral neck cortex: a case-control study of intracapsular hip fracture

NO is an osteocytic signaling molecule that can inhibit osteoclasts. The NO synthases eNOS and nNOS were expressed by >50% of osteonal osteocytes in controls. Hip fracture cases showed +NOS osteocytes only in deep osteonal bone, and 25-35% reduced expression overall. These data are consistent with increased osteonal vulnerability to deep osteoclastic attack.

INTRODUCTION

Osteocytes may regulate the response to mechanical stimuli in bone through the production of local signaling molecules such as NO derived from the NO synthase eNOS. Because NO is inhibitory to osteoclastic resorption, it has been suggested that osteocytes expressing eNOS act as sentinels, confining resorption within single osteons. Recently, nNOS has been shown to be present in osteocytes of adult human bone.

MATERIALS AND METHODS

Cross-sections of the femoral neck (eight female cases of intracapsular hip fracture and seven postmortem controls; age, 68-91 years) were analyzed by immunohistochemistry. The percentages of osteocytes expressing each of these two isoforms were calculated, and their distances to the nearest canal surface were measured.

RESULTS

The percentage of +nNOS osteocytes was lower in the fracture cases than in the controls (cases: 43.12 +/- 1.49, controls: 56.68 +/- 1.45; p < 0.0001). Compared with nNOS, eNOS expression was further reduced (p = 0.009) in the cases but was not different in the controls (cases: 36.41 +/- 1.53, controls: 56.47 +/- 2.41; p < 0.0001). The minimum distance of +eNOS or +nNOS osteocytes to a canal surface was higher in the cases compared with controls (eNOS: controls; 44.4 +/- 2.2 microm, cases: 61.7 +/- 2.0 microm; p < 0.0001; nNOS: controls: 52.4 +/- 1.7 microm, cases: 60.2 +/- 2.1 microm; p = 0.0039). +eNOS osteocytes were closer to the canal surfaces than +nNOS osteocytes in the controls by 8.00 +/- 4.0 microm (p = 0.0012).

CONCLUSION

The proportions of osteocytes expressing nNOS and eNOS were both reduced in the fracture cases, suggesting that the capacity to generate NO might be reduced. Furthermore, the reduction in NOS expression occurs in those osteocytes closest to the canal surface, suggesting that the ability of NO to minimize resorption depth might be impaired. Further studies are needed on the regulation of the expression and activity of these distinct NOS isoforms.

Modulation of bone ingrowth of rabbit femur titanium implants by in vivo axial micromechanical loading

Titanium implants commonly used in orthopedics and dentistry integrate into host bone by a complex and coordinated process. Despite increasingly well illustrated molecular healing processes, mechanical modulation of implant bone ingrowth is poorly understood. The objective of the present study was to determine whether micromechanical forces applied axially to titanium implants modulate bone ingrowth surrounding intraosseous titanium implants. We hypothesized that small doses of micromechanical forces delivered daily to the bone-implant interface enhance implant bone ingrowth. Small titanium implants were placed transcortically in the lateral aspect of the proximal femur in 15 New Zealand White rabbits under general anesthesia and allowed to integrate with the surrounding bone for 6 wk. Micromechanical forces at 200 mN and 1 Hz were delivered axially to the right femur implants for 10 min/day over 12 consecutive days, whereas the left femur implants served as controls. The average bone volume 1 mm from mechanically loaded implants (n = 15) was 73 +/- 12%, which was significantly greater than the average bone volume (52 +/- 21%) of the contralateral controls (n = 15) (P < 0.01). The average number of osteoblast-like cells per endocortical bone surface was 55 +/- 8 cells/mm(2) for mechanically loaded implants, which was significantly greater than the contralateral controls (35 +/- 6 cells/mm(2)) (P < 0.01). Dynamic histomorphometry showed a significant increase in mineral apposition rate and bone-formation rate of mechanically stressed implants (3.8 +/- 1.2 microm/day and 2.4 +/- 1.0 microm(3).microm(-2).day(-1), respectively) than contralateral controls (2.2 +/- 0.92 microm/day and 1.2 +/- 0.60 microm(3).microm(-2).day(-1), respectively; P < 0.01). Collectively, these data suggest that micromechanical forces delivered axially on intraosseous titanium implants may have anabolic effects on implant bone ingrowth.

Bending properties, porosity, and ash fraction of black bear (Ursus americanus) cortical bone are not compromised with aging despite annual periods of disuse

In many species, including humans, disuse causes an imbalance in bone remodeling that leads to increased bone porosity as a result of increased bone resorption and decreased bone formation. However, black bears (Ursus americanus) may not develop disuse osteopenia, to the extent that other animals do, during long periods of disuse (i.e. hibernation) because they maintain osteoblastic bone formation during hibernation, even though bone resorption is increased during hibernation. Black bears may also have a mechanism to rapidly and completely recover the bone lost (by increased resorption during hibernation) during their remobilization period. Our findings suggest that cortical bone bending strength (211-328 MPa), bending modulus (16.0-29.5 MPa), fracture energy (0.0118-0.0205 J mm(-2)), porosity (2.3-7.1%), and ash fraction (0.638-0.672) are not compromised with age in black bears, despite annual periods of disuse. In fact, the ultimate strength (p=0.01), modulus (p=0.04), and ash fraction (p=0.03) of cortical bone were shown to significantly increase with age (2-14 yrs). Female bears give birth and nurse during hibernation; however, we found no significant (p>0.16) differences between male and female bone properties. Other animals require remobilization periods 2-3 times longer than the immobilization period to recover the bone lost during disuse. Our findings support the idea that black bears, which hibernate 5-7 months annually, have evolved a biological mechanism to mitigate the adverse effects of disuse on bone porosity and mechanical behavior.

Lifestyle factors and the development of bone mass and bone strength in young women

OBJECTIVE

To evaluate the contributions of adolescent calcium intake, oral contraceptive use, and exercise on bone mass and bone strength.Study design Eighty white women participated in 10 years of the Penn State Young Women's Health Study, a longitudinal study of community participants. We measured bone mineral mass (g), density (BMD, g/cm(2)), and body composition from dual energy x-ray absorptiometry and estimated proximal femur section modulus (bone bending strength). Calcium intake was determined from 45 days of prospective food records at regular intervals between the ages of 12 and 22 years. Exercise history and oral contraceptive use were assessed by questionnaire.

RESULTS

Daily calcium intakes between the ages of 12 and 22 years ranged from 500 to 1900 mg/d and were not significantly associated with bone gain or bone strength. Oral contraceptive use during adolescence was not correlated with bone or body composition measurements. Femoral neck BMD did not change from 17 to 22 years of age, but section modulus increased 3% (P <.05). Only exercise during adolescence was significantly associated with increased BMD and bone bending strength.

CONCLUSIONS

Adolescent lifestyle patterns can influence young adult bone strength. Our data suggest that exercise is the predominant lifestyle determinant of bone strength for this cohort.

Disorders associated with acute rapid and severe bone loss

We describe a constellation of bone diseases characterized by the common feature of acute, rapid, and severe bone loss accompanied by dramatic fracture rates. These disorders are poorly recognized, resulting mainly from systemic diseases, frailty, immobilization, and immunosuppressive drugs, such as glucocorticoids and the calcineurin inhibitors. The opportunity to prevent or treat fractures is commonly missed because they are often not detected. Ideally, patients need to be identified early and preventative therapy initiated promptly to avoid the rapid bone loss and fractures. The most effective therapy at present seems to be the bisphosphonates, particularly when bone resorption is predominant. However, more severe forms of bone loss that result from an osteoblastic defect and reduced bone formation may benefit potentially more from newer anabolic agents, such as recombinant human parathyroid hormone (rhPTH).

Ontogenetic and regional morphologic variations in the turkey ulna diaphysis: implications for functional adaptation of cortical bone

This study examines relationships between bone morphology and mechanically mediated strain/fluid-flow patterns in an avian species. Using mid-diaphyseal transverse sections of domestic turkey ulnae (from 11 subadults and 11 adults), we quantified developmental changes in predominant collagen fiber orientation (CFO), mineral content (%ash), and microstructure in cortical octants or quadrants (i.e., %ash). Geometric parameters were examined using whole mid-diaphyseal cross-sections. The ulna undergoes habitual bending and torsion, and demonstrates nonuniform matrix fluid-flow patterns, and high circumferential strain gradients along the neutral axis (cranial-caudal) region at mid-diaphysis. The current results showed significant porosity differences: 1) greater osteocyte lacuna densities (N.Lac/Ar) (i.e., "non-vascular porosity") in the caudal and cranial cortices in both groups, 2) greater N.Lac/Ar in the pericortex vs. endocortex in mature bones, and 3) greater nonlacunar porosity (i.e., "vascular porosity") in the endocortex vs. pericortex in mature bones. Vascular and nonvascular porosities were not correlated. There were no secondary osteons in subadults. In adults, the highest secondary osteon population densities and lowest %ash occurred in the ventral-caudal, caudal, and cranial cortices, where shear strains, circumferential strain gradients, and fluid displacements are highest. Changes in thickness of the caudal cortex explained the largest proportion of the age-related increase in cranial-caudal breadth; the thickness of other cortices (dorsal, ventral, and cranial) exhibited smaller changes. Only subadult bones exhibited CFO patterns corresponding to habitual tension (ventral) and compression (dorsal). These CFO variations may be adaptations for differential mechanical requirements in "strain-mode-specific" loading. The more uniform oblique-to-transverse CFO patterns in adult bones may represent adaptations for shear strains produced by torsional loading, which is presumably more prevalent in adults. The micro- and ultrastructural heterogeneities may influence strain and fluid-flow dynamics, which are considered proximate signals in bone adaptation.

Patterns of osteocytic endothelial nitric oxide synthase expression in the femoral neck cortex: differences between cases of intracapsular hip fracture and controls

Evidence indicates that extensive amalgamation of adjacent resorbing osteons is responsible for destroying the microstructural integrity of the femoral neck's inferior cortex in osteoporotic hip fracture. Such osteonal amalgamation is likely to involve a failure to limit excessive resorption, but its mechanistic basis remains enigmatic. Nitric oxide (NO) inhibits osteoclastic bone destruction, and in normal bone cells its generation by endothelial nitric oxide synthase (eNOS, the predominant bone isoform) is enhanced by mechanical stimuli and estrogen, which both protect against fracture. To determine whether eNOS expression in osteocytes reflects their proposed role in regulating remodeling, we have examined patterns of osteocyte eNOS immunolabeling in the femoral neck cortex of seven cases of hip fracture and seven controls (females aged 68-96 years). The density of eNOS+ cells (mm(-2)) was 53% lower in the inferior cortex of the fracture cases (p < 0.0004), but was similar in the superior cortex. eNOS+ osteocytes were, on average, 22% further from their nearest blood supply, than osteocytes in general (p < 0.0001) and the nearest eNOS+ osteocyte was 57% further from its nearest canal surface (p < 0.0001). This differential distribution of eNOS+ osteocytes was significantly more pronounced in the cortices of fracture cases (p < 0.0001). We conclude that the normal regional and osteonal pattern of eNOS expression by osteocytes is disrupted in hip fracture, particularly at sites that are loaded most by physical activity. These results suggest that eNOS+ osteocytes may normally act as sentinels confining resorption within single osteons. A reduction in their number, coupled to an increase in their remoteness from canal surfaces, may thus permit the irreversible merging of resorbing osteons, and thus contribute to the marked increase in the fragility of osteoporotic bone.

Material properties of interstitial lamellae reflect local strain environments

The objective of this study was to determine if the material properties of bone at the lamellar level are related to the predominant mode and magnitude of mechanical strain experienced in situ. The tibia and first metatarsal bones of five unpaired cadaveric lower extremities were instrumented with strain gauge rosettes and subjected to repeated loading trials in an apparatus that replicates the muscle forces and external loads experienced by the foot and shank while walking. The spatial distributions of axial strain within diaphyseal cross-sections taken from each bone were subsequently determined. Nanoindentation measurements were then performed on the same cross-sections to determine the compressive elastic moduli of individual lamellae located within osteonal, interstitial, and outer circumferential microstructures. Twenty percent of the variance in interstitial elastic modulus within cross-sections of diaphyseal bone was explained by local strain magnitude. Lamellae residing in regions of compressive strain displayed significantly higher compressive elastic modulus values than those located in predominantly tensile regions (19.9 +/- 1.6 GPa compared to 17.9 +/- 1.7 GPa, p < 0.05). Elastic moduli of interstitial lamellae were 11% greater than those of osteonal or outer circumferential lamellae, irrespective of strain or anatomical location (p < 0.001). Differences exist in the material properties of individual bone lamellae located within different anatomical regions and different microstructures, and these differences are related to the distribution of axial strain. These findings suggest that mechanical strain, or another closely related variable, may influence the design and ultimate mechanical behavior of the extra-cellular matrix found in lamellar bone. This tissue heterogeneity is of potential importance in bone fragility and adaptation.

Contact Stresses in the Human Hip: Implications for Disease and Treatment

Contact stresses in the hip articular surfaces relate in some way to normal maintenance as well as destruction of joints. In vivo determinations of cartilage-on-cartilage contact pressure histories have never been reported, and current technology does not allow such measurements without the potential for artifact: all experimental methods require introducing some material between the surfaces, and all numerical methods have yet to be fully validated. Nonetheless, a variety of distinct experimental and numerical approaches lead to estimates of contact stresses and surprisingly, despite the choice of technique, values for peak contact stresses lie within a range of one order of magnitude (i.e. 0.5–5.0 MPa) and usually closer. Pathological conditions increase this to the range of over 5.0 MPa, while surgical procedures designed to reduce peak pressures theoretically can achieve reductions. Two critical unresolved issues are 1.) What aspect of the contact stress history (e.g. contact stress gradients over time) in fact cause the biological responses? 2.) What level of contact stress history is tolerated by the cartilage? Future research will need to address these critical issues.

The open section effect in a long bone with a longitudinal defect - a theoretical modeling study

A longitudinal defect dramatically alters the stress distribution within a long bone. The altered stress distribution can influence the structural properties of the bone and the stimulus for repair and remodeling of the defect and the surrounding bone. For applied torsion, the defect interrupts the normal shear flow around the bone. Reversal of the shear flow along the inner cortex of the bone is the primary characteristic of the "open-section" effect. Stress concentration effects also produce large stresses at the defect corners. A finite element model of a femur mid-diaphysis with a rectangular defect in the posterior cortex was developed to quantify the femur stress distribution and torsional stiffness for defect widths ranging from one-tenth of the femur outer diameter (0.1 OD) to 0.3 OD, and defect lengths ranging from 0.5 to 5 OD. Defects with a length of 1 OD or shorter had little influence on the femur torsional stiffness or the femur shear-stress distribution. The torsional stiffness decreased most dramatically as the defect length increased from 2 to 3 OD, but began to approach an asymptote near 5 OD. Shear flow reversal peaked at the center of the defect for defects longer than 1 OD, and the magnitude of the reversal began to approach an asymptote near 5 OD. For each defect, the largest stresses within the bone, developed at the defect corners. The results indicate that the open-section effect decreases the torsional stiffness and stress concentration effects decrease the torsional strength of a long bone with a longitudinal defect.

Loading conditions and cortical bone construction of an artiodactyl calcaneus

Customary nonuniform distributions of physiological bone strains are thought to evoke heterogeneous material adaptation in diaphyseal cortices of some limb bones. Recent studies of artiodactyl calcanei have suggested that the regional prevalence of specific mechanical strain features such as mode and magnitude correlate with specific variations in cortical bone ultrastructure, microstructure and mineralization. These data are also consistent with predictions of current algorithms of mechanically induced bone adaptation. However, detailed characterization of the customary functional strain environment of these bones is needed to understand better the mechanisms of these adaptations. An in vitro loading method and rosette strain gauges were used to record principal strains, maximum shear strains and principal strain angles at multiple locations on ten calcanei of adult male mule deer (Odocoileus hemionus hemionus). Each hind limb was fixed in an apparatus to mimic the mid-support phase of the gait and loaded via the Achilles tendon over a broad range of functional loads (0 to 2943 N). Strains were recorded on the craniolateral, craniomedial, caudal, medial and lateral cortices at mid-diaphysis. Loading variations included the progressive elimination of the ligament and tendon along the caudal calcaneus. The results showed that the cranial cortex experiences longitudinal compressive strains that are nearly equal to the principal minimum strains and that the caudal cortex receives longitudinal tensile strains that are nearly equal to the principal maximum strains. With a 981 N load, the mean principal compressive strain on the cranial cortex was −636+/−344 micro(ε) (mean +/− s.d., N=9) and the mean principal tensile strain on the caudal cortex was 1112+/−68 micro;(ε)x (N=9). In contrast to the cranial and caudal cortices, principal strains in the medial and lateral cortices displayed relatively large deviations from the longitudinal axis (medial, 24 degrees cranial; lateral, 27 degrees caudal). Although shear strains predominated at all gauge sites, variations in maximum shear strains showed no apparent regional pattern or consistent regional predominance. The plantar ligament and tendon of the superficial digital flexor muscle were shown to have important load-sharing functions. These results demonstrate that the functionally loaded artiodactyl calcaneus generally behaves like a cantilevered beam with longitudinal compression and tension strains predominating in opposing cranial and caudal cortices, respectively. Differences in osteon remodeling rates, osteon morphology and mineral content reported previously between the cranial and caudal cortices correlate, in part, with the magnitudes of the principal compressive and tensile strains, respectively. However, material differences that distinguish the medial and lateral cortices from the cranial and caudal cortices could not be primarily attributed to locally increased shear strains as previously suggested. Variations in osteon and/or collagen fiber orientation may correlate more strongly with principal strain direction.

Does bone perfusion/reperfusion initiate bone remodeling and the stress fracture syndrome?

Stress fractures have been proposed to arise from repetitive activity of training inducing an accumulation of microfractures in locations of peak strain. However, stress fractures most often occur long before accumulation of material damage could occur; they occur in cortical locations of low, not high, strain; and intracortical osteopenia precedes any evidence of micro-cracks. We propose that this lesion arises from a focal remodeling response to site-specific changes in bone perfusion during redundant axial loading of appendicular bones. Intramedullary pressures significantly exceeding peak arterial pressure are generated by strenuous exercise and, if the exercise is maintained, the bone tissue can suffer from ischemia caused by reduced blood flow into the medullary canal and hence to the inner two-thirds of the cortex. Site specificity is caused by the lack, in certain regions of the cortex, of compensating matrix-consolidation-driven fluid flow which brings nutrients from the periosteal surface to portions of the cortex. Upon cessation of the exercise, re-flow of fresh blood into the vasculature leads to reperfusion injury, causing an extended no-flow or reduced flow to that portion of the bone most strongly denied perfusion during the exercise. This leads to a cell-stress-initiated remodeling which ultimately weakens the bone, predisposing it to fracture.

The incidence and influence of abnormal styloid conditions on the etiology of craniomandibular functional disorders

This study aimed to examine the incidence and influence of craniomandibular functional disorders caused by abnormal styloid-stylohyoid chains. Seven hundred sixty-five patients with temporomandibular joint (TMJ) disorders were divided into two groups (with and without radiographically visible abnormal styloid conditions). In the group with abnormal stylohyoid conditions, the etiology of TMJ disorders was further subdivided into poly-, oligo- and monoetiological factors, and, after this classification, evaluated regarding a clear, possible or unlikely involvement of abnormal stylohyoid conditions in TMJ disorders. One hundred thirty-six out of 765 patients presented abnormal styloid-stylohyoid chains. One hundred five of the patients (77.2%) demonstrated polyetiological causes of TMJ symptoms with an unlikely involvement of the abnormal styloid-stylohyoid chain. Twenty-nine of the patients (21.3%) showed oligoetiological causes with possible involvement of the abnormal styloid-stylohyoid chain. In two patients (1.5%), the abnormal styloid conditions showed up as the only definite cause of TMJ symptoms (monoetiological). Detailed knowledge of variations and possible effects of suprahyoid structures is important for an accurate diagnosis of TMJ disorders. All in all, the incidence of a stylohyoid involvement in TMJ disorders is very low. However, after an initial subdivision into abnormal and normal stylohyoid conditions, the incidence of pathological stylohyoid chains gains significant importance in the etiology of TMJ disorders.

Loading of healing bone, fibrous tissue, and muscle: implications for orthopaedic practice

One of the most important concepts in orthopaedics in this century is the understanding that loading accelerates healing of bone, fibrous tissue, and skeletal muscle. Basic scientific and clinical investigations have shown that these tissues respond to certain patterns of loading by increasing matrix synthesis and in many instances by changing the composition, organization, and mechanical properties of their matrices. Although new approaches to facilitate bone and fibrous tissue healing have shown promise (e.g., the use of cytokines, cell transplants, and gene therapy), none has been proved to offer beneficial effects comparable to those produced by loading of healing tissues. For these reasons, patients with musculoskeletal injuries and those who have recently undergone surgery are now being treated with controlled physical activity that loads their healing tissues. Evaluation of new approaches to the promotion of healing of bone, fibrous tissue, and muscle should include consideration of the effects of loading on tissue repair and remodeling.

Osteocyte hypoxia: a novel mechanotransduction pathway

Bone is a unique tissue in which to examine mechanotransduction due to its essential role in weight bearing. Within bone, the osteocyte is an ideal cellular mechanotransducer candidate. Because osteocytes reside distant from the blood supply, their metabolic needs are met by a combination of passive diffusion and enhanced diffusion, arising when the tissue is loaded during functional activity. Therefore, we hypothesized that depriving a bone of mechanical loading (and thus eliminating diffusion enhanced by loading) would rapidly induce osteocyte hypoxia. Using the avian ulna model of disuse osteopenia, we found that 24 h of unloading results in significant osteocyte hypoxia (8.4 +/- 1.8%) compared with control levels (1.1 +/- 0.5%; P = 0.03). Additionally, we present preliminary data suggesting that a brief loading regimen is sufficient to rescue osteocytes from this fate. The rapid onset of the observed osteocyte hypoxia, the inhibition of hypoxia by brief loading, and the cellular consequences of oxygen deprivation are suggestive of a novel mechanotransduction pathway with implications across organ systems.

Steady and transient fluid shear stress stimulate NO release in osteoblasts through distinct biochemical pathways

Fluid flow has been shown to be a potent stimulus in osteoblasts and osteocytes and may therefore play an important role in load-induced bone remodeling. The objective of this study was to investigate the characteristics of flow-activated pathways. Previously we reported that fluid flow stimulates rapid and continuous release of nitric oxide (NO) in primary rat calvarial osteoblasts. Here we demonstrate that flow-induced NO release is mediated by shear stress and that this response is distinctly biphasic. Transients in shear stress associated with the onset of flow stimulated a burst in NO production (8.2 nmol/mg of protein/h), while steady flow stimulated sustained NO production (2.2 nmol/mg of protein/h). Both G-protein inhibition and calcium chelation abolished the burst phase but had no effect on sustained production. Activation of G-proteins stimulated dose-dependent NO release in static cultures of both calvarial osteoblasts and UMR-106 osteoblast-like cells. Pertussis toxin had no effect on NO release. Calcium ionophore stimulated low levels of NO production within 15 minutes but had no effect on sustained production. Taken together, these data suggest that fluid shear stress stimulates NO release by two distinct pathways: a G-protein and calcium-dependent phase sensitive to flow transients, and a G-protein and calcium-independent pathway stimulated by sustained flow.

Increased expression of matrix metalloproteinase-1 in osteocytes precedes bone resorption as stimulated by disuse: evidence for autoregulation of the cell's mechanical environment?

An in vivo animal model of bone adaptation was used to examine a possible role for matrix metalloproteinase-1 in the local mediation of bone remodeling: to corrode the coupling of osteocytes to the matrix in an attempt to autoregulate the cell's perception of its mechanical environment. Twelve young (12-16 months old) skeletally mature turkeys were separated into groups to be studied for stimulus periods of either 3 or 30 days. In each animal, the left ulna was functionally isolated and subjected to either disuse or 3,000 microstrain at 1 Hz for 10 minutes per day. The right ulna remained intact and served as an intra-animal control. No significant differences in bone area were detected at 3 days; however, ulnae subjected to disuse lost 8 +/- 4% (+/-SD) of bone area by 30 days. Over the same period, ulnae subjected to the mechanical stimulus gained 21 +/- 9% of bone area. With use of in situ reverse transcription-polymerase chain reaction, less than 2% of the osteocytes examined from the intact control ulnae stained positively for matrix metalloproteinase-1 mRNA. An antibody raised against matrix metalloproteinase-1 revealed no positively labeled osteocytes in the intact ulnae. This low percentage of osteocytes expressing matrix metalloproteinase-1 mRNA was similar to that seen in ulnae subjected to the osteogenic mechanical stimuli. In contrast, ulnae subjected to either 3 or 30 days of disuse showed evidence of matrix metalloproteinase-1 mRNA activity in a high percentage of osteocytes (89 +/- 5 and 66 +/- 8%, respectively; each time point significantly different from intact ulnae, as well as from each other, p < 0.05). The percentage of osteocytes labeled with the anti-matrix metalloproteinase-1 antibody was also highly elevated following 3 days of disuse (74 +/- 17%). These data demonstrate that an early response of bone to disuse is the upregulation of matrix metalloproteinase-1 activity in osteocytes. It is proposed that this upregulation of collagenase activity is indicative of the cell's degradation of coupling to the matrix, and it thus reflects the osteocyte's regulation of its own mechanical environment. We believe that such autoregulation of the osteocyte's physical environment will accommodate subtle changes in the bone's functional environment without the need to add or resorb bone tissue.

Bone hyperemia precedes disuse-induced intracortical bone resorption

An in vivo model was used to determine whether bone hyperemia precedes increased intracortical porosity induced by disuse. Twenty-four adult male roosters (age 1 yr) were randomly assigned to intact-control, 7-days-sham-surgery, 7-days-disuse, and 14-days-disuse groups. Disuse was achieved by isolating the left ulna diaphysis from physical loading via parallel metaphyseal osteotomies. The right ulna served as an intact contralateral control. Colored microspheres were used to assess middiaphyseal bone blood flow. Bone blood flow was symmetric between the left and right ulnae of the intact-control and sham-surgery groups. After 7 days of disuse, median (+/-95% confidence interval) standardized blood flow was significantly elevated compared with the contralateral bone (6.5 +/- 5.2 vs. 1.0 +/- 0.8 ml x min-1 x 100 g-1; P = 0.03). After 14 days of disuse, blood flow was also elevated but to a lesser extent. Intracortical porosity in the sham-surgery and 7-days-disuse bones was not elevated compared with intact-control bones. At 14 days of disuse, the area of intracortical porosity was significantly elevated compared with intact control bones (0.015 +/- 0.02 vs. 0. 002 +/- 0.002 mm2; P = 0.03). We conclude that disuse induces bone hyperemia before an increase in intracortical porosity. The potential interaction between bone vasoregulation and bone cell dynamics remains to be studied.

Randomized controlled study of effects of sudden impact loading on rat femur

Physical loading creating high peak strains on the skeleton at high strain rates is suggested to be the most effective type of activity in terms of bone mineral acquisition. This study assessed the effects of sudden impact loading on mineral and mechanical bone properties in 13-week-old Sprague-Dawley rats. The rats were randomly assigned as sedentary controls (SED, n = 10), control animals receiving low-intensity exercise (EX, n = 15), and experimental animals receiving low-intensity exercise combined with sudden impact-loading (EX + IMP, n = 15). In the EX group, the rats walked in a walking mill at a speed of 10 cm/s for 20 minutes/day, 5 days/week for 9 weeks. In the EX + IMP group, the program was identical to the EX group except for the additional sudden impacts administered to their skeleton during the walking exercise. At the start, there were 50 impacts per session, after which their number was gradually increased to 200 impacts per session by week 6 and then kept constant until the end of the experiment, week 9. These horizontally and vertically directed body impacts were produced by a custom-made walking mill equipped with computer-controlled high-pressure air cylinders. After sacrifice, both femora of each rat were removed and their dimensions, bone mineral content (BMC) by dual-energy X-ray absorptiometry, and mechanical properties by femoral shaft three-point bending and femoral neck compression were determined. The cortical wall thickness increased significantly in the EX and EX + IMP groups as compared with SEDs (+7.6%, p = 0.049 and +10%, p = 0.020, respectively). The EX + IMP group showed +9.0% (p = 0.046) higher cross-sectional moment of inertia values than the EX group. No significant intergroup differences were seen in the BMC values, while the breaking load of the femoral shaft (EX + IMP vs. SED +8.8%,p = 0.047) and femoral neck (EX + IMP vs. SED +14.1%, p = 0.013) was significantly enhanced by the impact loading. In conclusion, this study indicates that mechanical loading can substantially improve the mechanical characteristics of a rat femur without simultaneous gain in its mineral mass. If this is true in humans too, our finding gives an interesting perspective to the numerous longitudinal exercise studies (of women) in which the exercise-induced gains in bone mass and density have remained mild to moderate only.

Fracture site motion with Ilizarov and "hybrid" external fixation

OBJECTIVES

To evaluate differences in fracture site motion by using different external fixators.

DESIGN

A wooden dowel was used to simulate a long bone with a transverse diaphyseal fracture. Ilizarov, "hybrid," and strutaugmented "hybrid" external fixation was used to stabilize the "fracture." The wooden dowel was subjected to separate axial, four-point bending, and torsional loads. Fracture site motion in the axial plane, off-axis motion (shear and bending), and rotation were measured.

SETTING

All mechanical testing was performed with a sevohydraulic test frame (MTS Systems, Minneapolis, MN, U.S.A.). Fracture site motion was measured with an interfragment motion device developed in this laboratory.

INTERVENTION

Comparison was made between a traditional fourring Ilizarov fixator, a "hybrid" fixator using rings and threaded pins attached by a unilateral aluminum bar, and a "hybrid" fixator augmented with a V-shaped strut.

MAIN OUTCOME MEASUREMENT

Load-deformation behavior in axial displacement, shear displacement, and bending displacement were compared between the different configurations under identical conditions of axial loading, torsional loading, and four-point bending. In torsional loading, rotational displacement was also measured.

RESULTS

The Ilizarov configuration allowed significantly less off-axis fracture site motion in all loading modes than either "hybrid" configuration while still allowing axial compression of the fracture ends.

CONCLUSIONS

In a completely unstable fracture with poor bone apposition, the mechanical behavior of a four-ring Ilizarov external fixator is superior to the mechanical behavior of a unilateral "hybrid" frame.

Strain gradients correlate with sites of exercise-induced bone-forming surfaces in the adult skeleton

Physical activity is capable of increasing adult bone mass. The specific osteogenic component of the mechanical stimulus is, however, unknown. Using an exogenous loading model, it was recently reported that circumferential gradients of longitudinal normal strain are strongly associated with the specific sites of periosteal bone formation. Here, we used high-speed running to test this proposed relation in an exercise model of bone adaptation. The strain environment generated during running in a mid-diaphyseal tarsometatarsal section was determined from triple-rosette strain gages in six adult roosters (>1 year). A second group of roosters was run at a high speed (1500 loading cycles/day) on a treadmill for 3 weeks. Periosteal surfaces were activated in five out of eight animals. Mechanical parameters as well as periosteal activation (as measured by incorporated fluorescent labels) were quantified site-specifically in 12 30 degrees sectors subdividing a mid-diaphyseal section. The amount of periosteal mineralizing surface per sector correlated strongly (R2 = 0.63) with the induced peak circumferential strain gradients. Conversely, peak strain magnitude and peak strain rate were only weakly associated with the sites of periosteal activation. The unique feature of this study is that a specific mechanical stimulus (peak circumferential strain gradients) was successfully correlated with specific sites of periosteal bone activation induced in a noninvasive bone adaptation model. The knowledge of this mechanical parameter may help to design exercise regimens that are able to deposit bone at sites where increased structural strength is most needed.

Testing the daily stress stimulus theory of bone adaptation with natural and experimentally controlled strain histories

Theories of bone adaptation generally consider that a departure in some feature of the normal homeostatic mechanical stimulus governs mechanical adaptation. Specifically, the 'daily stress stimulus' theory commonly used in computational models of bone adaptation suggests that the mechanical stimulus arises from a synthesis of the peak magnitudes from each loading event during a day. In this study, the homeostatic daily strain history of the adult turkey ulna was established by categorizing and counting the natural wing activities of adult male turkeys over a full 24h period. Strain signals were recorded in vivo for each activity type at three mid-diaphysis sites using stacked rosette strain gages. Following surgical isolation and transverse metaphyseal pinning of the ulnae, additional strain signals were recorded during controlled axial and torsional loading regimens associated with documented maintenance, loss, or addition of bone mass. When the present data were incorporated into the daily stress stimulus formulation, the theory did not consistently discriminate maintenance versus formation regimens, i.e., some maintenance regimens were associated with a substantially higher daily stimulus than some regimens causing bone formation.

Accelerated healing of distal radial fractures with the use of specific, low-intensity ultrasound. A multicenter, prospective, randomized, double-blind, placebo-controlled study

A multicenter, prospective, randomized, double-blind, placebo-controlled clinical trial was conducted to test the efficacy of a specifically programmed, low-intensity, non-thermal, pulsed ultrasound medical device for shortening the time to radiographic healing of dorsally angulated fractures (negative volar angulation) of the distal aspect of the radius that had been treated with manipulation and a cast. Sixty patients (sixty-one fractures) were enrolled in the study within seven days after the fracture. The patients used either an active ultrasound device (thirty fractures) or a placebo device (thirty-one fractures) daily for twenty minutes at home for ten weeks. The two types of devices were identical except that the placebo devices emitted no ultrasound energy. Clinical examination was performed and radiographs were made at one, two, three, four, five, six, eight, ten, twelve, and sixteen weeks after the fracture by each site investigator. The time to union was significantly shorter for the fractures that were treated with ultrasound than it was for those that were treated with the placebo (mean [and standard error], 61 +/- 3 days compared with 98 +/- 5 days; p < 0.0001). Each radiographic stage of healing also was significantly accelerated in the group that was treated with ultrasound as compared with that treated with the placebo. Compared with treatment with the placebo, treatment with ultrasound was associated with a significantly smaller loss of reduction (20 +/- 6 per cent compared with 43 +/- 8 per cent; p < 0.01), as determined by the degree of volar angulation, as well as with a significant decrease in the mean time until the loss of reduction ceased (12 +/- 4 days compared with 25 +/- 4 days; p < 0.04). We concluded that this specific ultrasound signal accelerates the healing of fractures of the distal radial metaphysis and decreases the loss of reduction during fracture-healing.

Strain gradients correlate with sites of periosteal bone formation

We examined the hypothesis that peak magnitude strain gradients are spatially correlated with sites of bone formation. Ten adult male turkeys underwent functional isolation of the right radius and a subsequent 4-week exogenous loading regimen. Full field solutions of the engendered strains were obtained for each animal using animal-specific, orthotropic finite element models. Circumferential, radial, and longitudinal gradients of normal strain were calculated from these solutions. Site-specific bone formation within 24 equal angle pie sectors was determined by automated image analysis of microradiographs taken from the mid-diaphysis of the experimental radii. The loading regimen increased mean cortical area (+/-SE) by 32.3 +/- 10.5% (p = 0.01). Across animals, some periosteal bone formation was observed in every sector. The amount of periosteal new bone area contained within each sector was not uniform. Circumferential strain gradients (r2 = 0.36) were most strongly correlated with the observed periosteal bone formation. SED (a scalar measure of stress/strain magnitude with minimal relation to fluid flow) was poorly correlated with periosteal bone formation (r2 = 0.01). The combination of circumferential, radial, and longitudinal strain gradients accounted for over 60% of the periosteal new bone area (r2 = 0.63). These data indicate that strain gradients, which are readily determined given a knowledge of the bone's strain environment and geometry, may be used to predict specific locations of new bone formation stimulated by mechanical loading.

Correlation of bony ingrowth to the distribution of stress and strain parameters surrounding a porous-coated implant

The ability of shear strains to inhibit bony ingrowth was investigated by use of a transcortical porous-coated cylindrical plug implant in a functionally isolated turkey ulna model in which the mechanical loading environment could be accurately controlled and rigorously defined. The distribution of ingrowth at the bone-implant interface was quantified following 8 weeks of in vivo loading consisting of 100 seconds per day of a 20 Hz sinusoidal stimulus sufficient to cause a local peak strain of approximately 100 microstrain in the cortex at the bone-implant interface in four turkeys. A nonuniform but repeatable pattern of bony ingrowth, from 33 +/- 6 to 72 +/- 6% (mean +/- SE), was observed. The mechanical environment in the vicinity of the bone-implant interface was calculated using a three-dimensional elastic orthotropic finite element model. The general stress-strain state of the bone as predicted by the finite element model was validated in two additional turkeys using four three-element rosette strain gauges, while high resolution moiré interferometry was used to determine the mechanical state of the region immediately adjacent to the implant itself. Shear strains and stresses were evaluated at the interface and correlated to the pattern of bony ingrowth circumscribing the implant interface. Linear regressions between ingrowth and both shear strain and shear stress were negative, with the values of R = -0.75 and R = -0.78 (p < 0.001), respectively, indicating significant inhibition of ingrowth where shear components were maximal. These results suggest that the minimization of shear stress and strain components is a major determinant in achieving successful ingrowth of bone into a prosthesis.