In vitro replication of spontaneous fractures of the proximal human femur

Biomechanical evaluation of a central collinear entry reconstruction nail for femoral neck fracture prophylaxis

INTRODUCTION

Reconstruction nails are commonly used to treat proximal femur fractures, with cephalic screw placement for femoral neck "prophylaxis" becoming standard practice. These implants are traditionally introduced through piriformis fossa (PF) or greater trochanter (GT) entry portals. A third "central collinear" (CC) portal has been proposed that allows entry along the femoral anatomic axis and central placement of cephalic screws. The present study aimed to quantify and compare the CC portal femoral neck strength with the two traditional (PF and GT) entry portals.

MATERIALS AND METHODS

Eighteen cadaveric femur specimens (nine matched pairs) were divided into three groups using a balanced incomplete block design to control for variations in age and sex: (1) GT, (2) CC, and (3) PF entry points. Specimens and implants were cut to a standard length and instrumented with straight or valgus bend nails of appropriate laterality and two cephalic screws. Specimens were mounted on a custom jig replicating load distribution along the mechanical axis. A 100 N compressive preload was applied to the femoral head, followed by loading to failure at a rate of 10 mm/s until fracture, indicated by 30 % drop in axial force.

RESULTS

THE THREE ENTRY POINTS DID NOT DIFFER IN LOAD-TO-FAILURE: GT (6378.7 ± 1494.9 N), P (6912.4 ± 4924.1 N) and CC (7044.2 ± 2911.4 N) (P = 0.948) or maximum displacement, stiffness, and toughness. Most PF specimens failed at the basicervical neck, whereas most GT specimens failed at the subcapital neck; these differences were not significant. CC specimens failed evenly split between subcapital and basicervical.

CONCLUSION

There were no significant difference in femoral neck load-to-failure after placement of a reconstruction nail through a CC entry portal when compared to both GT and PF entry. Clinically, this suggests the CC entry portal is a viable option when clinical considerations warrant its use.

Patient-specific finite element analysis for assessing hip fracture risk in aging populations

The femur is one of the most important bone in the human body, as it supports the body's weight and helps with movement. The aging global population presents a significant challenge, leading to an increasing demand for artificial joints, particularly in knee and hip replacements, which are among the most prevalent surgical procedures worldwide. This study focuses on hip fractures, a common consequence of osteoporotic fractures in the elderly population. To accurately predict individual bone properties and assess fracture risk, patient-specific finite element models (FEM) were developed using CT data from healthy male individuals. The study employed ANSYS 2023 R2 software to estimate fracture loads under simulated single stance loading conditions, considering strain-based failure criteria. The FEM bone models underwent meticulous reconstruction, incorporating geometrical and mechanical properties crucial for fracture risk assessment. Results revealed an underestimation of the ultimate bearing capacity of bones, indicating potential fractures even during routine activities. The study explored variations in bone density, failure loads, and density/load ratios among different specimens, emphasizing the complexity of bone strength determination. Discussion of findings highlighted discrepancies between simulation results and previous studies, suggesting the need for optimization in modelling approaches. The strain-based yield criterion proved accurate in predicting fracture initiation but required adjustments for better load predictions. The study underscores the importance of refining density-elasticity relationships, investigating boundary conditions, and optimizing models throughin vitrotesting for enhanced clinical applicability in assessing hip fracture risk. In conclusion, this research contributes valuable insights into developing patient-specific FEM bone models for clinical hip fracture risk assessment, emphasizing the need for further refinement and optimization for accurate predictions and enhanced clinical utility.

QCT-based 3D finite element modeling to assess patient-specific hip fracture risk and risk factors

Early assessment of hip fracture risk may play a critical role in designing preventive mechanisms to reduce the occurrence of hip fracture in geriatric people. The loading direction, clinical, and morphological variables play a vital role in hip fracture. Analyzing the effects of these variables helps predict fractures risk more accurately; thereby suggesting the critical variable that needs to be considered. Hence, this work considered the fall postures by varying the loading direction on the coronal plane (α) and on the transverse plane (β) along with the clinical variables-age, sex, weight, and bone mineral density, and morphological variables-femoral neck axis length, femoral neck width, femoral neck angle, and true moment arm. The strain distribution obtained via finite element analysis (FEA) shows that the angle of adduction (α) during a fall increases the risk of fracture at the greater trochanter and femoral neck, whereas with an increased angle of rotation (β) during the fall, the FRI increases by ∼1.35 folds. The statistical analysis of clinical, morphological, and loading variables (αandβ) delineates that the consideration of only one variable is not enough to realistically predict the possibility of fracture as the correlation between individual variables and FRI is less than 0.1, even though they are shown to be significant (p<0.01). On the contrary, the correlation (R2=0.48) increases as all variables are considered, suggesting the need for considering different variables fork predicting FRI. However, the effect of each variable is different. While loading, clinical, and morphological variables are considered together, the loading direction on transverse plane (β) has high significance, and the anatomical variabilities have no significance.

Biomechanical Behavior of Dynamic vs. Static Distal Locking Intramedullary Nails in Subtrochanteric Femur Fractures

OBJECTIVE

Hip fractures are one of the most frequent fractures presenting to the emergency department and orthopedic trauma teams. The aim of this study was to determine the best indication and therapeutic technique for subtrochanteric fractures and unifying criteria when choosing the most suitable type of nail.

MATERIALS AND METHODS

To analyze the influence of the material and the type of distal locking of intramedullary nails (static or dynamic), a femur model with a fracture in the subtrochanteric region stabilized with a long Gamma intramedullary nail was applied using finite element method (FEM) simulation.

RESULTS

The mechanical study shows that titanium nails allow for greater micromobility at the fracture site, which could act as a stimulus for the formation of callus and consolidation of the fracture. In the mechanical study, the type of distal locking mainly affects mobility at the fracture site and stress in the cortical bone around the distal screws, without in any case exceeding values that may compromise the viability of the assembly or that may result in detrimental effects (in terms of mobility at the fracture site) for the consolidation process.

CONCLUSION

Subtrochanteric fractures treated with titanium nail and static distal locking is safe and does not hinder consolidation.

Experimental and numerical analysis of the influence of intramedullary nail position on the cut-out phenomenon

BACKGROUND AND OBJECTIVE

Proximal femur fractures, colloquially known as hip fractures, are a common pathology with increasing incidence in the last years due to the enhanced ageing population. Regarding the extracapsular fracture, the treatment for this pathology consists of a fixation of the fragments using an osteosynthesis device, mainly the intramedullary nail. This repairing method implies several complications, which may include the failure of the fixation device, frequently occurring due to the "cut-out" mechanism. The present work focuses on the study of how the position of the cephalic screw, which should be fixed during surgery, affects the cut-out risk. Through experimental tests and numerical models some variables that can be critical for the cut-out phenomenon are analysed.

METHODS

This study has been carried out through a numerical model based on the finite element method and experimental tests. The digital image correlation technique has been used in experimental tests to measure displacements on the femoral surface with the objective of numerical model validation. Some basic daily activities with different intramedullary nail positions have been analysed through the numerical model, considering variables that can induce the cut-out complication.

RESULTS

The results show how the intramedullary nail position clearly influences the cut-out risk, showing that displacements in the upper, anterior and posterior direction increase the cut-out risk, while displacement in the lower direction endangers the intramedullary nail itself. Thus, the centred position is the one which reduces the cut-out risk.

CONCLUSIONS

This work supposes an improvement in the knowledge of the cut-out phenomenon thanks to the combination of experimental testing and validated numerical models. The effects of different intramedullary nail positions in the femoral head are studied, including a novelty variable as torque, which is critical for the structural integrity of the fixation. The main conclusion of the work is the determination of the central intramedullary nail position as the most favourable one for decreasing the cut-out risk.

Hip joint load prediction using inverse bone remodeling with homogenized FE models: Comparison to micro-FE and influence of material modeling strategy

BACKGROUND AND OBJECTIVE

Measuring physiological loading conditions in vivo can be challenging, as methods are invasive or pose a high modeling effort. However, the physiological loading of bones is also imprinted in the bone microstructure due to bone (re)modeling. This information can be retrieved by inverse bone remodeling (IBR). Recently, an IBR method based on micro-finite-element (µFE) modeling was translated to homogenized-FE (hFE) to decrease computational effort and tested on the distal radius. However, this bone has a relatively simple geometry and homogeneous microstructure. Therefore, the objective of this study was to assess the agreement of hFE-based IBR with µFE-based IBR to predict hip joint loading from the head of the femur; a bone with more complex loading as well as more heterogeneous microstructure.

METHODS

hFE-based IBR was applied to a set of 19 femoral heads using four different material mapping laws. One model with a single homogeneous material for both trabecular and cortical volume and three models with a separated cortex and either homogeneous, density-dependent inhomogeneous, or density and fabric-dependent orthotropic material. Three different evaluation regions (full bone, trabecular bone only, head region only) were defined, in which IBR was applied. µFE models were created for the same bones, and the agreement of the predicted hip joint loading history obtained from hFE and µFE models was evaluated. The loading history was discretized using four unit load cases.

RESULTS

The computational time for FE solving was decreased on average from 500 h to under 1 min (CPU time) when using hFE models instead of µFE models. Using more information in the material model in the hFE models led to a better prediction of hip joint loading history. Inhomogeneous and inhomogeneous orthotropic models gave the best agreement to µFE-based IBR (RMSE% <14%). The evaluation region only played a minor role.

CONCLUSIONS

hFE-based IBR was able to reconstruct the dominant joint loading of the femoral head in agreement with µFE-based IBR and required considerably lower computational effort. Results indicate that cortical and trabecular bone should be modeled separately and at least density-dependent inhomogeneous material properties should be used with hFE models of the femoral head to predict joint loading.

Denosumab prevented periprosthetic bone resorption better than risedronate after total hip arthroplasty

INTRODUCTION

Periprosthetic fracture caused by periprosthetic bone loss is an important concern in total hip arthroplasty (THA). Denosumab has been approved for postmenopausal women with osteoporosis who are at high risk of fracture. In this randomized controlled trial, we compared the effects of denosumab and risedronate on periprosthetic bone mineral density (BMD) after THA.

MATERIALS AND METHODS

The current study analyzed 108 patients who were scheduled to have THA. For 2 years, the patients were randomly assigned to the following two treatment groups: denosumab (60 mg subcutaneously every 6 months) or risedronate (17.5 mg oral weekly). The BMD changes in all Gruen zones and bone turnover markers were measured at the 5th postoperative day (baseline) and 6, 12, 18, and 24 months postoperatively.

RESULTS

The mean BMD in zones 1, 2, 6, and 7 was significantly higher with denosumab all administration at all postoperative time points compared to the risedronate group. The mean percentage changes in the BMD in these zones from baseline to 24 months postoperatively were + 11.9, + 2.9, + 8.1, and + 5.9% with denosumab group and - 9.6% -3.6, - 2.3, and - 19.2% with risedronate, respectively. The osteoclastic marker, tartrate-resistant acid phosphatase-5b (TRACP-5b), was significantly lower in the denosumab group compared to the risedronate group by 2 months.

CONCLUSION

Denosumab is more effective in preventing periprosthetic bone resorption than risedronate in the proximal femur. It also increased BMD around the stem implant following THA.

Geometry and bone mineral density determinants of femoral neck strength changes following exercise

Physical exercise induces spatially heterogeneous adaptation in bone. However, it remains unclear where the changes in BMD and geometry have the greatest impact on femoral neck strength. The aim of this study was to determine the principal BMD-and-geometry changes induced by exercise that have the greatest effect on femoral neck strength. Pre- and post-exercise 3D-DXA images of the proximal femur were collected of male participants from the LIFTMOR-M exercise intervention trial. Meshes with element-by-element correspondence were generated by morphing a template mesh to each bone to calculate changes in BMD and geometry. Finite element (FE) models predicted femoral neck strength changes under single-leg stance and sideways fall load. Partial least squares regression (PLSR) models were developed with BMD-only, geometry-only, and BMD-and-geometry changes to determine the principal modes that explained the greatest variation in neck strength changes. The PLSR models explained over 90% of the strength variation with 3 PLS components using BMD-only (R² > 0.92, RMSE < 0.06 N) and 8 PLS components with geometry-only (R² > 0.93, RMSE < 0.06 N). Changes in the superior neck and distal cortex were most important during single-leg stance while the superior neck, medial head, and lateral trochanter were most important during a sideways fall. Local changes in femoral neck and head geometry could differentiate the exercise groups from the control group. Exercise interventions may target BMD changes in the superior neck, inferior neck, and greater trochanter for improved femoral neck strength in single-leg stance and sideways fall.

Finite Element Model-Computed Mechanical Behavior of Femurs with Metastatic Disease Varies Between Physiologic and Idealized Loading Simulations

Background and objectives:

Femurs affected by metastatic bone disease (MBD) frequently undergo surgery to prevent impending pathologic fractures due to clinician-perceived increases in fracture risk. Finite element (FE) models can provide more objective assessments of fracture risk. However, FE models of femurs with MBD have implemented strain- and strength-based estimates of fracture risk under a wide variety of loading configurations, and “physiologic” loading models typically simulate a single abductor force. Due to these variations, it is currently difficult to interpret mechanical fracture risk results across studies of femoral MBD. Our aims were to evaluate (1) differences in mechanical behavior between idealized loading configurations and those incorporating physiologic muscle forces, and (2) differences in the rankings of mechanical behavior between different loading configurations, in FE simulations to predict fracture risk in femurs with MBD.

Methods:

We evaluated 9 different patient-specific FE loading simulations for a cohort of 54 MBD femurs: strain outcome simulations—physiologic (normal walking [NW], stair ascent [SA], stumbling), and joint contact only (NW contact force, excluding muscle forces); strength outcome simulations—physiologic (NW, SA), joint contact only, offset torsion, and sideways fall. Tensile principal strain and femur strength were compared between simulations using statistical analyses.

Results:

Tensile principal strain was 26% higher ( R2 = 0.719, P < .001) and femur strength was 4% lower ( R2 = 0.984, P < .001) in simulations excluding physiologic muscle forces. Rankings of the mechanical predictions were correlated between the strain outcome simulations (ρ = 0.723 to 0.990, P < .001), and between strength outcome simulations (ρ = 0.524 to 0.984, P < .001).

Conclusions:

Overall, simulations incorporating physiologic muscle forces affected local strain outcomes more than global strength outcomes. Absolute values of strain and strength computed using idealized (no muscle forces) and physiologic loading configurations should be used within the appropriate context when interpreting fracture risk in femurs with MBD.

[Research progress in biomechanics of common internal fixation for femoral neck fracture]

OBJECTIVE

To summarize the characteristics and biomechanical research progress of common internal fixation for femoral neck fractures in recent years, so as to provide reference to clinical treatment of femoral neck fracture.

METHODS

The domestic and foreign relevant literature on biomechanics of internal fixation of femoral neck fracture in recent years was reviewed, and the biomechanical research progress was summarized.

RESULTS

Among the internal fixations currently used in the treatment of femoral neck fractures, three cannulated screws can provide sliding compression at the end of the fracture, but the shear resistance is weak, and the risk of long-term internal fixation failure is high; dynamic hip screw and proximal femoral locking plate have excellent angle stability and overall strength; medial buttress plate can transform vertical shear force into compressive stress to promote fracture healing and produce a certain anti-rotation effect; femoral neck system can support the fracture in multi-axial direction, with excellent anti-rotation and anti-shortening properties; and cephalomedullary nails have high overall strength and failure load. Different internal fixations have their own indications due to differences in structure and biomechanics.

CONCLUSION

At present, there is no detailed standard guidance of internal fixation selection. Clinically, the appropriate treatment should be selected according to the fracture types of patients.

Varus malalignment of the lower limb increases the risk of femoral neck fracture: A biomechanical study using a finite element method

INTRODUCTION

The understanding of the stresses and strains and their dependence on loading direction caused by an axial deformity is very important for understanding the mechanism of femural neck fractures. The hypothesis of this study is that lower limb malalignment is correlated with a substantial stress variation on the upper end of the femur. The purpose of this biomechanical trial using the finite element method is to determine the effect of the loading direction on the proximal femur regarding the malalignment of the lower limb, and also enlighten the relation between the lower limb alignment and the risk of a femoral neck fracture.

METHODS

Ten segmentations of CT scans were considered. An axial compression load was applied to the femoral head to digitally simulate the physiological configuration in neutral position as well as in different axial positions in varus/valgus alignment.

RESULTS

The stress at the proximal femur changes as the varus _valgus angle does. It can be observed the smaller absolute stress at angle 10° (valgus) and the higher absolute stress at angle -10° (varus). The mean maximum von Mises stress value was 14.1 (SD=±3.48) MPa for 0°, while the mean maximum von Mises stress value was 17.96 MPa (SD=4.87) for -10° in varus. The fracture risk indicator of the proximal femoral epiphyses changes inversely with angle direction. The FRI was the highest at -10° and the lowest at 10°.

CONCLUSION

Based on the biomechanical findings and the fracture risk indicator determined in this preliminary study, varus malalignment increases the risk of femoral neck fracture. Consideration of other parameters such as bone mineral density and morphological parameters should also help to plan preventive medical strategy in the elderly.

Study of the significance of parameters and their interaction on assessing femoral fracture risk by quantitative statistical analysis

Early assessment of hip fracture helps develop therapeutic and preventive mechanisms that may reduce the occurrence of hip fracture. An accurate assessment of hip fracture risk requires proper consideration of the loads, the physiological and morphological parameters, and the interactions between these parameters. Hence, this study aims at analyzing the significance of parameters and their interactions by conducting a quantitative statistical analysis. A multiple regression model was developed considering different loading directions during a sideways fall (angle [Formula: see text] and [Formula: see text] on the coronal and transverse planes, respectively), age, gender, patient weight, height, and femur morphology as independent parameters and Fracture Risk Index (FRI) as a dependent parameter. Strain-based criteria were used for the calculation of FRI with the maximum principal strain obtained from quantitative computed tomography-based finite element analysis. The statistical result shows that [Formula: see text] [Formula: see text], age [Formula: see text], true moment length [Formula: see text], gender [Formula: see text], FNA [Formula: see text], height [Formula: see text], and FSL [Formula: see text] significantly affect FRI where [Formula: see text] is the most influential parameter. The significance of two-level interaction [Formula: see text] and three-level interaction [Formula: see text] shows that the effect of parameters is dissimilar and depends on other parameters suggesting the variability of FRI from person to person.

Real-time replication of three-dimensional and time-varying physiological loading cycles for bone and implant testing: A novel protocol demonstrated for the proximal human femur while walking

In vitro real-time replication of three-dimensional, time-varying load profiles acting on human bones during physical activity can advance bone and implant testing protocols. This study aimed to develop a novel protocol for applying the three-dimensional, time-varying hip contact force while walking to a human femur specimen. The target force profile was obtained from the literature. A proximal femur from an elderly female donor was instrumented using ten rosette strain gages and tested using a custom-made hexapod robot. A load-control algorithm determined the robot position generating the target force at low frequency (0.0004 Hz). Five cycles of the robot position were played back at five intermediate frequencies up to real-time (0.04, 0.08, 0.16, 0.4, and 0.8 Hz). The hip reaction force, the length of the actuators (position), and cortical strains were compared. The error in the load-control force was 0.3 ± 4.2 N (mean ± SD). The last three force, position, and strain cycles varied by less than 1.1% for every frequency analyzed. Across frequencies, the force increased by 28% at 0.8 Hz as a logarithmic function of frequency (R² = 0.98). The position and strain error linearly increased with frequency up to 0.4 Hz. The median position error and the interquartile range of the strain error reached 15% and 13% at 0.8 Hz. Changes of force and cortical strain at increasing frequencies were linearly related (R² = 0.99). Therefore, the protocol developed can provide repeatable three-dimensional time-varying load profiles, although the comparison of the specimen deformation obtained across frequencies should be considered with care, particularly in the higher frequency range. This information supports the design of dynamic tests of bone and implants.

Finite element modeling of multiple density materials of bone specimens for biomechanical behavior evaluation

The finite elements method allied with the computerized axial tomography (CT) is a mathematical modeling technique that allows constructing computational models for bone specimens from CT data. The objective of this work was to compare the experimental biomechanical behavior by three-point bending tests of porcine femur specimens with different types of computational models generated through the finite elements’ method and a multiple density materials assignation scheme. Using five femur specimens, 25 scenarios were created with differing quantities of materials. This latter was applied to computational models and in bone specimens subjected to failure. Among the three main highlights found, first, the results evidenced high precision in predicting experimental reaction force versus displacement in the models with larger number of assigned materials, with maximal results being an R2 of 0.99 and a minimum root-mean-square error of 3.29%. Secondly, measured and computed elastic stiffness values follow same trend with regard to specimen mass, and the latter underestimates stiffness values a 6% in average. Third and final highlight, this model can precisely and non-invasively assess bone tissue mechanical resistance based on subject-specific CT data, particularly if specimen deformation values at fracture are considered as part of the assessment procedure.

Standardized artificially created stable pertrochanteric femur fractures present more homogenous results compared to osteotomies for orthopaedic implant testing

Background

With regard to biomechanical testing of orthopaedic implants, there is no consensus on whether artificial creation of standardized bone fractures or their simulation by means of osteotomies result in more realistic outcomes. Therefore, the aim of this study was to artificially create and analyze in an appropriate setting the biomechanical behavior of standardized stable pertrochanteric fractures versus their simulation via osteotomizing.

Methods

Eight pairs of fresh-frozen human cadaveric femora aged 72.7 ± 14.9 years (range 48–89 years) were assigned in paired fashion to two study groups. In Group 1, stable pertrochanteric fractures AO/OTA 31-A1 were artificially created via constant force application on the anterior cortex of the femur through a blunt guillotine blade. The same fracture type was simulated in Group 2 by means of osteotomies. All femora were implanted with a dynamic hip screw and biomechanically tested in 20° adduction under progressively increasing physiologic cyclic axial loading at 2 Hz, starting at 500 N and increasing at a rate of 0.1 N/cycle. Femoral head fragment movements with respect to the shaft were monitored by means of optical motion tracking.

Results

Cycles/failure load at 15° varus deformation, 10 mm leg shortening and 15° femoral head rotation around neck axis were 11324 ± 848/1632.4 ± 584.8 N, 11052 ± 1573/1605.2 ± 657.3 N and 11849 ± 1120/1684.9 ± 612.0 N in Group 1, and 10971 ± 2019/1597.1 ± 701.9 N, 10681 ± 1868/1568.1 ± 686.8 N and 10017 ± 4081/1501.7 ± 908.1 N in Group 2, respectively, with no significant differences between the two groups, p ≥ 0.233.

Conclusion

From a biomechanical perspective, by resulting in more consistent outcomes under dynamic loading, standardized artificial stable pertrochanteric femur fracture creation may be more suitable for orthopaedic implant testing compared to osteotomizing the bone.

Assessment of femoral neck strength and bone mineral density changes following exercise using 3D-DXA images

Physical exercise induces spatially heterogeneous bone changes in the proximal femur. Recent advances have enabled 3D dual-energy X-ray Absorptiometry (DXA)-based finite element (FE) models to estimate bone strength. However, its ability to detect exercise-induced BMD and strength changes is unclear. The aim of this study was to quantify the repeatability of vBMD and femoral neck strength obtained from 3D-DXA images and determine the changes due an exercise intervention. The DXA scans included pairs of same-day repeated scans from ten healthy females and pre- and post-exercise intervention scans of 26 males. FE models with element-by-element correspondence were generated by morphing a template mesh to each bone. BMD and femoral strength under single-leg-stance and sideways fall loading configurations were obtained for both groups and compared. In the repeated images, the total hip vBMD difference was 0.5 ± 2.5%. Element-by-element BMD differences reached 30 ± 50%. The strength difference in single-leg stance was 2.8 ± 13% and in sideways fall was 4.5% ± 19%. In the exercise group, strength changes were 6 ± 19% under single-leg stance and 1 ± 18% under sideways fall. vBMD parameters were weakly correlated to strength (R² < 0.31). The exercise group had a mean bone accrual exceeding repeatability values in the femoral head and cortical regions. The case with the highest vBMD change (6.4%) caused 18% and -7% strength changes under single-leg stance and sideways fall. 3D-DXA technology can assess the effect of exercise interventions in large cohorts but its validity in individual cases should be interpreted with caution.

Numerical analysis of hip fracture due to a sideways fall

The primary purpose of this paper is to outline a methodology for evaluating the likelihood of cortical bone fracture in the proximal femur in the event of a sideways fall. The approach includes conducting finite element (FE) analysis in which the cortical bone is treated as an anisotropic material, and the admissibility of the stress field is validated both in tension and compression regime. In assessing the onset of fracture, two methodologies are used, namely the Critical Plane approach and the Microstructure Tensor approach. The former is employed in the tension regime, while the latter governs the conditions at failure in compression. The propagation of localized damage is modeled using a constitutive law with embedded discontinuity (CLED). In this approach, the localized deformation is described by a homogenization procedure in which the average properties of cortical tissue intercepted by a macrocrack are established. The key material properties governing the conditions at failure are specified from a series of independent material tests conducted on cortical bone samples tested at different orientations relative to the loading direction. The numerical analysis deals with simulations of experiments involving the sideways fall, and the results are compared with the experimental data. This includes both the evolution of fracture pattern and the local load-displacement characteristics. The proposed approach is numerically efficient, and the results do not display a pathological mesh-dependency. Also, in contrast to the XFEM approach, the analysis does not require any extra degrees of freedom.

Comparison of femur strain under different loading scenarios: Experimental testing

Bone fracture, formation and adaptation are related to mechanical strains in bone. Assessing bone stiffness and strain distribution under different loading conditions may help predict diseases and improve surgical results by determining the best conditions for long-term functioning of bone-implant systems. In this study, an experimentally wide range of loading conditions (56) was used to cover the directional range spanned by the hip joint force. Loads for different stance configurations were applied to composite femurs and assessed in a material testing machine. The experimental analysis provides a better understanding of the influence of the bone inclination angle in the frontal and sagittal planes on strain distribution and stiffness. The results show that the surface strain magnitude and stiffness vary significantly under different loading conditions. For the axial compression, maximal bending is observed at the mid-shaft, and bone stiffness is also maximal. The increased inclination leads to decreased stiffness and increased magnitude of maximum strain at the distal end of the femur. For comparative analysis of results, a three-dimensional, finite element model of the femur was used. To validate the finite element model, strain gauges and digital image correlation system were employed. During validation of the model, regression analysis indicated robust agreement between the measured and predicted strains, with high correlation coefficient and low root-mean-square error of the estimate. The results of stiffnesses obtained from multi-loading conditions experiments were qualitatively compared with results obtained from a finite element analysis of the validated model of femur with the same multi-loading conditions. When the obtained numerical results are qualitatively compared with experimental ones, similarities can be noted. The developed finite element model of femur may be used as a promising tool to estimate proximal femur strength and identify the best conditions for long-term functioning of the bone-implant system in future study.

Sub-trabecular strain evolution in human trabecular bone

To comprehend the most detrimental characteristics behind bone fractures, it is key to understand the material and tissue level strain limits and their relation to failure sites. The aim of this study was to investigate the three-dimensional strain distribution and its evolution during loading at the sub-trabecular level in trabecular bone tissue. Human cadaver trabecular bone samples were compressed in situ until failure, while imaging with high-resolution synchrotron radiation X-ray tomography. Digital volume correlation was used to determine the strains inside the trabeculae. Regions without emerging damage were compared to those about to crack. Local strains in close vicinity of developing cracks were higher than previously reported for a whole trabecular structure and similar to those reported for single isolated trabeculae. Early literature on bone fracture strain thresholds at the tissue level seem to underestimate the maximum strain magnitudes in trabecular bone. Furthermore, we found lower strain levels and a reduced ability to capture detailed crack-paths with increased image voxel size. This highlights the dependence between the observed strain levels and the voxel size and that high-resolution is needed to investigate behavior of individual trabeculae. Furthermore, low trabecular thickness appears to be one predictor of developing cracks. In summary, this study investigated the local strains in whole trabecular structure at sub-trabecular resolution in human bone and confirmed the high strain magnitudes reported for single trabeculae under loading and, importantly extends its translation to the whole trabecular structure.

Image-based finite-element modeling of the human femur

Fracture is considered a critical clinical endpoint in skeletal pathologies including osteoporosis and bone metastases. However, current clinical guidelines are limited with respect to identifying cases at high risk of fracture, as they do not account for many mechanical determinants that contribute to bone fracture. Improving fracture risk assessment is an important area of research with clear clinical relevance. Patient-specific numerical musculoskeletal models generated from diagnostic images are widely used in biomechanics research and may provide the foundation for clinical tools used to quantify fracture risk. However, prior to clinical translation, in vitro validation of predictions generated from such numerical models is necessary. Despite adopting radically different models, in vitro validation of image-based finite element (FE) models of the proximal femur (predicting strains and failure loads) have shown very similar, encouraging levels of accuracy. The accuracy of such in vitro models has motivated their application to clinical studies of osteoporotic and metastatic fractures. Such models have demonstrated promising but heterogeneous results, which may be explained by the lack of a uniform strategy with respect to FE modeling of the human femur. This review aims to critically discuss the state of the art of image-based femoral FE modeling strategies, highlighting principal features and differences among current approaches. Quantitative results are also reported with respect to the level of accuracy achieved from in vitro evaluations and clinical applications and are used to motivate the adoption of a standardized approach/workflow for image-based FE modeling of the femur.

Modelling Human Locomotion to Inform Exercise Prescription for Osteoporosis

PURPOSE OF REVIEW

We review the literature on hip fracture mechanics and models of hip strain during exercise to postulate the exercise regimen for best promoting hip strength.

RECENT FINDINGS

The superior neck is a common location for hip fracture and a relevant exercise target for osteoporosis. Current modelling studies showed that fast walking and stair ambulation, but not necessarily running, optimally load the femoral neck and therefore theoretically would mitigate the natural age-related bone decline, being easily integrated into routine daily activity. High intensity jumps and hopping have been shown to promote anabolic response by inducing high strain in the superior anterior neck. Multidirectional exercises may cause beneficial non-habitual strain patterns across the entire femoral neck. Resistance knee flexion and hip extension exercises can induce high strain in the superior neck when performed using maximal resistance loadings in the average population. Exercise can stimulate an anabolic response of the femoral neck either by causing higher than normal bone strain over the entire hip region or by causing bending of the neck and localized strain in the superior cortex. Digital technologies have enabled studying interdependences between anatomy, bone distribution, exercise, strain and metabolism and may soon enable personalized prescription of exercise for optimal hip strength.

Perspectives on the non-invasive evaluation of femoral strength in the assessment of hip fracture risk

We reviewed the experimental and clinical evidence that hip bone strength estimated by BMD and/or finite element analysis (FEA) reflects the actual strength of the proximal femur and is associated with hip fracture risk and its changes upon treatment.

INTRODUCTION

The risk of hip fractures increases exponentially with age due to a progressive loss of bone mass, deterioration of bone structure, and increased incidence of falls. Areal bone mineral density (aBMD), measured by dual-energy X-ray absorptiometry (DXA), is the most used surrogate marker of bone strength. However, age-related declines in bone strength exceed those of aBMD, and the majority of fractures occur in those who are not identified as osteoporotic by BMD testing. With hip fracture incidence increasing worldwide, the development of accurate methods to estimate bone strength in vivo would be very useful to predict the risk of hip fracture and to monitor the effects of osteoporosis therapies.

METHODS

We reviewed experimental and clinical evidence regarding the association between aBMD and/orCT-finite element analysis (FEA) estimated femoral strength and hip fracture risk as well as their changes with treatment.

RESULTS

Femoral aBMD and bone strength estimates by CT-FEA explain a large proportion of femoral strength ex vivo and predict hip fracture risk in vivo. Changes in femoral aBMD are strongly associated with anti-fracture efficacy of osteoporosis treatments, though comparable data for FEA are currently not available.

CONCLUSIONS

Hip aBMD and estimated femoral strength are good predictors of fracture risk and could potentially be used as surrogate endpoints for fracture in clinical trials. Further improvements of FEA may be achieved by incorporating trabecular orientations, enhanced cortical modeling, effects of aging on bone tissue ductility, and multiple sideway fall loading conditions.

Influence of femoral external shape on internal architecture and fracture risk

The internal architecture of the femur and its fracture behaviour vary greatly between subjects. Femoral architecture and subsequent fracture risk are strongly influenced by load distribution during physical activities of daily living. The objective of this work is to evaluate the impact of outer cortical surface shape as a key affector of load distribution driving femoral structure and fracture behaviour. Different femur cortical shapes are generated using a statistical shape model. Their mesoscale internal architecture is predicted for the same activity regime using a structural optimisation approach previously reported by the authors and fracture under longitudinal compression is simulated. The resulting total volume of bone is similar in all geometries although substantial differences are observed in distribution between trabecular and cortical tissue. Greater neck-shaft and anteversion angles show a protective effect in longitudinal compression while a thinner shaft increases fracture risk.

Previous Damage Accumulation Can Influence Femoral Fracture Strength: A Finite Element Study

To manage osteoporotic hip fracture risk, it is necessary to understand failure mechanisms of bone at both the material and organ level. The structural response of bone is dependent on load history. Repeated loading causes progressive microstructural cracking, resulting in reduced apparent-level stiffness and, if damage is significant, reductions to peak load bearing capability. However, the effect of previous damage accumulation has not been well explored at the organ level. It was hypothesized that femoral fracture load and fracture pattern may be sensitive to damage accumulation from previous loading events. Six cadaveric specimens were used to develop patient specific finite element (FE) models from quantitative tomographic (qCT) scans. Material properties were assigned from qCT intensity at each element location, and damage evolution was predicted using a previously validated quasi-brittle FE model. Three scenarios were investigated: stumble followed by another stumble (S-S), fall followed by another fall (F-F), and stumble followed by a fall (S-F). Fracture load and pattern were compared to FE predictions for a single stumble (S) or single fall (F) loading event. Most specimens were resilient to accumulated damage, showing little (<5%) change in fracture load from the multiple-load scenarios (S-S, F-F, and S-F) compared to an equivalent single load scenario (S or F). Only one specimen demonstrated moderate (5-15%) reductions in strength from all three multiple-load scenarios. However, two specimens experienced moderate (20-30%) increase in fracture load in some load cases. In these cases, initial damage caused the load to be more evenly distributed upon subsequent loading events. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2197-2203, 2019.

QCT-based finite element prediction of pathologic fractures in proximal femora with metastatic lesions

Predicting pathologic fractures in femora with metastatic lesions remains a clinical challenge. Currently used guidelines are inaccurate, especially to predict non-impeding fractures. This study evaluated the ability of a nonlinear quantitative computed tomography (QCT)-based homogenized voxel finite element (hvFE) model to predict patient-specific pathologic fractures. The hvFE model was generated highly automated from QCT images of human femora. The femora were previously loaded in a one-legged stance setup in order to assess stiffness, failure load, and fracture location. One femur of each pair was tested in its intact state, while the contralateral femur included a simulated lesion on either the superolateral- or the inferomedial femoral neck. The hvFE model predictions of the stiffness (0.47 < R² < 0.94), failure load (0.77 < R² < 0.98), and exact fracture location (68%) were in good agreement with the experimental data. However, the model underestimated the failure load by a factor of two. The hvFE models predicted significant differences in stiffness and failure load for femora with superolateral- and inferomedial lesions. In contrast, standard clinical guidelines predicted identical fracture risk for both lesion sites. This study showed that the subject-specific QCT-based hvFE model could predict the effect of metastatic lesions on the biomechanical behaviour of the proximal femur with moderate computational time and high level of automation and could support treatment strategy in patients with metastatic bone disease.

Assessment of finite element models for prediction of osteoporotic fracture

With increasing life expectancy and mortality rates, the burden of osteoporotic hip fractures is continually on an upward trend. In terms of prevention, there are several osteoporosis treatment strategies such as anti-resorptive drug treatments, which attempt to retard the rate of bone resorption, while promoting the rate of formation. With respect to prediction, several studies have provided insights into obtaining bone strength by non-invasive means through the application of FE analysis. However, what valuable information can we obtain from FE studies that have focused on osteoporosis research, with respect to the prediction of osteoporotic fractures? This paper aims to fine studies that have used FE analysis to predict fractures in the proximal femur through a systematic search of literature using PUBMED, with the main objective of supporting the diagnosis of osteoporosis. The focus of these FE studies is first discussed, and the methodological aspects are summarized, by mainly comparing and contrasting their meshing properties, material properties, and boundary conditions. The implications of these methodological differences in FE modelling processes and propositions with the aim of consolidating or minimalizing these differences are further discussed. We proved that studies need to start converging in terms of their input parameters to make the FE method applicable to clinical settings. This, in turn, will decrease the time needed for in vitro tests. Current advancements in FE analysis need to be consolidated before any further steps can be taken to implement engineering analysis into the clinical scenario.

Numerical modelling of hip fracture patterns in human femur

BACKGROUND AND OBJECTIVE

Hip fracture morphology is an important factor determining the ulterior surgical repair and treatment, because of the dependence of the treatment on fracture morphology. Although numerical modelling can be a valuable tool for fracture prediction, the simulation of femur fracture is not simple due to the complexity of bone architecture and the numerical techniques required for simulation of crack propagation. Numerical models assuming homogeneous fracture mechanical properties commonly fail in the prediction of fracture patterns. This paper focuses on the prediction of femur fracture based on the development of a finite element model able to simulate the generation of long crack paths.

METHODS

The finite element model developed in this work demonstrates the capability of predicting fracture patterns under stance loading configuration, allowing the distinction between the main fracture paths: intracapsular and extracapsular fractures. It is worth noting the prediction of different fracture patterns for the same loading conditions, as observed during experimental tests.

RESULTS AND CONCLUSIONS

The internal distribution of bone mineral density and femur geometry strongly influences the femur fracture morphology and fracture load. Experimental fracture paths have been analysed by means of micro-computed tomography allowing the comparison of predicted and experimental crack surfaces, confirming the good accuracy of the numerical model.

Ageing Effects on 3-Dimensional Femoral Neck Cross-Sectional Asymmetry: Implications for Age-Related Bone Fragility in Falling

This paper explores the effects of aging on femoral neck (FN) anatomy in a study of women aged 20-90years in relation to implications for FN fracture propensity in buckling. Five hundred and four participants were scanned by Quantitative Computed Tomography and analyzed using Quantitative Computed Tomography Pro BIT (Mindways). FN cross-section was split through geometric center into superior and inferior sectors. Bone mass, structural measurements, and bone mineral density were analyzed. Buckling ratio was calculated as ratio of buckling radius to cortical thickness. Between 2nd decade and 8th decade, age-related integral bone mass reduction in superior sector was substantially larger than in inferior sector (33% compared to 21%), especially in cortical bone superiorly compared to inferiorly (53% vs 21%; p < 0.001), principally due to reduction in cortical thickness, averaged cortical thickness (56%) with little difference in density. Superior and inferior sector trabecular bone mineral density reduction was similar at 41% and 43% respectively. Differential cortical bone loss in superior sector resulted in a 59% inferior displacement (δ) of center-of-mass from geometric center. Differences in δ and averaged cortical thickness with age accounted for a 151% increase in mean superior buckling ratio from 9 to 23. Analysis confirms significant progressive age-related superior cortical bone loss as the major age effect on FN structure with relative preservation of inferior cortex probably related to maintenance of inferior sector by regular loading as a result of standing and walking. Computation of buckling ratio may allow prediction of fracture propensity in a sideways fall.

Are piriformis reconstruction implants ideal for prophylactic femoral neck fixation?

OBJECTIVES

Prophylactic femoral neck fixation may be performed in the setting of geriatric diaphyseal femur fracture, pathologic or impending atypical femur fractures. Fixation constructs often utilize cephalomedullary implants with one or two proximal interlocking screws into the femoral head/neck. Variations in proximal femoral anatomy and implant design can interfere with the placement of two screws in the femoral head and neck. Our objective was to assess the strength of piriformis entry reconstruction implants with one versus two proximal interlock screws for prophylactic femoral neck fixation.

METHODS

Thirty fourth generation synthetic femur models were separated into 5 groups. The control group was an intact femur, and the second group was an intact femur with an entry hole in the piriformis fossa. The remaining groups had an intramedullary nail placed with either 0, 1, or 2 screws placed into the femoral head and neck. Each femur was mechanically loaded along the mechanical axis through the femoral head. Load to failure and failure displacement were recorded.

RESULTS

Mean load to failure was 5583 ± 543 N in the intact femur. Constructs with 2 screws had a significantly higher mean load to failure (3223 ± 474 N) compared to one screw constructs (2368 ± 280 N). All of the experimental groups remained significantly lower than the intact femur model (p < 0.05).

CONCLUSION

Our results demonstrate that piriformis entry reconstruction implants have a significantly lower load to failure compared to an intact femur irrespective of screw construct. Further studies are needed to investigate this potential iatrogenic weakening.

Patient-Specific Phantomless Estimation of Bone Mineral Density and Its Effects on Finite Element Analysis Results: A Feasibility Study

Objectives

This study proposes a regression model for the phantomless Hounsfield units (HU) to bone mineral density (BMD) conversion including patient physical factors and analyzes the accuracy of the estimated BMD values.

Methods

The HU values, BMDs, circumferences of the body, and cross-sectional areas of bone were measured from 39 quantitative computed tomography images of L2 vertebrae and hips. Then, the phantomless HU-to-BMD conversion was derived using a multiple linear regression model. For the statistical analysis, the correlation between the estimated BMD values and the reference BMD values was evaluated using Pearson's correlation test. Voxelwise BMD and finite element analysis (FEA) results were analyzed in terms of root-mean-square error (RMSE) and strain energy density, respectively.

Results

The HU values and circumferences were statistically significant (p < 0.05) for the lumbar spine, whereas only the HU values were statistically significant (p < 0.05) for the proximal femur. The BMD values estimated using the proposed HU-to-BMD conversion were significantly correlated with those measured using the reference phantom: Pearson's correlation coefficients of 0.998 and 0.984 for the lumbar spine and proximal femur, respectively. The RMSEs of the estimated BMD values for the lumbar spine and hip were 4.26 ± 0.60 (mg/cc) and 8.35 ± 0.57 (mg/cc), respectively. The errors of total strain energy were 1.06% and 0.91%, respectively.

Conclusions

The proposed phantomless HU-to-BMD conversion demonstrates the potential of precisely estimating BMD values from CT images without the reference phantom and being utilized as a viable tool for FEA-based quantitative assessment using routine CT images.

Biomechanics of Femoral Neck Fractures and Implications for Fixation

Fractures of the femoral neck can occur in young healthy individuals due to high loads occurring during motor vehicle accidents, impacts, or falls. Failure forces are lower if impacts occur sideways onto the greater trochanter as compared with vertical loading of the hip. Bone density, bone geometry, and thickness of cortical bone at the femoral neck contribute to its mechanical strength. Femoral neck fractures in young adults require accurate reduction and stable internal fixation. The available techniques for fracture fixation at the femoral neck (cannulated screws, hip screw systems, proximal femur plates, and cephallomedullary nails) are reviewed with respect to their competence to provide biomechanical stability. Mechanically unstable fractures require a load-bearing implant, such as hip screws, with antirotational screws or intramedullary nails. Subcapital or transcervical fracture patterns and noncomminuted fractures enable load sharing and can be securely fixed with cannulated screws or solitary hip screw systems without compromising fixation stability.

Experimental validation of finite elements model in hip fracture and its clinical applicability

Fracture of the proximal extremity of the femur is the subject of research interest. The complexity of the bone framework and the structural inefficiency associated with ageing leave many variables yet to be understood from an experimental perspective. However, there is no clearly defined structural and biomechanical research model for hip fracture. The hypothesis of this paper is that it is possible to create a computational experimentation model that characterises the bone of the proximal extremity of the femur as a heterogeneous material from directly translating the mechanical parameters obtained from anatomical experimentation specimens.

MATERIAL AND METHOD

An experimental paper comparing real experimentation on cadavers and a numerical model based on finite element analysis (FEA). The variables uses were: the start point of the fracture, propagation of the fracture, progressive load and maximum load until fracture. The real mechanical parameters obtained from the anatomical specimens were translated to the computational model based on the relationship between the Hounsfield units of the high resolution CAT scan and the bone mineral density of each virtual element, whereas the propagation of the fracture was modelled by the research team's own computational design, reducing the mechanical properties of the damaged elements as the fracture line advanced.

RESULTS

The computational model was able to determine the start point of the fracture, with a slight tendency towards anatomical medialisation of this point compared to what happened experimentally. The degree of correlation was very high on comparing the real value of progressive deformation of the samples compared to that obtained by the computational model. Over 32 points analysed, a slope of 1.03 in lineal regression was obtained, with a relative error between the deformations of 16% and a Pearson's coefficient of R²=.99. The computational model slightly underestimated the maximum fracture load, with a relative error of approximately 10%.

CONCLUSION

The FEA computational model developed by this multi-disciplinary research team could be considered, as a whole, a complete FEA model of the proximal extremity of the femur with future clinical applicability since it was able to simulate and imitate the biomechanical behaviour of human femurs contrasted with a traditional experimental model made from anatomical specimens. On this basis, qualitative and quantitative interactions can be assessed which consolidate it as a powerful computational experimentation test bench for the human proximal femur.

Rate and age-dependent damage elasticity formulation for efficient hip fracture simulations

Prediction of bone failure is beneficial in a range of clinical situations from screening of osteoporotic patients with high fracture risk to assessment of protective equipment against trauma. Computational efficiency is an important feature to consider when developing failure models for iterative applications, such as patient-specific diagnosis or design of orthopaedic devices. The authors previously developed a methodology to generate efficient mesoscale structural full bone models. The aim of this study was to implement a damage elasticity formulation representative of an elasto-plastic material model with age and strain rate dependencies compatible with these structural models. This material model was assessed in the prediction of femoral fractures in longitudinal compression and side fall scenarios. The simulations predicted failure loads and fracture patterns in good agreement with reported results from experimental studies. The observed influence of strain rate on failure load was consistent with literature. The superiority of a simplified elasto-plastic formulation over an elasto-brittle bone material model was assessed. This computationally efficient damage elasticity formulation was capable of capturing fracture development after onset.

Mechanical Strength of the Proximal Femur After Arthroscopic Osteochondroplasty for Femoroacetabular Impingement: Finite Element Analysis and 3-Dimensional Image Analysis

PURPOSE

To examine the influence of femoral neck resection on the mechanical strength of the proximal femur in actual surgery.

METHODS

Eighteen subjects who received arthroscopic cam resection for cam-type femoroacetabular impingement (FAI) were included. Finite element analyses (FEAs) were performed to calculate changes in simulative fracture load between pre- and postoperative femur models. The finite element femur models were constructed from computed tomographic images; thus, the models represented the shape of the original femur, including the bone resection site. Three-dimensional image analysis of the bone resection site was performed to identify morphometric factors that affect strength in the postoperative femur model. Four oblique sagittal planes running perpendicular to the femoral neck axis were used as reference planes to measure the bone resection site.

RESULTS

At the transcervical reference plane, both the bone resection depth and the cross-sectional area at the resection site correlated strongly with postoperative changes in the simulated fracture load (R² = 0.6, P = .0001). However, only resection depth was significantly correlated with the simulated fracture load at the reference plane for the head-neck junction. The resected bone volume did not correlate with the postoperative changes in the simulated fracture load.

CONCLUSIONS

The results of our FEA suggest that the bone resection depth measured at the head-neck junction and transcervical reference plane correlates with fracture risk after osteochondroplasty. By contrast, bone resection at more proximal areas did not have a significant effect on the postoperative femur model strength in our FEA. The total volume of resected bone was also not significantly correlated with postoperative changes in femur model strength.

CLINICAL RELEVANCE

This biomechanical study using FEA suggest that there is a risk of femoral neck fracture after arthroscopic cam resection, particularly when the resected lesion is located distally.

Fully automated segmentation of a hip joint using the patient-specific optimal thresholding and watershed algorithm

BACKGROUND AND OBJECTIVE

Automated segmentation with high accuracy and speed is a prerequisite for FEA-based quantitative assessment with a large population. However, hip joint segmentation has remained challenging due to a narrow articular cartilage and thin cortical bone with a marked interindividual variance. To overcome this challenge, this paper proposes a fully automated segmentation method for a hip joint that uses the complementary characteristics between the thresholding technique and the watershed algorithm.

METHODS

Using the golden section method and load path algorithm, the proposed method first determines the patient-specific optimal threshold value that enables reliably separating a femur from a pelvis while removing cortical and trabecular bone in the femur at the minimum. This provides regional information on the femur. The watershed algorithm is then used to obtain boundary information on the femur. The proximal femur can be extracted by merging the complementary information on a target image.

RESULTS

For eight CT images, compared with the manual segmentation and other segmentation methods, the proposed method offers a high accuracy in terms of the dice overlap coefficient (97.24 ± 0.44%) and average surface distance (0.36 ± 0.07 mm) within a fast timeframe in terms of processing time per slice (1.25 ± 0.27 s). The proposed method also delivers structural behavior which is close to that of the manual segmentation with a small mean of average relative errors of the risk factor (4.99%).

CONCLUSION

The segmentation results show that, without the aid of a prerequisite dataset and users' manual intervention, the proposed method can segment a hip joint as fast as the simplified Kang (SK)-based automated segmentation, while maintaining the segmentation accuracy at a similar level of the snake-based semi-automated segmentation.

Plausibility and parameter sensitivity of micro-finite element-based joint load prediction at the proximal femur

A micro-finite element-based method to estimate the bone loading history based on bone architecture was recently presented in the literature. However, a thorough investigation of the parameter sensitivity and plausibility of this method to predict joint loads is still missing. The goals of this study were (1) to analyse the parameter sensitivity of the joint load predictions at one proximal femur and (2) to assess the plausibility of the results by comparing load predictions of ten proximal femora to in vivo hip joint forces measured with instrumented prostheses (available from www.orthoload.com ). Joint loads were predicted by optimally scaling the magnitude of four unit loads (inclined [Formula: see text] to [Formula: see text] with respect to the vertical axis) applied to micro-finite element models created from high-resolution computed tomography scans ([Formula: see text]m voxel size). Parameter sensitivity analysis was performed by varying a total of nine parameters and showed that predictions of the peak load directions (range 10[Formula: see text]-[Formula: see text]) are more robust than the predicted peak load magnitudes (range 2344.8-4689.5 N). Comparing the results of all ten femora with the in vivo loading data of ten subjects showed that peak loads are plausible both in terms of the load direction (in vivo: [Formula: see text], predicted: [Formula: see text]) and magnitude (in vivo: [Formula: see text], predicted: [Formula: see text]). Overall, this study suggests that micro-finite element-based joint load predictions are both plausible and robust in terms of the predicted peak load direction, but predicted load magnitudes should be interpreted with caution.

Validation of an alignment method using motion tracking system for in-vitro orientation of cadaveric hip joints with reduced set of anatomical landmarks

Accurate in-vitro orientation of cadaveric hip joints is challenging due to limited available anatomical landmarks. Published hip joint in-vitro investigations commonly lack details on methods used to achieve reported orientations and the accuracy with which the desired orientation has been achieved. The aim of this study was to develop an accurate method for orienting hip joints with limited anatomical landmarks for in-vitro investigations, and to compare this method against orientation using guiding axes and by visual approximation. The proposed orientation method resulted in orientation angles achieved to within one degree (SD ± 0.58°). For most specimens, orientation using physical tools resulted in errors of ±8° and ±12° in at least one of three orientation angles used to place the femur and pelvis in neutral orientation, respectively. Precision was also worse, with SDs ranging from ±1° to ±5° for orientation angles of femoral specimens and SDs ranging from ±1° to ±8° for pelvic specimens. The error in the orientation angles was worse for orientation by visual approximation and the range of SDs were greater for both the femur and pelvis. Finite element modeling was used to assess the effects of observed orientation errors, on prediction of fracture load. In most cases, the largest error in fracture load among all trials exceeded 30%, relative to a femur oriented without any error in the orientation angles.

Damage Identification on Vertebral Bodies During Compressive Loading Using Digital Image Correlation

MINI: Identifying fracture is important for understanding vertebral mechanics. Isolated cadaveric thoracolumbar vertebrae were compressed, and surface strains were measured using digital image correlation. Fracture locations from video analysis were qualitatively similar to the locations of high compressive strains and local damage occurred before the maximum force was reached.

STUDY DESIGN

Ex vivo compression experiments on isolated cadaveric vertebrae.

OBJECTIVE

To qualitatively compare the fracture locations identified in video analysis with the locations of high compressive strain measured with digital image correlation (DIC) on vertebral bodies and to evaluate the timing of local damage to the cortical shell relative to the global yield force.

SUMMARY OF BACKGROUND DATA

In previous ex vivo experiments, cortical bone fracture has been identified using various methods including acoustic emission sensors, strain gages, video analysis, or force signals. These methods are, however, limited in their ability to detect the location and timing of fracture. We propose use of DIC, a noncontact optical technique that measures surface displacement, to quantify variables related to damage.

METHODS

Isolated thoracolumbar human cadaveric vertebral bodies (n = 6) were tested in compression to failure at a quasi-static rate, and the force applied was measured using a load cell. The surface displacement and strain were measured using DIC. Video analysis was performed to identify fractures.

RESULTS

The location of fractures identified in the video corresponded well with the locations of high compressive strain on the bone. Before reaching the global yield force, more than 10% of the DIC measurements reached a minimum principal strain of 1.0%, a previously reported threshold for cortical bone damage.

CONCLUSION

DIC measurements provide an objective measure that can be used to identify the location and timing of fractures during ex vivo vertebral experiments. This is important for understanding fracture mechanics and for validating vertebral computational models that incorporate failure.

LEVEL OF EVIDENCE

N /A.

Are DXA/aBMD and QCT/FEA Stiffness and Strength Estimates Sensitive to Sex and Age?

Dual X-ray absorptiometry (DXA) measures areal bone mineral density (aBMD) by simplifying a complex 3D bone structure to a 2D projection and is not equally effective for explaining fracture strength in women and men. Unlike DXA, subject-specific quantitative computed tomography-based finite element analysis (QCT/FEA) estimates fracture strength using 3D bone mineral distribution and geometry. By using experimentally-measured femoral stiffness and strength from a one hundred sample cadaveric cohort that included variations in sex and age, we wanted to determine if QCT/FEA estimates were able to better predict the experimental variations than DXA/aBMD. For each femur, DXA/aBMD was assessed and a QCT/FEA model was developed to estimate femoral stiffness and strength. Then, the femur was mechanically tested to fracture in a sideways fall on the hip position to measure stiffness and strength. DXA/aBMD and QCT/FEA estimates were compared for their sensitivity to sex and age with multivariate statistical analyses. When comparing the measured data with DXA/aBMD predictions, both age and sex were significant (p ≤ 0.0398) for both femoral stiffness and strength. However, QCT/FEA predictions of stiffness and strength showed sex was insignificant (p ≥ 0.23). Age was still significant (p ≤ 0.0072). These results indicate that QCT/FEA, unlike DXA/aBMD, accounted for bone differences due to sex.

The Femoral Neck Mechanoresponse to Hip Extensors Exercise: A Case Study

Physical activity is recommended to prevent age-related bone loss. However, the proximal femur mechanoresponse is variable, possibly because of a muscle-dependant mechanoresponse. We compared the proximal femur response with the femoral strain pattern generated by the hip extensor muscles. A healthy participant underwent a six-month unilateral training of the hip extensor muscles using a resistance weight regularly adjusted to the 80% of the one-repetition maximum weight. DXA-based measurements of the areal Bone Mineral Density (aBMD) in the exercise leg were adjusted for changes in the control leg. The biomechanical stimulus for bone adaptation (BS) was calculated using published models of the musculoskeletal system and the average hip extension moment in elderly participants. Volumetric (ΔvBMD) and areal (ΔaBMD) BMD changes were calculated. The measured and calculated BMD changes consistently showed a positive and negative effect of exercise in the femoral neck (ΔaBMD = +0.7%; ΔvBMD = +0.8%) and the trochanter region (ΔaBMD = -4.1%; ΔvBMD = -0.5%), respectively. The 17% of the femoral neck exceeded the 75th percentile of the spatially heterogeneous BS distribution. Hip extensor exercises may be beneficial in the proximal femoral neck but not in the trochanteric region. DXA-based measurements may not capture significant aBMD local changes.

Can CT image deblurring improve finite element predictions at the proximal femur?

The aim of this study was to determine if a CT image deblurring algorithm can improve CT-based FE modelling accuracy at the proximal femur. Experimental data (CT scans of fourteen proximal fresh-frozen cadaveric femurs, non-destructive surface strain measurements in stance and sideways fall loading configurations on all femurs, and failure loads obtained in stance for seven specimens, in sideways fall for the other seven) were taken from a recent study (Schileo et al., 2014). An estimate of the 3D Point Spread Function for each CT scan was used within a deconvolution solver to perform the deblurring. The most proximal regions of three specimens were scanned using an HRpQCT scanner and compared to the original and deblurred CT images to quantify errors in bone contour estimates and determine correlation of intensity values within the bone contours. Subject-specific FE models of the proximal femur were generated. The accuracy of deblurred FE predictions against experimental measurements was compared to the published (non-deblurred) FE results. When compared to HRpQCT, CT deblurring led to lower mean surface distances (0.31 vs. 0.49mm) and higher CT intensity correlations with respect to the original CT. All indicators of strain prediction accuracy were significantly improved in deblurred FE models, more markedly at the femoral neck (peak error reduced by 38%). Failure load prediction, based on a simple elastic limit model, was also improved in deblurred FE models, although differently for stance and sideways fall loading conditions. In stance, correlation was unchanged, but specimen-wise errors were reduced (mean error 10% vs. 15%). In sideways fall, correlation notably increased (R(2)=0.95 vs. 0.81), despite a general overestimation of failure load. In summary, the proposed CT deblurring technique yielded moderate but significant improvements in FE predictions, and may thus be considered a first step toward the improvement of CT-based FE models of the human femur.

In vitro implant-bone interface pressure measurements for a cementless femoral implant. A preliminary study

PURPOSE

Implants endurance as well as a good clinical tolerance depends on the recovery of a physiological stress distribution within bone after implantation. The purpose of the present work was to develop an alternative technique using Force Sensing Resistors (FSR) to gather in vitro pressure values at the implant-bone interface for a cementless implant.

METHOD

Eight cementless femoral stems were instrumented with six calibrated FSR bonded on each facet and then implanted in eight cadaver femurs. Compression tests were performed until failure and FSR pressure values were recorded.

RESULTS

The average failure load was 4241 N. The maximum contact pressure measured with the FSR averaged 1.965 MPa.

CONCLUSION

FSR reached many of the requirements for an ideal implant-bone interfacial sensor. This experimentation provided in vitro quantitative data on contact pressure at the implant-bone interface, which could help understanding stress shielding phenomenon and developing relevant numerical model.

Prophylactic augmentation of the proximal femur: an investigation of two techniques

INTRODUCTION

Osteoporotic hip fractures are an increasing problem in an ageing population. They result in high morbidity, mortality and high socioeconomic costs. For patients with poor bone quality, prophylactic augmentation of the proximal femur might be an option for fracture prevention.

METHODS

In two groups of paired human femora the potential of limited polymethyl-methacrylate (PMMA) augmentation (11-15 ml) in a V-shape pattern and the insertion of a proximal femur nail antirotation (PFNA) blade were investigated. The testing was carried out pair wise simulating the single leg stand. The untreated femur in each pair served as control. An axial load was applied until failure. Load displacement parameters and temperature increase during the augmentation process were recorded.

RESULTS

In the PMMA group no significant difference was found between the augmented and non-augmented specimen concerning load to failure (p = 0.35) and energy to failure (p = 0.9). A median temperature increase of 9.5 °C was observed in the augmented specimen. A significant correlation was found between the amount of applied PMMA and the temperature increase (Cor. Coef. = 0.82, p = 0.042). In the PFNA group, a significant decrease of load to failure and a non-significant decrease of energy to failure were observed (p = 0.037 and p = 0.075).

CONCLUSION

Limited V-shaped PMMA augmentation and PFNA blade insertion did not show any improvement in failure load or energy to failure. Volumes of up to 15 ml PMMA did not cause a critical surface temperature increase.

Translational Research in Pediatrics IV: Solid Tissue Collection and Processing

Solid tissues are critical for child-health research. Specimens are commonly obtained at the time of biopsy/surgery or postmortem. Research tissues can also be obtained at the time of organ retrieval for donation or from tissue that would otherwise have been discarded. Navigating the ethics of solid tissue collection from children is challenging, and optimal handling practices are imperative to maximize tissue quality. Fresh biopsy/surgical specimens can be affected by a variety of factors, including age, gender, BMI, relative humidity, freeze/thaw steps, and tissue fixation solutions. Postmortem tissues are also vulnerable to agonal factors, body storage temperature, and postmortem intervals. Nonoptimal tissue handling practices result in nucleotide degradation, decreased protein stability, artificial posttranslational protein modifications, and altered lipid concentrations. Tissue pH and tryptophan levels are 2 methods to judge the quality of solid tissue collected for research purposes; however, the RNA integrity number, together with analyses of housekeeping genes, is the new standard. A comprehensive clinical data set accompanying all tissue samples is imperative. In this review, we examined: the ethical standards relating to solid tissue procurement from children; potential sources of solid tissues; optimal practices for solid tissue processing, handling, and storage; and reliable markers of solid tissue quality.