Extracorporeal irradiation of an excised tumour-bearing segment of bone followed by its re-implantation is a technique used in bone sarcoma surgery for limb salvage when the bone is of reasonable quality. There is no agreement among previous studies about the dose of irradiation to be given: up to 300 Gy have been used.

We investigated the influence of extracorporeal irradiation on the elastic and viscoelastic properties of bone. Bone was harvested from mature cattle and subdivided into 13 groups: 12 were exposed to increasing levels of irradiation: one was not and was used as a control. The specimens, once irradiated, underwent mechanical testing in saline at 37°C.

The mechanical properties of each group, including Young’s modulus, storage modulus and loss modulus, were determined experimentally and compared with the control group.

There were insignificant changes in all of these mechanical properties with an increasing level of irradiation.

We conclude that the overall mechanical effect of high levels of extracorporeal irradiation (300 Gy) on bone is negligible. Consequently the dose can be maximised to reduce the risk of local tumour recurrence.

Cite this article: Bone Joint J 2015;97-B:1152–6.

Introduction. The fixation of press-fit orthopaedic devices depends on the mechanical properties of the bone that is in contact with the implants. During the press-fit implantation, bone is compacted and permanently deformed, finally resulting in the mechanical interlock between implant and bone. For the development and design of new devices, it is imperative to understand these non-linear interactions. One way to investigate primary fixation is by using computational models based on Finite Element (FE) analysis. However, for a successful simulation, a proper material model is necessary that accurately captures the non-linear response of the bone. In the current study, we combined experimental testing with FE modeling to establish a Crushable Foam model (CFM) to represent the non-linear bone biomechanics that influences implant fixation. Methods. Mechanical testing of human tibial trabecular bone was done under uniaxial and confined compression configurations. We examined 62 human trabecular bone samples taken from 8 different cadaveric tibiae to obtain all the required parameters defining the CFM, dependent on local bone mineral density (BMD). The derived constitutive rule was subsequently applied using an in-house subroutine to the FE models of the bone specimens, to compare the model predictions against the experimental results. Results. The crushable foam model provided an accurate simulation of the experimental compression test, and was able to replicate the ultimate compression strength measured in the experiments [Figure 1]. The CFM was able to simulate the post-failure behavior that was observed in the experimental specimens up to strain levels of 50% [Figure 2]. Also, the distribution of yield strains and permanent displacement was qualitatively very similar to the experimental deformation of the bone specimens [Figure 3]. Conclusion. The crushable foam model developed in the current study was able to accurately replicate the mechanical behavior of the human trabecular bone under compression loading beyond the yield point. This advanced bone model enables realistic simulations of the primary fixation of orthopaedic devices, allowing for the analysis of the influence of interference fit and frictional properties on implant stability. In addition, the model is suitable for failure analysis of reconstructions, such as the tibial collapse of total knee arthroplasty. For any figures or tables, please contact the authors directly

The April 2024 Trauma Roundup³⁶⁰ looks at: The infra-acetabular screw in acetabular fracture surgery; Is skin traction helpful in patients with intertrochanteric hip fractures?; Reducing pain and improving function following hip fracture surgery; Are postoperative splints helpful following ankle fracture fixation?; Biomechanics of internal fixation in Hoffa fractures: a comparison of four different constructs; Dual-plate fixation of periprosthetic distal femur fractures; Do direct oral anticoagulants necessarily mean a delay to hip fracture surgery?; Plate or retrograde nail for low distal femur fractures?.

Aims

This study aimed to demonstrate the promoting effect of elastic fixation on fracture, and further explore its mechanism at the gene and protein expression levels.

Aims

This study examined whether systemic administration of melatonin would have different effects on osseointegration in ovariectomized (OVX) rats, depending on whether this was administered during the day or night.

Aims

To draw a comparison of the pullout strengths of buttress thread, barb thread, and reverse buttress thread bone screws.

Background: The Hansson Twin Hook (HTH) is an alternative to the sliding hip screw in the treatment of trochanteric fractures. In osteoporotic bone, biomechanical tests indicate better fixation properties of the HTH than of the lag screw. Our aim was to evaluate the technical results of the HTH in a larger series of osteoporotic patients with intertrochanteric fractures. Many surgeons were involved to assess, if the device was user-friendly. Patients and Methods: In a prospective bicentric study, 55 surgeons used the HTH and a standard plate in 157 consecutive patients with intertrochanteric fractures, of which 83% were unstable. The mean age of the patients was 83 years. The patients were followed regularly clinically and radiographically for at least 4 months with a final control at 2 years. Results: Technical intraoperative errors were done in 7 of the patients. The reduction of the fracture was inaccurate in these cases; hence the HTH had not been placed centrally in the femoral head. Two of the 7 intraoperative errors developed into failures of fixation (1.3%) during the 2-year period. Interpretation: The HTH achieves adequate fixation purchase in osteoporotic bone, has a low failure rate and is easy to use

Aims

The processes linking long-term bisphosphonate treatment to atypical fracture remain elusive. To establish a means of exploring this link, we have examined how long-term bisphosphonate treatment with prior ovariectomy modifies femur fracture behaviour and tibia mass and shape in murine bones.

Aim: Nanoindentation is a technique, developed over the last 15 years which is now widely used in the materials science for probing the mechanical properties of thin films. The properties most commonly measured are Young’s modulus (E), and Hardness (H). One of the great advantages of the technique is its ability to probe a surface and map its properties on a spatially – resolved basis, often with a resolution of better than 1μm. Materials and methods: specimens from 5 lumbar vertebrae (L-4) were obtained from fresh, unembalmed human cadavers (2 males and 3 females), aged from 16 to 90 years. After carefully removing posterior elements and soft tissues, the vertebral bodies were cut to a thickness of 5mm and embedded in epoxy resin to provide support for the porous network. Then the samples were metallograpically polished to produce smooth testing surfaces and nanoindentation tests were conducted to measure Young’s modulus and hardness of individual trabeculae. Measurements were made in both longitudinal and transverse direction in relation to the longitudinal axes of the trabeculae. The indentation load – displacement data obtained in these tests were analyzed, using the method of Oliver and Pharr. Results: a total of 719 nanoindentations were produced in this research. A mean of 7–8 indentations were made in 103 separate trabeculae both in longitudinal and transverse direction. The mean Young’s modulus was found to be 13.7(2.5) Gpa, which is higher than the one obtained by classic micromechanical tests. There were no significant differences of elastic moduli among the longitudinal and the transverse directions of the trabeculae (13.8. Gpa and 13.5 Gpa, respectively). Conclusion: nanoindentation is a very promising technique for evaluating intrinsic mechanical properties of bone at sub-micro level of organization. It may have many applications and may contribute to the improvement of our knowledge concerning bone biomechanics, the effects of metabolic bone diseases on bone mechanical properties and the capabilities of surgical treatment

Aims: evaluate the relationship between Singh index (SI), bone mineral density (BMD) examining bone mechanical properties from ex-vivo human femoral heads. Methods: we collected the femoral heads of 22 patients that underwent arthroplastic for fracture of femoral head under low energy trauma. 5 patients were male while 17 were female. In each patient a pelvis X-ray was performed to estimate Singh Index. From 2 to 3 bone cylinders of cancellous bone were obtained from each femoral head. 52 bone cylinders (7x10mm) were obtained. In each specimen densitometric scans were performed by means of a Hologic QDR 4500 X-ray densitometer, using a small animal software. The coefficient of variation (CV) was calculated by repositioning a sample for 5 scans by different operators. The data obtained were expressed as bone mineral content (BMC) and bone mineral density (BMD). Compression tests with a JJ Instruments T5K machine were conducted on 52 spongy bone cylinders. Each specimen was loaded in movement control; maximum failure load and Young modulus were recorded. Results The CV for the precision was 1.8% for BMC and 2.7% for BMD. There are no differences between males and females in age, BMC, BMD and Young modulus, while there is a significant difference in maximum load and SI. As regards SI values, there are significant differences among different categories of SI for age, sex, BMC, BMD, Young modulus and maximum failure load. Considering each sample position, namely 1, 2 or 3, there was no significant difference in densitometric parameters and in mechanical properties Statistical analyses of correlations by Pearson’s coefficient showed significant inverse correlations between age and mechanical bone properties (Young modulus and maximum failure load), while the correlations between BMC, BMD and biomechanical bone behaviour were strictly direct Linear regression model demonstrated only maximum load predictors are Young modulus and BMD. Conclusions The maximum failure load is lower in females than in males with similar BMD but lower SI for different SI categories there are significant differences both in biomechanical behaviour both in densitometric parameters.The age is inversely correlated with bone densitometric features and bone biomechanical behaviour, while bone density is directly correlated with bone strength and elastic modulus.The bone strength is predicted with 93% accuracy by Young modulus and BMD

Periprosthetic fractures after total hip arthroplasty lead to considerable morbidity in terms of loss of component fixation, bone loss and subsequent functional compromise. The prevention, early recognition and appropriate management of such fractures are therefore critical. The pathogenesis of periprosthetic factors is multi-factorial. There are a number of intrinsic patient influences such as poor bone stock, biomechanics and compliance. There are also a host of extrinsic factors over which the surgeon has more control. The key tenets for fracture avoidance include careful planning, identifying the risk, choosing the correct implant, understanding the anatomy, and using appropriate surgical technique. There are a number of recognised risk factors for periprosthetic hip fractures The prevalence of intraoperative fractures during total hip arthroplasty is higher in the patient with osteopenia / osteoporosis. Other conditions causing increased bone fragility, such as osteomalacia, Paget's disease, osteopetrosis, and osteogenesis imperfecta are also at a higher risk of intraoperative fracture. The use of more and more press fit cementless components has also increased the number of periprosthetic femoral fractures because of the force required to obtain such a fit. Complex deformities of the proximal femur, particularly when associated with a narrow medullary canal, may also increase the risk of intraoperative fractures. Revision surgery is associated with a higher risk of intraoperative fracture than primary hip replacement surgery. These fractures typically occur during hip dislocation, cement extraction, or reaming through old cement. Other risk factors for postoperative femoral fractures following total hip replacement include loosening of the prosthesis with cortical bone loss, local osteolysis, stress risers within the cortex, such as old screw holes, the ends of plates, or impingement of a loose stem against the lateral femoral cortex. The management of periprosthetic fractures requires appropriate preoperative imaging, planning and templating, the availability of the necessary expertise and equipment, and knowledge of the potential pitfalls so that these can be avoided both intraoperatively and in follow-up. There is a danger that these cases fall between the expertise of the trauma surgeon and that of the revision arthroplasty surgeon. The past two decades have afforded us clear treatment algorithms based on fracture location, component fixation and the available bone stock. We still nevertheless face the enduring challenge of an elderly population with a high level of comorbidity who struggle to rehabilitate after such injuries. Perioperative optimization is critical as we have seen prolonged hospital stays, high rates of systemic complications and a significant short term mortality in this cohort. We have also been presented with new difficult fracture patterns around anatomic cementless stems and in relation to tapered cemented and cementless stems, as well as biologically challenging transverse or oblique fractures at the tip of a stem. In many cases, fixation techniques are biomechanically and biologically doomed to fail and intramedullary stability, achieved through complex revision is required. The sequelae of periprosthetic fractures include the financial cost of fixation or revision surgery, the associated morbidity and mortality in an elderly frail population, the difficulty with mobilization if the patient cannot fully weight bear, and a poor functional outcome in a proportion of cases. The battle over which patients or fractures require fixation and which require revision surgery continues

Objectives

Advanced glycation end-products (AGEs) are a post-translational modification of collagen that form spontaneously in the skeletal matrix due to the presence of reducing sugars, such as glucose. The accumulation of AGEs leads to collagen cross-linking, which adversely affects bone quality and has been shown to play a major role in fracture risk. Thus, intervening in the formation and accumulation of AGEs may be a viable means of protecting bone quality.

Periprosthetic fractures in total hip arthroplasty lead to considerable morbidity in terms of loss of component fixation, bone loss and subsequent function. The prevention, early recognition and appropriate management of such fractures are therefore critical. The pathogenesis of periprosthetic factors is multi-factorial. There are a number of intrinsic patient influences such as bone stock, biomechanics and compliance. There are also a host of extrinsic factors over which the surgeon has more control. The prevention of periprosthetic fractures requires careful pre-operative planning and templating, the availability of the necessary expertise and equipment, and knowledge of the potential pitfalls so that these can be avoided both intra-operatively and in follow-up. The key issues here are around identifying the risk, choosing the correct implant, understanding the anatomy, understanding the possible risks and avoiding them and using appropriate technique. There are a number of recognized risk factors for periprosthetic hip fractures. The prevalence of intra-operative fractures during total hip arthroplasty is higher in the patient with osteopenia/osteoporosis. Other conditions causing increased bone fragility, such as osteomalacia, Paget's disease, osteopetrosis, and osteogenesis imperfecta are also at a higher risk of intra-operative fracture. The use of more and more press fit cementless components has also increased the number of periprosthetic femoral fractures because of the force required to obtain such a fit. Complex deformities of the proximal femur, particularly when associated with a narrow medullary canal, as seen in secondary degenerative joint disease following developmental dysplasia of the hip may also increase the risk of intra-operative fractures. Revision surgery is associated with a higher risk of intra-operative fracture than primary hip replacement surgery. These fractures typically occur during hip dislocation, cement extraction, or reaming through old cement. Other risk factors for post-operative femoral fractures include loosening of the prosthesis with cortical bone loss, local osteolysis, stress risers within the cortex, such as old screw holes, the ends of plates, or impingement of a loose stem against the lateral femoral cortex. Periprosthetic acetabular fractures are increasingly recognized. This is in part due to the popularity of press fit components, which increase fracture risk both at the time of insertion and later due to medial wall stress shielding and pelvic osteolysis, and partly due to the increasing frequency of severe defects encountered at the time of revision surgery. Both over- and under-reaming are significant risk factors for acetabular fractures during total hip replacement. It is imperative to deal with the osteopenic patient gently and appropriately, being aware of the rim on the acetabular side and having the capacity for screw fixation where needed, having an understanding of where you wish to place your components and creating the appropriate runways for them, thinking about the stability of an implant as it is inserted and understanding that an implant that is less stable than expected probably is associated with either a size mismatch, a fracture or an implant that will not sit properly probably requires more or a different direction of reaming rather than harder blows with a hammer. A typical example where extra care is required is the scenario of a fractured neck of femur that requires total hip arthroplasty. The virgin native acetabulum in a patient likely to have some bony deficiency may be more difficult to deal with as it has a higher fracture risk. Pre-operative templating helps to identify the correct entry point for preparation of the lateral runway for linear insertion of a femoral stem. If resistance is met during insertion, the situation should be re-appraised to ensure that the direction and level of the rasp and prosthesis are the same. This reduces the risk of varus/valgus positioning which increases the risk of intra- and post-operative fractures. It is also important to avoid a change of version during insertion of the prosthesis as this can lead to high stresses

Since cementless stem fixation in hip arthroplasty is becoming more and more common, the overall incidence of intraoperative femoral fractures has risen considerably. Depending on primary or revision arthroplasty, literature reports fracture rates between a few percent up to one third of the cases. In this study, methods commonly applied in the field of structural testing were customized for this specified interference fit situation. A cementless hip system (ABG II, Stryker) was used on animal bones and biomechanical bones. Transient excitation in the form of regular hammer strokes and sinusoidal excitation using a shaker served as an input. The output of the system under test was measured on the greater trochanter using a piezoelectric accelerometer. The signals were digitized with a high-speed data acquisition system and analyzed in real-time with spectrum analysis software. Analysis included threshold detection in the time domain to determine the time delay between the input and output transducer. Spectrum analysis in the frequency domain included FFT analysis and frequency response function analysis to identify shifts of fundamental frequencies and harmonics to describe the vibrational changes with increasing stability. A digital imaging system was set up to take pictures of the metal-bone site to measure inducible displacement with each hammer impact and correlate it with the vibrometry results. Furthermore a strain gauge circularly mounted around the proximal femur monitored accurately any hairline fracture. This study shows that changes of the vibrational spectrum are directly related to implant fit. The range of interest is well in the sonic range, which apparently is the reason for many surgeons to listen and ‘feel’ carefully during advancing the broach or the final implant into the femur. The study is trying to extract critical vibrational parameters correlated with stability and femoral integrity. Due to the different dimensions of the tested animal bones and lack of soft tissue damping, further experiments on cadavers need to be carried out. Vibrational spectrum analysis could prove to be a useful tool to readily assess implant stability and femoral integrity. It seems to be most beneficial in revision surgery or minimally invasive hip replacement, where the risk of femoral fractures is increased or fissures could easily be missed

Objectives

This study tests the biomechanical properties of adjacent locked plate constructs in a femur model using Sawbones. Previous studies have described biomechanical behaviour related to inter-device distances. We hypothesise that a smaller lateral inter-plate distance will result in a biomechanically stronger construct, and that addition of an anterior plate will increase the overall strength of the construct.

In 1999, we developed a technique for biological reconstruction after excision of a bone tumour, which involved using autografts of the bone containing the tumour treated with liquid nitrogen. We have previously reported the use of this technique in 28 patients at a mean follow up of 27 months (10 to 54).

In this study, we included 72 patients who underwent reconstruction using this technique. A total of 33 patients died and three were lost to follow-up, at a mean of 23 months (2 to 56) post-operatively, leaving 36 patients available for a assessment at a mean of 101 months 16 to 163) post-operatively. The methods of reconstruction included an osteo-articular graft in 16, an intercalary in 13 and, a composite graft with prosthesis in seven.

Post-operative function was excellent in 26 patients (72.2%), good in seven (19.4%), and fair in three (8.3%) according to the functional evaluation system of Enneking. No recurrent tumour occurred within the grafts. The autografts survived in 29 patients (80.6%), and the rates of survival at five and ten years were 86.1% and 80.6 %, respectively. Seven of 16 osteo-articular grafts (44%) failed because of fracture or infection, but all the composite and intercalary grafts survived.

The long-term outcomes of frozen autografting, particularly using composite and intercalary grafts, are satisfactory and thus represent a good method of treatment for patients with a sarcoma of bone or soft tissue.

Cite this article: Bone Joint J 2014;96-B:555–61.

Objectives

One commonly used rat fracture model for bone and mineral research is a closed mid-shaft femur fracture as described by Bonnarens in 1984. Initially, this model was believed to create very reproducible fractures. However, there have been frequent reports of comminution and varying rates of complication. Given the importance of precise anticipation of those characteristics in laboratory research, we aimed to precisely estimate the rate of comminution, its importance and its effect on the amount of soft callus created. Furthermore, we aimed to precisely report the rate of complications such as death and infection.

Fibrin glue, also known as fibrin sealant, is now established as a haemostatic agent in surgery, but its role in orthopaedic surgery is neither well known nor clearly defined. Although it was originally used over 100 years ago, concerns about transmission of disease meant that it fell from favour. It is also available as a slow-release drug delivery system and as a substrate for cellular growth and tissue engineering. Consequently, it has the potential to be used in a number of ways in orthopaedic surgery. The purpose of this review is to address its use in surgery of the knee in which it appears to offer great promise.

We describe a new method of stabilising a painful unstable sternoclavicular joint using the sternocleidomastoid tendon and passing it through the medial clavicle and onto the manubrium sternum. This method is simple, reproducible and avoids the potential risks of reefing the joint to the first rib. The technique was used in seven cases of sternoclavicular joint instability in six patients who were reviewed at a mean of 39.7 months (15 to 63). Instability was markedly reduced or eliminated in all cases, but in one there was occasional persistant subluxation. There were minor scar complications after two procedures and one patient had transient ulnar neuritis.

This procedure provides satisfactory results in the medium term.