Effects of mechanical factors on the fracture healing process.

An interdisciplinary study based on animal experiments, cell culture studies, and finite element models is presented. In a sheep model, the influence of the osteotomy gap size and interfragmentary motion on the healing success was investigated. Increasing gap sizes delayed the healing process. Increasing movement stimulated callus formation but not tissue quality. Typical distributions of intramembranous bone, endochondral ossification, and connective tissue in the fracture gap are quantified. The comparison of the mechanical data determined by a finite element model with the histologic images allowed the attribution of certain mechanical conditions to the type of tissue differentiation. Intramembranous bone formation was found for strains smaller than approximately 5% and small hydrostatic pressure (< 0.15 MPa). Strains less than 15% and hydrostatic pressure more than 0.15 MPa stimulated endochondral ossification. Larger strains led to connective tissue. Cell culture studies on the influence of strain on osteoblasts supported these findings. Proliferation and transforming growth factor beta production was increased for strains up to 5% but decreased for larger strains. Osteoblasts under larger strains (> 4%) turned away from the principal strain axis and avoided larger deformations. It is hypothesized that gap size and the amount of strain and hydrostatic pressure along the calcified surface in the fracture gap are the fundamental mechanical factors involved in bone healing.

Identification and distribution of synthetic ligament wear particles in sheep.

After one year, wear of medial collateral ligament replacements in sheep resulted in the presence of large numbers of wear particles and fibers in the joint space. This study examined the frequency of transport of these particles to the regional lymph nodes and to the liver and spleen. Inguinal, iliac, and paraaortic nodes were examined with regular and polarized light for the presence of particles presumably originating from polyethylene, aramid, polytetrafluoroethylene, polyesterterephthalate, polylacticacid, and carbon ligaments. Lymph nodes from sheep that had received tendon autograft replacements were also evaluated. Particles were observed in 33% of all nodes and in at least one node in 84% of all sheep. Particles were found in contralateral nodes, but not in the spleen or liver. Particles were observed usually as intracellular in foamy histiocytes, although extracellular carbon fibers and extracellular aramid fibers were also seen. Giant cells were occasionally detected in the polytetrafluoroethylene, polyethylene, and aramid nodes. In the polytetrafluoroethylene nodes and in the autograft nodes particles containing Mg, Si, and Fe were identified by elemental analysis. The morphological similarities between various birefringent particles and the particles indirectly identified as talc have led us to question the identification of wear debris solely on the basis of birefringence.

Effect of dynamization on gap healing of diaphyseal fractures under external fixation.

We asked whether dynamization of externally fixed diaphyseal fractures could improve bone healing in comparison to rigid fixation of fractures having similar remaining gap sizes. To answer this question we evaluated metatarsal osteotomies in 12 sheep. The osteotomy with a 0.6-mm gap was stabilized with a specially designed high bending and torsional stiffness external ring fixator. Osteotomies in six sheep were stabilized rigidly (axial movement < 0.06 mm) or dynamically (axial movement 0.15-0.34 mm). The cyclical axial interfragmentary movement was caused by the load-bearing of the operated limb. With increasing healing time, the initially allowed movement was decreased by callus formation around the osteotomy. The reduction in interfragmentary movement was measured and monitored by a linear variable displacement transducer at the external fixator and a telemetry system. After 9 weeks the sheep were sacrificed and the healed bones were investigated biomechanically and histomorphologically. Compared to the rigidly fixed osteotomies, the dynamized osteotomies showed significantly (P < 0.05) greater (+41%) callus formation and 45% greater tensile strength of the newly formed bone in the cortical osteotomy gap. Histological analysis indicated that the effect of dynamization occurred mainly after the 5th week. RELEVANCE: From these results we conclude that dynamic fixation of diaphyseal gaps is advantageous in comparison to stable external fixation.

Biological response to ligament wear particles.

In ligament replacement cases where the artificial ligament has worn and partially or totally ruptured, the released wear particles have been associated with a chronic synovitis that inhibits integration of the ligament and contributes to the ultimate failure of the device. In this study, the biological response to ligament wear particles from nine different artificial ligaments was quantitatively evaluated in vivo. Wear particles, the majority of which were < 7 microns, were generated in vitro. These particles were injected into rabbit knee joints, and the biological response as well as the systemic migration of the particles were evaluated histologically after 4 weeks. The extent of the inflammatory reaction to the ligament wear particles was found to be significantly (p < 0.05) influenced by the type of material implanted. No particles were found in the regional lymph nodes or in the spleen, liver, kidney, or lung.

Isolation and characterization of debris in membranes around total joint prostheses.

Particles of wear debris have been implicated in osteolysis around and aseptic loosening of total joint prostheses, but the number and size distribution of particles present in periprosthetic tissues are unknown. A method of particle assay was developed, consisting of nitric-acid digestion of tissue followed by collection of particles, electronic quantitation, and parallel morphological and chemical characterization. Nitric acid had minimum deleterious effects on control samples of titanium, cobalt-chromium alloy, and polyethylene particles, as determined by atomic absorption spectroscopy, scanning electron microscopy, and electronic measurements of the sizes of the particles. Acid digestion of twelve control samples of tissue, including tissue rich in hemosiderin, resulted in particle counts that were no higher than that in the digestion solution background. Other digestion preparations, including hydrochloric acid and sodium hypophosphate, were not as effective as nitric acid. With the low size limit of detection of approximately 0.58 micrometer, particle analysis of tissue adjacent to twenty retrieved total joint implants indicated a range of concentration of 0.85 to 141.85 x 10(9) particles per gram of tissue (dry weight). Although a few particles of more than 100 micrometers were detected, the mode of particle diameter from each sample ranged from the lower limit of detection (approximately 0.58 micrometer) to 0.79 micrometer. The findings of morphological studies and x-ray spectroscopy of isolated particles corresponded with those of light microscopy of the fibrous membranes. These data indicate that most of the particles in implant membranes are smaller than the resolution of the light microscope and that tissue digestion is necessary for quantitation and characterization.