Mapping anisotropy improves QCT-based finite element estimation of hip strength in pooled stance and side-fall load configurations.

Hip fractures are one of the most severe consequences of osteoporosis. Compared to the clinical standard of DXA-based aBMD at the femoral neck, QCT-based FEA delivers a better surrogate of femoral strength and gains acceptance for the calculation of hip fracture risk when a CT reconstruction is available. Isotropic, homogenised voxel-based, finite element (hvFE) models are widely used to estimate femoral strength in cross-sectional and longitudinal clinical studies. However, fabric anisotropy is a classical feature of the architecture of the proximal femur and the second determinant of the homogenised mechanical properties of trabecular bone. Due to the limited resolution, fabric anisotropy cannot be derived from clinical CT reconstructions. Alternatively, fabric anisotropy can be extracted from HR-pQCT images of cadaveric femora. In this study, fabric anisotropy from HR-pQCT images was mapped onto QCT-based hvFE models of 71 human proximal femora for which both HR-pQCT and QCT images were available. Stiffness and ultimate load computed from anisotropic hvFE models were compared with previous biomechanical tests in both stance and side-fall configurations. The influence of using the femur-specific versus a mean fabric distribution on the hvFE predictions was assessed. Femur-specific and mean fabric enhance the prediction of experimental ultimate force for the pooled, i.e. stance and side-fall, (isotropic: r2=0.81, femur-specific fabric: r2=0.88, mean fabric: r2=0.86,p<0.001) but not for the individual configurations. Fabric anisotropy significantly improves bone strength prediction for the pooled configurations, and mapped fabric provides a comparable prediction to true fabric. The mapping of fabric anisotropy is therefore expected to help generate more accurate QCT-based hvFE models of the proximal femur for personalised or multiple load configurations.

Characterizing microcrack orientation distribution functions in osteonal bone samples.

Prefailure microdamage in bone tissue is considered to be the most detrimental factor in defining its strength and toughness with respect to age and disease. To understand the influence of microcracks on bone mechanics it is necessary to assess their morphology and three-dimensional distribution. This requirement reaches beyond classic histology and stereology, and methods to obtain such information are currently missing. Therefore, the aim of the study was to develop a methodology that allows to characterize three-dimensional microcrack distributions in bulk bone samples. Four dumbbell-shaped specimens of human cortical bone of a 77-year-old female donor were loaded beyond yield in either tension, compression or torsion (one control). Subsequently, synchrotron radiation micro-computed tomography (SRµCT) was used to obtain phase-contrast images of the damaged samples. A microcrack segmentation algorithm was developed and used to segment microcrack families for which microcrack orientation distribution functions were determined. Distinct microcrack families were observed for each load case that resulted in distinct orientation distribution functions. Microcracks had median areas of approximately 4.7 µm2 , 33.3 µm2 and 64.0 µm2 for tension, compression and torsion. Verifying the segmentation algorithm against a manually segmented ground truth showed good results when comparing the microcrack orientation distribution functions. A size dependence was noted when investigating the orientation distribution functions with respect to the size of the volume of interest used for their determination. Furthermore, a scale separation between tensile, compressive and torsional microcracks was noticeable. Visual comparison to classic histology indicated that microcrack families were successfully distinguished. We propose a methodology to analyse three-dimensional microcrack distributions in overloaded cortical bone. Such information could improve our understanding of bone microdamage and its impact on bone failure in relation to tissue age and disease.

Effect of boundary conditions on yield properties of human femoral trabecular bone.

Trabecular bone plays an important mechanical role in bone fractures and implant stability. Homogenized nonlinear finite element (FE) analysis of whole bones can deliver improved fracture risk and implant loosening assessment. Such simulations require the knowledge of mechanical properties such as an appropriate yield behavior and criterion for trabecular bone. Identification of a complete yield surface is extremely difficult experimentally but can be achieved in silico by using micro-FE analysis on cubical trabecular volume elements. Nevertheless, the influence of the boundary conditions (BCs), which are applied to such volume elements, on the obtained yield properties remains unknown. Therefore, this study compared homogenized yield properties along 17 load cases of 126 human femoral trabecular cubic specimens computed with classical kinematic uniform BCs (KUBCs) and a new set of mixed uniform BCs, namely periodicity-compatible mixed uniform BCs (PMUBCs). In stress space, PMUBCs lead to 7-72 % lower yield stresses compared to KUBCs. The yield surfaces obtained with both KUBCs and PMUBCs demonstrate a pressure-sensitive ellipsoidal shape. A volume fraction and fabric-based quadric yield function successfully fitted the yield surfaces of both BCs with a correlation coefficient [Formula: see text]. As expected, yield strains show only a weak dependency on bone volume fraction and fabric. The role of the two BCs in homogenized FE analysis of whole bones will need to be investigated and validated with experimental results at the whole bone level in future studies.

Rebound-associated vertebral fractures after discontinuation of denosumab-from clinic and biomechanics.

UNLABELLED: Rebound-associated vertebral fractures may follow treatment discontinuation of highly potent reversible bone antiresorptives, resulting from the synergy of rapid bone resorption and accelerated microdamage accumulation in trabecular bone. INTRODUCTION: The purposes of this study are to characterize rebound-associated vertebral fractures following the discontinuation of a highly potent reversible antiresorptive therapy based on clinical observation and propose a pathophysiological rationale. METHODS: This study is a case report of multiple vertebral fractures early after discontinuation of denosumab therapy in a patient with hormone receptor-positive non-metastatic breast cancer treated with an aromatase inhibitor. RESULTS: Discontinuation of highly potent reversible bone antiresorptives such as denosumab may expose patients to an increased fracture risk due to the joined effects of absent microdamage repair during therapy followed by synchronous excess activation of multiple bone remodelling units at the time of loss-of-effect. We suggest the term rebound-associated vertebral fractures (RVF) for this phenomenon characterized by the presence of multiple new clinical vertebral fractures, associated with either no or low trauma, in a context consistent with the presence of high bone turnover and rapid loss of lumbar spine bone mineral density (BMD) occurring within 3 to 12 months after discontinuation (loss-of-effect) of a reversible antiresorptive therapy in the absence of secondary causes of bone loss or fractures. Unlike atypical femoral fractures that emerge from failure of microdamage repair in cortical bone with long-term antiresorptive treatment, RVF originate from the synergy of rapid bone resorption and accelerated microdamage accumulation in trabecular bone triggered by the discontinuation of highly potent reversible antiresorptives. CONCLUSIONS: Studies are urgently needed to i) prove the underlying pathophysiological processes suggested above, ii) establish the predictive criteria exposing patients to an increased risk of RVF, and iii) determine appropriate treatment regimens to be applied in such patients.

Quantitative analysis of imprint shape and its relation to mechanical properties measured by microindentation in bone.

Microindentation in bone is a micromechanical testing technique routinely used to extract material properties related to bone quality. As the analysis of microindentation data is based on assumptions about the contact between sample and surface, the aim of this study was to quantify the topological variability of indentations in bone and examine its relationship with mechanical properties. Indentations were performed in dry human and ovine bone in axial and transverse directions and their topology was measured by atomic force microscopy. Statistical shape modeling of the residual imprint allowed to define a mean shape and to describe the variability in terms of 21 principal components related to imprint depth, surface curvature and roughness. The indentation profile of bone was found to be highly consistent and free of any pile up while differing mostly by depth between species and direction. A few of the topological parameters, in particular depth, showed significant but rather weak and inconsistent correlations to variations in mechanical properties. The mechanical response of bone as well as the residual imprint shape was highly consistent within each category. We could thus verify that bone is rather homogeneous in its micromechanical properties and that indentation results are not strongly influenced by small deviations from an ideally flat surface.

Cathepsin S controls adipocytic and osteoblastic differentiation, bone turnover, and bone microarchitecture.

Cathepsin S is a cysteine protease that controls adipocyte differentiation and has been implicated in vascular and metabolic complications of obesity. Considering the inverse relation of osteoblasts and adipocytes and their mutual precursor cell, we hypothesized that cathepsin S may also affect osteoblast differentiation and bone remodeling. Thus, the fat and bone phenotypes of young (3 months old) and aged (12 or 18 months old) cathepsin S knock-out (KO) and wild-type (WT) mice were determined. Cathepsin S KO mice had a normal body weight at both ages investigated, even though the amount of subscapular and gonadal fat pads was reduced by 20%. Further, cathepsin S deficiency impaired adipocyte formation (-38%, p<0.001), which was accompanied by a lower expression of adipocyte-related genes and a reduction in serum leptin, IL-6 and CCL2 (p<0.001). Micro-CT analysis revealed an unchanged trabecular bone volume fraction and density, while tissue mineral density was significantly lower in cathepsin S KO mice at both ages. Aged KO mice further had a lower cortical bone mass (-2.3%, p<0.05). At the microarchitectural level, cathepsin S KO mice had thinner trabeculae (-8.3%), but a better connected trabecular network (+24%). Serum levels of the bone formation marker type 1 procollagen amino-terminal-propeptide and osteocalcin were both 2-3-fold higher in cathepsin S KO mice as was the mineralized surface. Consistently, osteogenic differentiation was increased 2-fold along with an increased expression of osteoblast-specific genes. Interestingly, serum levels of C-terminal telopeptide of type I collagen were also higher (+43%) in cathepsin S KO mice as were histological osteoclast parameters and ex vivo osteoclast differentiation. Thus, cathepsin S deficiency alters the balance between adipocyte and osteoblast differentiation, increases bone turnover, and changes bone microarchitecture. Therefore, bone and fat metabolisms should be monitored when using cathepsin S inhibitors clinically.

Early changes in biochemical markers of bone formation during teriparatide therapy correlate with improvements in vertebral strength in men with glucocorticoid-induced osteoporosis.

UNLABELLED: Changes of the bone formation marker PINP correlated positively with improvements in vertebral strength in men with glucocorticoid-induced osteoporosis (GIO) who received 18-month treatment with teriparatide, but not with risedronate. These results support the use of PINP as a surrogate marker of bone strength in GIO patients treated with teriparatide. INTRODUCTION: To investigate the correlations between biochemical markers of bone turnover and vertebral strength estimated by finite element analysis (FEA) in men with GIO. METHODS: A total of 92 men with GIO were included in an 18-month, randomized, open-label trial of teriparatide (20 µg/day, n = 45) and risedronate (35 mg/week, n = 47). High-resolution quantitative computed tomography images of the 12th thoracic vertebra obtained at baseline, 6 and 18 months were converted into digital nonlinear FE models and subjected to anterior bending, axial compression and torsion. Stiffness and strength were computed for each model and loading mode. Serum biochemical markers of bone formation (amino-terminal-propeptide of type I collagen [PINP]) and bone resorption (type I collagen cross-linked C-telopeptide degradation fragments [CTx]) were measured at baseline, 3 months, 6 months and 18 months. A mixed-model of repeated measures analysed changes from baseline and between-group differences. Spearman correlations assessed the relationship between changes from baseline of bone markers with FEA variables. RESULTS: PINP and CTx levels increased in the teriparatide group and decreased in the risedronate group. FEA-derived parameters increased in both groups, but were significantly higher at 18 months in the teriparatide group. Significant positive correlations were found between changes from baseline of PINP at 3, 6 and 18 months with changes in FE strength in the teriparatide-treated group, but not in the risedronate group. CONCLUSIONS: Positive correlations between changes in a biochemical marker of bone formation and improvement of biomechanical properties support the use of PINP as a surrogate marker of bone strength in teriparatide-treated GIO patients.

A generalized anisotropic quadric yield criterion and its application to bone tissue at multiple length scales.

Nonlinear computational analysis of materials showing elasto-plasticity or damage relies on knowledge of their yield behavior and strengths under complex stress states. In this work, a generalized anisotropic quadric yield criterion is proposed that is homogeneous of degree one and takes a convex quadric shape with a smooth transition from ellipsoidal to cylindrical or conical surfaces. If in the case of material identification, the shape of the yield function is not known a priori, a minimization using the quadric criterion will result in the optimal shape among the convex quadrics. The convexity limits of the criterion and the transition points between the different shapes are identified. Several special cases of the criterion for distinct material symmetries such as isotropy, cubic symmetry, fabric-based orthotropy and general orthotropy are presented and discussed. The generality of the formulation is demonstrated by showing its degeneration to several classical yield surfaces like the von Mises, Drucker-Prager, Tsai-Wu, Liu, generalized Hill and classical Hill criteria under appropriate conditions. Applicability of the formulation for micromechanical analyses was shown by transformation of a criterion for porous cohesive-frictional materials by Maghous et al. In order to demonstrate the advantages of the generalized formulation, bone is chosen as an example material, since it features yield envelopes with different shapes depending on the considered length scale. A fabric- and density-based quadric criterion for the description of homogenized material behavior of trabecular bone is identified from uniaxial, multiaxial and torsional experimental data. Also, a fabric- and density-based Tsai-Wu yield criterion for homogenized trabecular bone from in silico data is converted to an equivalent quadric criterion by introduction of a transformation of the interaction parameters. Finally, a quadric yield criterion for lamellar bone at the microscale is identified from a nanoindentation study reported in the literature, thus demonstrating the applicability of the generalized formulation to the description of the yield envelope of bone at multiple length scales.

An anisotropic elastic-viscoplastic damage model for bone tissue.

A new anisotropic elastic-viscoplastic damage constitutive model for bone is proposed using an eccentric elliptical yield criterion and nonlinear isotropic hardening. A micromechanics-based multiscale homogenization scheme proposed by Reisinger et al. is used to obtain the effective elastic properties of lamellar bone. The dissipative process in bone is modeled as viscoplastic deformation coupled to damage. The model is based on an orthotropic ecuntric elliptical criterion in stress space. In order to simplify material identification, an eccentric elliptical isotropic yield surface was defined in strain space, which is transformed to a stress-based criterion by means of the damaged compliance tensor. Viscoplasticity is implemented by means of the continuous Perzyna formulation. Damage is modeled by a scalar function of the accumulated plastic strain [Formula: see text] , reducing all element s of the stiffness matrix. A polynomial flow rule is proposed in order to capture the rate-dependent post-yield behavior of lamellar bone. A numerical algorithm to perform the back projection on the rate-dependent yield surface has been developed and implemented in the commercial finite element solver Abaqus/Standard as a user subroutine UMAT. A consistent tangent operator has been derived and implemented in order to ensure quadratic convergence. Correct implementation of the algorithm, convergence, and accuracy of the tangent operator was tested by means of strain- and stress-based single element tests. A finite element simulation of nano- indentation in lamellar bone was finally performed in order to show the abilities of the newly developed constitutive model.

The mechanical behavior of PMMA/bone specimens extracted from augmented vertebrae: a numerical study of interface properties, PMMA shrinkage and trabecular bone damage.

Recently published compression tests on PMMA/bone specimens extracted after vertebral bone augmentation indicated that PMMA/bone composites were not reinforced by the trabecular bone at all. In this study, the reasons for this unexpected behavior should be investigated by using non-linear micro-FE models. Six human vertebral bodies were augmented with either standard or low-modulus PMMA cement and scanned with a HR-pQCT system before and after augmentation. Six cylindrical PMMA/bone specimens were extracted from the augmented region, scanned with a micro-CT system and tested in compression. Four different micro-FE models were generated from these images which showed different bone tissue material behavior (with/without damage), interface behavior (perfect bonding, frictionless contact) and PMMA shrinkage due to polymerization. The non-linear stress-strain curves were compared between the different micro-FE models as well as to the compression tests of the PMMA/bone specimens. Micro-FE models with contact between bone and cement were 20% more compliant compared to those with perfect bonding. PMMA shrinkage damaged the trabecular bone already before mechanical loading, which further reduced the initial stiffness by 24%. Progressing bone damage during compression dominated the non-linear part of the stress-strain curves. The micro-FE models including bone damage and PMMA shrinkage were in good agreement with the compression tests. The results were similar with both cements. In conclusion, the PMMA/bone interface properties as well as the initial bone damage due to PMMA polymerization shrinkage clearly affected the stress-strain behavior of the composite and explained why trabecular bone did not contribute to the stiffness and strength of augmented bone.

The effects of bone and pore volume fraction on the mechanical properties of PMMA/bone biopsies extracted from augmented vertebrae.

Vertebroplasty forms a porous PMMA/bone composite which was shown to be weaker and less stiff than pure PMMA. It is not known what determines the mechanical properties of such composites in detail. This study investigated the effects of bone volume fraction (BV/TV), cement porosity (PV/(TV-BV), PV…pore volume) and cement stiffness. Nine human vertebral bodies were augmented with either standard or low-modulus PMMA cement and scanned with a HR-pQCT system before and after augmentation. Fourteen cylindrical PMMA/bone biopsies were extracted from the augmented region, scanned with a micro-CT system and tested in compression until failure. Micro-finite element (FE) models of the complete biopsies, of the trabecular bone alone as well as of the porous cement alone were generated from CT images to gain more insight into the role of bone and pores. PV/(TV-BV) and experimental moduli of standard/low-modulus cement (R(2)=0.91/0.98) as well as PV/(TV-BV) and yield stresses (R(2)=0.92/0.83) were highly correlated. No correlation between BV/TV (ranging from 0.057 to 0.138) and elastic moduli was observed (R(2)< 0.05). Interestingly, the micro-FE models of the porous cement alone reproduced the experimental elastic moduli of the standard/low-modulus cement biopsies (R(2)=0.75/0.76) more accurately than the models with bone (R(2)=0.58/0.31). In conclusion, the mechanical properties of the biopsies were mainly determined by the cement porosity and the cement material properties. The study showed that bone tissue inside the biopsies was mechanically "switched off" such that load was carried essentially by the porous PMMA.

Fabric-mechanical property relationships of trabecular bone allografts are altered by supercritical CO2 treatment and gamma sterilization.

Tissue grafts are implanted in orthopedic surgery every day. In order to minimize infection risk, bone allografts are often delipidated with supercritical CO2 and sterilized prior to implantation. This treatment may, however, impair the mechanical behavior of the bone graft tissue. The goal of this study was to determine clinically relevant mechanical properties of treated/sterilized human trabecular bone grafts, e.g. the apparent modulus, strength, and the ability to absorb energy during compaction. They were compared with results of identical experiments performed previously on untreated/fresh frozen human trabecular bone from the same anatomical site (Charlebois, 2008). We tested the hypothesis that the morphology-mechanical property relationships of treated cancellous allografts are similar to those of fresh untreated bone. The morphology of the allografts was determined by µCT. Subsequently, cylindrical samples were tested in unconfined and confined compression. To account for various morphologies, the experimental data was fitted to phenomenological mechanical models for elasticity, strength, and dissipated energy density based on bone volume fraction (BV/TV) and the fabric tensor determined by MIL. The treatment/sterilization process does not appear to influence bone graft stiffness. However, strength and energy dissipation of the bone grafts were found to be significantly reduced by 36% to 47% and 66% to 81%, respectively, for a broad range of volume fraction (0.14

Assessment of volume fraction and fabric in the distal radius using HR-pQCT.

The aim of this study was to investigate the capabilities of the state of the art HR-pQCT technique to predict mineral content, volume fraction and fabric of trabecular bone structure compared to the gold standard microCT. Four cadaveric human forearms were scanned with HR-pQCT and the dissected radius epiphyses with microCT. After registering the images, bone mineral density (BMD), volume fraction (BV/TV) and fabric were computed on corresponding cubical regions of interest for both image sources. In particular, the effect of the segmentation procedure on BV/TV was analyzed. Assessment of fabric was performed with three different methods comparing their efficiency and robustness against resolution change. The results showed that in order to achieve optimal results at the lower image resolution, different filtering and thresholding approaches needed to be selected for different tasks. Therefore, to preserve BV/TV, the BMD-based volume fraction provided best match with the reference values of microCT, while in case of Mean Intercept Length (MIL) fabric a Gaussian filter and a histogram-based threshold were optimal. Using the latter, MIL was found to be more robust against resolution change than the other approaches. Additionally, we proposed a linear model for describing the mathematical transformation that the second order fabric tensor undergoes when the resolution of the input images changes. As a conclusion, we found that the investigated properties of trabecular bone structure can be adequately predicted from the lower resolution technique that is available in vivo for peripheral bones, when proper image processing and corrections are applied.

Validation of an anatomy specific finite element model of Colles' fracture.

Osteoporotic fractures are harmful injuries and their number is on the rise. Distal radius fractures are precursors of other osteoporotic fractures. The wrist's bony geometry and trabecular architecture can be assessed in vivo using the recently introduced HR-pQCT. The goal of this study was the validation of a newly developed HR-pQCT based anatomy specific FE technique including separation of cortical and trabecular bone regions using an experimental model for producing Colles' fractures. Mechanical compression tests of 21 embalmed human radii were conducted. Continuum level FE models were built using HR-pQCT images of the bones and nonlinear analyses were performed using boundary conditions highly similar to the mechanical tests. Density and fabric based material properties were taken from previous tests on biopsies and no adjustments were made. Numerical results provided good prediction of the experimental stiffness (R(2)=0.793) and even better for strength (R(2)=0.874). High damage zones of the FE models coincided with the actual failure patterns of the specimens. These encouraging results allow to conclude that the developed method represents an attractive and efficient tool for simulation of Colles' fracture.

Sampling Sphere Orientation Distribution: an efficient method to quantify trabecular bone fabric on grayscale images.

A novel Sampling Sphere Orientation Distribution (SSOD) method based on mobile sampling spheres is developed for describing microstructural anisotropy of trabecular bone using grayscale images. Efficient implementation of SSOD on segmented and unsegmented 3D microCT images of human trabecular bone samples from different anatomical locations is demonstrated. The second order fabric tensor of SSOD corresponds well with the one derived from the mean intercept length (MIL) method applied on segmented images. The results of SSOD are extended to higher order fabric approximations and the effect of sampling sphere radius is examined. Finally, performance of the method on artificial microstructures is presented.

Compliance of the L5-S1 spinal unit: a comparative study between an unconstrained and a partially constrained system.

A comparison between an unconstrained and a partially constrained system for in vitro biomechanical testing of the L5-S1 spinal unit was conducted. The objective was to compare the compliance and the coupling of the L5-S1 unit measured with an unconstrained and a partially constrained test for the three major physiological motions of the human spine. Very few studies have compared unconstrained and partially constrained testing systems using the same cadaveric functional spinal units (FSUs). Seven human L5-S1 units were therefore tested on both a pneumatic, unconstrained, and a servohydraulic, partially constrained system. Each FSU was tested along three motions: flexion-extension (FE), lateral bending (LB) and axial rotation (AR). The obtained kinematics on both systems is not equivalent, except for the FE case, where both motions are similar. The directions of coupled motions were similar for both tests, but their magnitudes were smaller in the partially constrained configuration. The use of a partially constrained system to characterize LB and AR of the lumbosacral FSU decreased significantly the measured stiffness of the segment. The unconstrained system is today's "gold standard" for the characterization of FSUs. The selected partially constrained method seems also to be an appropriate way to characterize FSUs for specific applications. Care should be taken using the latter method when the coupled motions are important.

A finite element model of the L5-S1 functional spinal unit: development and comparison with biomechanical tests in vitro.

The main objective of this work is to develop a three-dimensional finite element model of the L5-S1 segment that is able to simulate its passive mobility measured in vitro. Due to their limited role in segment mobility, an isotropic linear elastic constitutive law was used for cartilage, cancellous and cortical bone. The intervertebral disk ground substance was modeled with a non-linear hyperelastic polynomial law. Fibers of the disk, as well as ligaments, were modeled with piecewise linear springs. Flexion-extension, axial rotation, and lateral bending torques were applied to the model. A comparison with the experimental results obtained on the same segment for these three major motions was conducted. The compliance of the segment subjected to pure torques was found to be similar between numerical and experimental results for all major motions. Coupled motions and translations were also similar, even in their amplitude. For lateral bending, the normal coupled motions originate from the geometry of the disk and not from the facet geometry.

Age, gender, and bone lamellae elastic moduli.

To enhance preventative and therapeutic strategies for metabolic bone diseases and bone fragility disorders, we began to explore the physical properties of bone tissue at the cellular level. Proximal femurs were harvested from 27 cadavera (16 male and 11 female) for in vitro measurement of the mechanical properties. We measured the variations in lamellar-level elastic modulus and hardness in human bone as a function of age and gender to identify microstructural properties responsible for age and gender-related reductions in the mechanical integrity. The lateral femoral necks were examined, and age, gender, height, body mass, and body mass index were not found to correlate with lamellar-level elastic modulus or hardness. This result was consistent for osteonal, interstitial, and trabecular tissue. These data suggest that increased bone mass maintenance, known to occur in heavier individuals, is not accompanied by increases in the lamellar-level elastic modulus or hardness. The independence of elastic modulus and hardness from age and gender suggests that age and gender-related decreases in mechanical integrity do not involve alterations in elastic modulus or hardness of the extracellular matrix. Lamellar-level ultimate, fatigue, and fracture toughness properties should also be investigated. Other factors, such as tissue mass and organization, may also contribute to age and gender-related decreases in the mechanical integrity.