Distal Fibula Pro-Tibial Screws in Salvage Fixation of Bimalleolar Ankle Fractures in Osteoporotic Bone - A Novel Technique.

Here we present a novel adaptation of the previously described fibula pro-tibial fixation in a case requiring salvage fixation of a bimalleolar ankle fracture in an osteoporotic patient. Unstable osteoporotic ankle fractures are a challenging injury to manage and typically occur in a frail and comorbid subgroup of patients. Various techniques have been described in the evolution of managing these injuries, e.g. hindfoot nailing and anatomical locking plates, however in this uniquely challenging case a novel strategy was required to mitigate bone loss in the distal fibular fracture fragment. There is some evidence to suggest fibular protibial fixation offers a lower complication profile to its alternatives. The novel use of distal fibula pro-tibial screws offers a new alternative to hindfoot nailing of bimalleolar ankle fracture in osteoporotic bone with compromised distal fibular fragment bone purchase. Further research is required to investigate the compatibility of this technique with early weightbearing.

Undersizing the Tibial Baseplate in Cementless Total Knee Arthroplasty has Only a Small Impact on Bone-Implant Interaction: A Finite Element Biomechanical Study.

BACKGROUND: The tibial component in total knee arthroplasty (TKA) is often chosen to maximize coverage of the tibial cut, which can result in excessive internal rotation of the component. Optimal rotational alignment may require a smaller baseplate with suboptimal coverage that could threaten fixation. We asked: "does undersizing the tibial component of a cementless TKA to gain external rotation increase the risk of bone failure?" METHODS: We developed computational finite element (FE) analysis models from the computed tomography (CT) scans of 12 patients scheduled for primary TKA. The models were implanted with a cementless tibial baseplate that maximized coverage and one or two sizes smaller and externally rotated by 5°. We calculated the risk of bone collapse under loads representative of stair ascent. RESULTS: Undersizing the implant increased the area at risk of collapse for eight patients. However, the area at risk of collapse for the undersized implant (range, 5.2%-16.4%) was no different (P = .24) to the optimally sized implant (range, 4.5%-17.9%). The bone at risk of collapse was concentrated along the posterior edge of the implant. The area at risk of collapse was not proportional to implant size, and for four subjects undersizing the implant actually decreased the area at risk of collapse. CONCLUSION: While implants should maximize coverage of the tibial cut and seek support on dense bone, undersizing the tibial component to gain external rotation had minimal impact on the load transfer to the underlying bone. This FE analysis model of a cementless tibial baseplate may require further validation and additional studies to investigate the long-term biomechanical effects of undersizing the tibial baseplate. In conclusion, while surgeons should strive to use the appropriate tibial baseplate for each patient, our model identified only minor biomechanical consequences of undersizing the implant for the immediate postoperative bone-implant interaction and implant subsidence.

Characterizing the Mechanical Behavior of Bone and Bone Surrogates in Compression Using pQCT.

Many axial and appendicular skeleton bones are subjected to repetitive loading during daily activities. Until recently, the structural analysis of fractures has been limited to 2D sections, and the dynamic assessment of fracture progression has not been possible. The structural failure was analyzed using step-wise micro-compression combined with time-lapsed micro-computed tomographic imaging. The structural failure was investigated in four different sample materials (two different bone surrogates, lumbar vertebral bodies from bovine and red deer). The samples were loaded in different force steps based on uniaxial compression tests. The micro-tomography images were used to create three-dimensional models from which various parameters were calculated that provide information about the structure and density of the samples. By superimposing two 3D images and calculating the different surfaces, it was possible to precisely analyze which trabeculae failed in which area and under which load. According to the current state of the art, bone mineral density is usually used as a value for bone quality, but the question can be raised as to whether other values such as trabecular structure, damage accumulation, and bone mineralization can predict structural competence better than bone mineral density alone.

Effect of varus alignment on the bone-implant interaction of a cementless tibial baseplate during gait.

Component alignment in total knee arthroplasty is a determining factor for implant longevity. Mechanical alignment, which provides balanced load transfer, is the most common alignment strategy. However, a retrospective review found that varus alignment, which could lead to unbalanced loading, can happen in up to 18% of tibial baseplates. This may be particularly burdensome for cementless tibial baseplates, which require low bone-implant micromotion and avoidance of bone overload to obtain bone ingrowth. Our aim was to assess the effect of varus alignment on the bone-implant interaction of cementless baseplates. We virtually implanted 11 patients with knee OA with a modern cementless tibial baseplate in mechanical alignment and in 2° of tibial varus alignment. We performed finite element simulations throughout gait, with loading conditions derived from literature. Throughout the stance phase, varus alignment had greater micromotion and percentage of bone volume at risk of failure than mechanical alignment. At mid-stance, when the most critical conditions occurred, the average increase in peak micromotion and amount of bone at risk of failure due to varus alignment were 79% and 59%, respectively. Varus alignment also resulted in the decrease of the surface area with micromotion compatible with bone ingrowth. However, for both alignments, this surface area was larger than the average area of ingrowth reported for well-fixed implants retrieved post-mortem. Our findings suggest that small varus deviations from mechanical alignment can adversely impact the biomechanics of the bone-implant interaction for cementless tibial baseplates during gait; however, the clinical implications of such changes remain unclear.

Prediction of the Inelastic Behaviour of Radius Segments: Damage-based Nonlinear Micro Finite Element Simulation vs Pistoia Criterion.

The Pistoia criterion (PC) is widely used to estimate the failure load of distal radius segments based on linear micro Finite Element (µFE) analyses. The advantage of the PC is that a simple strain-threshold and a tissue volume fraction can be used to predict failure properties. In this study, the PC is compared to materially nonlinear µFE analyses, where the bone tissue is modelled as an elastic, damageable material. The goal was to investigate for which outcomes the PC is sufficient and when a nonlinear (NL) simulation is required. Three types of simulation results were compared: (1) prediction of the failure load, (2) load sharing of cortical and trabecular regions, and (3) distribution of local damaged/overstrained tissue at the maximum sustainable load. The failure load obtained experimentally could be predicted well with both the PC and the NL simulations using linear regression. Although the PC strongly overestimated the failure load, it was sufficient to predict adequately normalized apparent results. An optimised PC (oPC) was proposed which uses experimental data to calibrate the individual volume of overstrained tissue. The main areas of local over-straining predicted by the oPC were the same as estimated by the NL simulation, although the oPC predicted more diffuse regions. However, the oPC relied on an individual calibration requiring the experimental failure load while the NL simulation required no a priori knowledge of the experimental failure load.

Acoustic emissions in vertebral cortical shell failure.

Understanding the initiation of bony failure is critical in assessing the progression of bone fracture and in developing injury criteria. Detection of acoustic emissions in bone can be used to identify fractures more sensitively and at an earlier inception time compared to traditional methods. However, high rate loading conditions, complex specimen-device interaction or geometry may cause other acoustic signals. Therefore, characterization of the isolated local acoustic emission response from cortical bone fracture is essential to distinguish its characteristics from other potential acoustic sources. This work develops a technique to use acoustic emission signals to determine when cortical bone failure occurs by characterization using both a Welch power spectral density estimate and a continuous wavelet transform. Isolated cortical shell specimens from thoracic vertebral bodies with attached acoustic sensors were subjected to quasistatic loading until failure. The resulting acoustic emissions had a wideband frequency response with peaks from 20 to 900 kHz, with the spectral peaks clustered in three bands of frequencies (166 ± 52.6 kHz, 379 ± 37.2 kHz, and 668 ± 63.4 kHz). Using these frequency bands, acoustic emissions can be used as a monitoring tool in biomechanical spine testing, distinguishing bone failure from structural response. This work presents a necessary set of techniques for effectively utilizing acoustic emissions to determine the onset of cortical bone fracture in biological material testing. Acoustic signatures can be developed for other cortical bone regions of interest using the presented methods.

Biomechanical evaluation of total ankle arthroplasty. Part II: Influence of loading and fixation design on tibial bone-implant interaction.

Finite element (FE) models to evaluate the burden placed on the interaction between total ankle arthroplasty (TAA) implants and the bone often rely on peak axial forces. However, the loading environment of the ankle is complex, and it is unclear whether peak axial forces represent a challenging scenario for the interaction between the implant and the bone. Our goal was to determine how the loads and the design of the fixation of the tibial component of TAA impact the interaction between the implant and the bone. To this end, we developed a framework that integrated robotic cadaveric simulations to determine the ankle kinematics, musculoskeletal models to determine the ankle joint loads, and FE models to evaluate the interaction between TAA and the bone. We compared the bone-implant micromotion and the risk of bone failure of three common fixation designs for the tibial component of TAA: spikes, a stem, and a keel. We found that the most critical conditions for the interaction between the implant and the bone were dependent on the specimen and the fixation design, but always involved submaximal forces and large moments. We also found that while the fixation design influenced the distribution and the peak value of bone-implant micromotion, the amount of bone at risk of failure was specimen dependent. To account for the most critical conditions for the interaction between the implant and the bone, our results support simulating multiple specimens under complex loading profiles that include multiaxial moments and span entire activity cycles.

Mechanical performance of cementless total knee replacements: It is not all about the maximum loads.

Finite element (FE) models are frequently used to assess mechanical interactions between orthopedic implants and surrounding bone. However, FE studies are often limited by the small number of bones that are modeled; the use of normal bones that do not reflect the altered bone density distributions that result from osteoarthritis (OA); and the application of simplified load cases usually based on peak forces and without consideration of tibiofemoral kinematics. To overcome these limitations, we undertook an integrated approach to determine the most critical scenario for the interaction between an uncemented tibial component and surrounding proximal tibial bone. A cementless component, based on a modern design, was virtually implanted using computed-tomography scans from 13 patients with knee OA. FE simulations were performed across a demanding activity, stair ascent, by combining in vivo experimental forces from the literature with tibiofemoral kinematics measured from patients who had received the same design of knee component. The worst conditions for the bone-implant interaction, in terms of micromotion and percentage of interfacial bone mass at risk of failure, did not arise from the maximum applied loads. We also found large variability among bones and tibiofemoral kinematics sets. Our results suggest that future FE studies should not focus solely on peak loads as this approach does not consistently correlate to worst-case scenarios. Moreover, multiple load cases and multiple bones should be considered to best reflect variations in tibiofemoral kinematics, anatomy, and tissue properties. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:350-357, 2019.

Aspecto morfológico da interface entre o compósito, constituído de quitosana e polimetilmetacrilato, e a falha óssea de tíbia de coelhos / Morphological aspect of the interface between the composite, made of chitosan and polymethylmethacrylate, and bone failure of the rabbit tibia

As afecções ortopédicas com perda de tecido ósseo são um desafio não só na medicina veterinária mas também na medicina humana. Analisou a interface entre compósito, constituído de esferas de quitosana e polimetilmetacrilato em falha óssea (leito receptor) de tíbia de coelhos, por meio de técnica radiológica, avaliação macroscópica e pela microscopia eletrônica de varredura, em diferentes tempos. Foram utilizados 12 coelhos adultos da raça Nova Zelândia, divididos em quatro Grupos Experimentais (E1, n=3; E2, n=3; E3, n=3 e E4, n=3), que tiveram as falhas ósseas das tibiais direitas preenchidas com compósito, e avaliadas no pós-operatório imediato, aos 30, 60 e 90 e 120 dias. Dos compósitos implantados nas tíbias de coelhos, apenas dois permaneceram em seus leitos receptores, enquanto que os demais se encontravam encapsulados no tecido subcutâneo. As esferas de quitosana, presentes nas superfícies dos biomateriais implantados, que mantiveram contato direto com o leito receptor de tíbias de coelhos apresentavam-se preservadas e não integraram ao tecido ósseo. Diante disso, para melhor compreensão do comportamento da quitosana como substituto ósseo, novas pesquisas serão necessárias.(AU)

Orthopedic diseases with bone loss are challenging in both veterinary and human medicine. The aim of this investigation was to analyze and compare the reactions at the interface between the composite, made of chitosan and polymethylmethacrylate, and the bone defect (receptor site) of the rabbits tibia through radiological and microscopic techniques and by scanning electron microscopy, in different periods. Twelve adult New Zealand rabbits were divided into four experimental groups (E1, n=3; E2, n=3; E3, n=3 and E4, n=3), which had the right tibial bone defects filled with the composite, and evaluated in the immediate postoperative, 30, 60, 90 and 120 days. Composite implanted in the tibia of rabbits, only two remained in their beds receivers, while the remaining were encapsulated in the subcutaneous tissue. Spheres of chitosan present in the biomaterial that has been deployed and were in direct contact with the bone defect, were preserved, however, were not integrated into the bone tissue. Therefore, to understand the behavior of chitosan as a bone substitute, further research is needed.(AU)

Sinus floor bone failures in maxillary sinus floor augmentation: a case-control study.

BACKGROUND: Extreme bone resorption in posterior maxilla may lead to absence of part of the sinus floor. This phenomenon has been termed sinus floor bone failure, and may compromise sinus floor augmentation. PURPOSE: The present article aims to evaluate risk factors related to sinus floor bone failures and to evaluate the influence of these failures in sinus floor augmentation outcomes in patients with severely atrophic posterior maxilla. MATERIAL AND METHODS: In this case-control study, patients were selected among those referred for sinus floor augmentation. Only patients presenting a ridge bone height of less than 3 mm were included. Cases were defined as presenting sinus floor bone failure, whereas controls did not present any interruption in the sinus floor bone. Information collected included clinical dental records and computed tomographic assessment of sinus width, septa, and schneiderian membrane. Risk estimates for sinus floor bone failures were calculated as adjusted odds ratios (AORs) with 95% confidence intervals (CIs) using conditional logistic regression analyses. A p value under 0.05 was considered statistically significant. In addition, sinus floor augmentation outcomes of both groups were also assessed. RESULTS: In all, 23 cases and 58 controls were included in the study. Sinus floor bone failures were significantly associated with the number of missing posterior teeth (AOR 3.67; 95% CI 0.86 to 15.63; p = .046) and a history of periodontitis (AOR 6.39; 95% CI 1.86 to 21.95; p = .002). Of the total, 15 cases and 27 controls underwent sinus floor augmentation. Schneiderian membrane perforation occurred during the surgery of two cases and of one control. No implants were lost during a mean postsurgical follow-up of 20 months. CONCLUSION: The number of missing posterior teeth and a history of periodontitis may be considered as risk factors for sinus floor bone failures.

Investigation of impact loading rate effects on the ligamentous cervical spinal load-partitioning using finite element model of functional spinal unit C2-C3.

The cervical spine functions as a complex mechanism that responds to sudden loading in a unique manner, due to intricate structural features and kinematics. The spinal load-sharing under pure compression and sagittal flexion/extension at two different impact rates were compared using a bio-fidelic finite element (FE) model of the ligamentous cervical functional spinal unit (FSU) C2-C3. This model was developed using a comprehensive and realistic geometry of spinal components and material laws that include strain rate dependency, bone fracture, and ligament failure. The range of motion, contact pressure in facet joints, failure forces in ligaments were compared to experimental findings. The model demonstrated that resistance of spinal components to impact load is dependent on loading rate and direction. For the loads applied, stress increased with loading rate in all spinal components, and was concentrated in the outer intervertebral disc (IVD), regions of ligaments to bone attachment, and in the cancellous bone of the facet joints. The highest stress in ligaments was found in capsular ligament (CL) in all cases. Intradiscal pressure (IDP) in the nucleus was affected by loading rate change. It increased under compression/flexion but decreased under extension. Contact pressure in the facet joints showed less variation under compression, but increased significantly under flexion/extension particularly under extension. Cancellous bone of the facet joints region was the only component fractured and fracture occurred under extension at both rates. The cervical ligaments were the primary load-bearing component followed by the IVD, endplates and cancellous bone; however, the latter was the most vulnerable to extension as it fractured at low energy impact.