The stem and the rasp for cemented arthroplasty are typically designed to obtain a cement mantle 2–5 mm thick. However, sometimes a line-to-line cementation is preferred, where the femoral cavity is prepared with the same dimension as the actual stem. There are contrasting reports [1,2] about the suitability of this technique to withstand the long-term fatigue loads. While the theoretical geometry allows no space for the cement, a sort of cement mantle is formed as the cement penetrates in the spongy bone. The scopes of this study were: 1) developing a dedicated in vitro method to test line-to-line cementation; 2) assessing if a short, polished hip stem designed for a standard cementation can be safely cemented line-to-line.

In order to perform long-term mechanical in vitro tests, composite bones must be used, as cadaveric bones cannot withstand millions of loading cycles [3]. For this study, the Sawbones Mod. 3406-4 were chosen: they feature an open-cell polyurethane core simulating low-density spongy bone. Post-implantation x-rays confirmed that a relevant cement-bone interdigitation was obtained. Four femurs were prepared with a CoreHip (Aesculap) with regular cement mantle (Regular). Another 4 femurs were rasped to the same rasp size, and implanted with line-to-line cementation with a larger stem (Line-to-line). The implanted femurs were subjected to an accelerated test derived from a validated protocol [3] which replicates the most demanding motor tasks of 24 years of patient activity. Implant elastic micromotions and permanent migrations were measured throughout the test. The implants were then sectioned and treated with dye penetrants to highlight the cement cracks.

Elastic and permanent motions did not show any loosening trend, and never exceeded few micrometers. As expected, some damage was visible in the cement mantles after test completion, for both types of implantation (similar to retrieved cement mantles surrounding stable implants [3]. The cement damage was similar in all specimens. No sign of major disruption was visible, neither within the Regular nor in the Line-to-line specimens: in fact, the cracks were limited in length, did not seem to cross the entire mantle thickness, and did not result in any loose cement fragments. The cracks in the line-to-line implants showed the same position and distribution compared to those found in the regular implants, but were slightly longer in some specimens.

This in vitro study confirmed the feasibility of simulating line-to-line cementation in vitro. Our results suggest that a stem designed for a regular cement mantle could induce slightly more damage when implanted line-to-line, but no significant trend toward loosening.

Aims

To verify whether secretory leucocyte protease inhibitor (SLPI) can promote early tendon-to-bone healing after anterior cruciate ligament (ACL) reconstruction.

Objectives

External fixators are the traditional fixation method of choice for contaminated open fractures. However, patient acceptance is low due to the high profile and therefore physical burden of the constructs. An externalised locking compression plate is a low profile alternative. However, the biomechanical differences have not been assessed. The objective of this study was to evaluate the axial and torsional stiffness of the externalised titanium locking compression plate (ET-LCP), the externalised stainless steel locking compression plate (ESS-LCP) and the unilateral external fixator (UEF).

Aims. Several artificial bone grafts have been developed but fail to achieve anticipated osteogenesis due to their insufficient neovascularization capacity and periosteum support. This study aimed to develop a vascularized bone-periosteum construct (VBPC) to provide better angiogenesis and osteogenesis for bone regeneration. Methods. A total of 24 male New Zealand white rabbits were divided into four groups according to the experimental materials. Allogenic adipose-derived mesenchymal stem cells (AMSCs) were cultured and seeded evenly in the collagen/chitosan sheet to form cell sheet as periosteum. Simultaneously, allogenic AMSCs were seeded onto alginate beads and were cultured to differentiate to endothelial-like cells to form vascularized bone construct (VBC). The cell sheet was wrapped onto VBC to create a vascularized bone-periosteum construct (VBPC). Four different experimental materials – acellular construct, VBC, non-vascularized bone-periosteum construct, and VBPC – were then implanted in bilateral L4-L5 intertransverse space. At 12 weeks post-surgery, the bone-forming capacities were determined by CT, biomechanical testing, histology, and immunohistochemistry staining analyses. Results. At 12 weeks, the VBPC group significantly increased new bone formation volume compared with the other groups. Biomechanical testing demonstrated higher torque strength in the VBPC group. Notably, the haematoxylin and eosin, Masson’s trichrome, and immunohistochemistry-stained histological results revealed that VBPC promoted neovascularization and new bone formation in the spine fusion areas. Conclusion. The tissue-engineered VBPC showed great capability in promoting angiogenesis and osteogenesis in vivo. It may provide a novel approach to create a superior blood supply and nutritional environment to overcome the deficits of current artificial bone graft substitutes. Cite this article: Bone Joint Res 2023;12(12):722–733

Integrin α2β1 is one of the major transmembrane receptors for fibrillary collagen. In native bone we could show that the absence of this protein led to a protective effect against age-related osteoporosis. The objective of this study was to elucidate the effects of integrin α2β1 deficiency on fracture repair and its underlying mechanisms. Standardised femoral fractures were stabilised by an intramedullary nail in 12 week old female C57Bl/6J mice (wild type and integrin α2. -/-. ). After 7, 14 and 28 days mice were sacrificed. Dissected femura were subjected to µCT and histological analyses. To evaluate the biomechanical properties, 28-day-healed femura were tested in a torsional testing device. Masson goldner staining, Alizarin blue, IHC and IF staining were performed on paraffin slices. Blood serum of the animals were measured by ELISA for BMP-2. Primary osteoblasts were analysed by in/on-cell western technology and qRT-PCR. Integrin α2β1 deficient animals showed earlier transition from cartilaginous callus to mineralized callus during fracture repair. The shift from chondrocytes over hypertrophic chondrocytes to bone-forming osteoblasts was accelerated. Collagen production was increased in mutant fracture callus. Serum levels of BMP-2 were increased in healing KO mice. Isolated integrin deficient osteoblast presented an earlier expression and production of active BMP-2 during the differentiation, which led to earlier mineralisation. Biomechanical testing showed no differences between wild-type and mutant bones. Knockout of integrin α2β1 leads to a beneficial outcome for fracture repair. Callus maturation is accelerated, leading to faster recovery, accompanied by an increased generation of extra-cellular matrix material. Biomechanical properties are not diminished by this accelerated healing. The underlying mechanism is driven by an earlier availability of BMP-2, one main effectors for bone development. Local inhibition of integrin α2β1 is therefore a promising target to accelerate fracture repair, especially in patients with retarded healing

Dislocation after total hip replacement (THR) is a devastating complication. Risk factors include patient and surgical factors. Mitigation of this complication has proven partially effective. This study investigated a new innovating technique to decrease this problem using rare earth magnets. Computer simulations with design and magnetic finite element analysis software were used to analyze and quantitate the forces around hip implants with embedded magnets into the components during hip range of motion. N52 Neodymium-Iron-Boron rare earth magnets were sized to fit within the existing acetabular shells and the taper of a hip system. Additionally, magnets placed within the existing screw holes were studied. A 50mm titanium acetabular shell and a 36mm ceramic liner utilizing a taper sleeve adapter were modeled which allowed for the use of a 12mm × 5mm magnet placed in the center hole, an 18mm × 15mm magnet within the femoral head, and 10mm × 5mm magnets in the screw holes. Biomechanical testing was also performed using in-vitro bone and implant models to determine retention forces through a range of hip motion. The novel system incorporating magnets generated retentive forces between the acetabular cup and femoral head of between 10 to 20 N through a range of hip motion. Retentive forces were stronger at the extreme position hip range of motion when additional magnets were placed in the acetabular screw holes. Greater retentive forces can be obtained with specially designed femoral head bores and acetabular shells specifically designed to incorporate larger magnets. Mechanical testing validated the loads obtained and demonstrated the feasibility of the magnet system to provide joint stability and prevent dislocations. Rare earth magnets provide exceptional attractive strength and can be used to impart stability and prevent dislocation in THR without the complications and limitations of conventional methods

Although bone morphogenetic protein 2 (BMP-2) has been FDA-approved for spinal fusion for decades, its disadvantages of promoting osteoclast-based bone resorption and suboptimal carrier (absorbable collagen sponge) leading to premature release of the protein limit its clinical applications. Our recent study showed an excellent effect on bone regeneration when BMP-2 and zoledronic acid (ZA) were co-delivered based on a calcium sulphate/hydroxyapatite (CaS/HA) scaffold in a rat critical-size femoral defect model. Therefore, the aim of this study was to evaluate whether local application of BMP-2 and ZA released from a CaS/HA scaffold is favorable for spinal fusion. We hypothesized that CaS/HA mediated controlled co-delivery of rhBMP-2 and ZA could show an improved effect in spinal fusion over BMP-2 alone. 120, 8-week-old male Wistar rats (protocol no. 25-5131/474/38) were randomly divided into six groups in this study (CaS/HA, CaS/HA + BMP-2, CaS/HA + systemic ZA, CaS/HA + local ZA, CaS/HA + BMP-2 + systemic ZA, CaS/HA + BMP-2 + local ZA). A posterolateral spinal fusion at L4 to L5 was performed bilaterally by implanting group-dependent scaffolds. At 3 weeks and 6 weeks, 10 animals per group were euthanized for µCT, histological staining, or mechanical testing. µCT and histological results showed that the CaS/HA + BMP-2 + local ZA group significantly promoted bone regeneration than other treated groups. Biomechanical testing showed breaking force in CaS/HA + BMP + local ZA group was significantly higher than other groups at 6 weeks. In conclusion, the CaS/HA-based biomaterial functionalized with bioactive molecules rhBMP-2 and ZA enhanced bone formation and concomitant spinal fusion outcome. Acknowledgements: Many thanks to Ulrike Heide, Anna-Maria Placht (assistance with surgeries) as well as Suzanne Manthey & Annett Wenke (histology)

Recently, a new suture was designed to minimize laxity in order to preserve consistent tissue approximation while improving footprint compression after tendon repair. The aims of this study were: (1) to compare the biomechanical competence of two different high strength sutures in terms of slippage and failure load, (2) to investigate the influence of both knots number and different media (air, saline and fat) on the holding capacity of the knots. Alternating surgical knots of two different high-strength sutures (group1: FibreWire; group2: DynaCord; n = 105) were tied on two roller bearings with 50N tightening force. Biomechanical testing was performed in each medium applying ramped monotonic tension to failure defined in terms of either knot slippage or suture rupture. For each group and medium, seven specimens with either 3, 4, 5, 6, or 7 knots each were tested, evaluating their knot slippage and ultimate load to failure. The minimum number of knots preventing slippage failure and thus resulting in suture rupture was determined in each group and medium, and taken as a criterium for better performance when comparing the groups. In each group and medium failure occurred via suture rupture in all specimens for the following minimum knot numbers: group1: air – 7, saline – 7, fat – 7; group2: air – 6; saline – 4; fat – 5. The direct comparison between the groups when using 7 knots demonstrated significantly larger slippage in group1 (6.5 ± 2.2 mm) versus group2 (3.5 ± 0.4 mm) in saline (p < 0.01) but not in the other media (p ≥0.52). Ultimate load was comparable between the two groups for all three media (p ≥ 0.06). The lower number of required knots providing sufficient repair stability, smaller slippage levels and identical suture strength, combined with the known laxity alleviation effect demonstrate advantages of DynaCord versus FibreWire

Abstract. Introduction. All-tissue quadriceps tendon (QT) is becoming an increasingly popular alternative to hamstrings tendon (HT) and bone-tendon-bone (BTB) autograft for anterior cruciate ligament (ACL) reconstruction. The relatively short graft length however dictates that one, or both, ends rely on suture fixation. The strength of this construct is therefore extremely important. This study evaluates whether the use of a novel fixation technique can improve the tensile properties of the construct compared to a Krackow suture, and a looped tendon (suture free) gold standard. Methods. Eighteen porcine flexor tendons were tested, across three groups; suture-tape Krackow, looped tendon, and the novel ‘strain suture’. Biomechanical testing simulated the different stages of ACL graft preparation and loading (60N preload for 10 minutes, 10 cycles from 10N to 75N, and 1000 cycles from 100N to 400N). Elongation and load to failure were recorded, and stiffness calculated for each construct. Results. The mean elongation was significantly improved for the strain suture compared to the suture tape Krackow for preload, 10 cycle and 1000 cycle testing protocols respectively (1.36mm vs 4.93mm, p<001; 0.60mm vs 2.72mm, p<0.001; 2.95mm vs 29.08mm, p<0.001). Compared with the looped tendon, the strain suture demonstrated similar results for preload and 10 cycle elongation, but greater elongation during the 1000 cycle stage. Stiffness of the latter two constructs was similar. Conclusions. Augmentation of the suture fixation using this novel technique provides a construct that is significantly superior to currently practised suture techniques, and similar in elongation and stiffness to a looped graft

The Adams-Berger reconstruction is an effective technique for treating distal radioulnar joint (DRUJ) instability. Graft preparation techniques vary amongst surgeons with insufficient evidence to support one technique over another. Our study evaluated the biomechanical properties of four graft preparation techniques. Extensor tendons were harvested from fresh frozen porcine trotters obtained from a local butcher shop and prepared in one of three configurations (n=5 per group): tendon only; tendon prepared with non-locking, running suture (2-0 FiberLoop, Arthrex, Naples, FL) spaced at 6 mm intervals; and tendon prepared with suture spaced at 12 mm intervals. A fourth configuration of suture alone was also tested. Tendons were allocated in a manner to ensure comparable average diameters amongst groups. Biomechanical testing occurred using custom jigs simulating radial and ulnar tunnels attached to a Bose Electroforce 3510 mechanical testing machine (TA Instruments). After being woven through the jigs, all tendons were sutured end-to-end with 2-0 PROLENE suture (Ethicon). Tendons then underwent a staircase cyclic loading protocol (5-25 Newtons [N] at 1 hertz [Hz] for 1000 cycles, then 5-50 N at 1 Hz for 1000 cycles, then 5-75 N at 1 Hz for 1000 cycles) until graft failure; if samples did not fail during the protocol, they were then loaded to failure. Samples were visually inspected for mode of failure after the protocol. A one-way analysis of variance was used to compare average tendon diameter; post-hac Tuhey tests were used to compare elongation and elongation rate. Survival to cyclic loading was analyzed using Kaplan-Meier survival curves with log rank. Statistical significance was set at a = 0.05. The average tendon diameter of each group was not statistically different [4.17 mm (tendon only), 4.33 mm (FiberLoop spaced 6 mm), and 4.30 mm (FiberLoop spaced 12 mm)]. The average survival of tendon augmented with FiberLoop was significantly higher than tendon only, and all groups had significantly improved survival compared to suture only. There was no difference in survival between FiberLoop spaced 6 mm and 12 mm. Elongation was significantly lower with suture compared to tendon augmented with FiberLoop spaced 6 mm. Elongation rate was significantly lower with suture compared to all groups. Modes of failure included rupture of the tendon, suture, or both at the simulated bone and suture and/or tendon interface, and elongation of the entire construct without rupture. In this biomechanical study, augmentation of porcine tendons with FiberLoop suture spaced at either 6 or 12 mm for DRUJ reconstruction significantly increased survival to a staircase cyclic loading protocol, as suture material was significantly stiffer than any of the tendon graft configurations

Cemented total hip replacement (THR) provides excellent outcomes and is cost-effective. Polished taper-slip (PTS) stems demonstrate successful results and have overtaken traditional composite-beam (CB) stems. Recent reports indicate they are associated with a higher risk of postoperative periprosthetic femoral fracture (PFF) compared to CB stems. This study evaluates risk factors influencing fracture characteristics around PTS and CB cemented stems. Data were collected for 584 PFF patients admitted to eight UK centres from 25/05/2006-01/03/2020. Radiographs were assessed for Unified Classification System (UCS) grade and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type. Statistical comparisons investigated relationships by age, gender, and stem fixation philosophy (PTS versus CB). The effect of multiple variables was estimated using multinomial logistic regression to estimate odds ratios (OR) with 95% confidence intervals (CI). Median (IQR) age was 79.1 (72.0–86.0) years, 312 (53.6%) patients were female, and 495 (85.1%) stems were PTS. The commonest UCS grade was type B1 (278, 47.6%). The commonest AO/OTA type was spiral (352, 60.3%). Metaphyseal-split fractures occurred only with PTS stems with an incidence of 10.1%. Male gender was associated with a five-fold reduction in odds of a type C fracture (OR 0.22, 95% CI 0.12 to 0.41, p<0.001) compared to a type B fracture. CB stems were associated with significantly increased odds of transverse fracture (OR 9.51, 95% CI 3.72 to 24.34, p <0.001) and wedge fracture (OR 3.72, 95% CI 1.16 to 11.95, p <0.05) compared to PTS stems. This is the largest study investigating PFF characteristics around cemented stems. The commonest fracture types are B1 and spiral fractures. PTS stems are exclusively associated with metaphyseal-split fractures, but their incidence is low. Males have lower odds of UCS grade C fractures compared to females. CB stems had higher odds of bending type fractures (transverse and wedge) compared to PTS stems. Biomechanical testing is needed for validation and investigation of modifiable factors which may reduce the risk of unstable fracture patterns requiring complex revision surgery over internal fixation

Mice are increasingly used for fracture healing research because of the possibility to use transgenic animals to conduct research on the molecular level. Mice from both sexes can be used, however, there is no consensus in the literature if fracture healing differs between female and male mice. Therefore, the aim of the present study was to analyze the similarities and differences in endochondral fracture healing between female and male C57BL/6J mice, since this mouse strain is mainly used in bone research. For that purpose, 12-weeks-old female and male mice received a standardized femur midshaft osteotomy stabilized by an external fixator. Mice were euthanized 10 and 21 days after fracture and bone regeneration was analyzed by biomechanical testing, µCT analysis, histology, immunohistochemistry and gene expression analysis. At day 21, male mice displayed a significantly larger fracture callus than female mice accompanied by higher number of osteoclasts, higher tissue mineral density and absolute values of bone volume, whereas relative bone volume to tissue volume ratio did not differ between the groups. Biomechanical testing revealed significantly increased bending stiffness in both fractured and intact femurs from male vs. female mice, whereas relative bending stiffness of fractured femurs related to the intact femurs did not differ. 10 days after fracture, male mice display significantly more cartilage and less fibrous tissue area in the fracture callus than female mice, whereas bone area did not differ. On the molecular level, male mice displayed increased active β-catenin expression in the fracture callus, whereas estrogen receptor α (ERα) expression was reduced. In conclusion, male mice showed more prominent cartilaginous callus formation, increased mineralization and whole callus tissue formation, whereas functional outcome after fracture did not differ from female mice. This might be due either to the heavier weight of male mice or because of differences in molecular signaling pathways

Femoral neck fractures account for half of all hip fractures and are recognized as a major public health problem associated with a high socioeconomic burden. Whilst internal fixation is preferred over arthroplasty for physiologically younger patients, no consensus exists about the optimal fixation device yet. The recently introduced implant Femoral Neck System (FNS) (DePuy Synthes, Zuchwil, Switzerland) was developed for dynamic fixation of femoral neck fractures and provides angular stability in combination with a minimally invasive surgical technique. Alternatively, the Hansson Pin System (HPS) (Swemac, Linköping, Sweden) exploits the advantages of internal buttressing. However, the obligate peripheral placement of the pins, adjacent to either the inferior or posterior cortex, renders the instrumentation more challenging. The aim of this study was to evaluate the biomechanical performance of FNS versus HPS in a Pauwels II femoral neck fracture model with simulated posterior comminution. Forty-degree Pauwels II femoral neck fractures AO 31-B2.1 with 15° posterior wedge were simulated in fourteen paired fresh-frozen human cadaveric femora, followed by instrumentation with either FNS or HPS in pair-matched fashion. Implant positioning was quantified by measuring the shortest distances between implant and inferior cortex (DI) as well as posterior cortex (DP) on anteroposterior and axial X-rays, respectively. Biomechanical testing was performed in 20° adduction and 10° flexion of the specimens in a novel setup with simulated iliopsoas muscle tension. Progressively increasing cyclic loading was applied until construct failure. Interfragmentary femoral head-to-shaft movements, namely varus deformation, dorsal tilting and rotation around the neck axis were measured by means of motion tracking and compared between the two implants. In addition, varus deformation and dorsal tilting were correlated with DI and DP. Cycles to 5/10° varus deformation were significantly higher for FNS (22490±5729/23007±5496) versus HPS (16351±4469/17289±4686), P=0.043. Cycles to 5/10° femoral head dorsal tilting (FNS: 10968±3052/12765±3425; HPS: 12244±5895/13357±6104) and cycles to 5/10° rotation around the femoral neck axis (FNS: 15727±7737/24453±5073; HPS: 15682±10414/20185±11065) were comparable between the implants, P≥0.314. For HPS, the outcomes for varus deformation and dorsal tilting correlated significantly with DI and DP, respectively (P=0.025), whereas these correlations were not significant for FNS (P≥0.148). From a biomechanical perspective, by providing superior resistance against varus deformation and performing in a less sensitive way to variations in implant placement, the angular stable Femoral Neck System can be considered as a valid alternative to the Hansson Pin System for the treatment of Pauwels II femoral neck fractures

No animal model currently exists for hip abductor tendon tears. We aimed to 1. Develop a large animal model of delayed abductor tendon repair and 2. To compare the results of acute and delayed tendon repair using this model. Fourteen adult Romney ewes underwent detachment of gluteus medius tendon using diathermy. The detached tendons were protected using silicone tubing. Relook was performed at six and 16 weeks following detachment, histological analysis of the muscle and tendon were performed. We then attempted repair of the tendon in six animals in the six weeks group and compared the results to four acute repairs (tendon detachment and repair performed at the same time). At 12 weeks, all animals were culled and the tendon–bone block taken for histological and mechanical analysis. Histology grading using the modified Movin score confirmed similar tendon degenerative changes at both six and 16 weeks following detachment. Biomechanical testing demonstrated inferior mechanical properties in both the 6 and 16 weeks groups compared to healthy controls. At 12 weeks post repair, the acute repair group had a lower Movin's score (6.9 vs 9.4, p=0.064), and better muscle coverage (79.4% of normal vs 59.8%). On mechanical testing, the acute group had a significantly improved Young's Modulus compared to the delayed repair model (57.5MPa vs 39.4MPa, p=0.032). A six week delay between detachment and repair is sufficient to produce significant degenerative changes in the gluteus medius tendon. There are significant histological and mechanical differences in the acute and delayed repair groups at 12 weeks post op, suggesting that a delayed repair model should be used to study the clinical problem

Restoration a joint's articular surface following degenerative or traumatic pathology to the osteochondral unit pose a significant challenge. Recent advances have shown the utility of collagen-based scaffolds in the regeneration of osteochondral tissue. To provide these collagen scaffolds with the appropriate superstructure novel techniques in 3D printing have been investigated. This study investigates the use of polyɛ-caprolactone (PCL) collagen scaffolds in a porcine cadaveric model to establish the stability of the biomaterial once implanted. This study was performed in a porcine cadaveric knee model. 8mm defects were created in the medial femoral trochlea and repaired with a PCL collagen scaffold. Scaffolds were secured by one of three designs; Press Fit (PF), Press Fit with Rings (PFR), Press Fit with Fibrin Glue (PFFG). Mobilisation was simulated by mounting the pig legs on a continuous passive motion (CPM) machine for either 50 or 500 cycles. Biomechanical tensile testing was performed to examine the force required to displace the scaffold. 18 legs were used (6 PF, 6 PFR, 6 PFFG). Fixation remained intact in 17 of the cohort (94%). None of the PF or PFFG scaffolds displaced after CPM cycling. Mean peak forces required to displace the scaffold were highest in the PFFG group (3.173 Newtons, Standard deviation = 1.392N). The lowest peak forces were observed in the PFR group (0.871N, SD = 0.412N), while mean peak force observed in the PF group was 2.436N (SD = 0.768). There was a significant difference between PFFG and PFR (p = 0.005). There was no statistical significance in the relationship between the other groups. PCL reinforcement of collagen scaffolds provide an innovative solution for improving stiffness of the construct, allowing easier handling for the surgeon. Increasing the stiffness of the scaffold also allows press fit solutions for reliable fixation. Press fit PCL collagen scaffolds with and without fibrin glue provide dependable stability. Tensile testing provides an objective analysis of scaffold fixation. Further investigation of PCL collagen scaffolds in a live animal model to establish quality of osteochondral tissue regeneration are required

Proximal humerus fractures are the third most common fragility fractures with treatment remaining challenging. Mechanical fixation failure rates of locked plating range up to 35%, with 80% of them being related to the screws perforating the glenohumeral joint. Secondary screw perforation is a complex and not yet fully understood process. Biomechanical testing and finite element (FE) analysis are expected to help understand the importance of various risk factors. Validated FE simulations could be used to predict perforation risk. This study aimed to (1) develop an experimental model for single screw perforation in the humeral head and (2) evaluate and compare the ability of bone density measures and FE simulations to predict the experimental findings. Screw perforation was investigated experimentally via quasi-static ramped compression testing of 20 cuboidal bone specimens at 1 mm/min. They were harvested from four fresh-frozen human cadaveric proximal humeri of elderly donors (aged 85 ± 5 years, f/m: 2/2), surrounded with cylindrical embedding and implanted with a single 3.5 mm locking screw (DePuy Synthes, Switzerland) centrally. Specimen-specific linear µFE (ParOSol, ETH Zurich) and nonlinear explicit µFE (Abaqus, SIMULIA, USA) models were generated at 38 µm and 76 µm voxel sizes, respectively, from pre- and post-implantation micro-Computed Tomography (µCT) images (vivaCT40, Scanco Medical, Switzerland). Bone volume (BV) around the screw and in front of the screw tip, and tip-to-joint distance (TJD) were evaluated on the µCT images. The µFE models and BV were used to predict the experimental force at the initial screw loosening and the maximum force until perforation. Initial screw loosening, indicated by the first peak of the load-displacement curve, occurred at a load of 64.7 ± 69.8 N (range: 10.2 – 298.8 N) and was best predicted by the linear µFE (R. 2. = 0.90), followed by BV around the screw (R. 2. = 0.87). Maximum load was 207.6 ± 107.7 N (range: 90.1 – 507.6 N) and the nonlinear µFE provided the best prediction (R. 2. = 0.93), followed by BV in front of the screw tip (R. 2. = 0.89). Further, the nonlinear µFE could better predict screw displacement at maximum force (R. 2. = 0.77) than TJD (R. 2. = 0.70). The predictions of non-linear µFE were quantitatively correct. Our results indicate that while density-based measures strongly correlate with screw perforation force, the predictions by the nonlinear explicit µFE models were even better and, most importantly, quantitatively correct. These models have high potential to be utilized for simulation of more realistic fixations involving multiple screws under various loading cases. Towards clinical applications, future studies should investigate if explicit FE models based on clinically available CT images could provide similar prediction accuracies

An established rabbit model was used to preliminarily investigate the effect of acellular triphase, namely bone-cartilage-tendon, scaffold (ATS) sandwiched with autologous bone mesenchymal stem cells (BMSCs) sheets on tendon-bone interface healing. Bone, fibrocartilage and tendon tissue were harvested from the rabbits and sectioned into a book-type scaffold. The scaffolds were decellularized and their characterization was presented. BMSCs were isolated and co-cultured with the scaffolds to verify their cytocompatibility. BMSCs sheets were fabricated and inserted into the book page of the scaffold to construct an autologous BMSCs-sheets/book-type ATS complex. The complex was implated in the right knee of rabbits which operated standard partial patellectomy for TBI regeneration using Imaging, histological and biomechanical examinations. The bone, fibrocartilage and tendon tissue were sectioned into a book-type scaffold before decellularization. Then we decellularized the above tissue and mostly preserved their microstructure and composition of the natural extracellular matrix, including collagen and proteoglycan. After the physicochemical and biological properties of the book-type ATS were evaluated, autologous BMSCs sheets were inserted into the book page of the scaffold to construct an autologous BMSCs-sheets/book-type ATS implants for TBI regeneration. In addition, the ATS has the advantages of non-toxicity, suitable for cell adhesion and growth as well as low immunogenicity while co-cultured with the BMSCs. At the same time, different scaffolds has the ability to induce the osteogenic, chondrogenic and tenogenic differentiation of BMSCs by immunofluorescence, reverse transcription-polymerase chain reaction and western blot analysis. To determine the efficacy of the tissue-engineered implants for TBI regeneration, we transplanted it into a rabbit patella-patellar tendon (PPT) injury model, and the rabbits were sacrificed at postoperative week 8 or 16 for the radiological, histological, and mechanical evaluation. Radiologically, Synchrotron radiation micro-computed tomography (SR-μCT) showed that BMSCs/ATS group significantly increased bone area, BV/TV, trabecular thickness and trabecular number at the healing interface as compared with other groups at postoperative week 8 or 16. Histologically, the BMSCs/ATS group showed more woven bone, and a more robust fibrocartilaginous junction with a characteristic matrix rich in proteoglycans was seen at the PPT healing interface in comparison with other groups after 8 weeks. At week 16, the healing interface in 3 groups displayed better remodeling with respect to postoperative week 8. Healing and remodeling at the PPT junction were almost complete, with a resemblance to a healthy BTI consisting of the characteristic 4 zones in all groups. At last, we used biomechanical test as functional parameters to evaluate the quality of tendon-bone healing. Biomechanical testing indicated that BMSCs/ATS group showed significantly higher failure load and stiffness than other groups at postoperative week 8 and 16. The complex composed of acellular triphase, namely bone-cartilage-tendon, scaffold (ATS) sandwiched with autologous bone mesenchymal stem cells (BMSCs) sheets can simulate the gradient structure of tendon-bone interface, inducing stem cell directional differentiation, so as to promote patella-patellar tendon interface healing effectively after injury

Objectives. Secondary fracture healing is strongly influenced by the stiffness of the bone-fixator system. Biomechanical tests are extensively used to investigate stiffness and strength of fixation devices. The stiffness values reported in the literature for locked plating, however, vary by three orders of magnitude. The aim of this study was to examine the influence that the method of restraint and load application has on the stiffness produced, the strain distribution within the bone, and the stresses in the implant for locking plate constructs. Methods. Synthetic composite bones were used to evaluate experimentally the influence of four different methods of loading and restraining specimens, all used in recent previous studies. Two plate types and three screw arrangements were also evaluated for each loading scenario. Computational models were also developed and validated using the experimental tests. Results. The method of loading was found to affect the gap stiffness strongly (by up to six times) but also the magnitude of the plate stress and the location and magnitude of strains at the bone-screw interface. Conclusions. This study demonstrates that the method of loading is responsible for much of the difference in reported stiffness values in the literature. It also shows that previous contradictory findings, such as the influence of working length and very large differences in failure loads, can be readily explained by the choice of loading condition. Cite this article: A. MacLeod, A. H. R. W. Simpson, P. Pankaj. Experimental and numerical investigation into the influence of loading conditions in biomechanical testing of locking plate fracture fixation devices. Bone Joint Res 2018;7:111–120. DOI: 10.1302/2046-3758.71.BJR-2017-0074.R2

Objectives. We investigated the effects on fracture healing of two up-regulators of inducible nitric oxide synthase (iNOS) in a rat model of an open femoral osteotomy: tadalafil, a phosphodiesterase inhibitor, and the recently reported nutraceutical, COMB-4 (consisting of L-citrulline, Paullinia cupana, ginger and muira puama), given orally for either 14 or 42 days. Materials and Methods. Unilateral femoral osteotomies were created in 58 male rats and fixed with an intramedullary compression nail. Rats were treated daily either with vehicle, tadalafil or COMB-4. Biomechanical testing of the healed fracture was performed on day 42. The volume, mineral content and bone density of the callus were measured by quantitative CT on days 14 and 42. Expression of iNOS was measured by immunohistochemistry. Results. When compared with the control group, the COMB-4 group exhibited 46% higher maximum strength (t-test, p = 0.029) and 92% higher stiffness (t-test, p = 0.023), but no significant changes were observed in the tadalafil group. At days 14 and 42, there was no significant difference between the three groups with respect to callus volume, mineral content and bone density. Expression of iNOS at day 14 was significantly higher in the COMB-4 group which, as expected, had returned to baseline levels at day 42. Conclusion. This study demonstrates an enhancement in fracture healing by an oral natural product known to augment iNOS expression. Cite this article: R. A. Rajfer, A. Kilic, A. S. Neviaser, L. M. Schulte, S. M. Hlaing, J. Landeros, M. G. Ferrini, E. Ebramzadeh, S-H. Park. Enhancement of fracture healing in the rat, modulated by compounds that stimulate inducible nitric oxide synthase: Acceleration of fracture healing via inducible nitric oxide synthase. Bone Joint Res 2017:6:–97. DOI: 10.1302/2046-3758.62.BJR-2016-0164.R2

Bone marrow concentrates are being used to augment soft tissue healing. However, only 0.01% of these cells meet the criteria of a mesenchymal stem cell (MSC), which likely accounts for the variability in reported results. Previous studies using an established rat rotator cuff repair model have demonstrated that bone marrow-derived MSCs had no effect on healing. In this study we evaluated the effect of purified human MSCs on rotator cuff healing in an athymic rat model. Hypothesis: Purified human MSCs added to the repair site will improve biomechanical strength and fibrocartilage formation of the healing tendon. Fifty-two athymic rats underwent unilateral detachment and repair of the supraspinatus tendon with either fibrin glue (control) or fibrin glue with 106 hMSCs (experimental) applied at the repair site. Flow cytometry verified the stem cell phenotype of the cells as CD73+, CD90+, CD105+, CD14-, CD34- and CD45-. Rats were sacrificed at 2 and 4 weeks, with 10 used for biomechanical testing and 3 for histologic analysis from each group. Biomechanical testing revealed a significant increase in failure load (11.5±2.4N vs. 8.5±2.4N, p=0.002) and stiffness (7.1±1.2 N/mm vs. 5.7±2.1 N/mm, p0.17). These data demonstrate the potential for stem cells to augment tendon healing. This is the first study to use purified stem cells, rather than simple bone marrow concentrate. In the future, cell sorting techniques and culture expansion could be used to select and expand the small population of true stem cells in bone marrow. Furthermore, healing could potentially be improved with repeat cell injection at an additional post-operative time point