Aims. Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture. Methods. This single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively. Results. Patients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival. Conclusion. This pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation. Level of evidence: III, Retrospective study. Cite this article: Bone Jt Open 2022;3(8):648–655

Objectives. Screw plugs have been reported to increase the fatigue strength of stainless steel locking plates. The objective of this study was to examine and compare this effect between stainless steel and titanium locking plates. Methods. Custom-designed locking plates with identical structures were fabricated from stainless steel and a titanium alloy. Three types of plates were compared: type I unplugged plates; type II plugged plates with a 4 Nm torque; and type III plugged plates with a 12 Nm torque. The stiffness, yield strength, and fatigue strength of the plates were investigated through a four-point bending test. Failure analyses were performed subsequently. Results. For stainless steel, type II and type III plates had significantly higher fatigue strength than type I plates. For titanium, there were no significant differences between the fatigue strengths of the three types of plates. Failure analyses showed local plastic deformations at the threads of screw plugs in type II and type III stainless steel plates but not in titanium plates. Conclusion. The screw plugs could increase the fatigue strength of stainless steel plates but not of titanium plates. Therefore, leaving screw holes open around fracture sites is recommended in titanium plates. Cite this article: L-W. Hung, C-K. Chao, J-R. Huang, J. Lin. Screw head plugs increase the fatigue strength of stainless steel, but not of titanium, locking plates. Bone Joint Res 2018;7:629–635. DOI: 10.1302/2046-3758.712.BJR-2018-0083.R1

Although 3D-printed porous dental implants may possess improved osseointegration potential, they must exhibit appropriate fatigue strength. Finite element analysis (FEA) has the potential to predict the fatigue life of implants and accelerate their development. This work aimed at developing and validating an FEA-based tool to predict the fatigue behavior of porous dental implants. Test samples mimicking dental implants were designed as 4.5 mm-diameter cylinders with a fully porous section around bone level. Three porosity levels (50%, 60% and 70%) and two unit cell types (Schwarz Primitive (SP) and Schwarz W (SW)) were combined to generate six designs that were split between calibration (60SP, 70SP, 60SW, 70SW) and validation (50SP, 50SW) sets. Twenty-eight samples per design were additively manufactured from titanium powder (Ti6Al4V). The samples were tested under bending compression loading (ISO 14801) monotonically (N=4/design) to determine ultimate load (F. ult. ) (Instron 5866) and cyclically at six load levels between 50% and 10% of F. ult. (N=4/design/load level) (DYNA5dent). Failure force results were fitted to F/F. ult. = a(N. f. ). b. (Eq1) with N. f. being the number of cycles to failure, to identify parameters a and b. The endurance limit (F. e. ) was evaluated at N. f. = 5M cycles. Finite element models were built to predict the yield load (F. yield. ) of each design. Combining a linear correlation between FEA-based F. yield. and experimental F. ult. with equation Eq1 enabled FEA-based prediction of F. e. . For all designs, F. e. was comprised between 10% (all four samples surviving) and 15% (at least one failure) of F. ult. The FEA-based tool predicted F. e. values of 11.7% and 12.0% of F. ult. for the validation sets of 50SP and 50SW, respectively. Thus, the developed FEA-based workflow could accurately predict endurance limit for different implant designs and therefore could be used in future to aid the development of novel porous implants. Acknowledgements: This study was funded by EU's Horizon 2020 grant No. 953128 (I-SMarD). We gratefully acknowledge the expert advice of Prof. Philippe Zysset

Aims. To determine whether half-threaded screw holes in a new titanium locking plate design can substantially decrease the notch effects of the threads and increase the plate fatigue life. Methods. Three types (I to III) of titanium locking plates were fabricated to simulate plates used in the femur, tibia, and forearm. Two copies of each were fabricated using full- and half-threaded screw holes (called A and B, respectively). The mechanical strengths of the plates were evaluated according to the American Society for Testing and Materials (ASTM) F382-14, and the screw stability was assessed by measuring the screw removal torque and bending strength. Results. The B plates had fatigue lives 11- to 16-times higher than those of the A plates. Before cyclic loading, the screw removal torques were all higher than the insertion torques. However, after cyclic loading, the removal torques were similar to or slightly lower than the insertion torques (0% to 17.3%), although those of the B plates were higher than those of the A plates for all except the type III plates (101%, 109.8%, and 93.8% for types I, II, and III, respectively). The bending strengths of the screws were not significantly different between the A and B plates for any of the types. Conclusion. Removing half of the threads from the screw holes markedly increased the fatigue life of the locking plates while preserving the tightness of the screw heads and the bending strength of the locking screws. However, future work is necessary to determine the relationship between the notch sensitivity properties and titanium plate design. Cite this article: Bone Joint Res 2020;9(10):645–652

Background. Structural bone allografts are an established treatment method for long-bone structural defects arising from such conditions as trauma, sarcoma, and osteolysis following total joint replacement. However, the quality of structural bone allografts is difficult to non-destructively assess prior to use. The functional lifetime of structural allografts depend on their ability to resist cyclic loading, which can lead to fracture even at stress levels well below the yield strength. Because allograft bone has limited capacity for remodeling, optimizing allograft selection for bone quality could decrease long-term fracture risk. Raman spectroscopy biomarkers can non-destructively assess the three primary components of bone (collagen, mineral, and water), and may predict the resistance of donor bone allografts to fracture from cyclic loads. The purpose of this study was to prospectively assess the ability of Raman biomarkers to predict number of cycles to fracture (“cyclic fatigue life”) of human allograft cortical bone. Methods. Twenty-one cortical bone specimens were from the mid-diaphysis of human donor bone tissue (bilateral femurs from 4 donors: 63M, 61M, 51F, 48F) obtained from the Musculoskeletal Transplant Foundation. Six Raman biomarkers were analyzed: collagen disorganization, type B carbonate substitution (a surrogate for mineral maturation), matrix mineralization, and 3 water compartments. Specimens underwent cyclic fatigue testing under fully reversed conditions at 35 and 45MPa (physiologically relevant stress levels for structural allografts). Specimens were tested to fracture or to 30 million cycles (“run-out”), simulating 15 years of moderate activity (i.e., 6000 steps per day). Multivariate regression analysis was performed using a tobit model (censored linear regression) for prediction of cyclic fatigue life. Specimens were right-censored at 30 million cycles. Results. All of the 6 biomarkers that were evaluated were independently associated with cyclic fatigue life (p < 0.05). The multivariate model explained 70% of the variance in cyclic fatigue life (R2=0.695, p<0.001,). Increasing disordered collagen (p<0.001) and loosely collagen-bound water compartments (p<0.001) were associated with decreased cyclic fatigue life. Increasing type B carbonate substitution (p<0.001), matrix mineralization (p<0.001), tightly collagen-bound water (p<0.001), and mineral-bound water (p=0.002) were associated with increased cyclic fatigue life. In the predictive model, 42% of variance in cyclic fatigue life was attributable to degree of collagen disorder, all bound water compartments accounted for 6%, and age and sex accounted for 17%. Conclusions. Raman biomarkers of three bone components (collagen, mineral, and water) predict cyclic fatigue life of human cortical bone. Increased baseline collagen disorder was associated with decreased cyclic fatigue life, and was the strongest determinant of cyclic fatigue life. Increased matrix mineralization and mineral maturation were associated with increased cyclic fatigue life. Bound-water compartments of bone contributed minimally to cyclic fatigue life. These results are complementary with prior Raman studies of monotonic testing of bone that reported decreased toughness and strength with increased collagen disorder and increased stiffness with increased bone mineralization and mineral maturation. This model should be prospectively validated. Raman analysis is a promising tool for the non-destructive evaluation of structural bone allograft quality and may be useful as a screening tool for selection of allograft bone. Acknowledgements. Supported by a grant from the Musculoskeletal Transplant Foundation. The Dudley P. Allen Fellowship (JYD), Wilbert J. Austin Professor of Engineering Chair (CMR) and the Leonard Case Jr. Professor of Engineering Chair (OA) are gratefully acknowledged

Introduction. Laser marking of implants surfaces is necessary in order to provide traceability during revisions which will help identify product problems more quickly, better execute product recalls and improve patient safety. There are several methods of marking employed within the medical field such as chemical etching, electro pencil marking, mechanical imprinting, casting of markings, marking with vibratory type contact, ink jet, hot foil and screen printing. However, these methods have various drawbacks including marking durability or addition of potentially toxic chemical compounds. As a result laser marking has become the preferred identification process for orthopedic implants. Laser marking is known for its high visual quality, good reproducibility and precision. However there are concerns about the laser marking potential to affect fatigue life of a device. There is a limited number of research papers that studied the effect of laser marking on fatigue life of implants. The objective of the current study is to investigate the effects of laser marking on the fatigue life of titanium alloy material. Material and Methods. Two groups of four point bend specimens were used to investigate the effect of laser marking on the fatigue life. The first group comprised of the specimens without laser marking while the second group comprised of specimens with laser marking currently utilized for the implant surfaces. Prior to conducting the fatigue testing, a non-destructive X-ray diffraction (XRD) residual stress analysis was conducted to determine if the laser marking had introduced any residual stresses. Imaging analysis was also conducted to examine any potential surface damage on the test sample's surface. A servo-hydraulic test machine was used for the fatigue four point bend testing regime where the inner and outer spans were 30 mm and 90 mm respectively. All testing was conducted at a frequency of 10 Hz, a stress ratio R=0.1, and sine-wave loading in air. Testing was stopped at 10 Million cycles or at failure of the specimen. Results & Discussion. Figure 1 shows that laser marking process can create a fine network of surface cracks. Table 1 shows the results of residual stress measurements. Laser making introduced high tensile stresses on the components whereas “as machined” component without laser marking exhibited compressive stresses inherent due to machining. The result from the S-N curve testing is shown in Figure 2. The current laser marking components demonstrated 41% reduction in fatigue strength compared to non-laser marked specimens. The reduction in fatigue strength is due to the residual tensile stresses generated at the laser marking location which can lead to crack propagation from small micro fractures created during the surface melting process. Conclusion. This study has shown conclusively that laser marking of implants if located at high stress regions can lead to early fatigue failure. Based on the results from the study it is advisable to locate the laser markings at the region of lowest or compressive stress areas and when possible the laser marking process should be selected as to create the minimal damage to the surface. For figures/tables, please contact authors directly.

Today, hip prostheses are validated with Standards for fatigue testing: The Standard ISO 7206-4 requires to test 6 components at 230daN during 5 × 10. 6. cycles without crack. For the neck region of stemmed femoral components, the Standard ISO 7206-6 requires 6 tests at 534daN during 10 × 10. 6. cycles without crack. But these tests don't provide provide any indication on reliability level for an implantation in population. At the same time, the number of hip prosthesis implantation is growing, patients are implanted younger and younger and they want to be able to maintain a “normal” life. This way the average “loading spectrum” is getting tougher and tougher, due to this modification of the use of prosthesis in comparison with some years ago. On the other hand, there is new materials, new processes (additive manufacturing), new methods (customized stems…) with no feedback on reliability. A method is then necessary to manage the reliability in fatigue for actual and new products. The objective of this study is to establish a statistical distribution of loading of hip prosthesis in order to define at best a minimum value of strength required for a good fatigue design. To define this strength, the Stress-Strength (well known in automotive sector) approach is applied (fig 1). This approach will allow better assess the reliability in a population, depending on the mean strength and the scattering in fatigue. The first step is to establish the distribution of the loads for a hip prosthesis. Then, for a given risk level, the required strength can be defined, knowing the scattering of this strength. The strategy to have the distribution is based on:. In vivo load recordings on hip prosthesis (find on . Orthoload.com. ),. Analysis of frequency of everyday activities,. Activity level of different category of the population,. Statistical distribution of key parameters, like weight, age…. All these data are collected in the literature, and combined, then processed with the software DEFFI. ®. The goal is first to assess the reliability reached by a “nominal” stem and compare it to the reliability described in implant registers. Another goal is to analyse the stress distribution and compare it to standard requests (ISO 7206-6), in order to assess the reliability of an implant that succeeded this standard. A last, this method is a way to define the minimum strength for implants dedicated to particular populations: young and active patients, patients with high Body Weight, etc…. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Summary. Lumbar spinal specimens exhibited high fatigue strength. The cycles to failure are not only dependent on the maximum peak load, but also on the load offset or the amplitude, respectably. Introduction. Spinal injury might be caused by whole body vibrations. The permitted exposure to vibration in the workplace is therefore limited. However, there is a lack in knowledge how external vibrations might cause internal damages. Numerical whole body models might provide the potential to estimate the dynamic spinal loading during different daily activities, but depends on knowledge about the corresponding fatigue strength. This study is aiming to determine the in vitro fatigue strength of spinal specimens from donors of working age. Patients & Methods. Lumbar functional spinal units (L2/L3 and L4/L5) from midlife donors (45–65 yrs, n = 24) and young donors (20–45 yrs, n = 6) were collected and stored deep frozen. CT scans were obtained to determine the endplate area and the bone mineral density of the vertebrae. Their product is referred to as vertebral capacity (VC). Muscles were removed from the thawed specimens, but apart from the transversal ligaments, all ligaments and the intervertebral disc were left intact. During the experiments, the specimens were immersed in saline solution (37°C) containing antibiotics (PAA, Austria) to reduce biological degeneration. After preconditioning (2.5 h) the specimens were exposed to continuous sinusoidal axial compression (5Hz, <300,000 cycles). Distinct changes in the characteristic creep curve of specimens’ height indicated fatigue failure. Specimens of midlife donors were equally assigned to three groups with different peak-to-peak loads (NORM: 0–2 kN; HIGH: 0–3 kN; OFFSET: 1–3 kN), while specimens from young donors were solely assigned to the HIGH group, since a previous study [1] had shown that young specimens hardly failed for NORM loading conditions. Findings from that previous study (midlife, n = 6; young, n = 6) were merged to NORM for analyses. Results. Within the NORM group, specimens only failed within 300,000 cycles when VC was below 2,000 cm. 2. mg K. 2. HPO. 4. /ml (8 of 20). Within the HIGH group, endplate failure occurred frequently within the test duration (10 of 13; 1 excluded). For the OFFSET group, specimen failure was occasionally observed (4 of 7; 1 excluded). Exponential regression of cycles to failure dependent on VC showed significant correlations for the specimen loaded in the NORM and HIGH group (r. 2. NORM. = 0.57, p = 0.029; r. 2. HIGH. = 0.47, p = 0.029; r. 2. OFFSET. = 0.83, p = 0.091). Discussion/Conclusion. Specimens’ fatigue failure strength depends on load offset and amplitude. The group with higher loading amplitudes (HIGH: 1.5 kN) resisted fewer loading cycles than those with the smaller amplitude (OFFSET: 1 kN), even though the maximum peak was the same (3 kN). The exponential regression is conservative, since several specimens did not fail within the predicted loading cycles. Vertebral capacity might suitable predict the fatigue strength of specimens. Together with numerical modelling, these findings might promote the appraisal of occupational diseases and might help to determine the duty cycles for new implants. The funding of FIOSH, Germany is thankfully acknowledged (project F2059 and F2069)

Introduction. During revision surgery, the active electrode of an electrocautery device may get close to the implant, potentially provoking a flashover. Incidents have been reported, where in situ retained hip stems failed after isolated cup revision. Different sizes of discoloured areas, probably induced by electrocautery contact, were found at the starting point of the fracture. The effect of the flashover on the implant material is yet not fully understood. The aim of this study was to investigate the fatigue strength reduction of Ti-6Al-4V titanium alloy after electrocautery contact. Material and Methods. 16 titanium rods (Ti-6Al-4V, extra low interstitial elements, according to DIN 17851, ⊘ 5 mm, 120 mm length) were stress-relief annealed (normal atmosphere, holding temperature 622 °C, holding time 2 h) and cooled in air. An implant specific surface roughness was achieved by chemical and electrolytic polishing (Ra = 0.307, Rz = 1.910). Dry (n = 6) and wet (n = 6, 5 µl phosphate buffered saline) flashovers were applied with a hand-held electrode of a high-frequency generator (Aesculap AG, GN 640, monopolar cut mode, output power 300 W, modelled patient resistance 500 Ω). The size of the generated discoloured area on the rod's surface - representative for the heat affected zone (HAZ) - was determined using laser microscopy (VK-150x, Keyence, Japan). Rods without flashover (n = 4) served as control. The fatigue strength of the rods was determined under dynamic (10 Hz, load ratio R = 0.1), force-controlled four-point bending (FGB Steinbach GmbH, Germany) with swelling load (numerical bending stress 852 MPa with a bending moment of 17.8 Nm) until failure of the rods. The applied bending stress was estimated using a finite-element-model of a hip stem during stumbling. Metallurgical cuts were made to analyse the microstructure. Results. The control rods failed at the pushers of the setup (median: 94,550, range: 194,000 cycles). The rods with flashover failed directly at the HAZ significantly earlier than the control rods (p = 0.018). The analysis of the microstructure showed a transformation of the equiaxed α+β microstructure to a bimodal state. The size of the HAZs were equal for the dry (median: 1.51 mm. 2. , range: 5.68 mm. 2. ) and wet flashovers (median: 0.92 mm. 2. , range: 2.50 mm. 2. , p = 0.792). The cycles to failure were smaller for the dry flashover (median: 22,650 cycles, range: 5,700) than the wet flashover but not reaching statistical significance (median: 32,200, range: 57,900; p = 0.052). No correlation between the dimension of the HAZs and the cycles to failure was found (dry: r. 2. = 0.019, p = 0.8; wet: r. 2. = 0.015, p = 0.721). Discussion. Flashovers induced by an electrocautery device reduce the fatigue strength of Ti-6Al-4V. Since no correlation between the size of the HAZs and the cycles to failure was found, every contact between electrocautery devices and metal implants should be avoided. For any figures or tables, please contact authors directly

Introduction. The fatigue strength of ultrahigh molecular weight polyethylene (UHMWPE) in total joint implants is crucial to its long term success in high demand applications, such as in the knee, and is typically determined by measuring the crack propagation resistance in razor-notched specimens under cyclic load [1]. This only tells part of the story: that is, how well the material resists crack propagation once a crack is present. A second, equally important component of fatigue strength is how well the material resists crack formation. Previous studies cyclically loaded a cantilevered post until failure [2], postulating that the post would break very quickly after crack initiation. Parran et. al. proposed a novel method to measure the crack initiation time by holding a sample in constant tension until a crack was visually observed [3]. We hypothesize that the crack initiation times of various UHMWPEs will follow similar trends as the more omnipresent crack propagation resistance tests. Materials and Methods. The following UHMWPE formulations were tested: (i) virgin, (ii) gamma sterilized in vacuum, (iii) 91 kGy gamma irradiated, and (iv) 91 kGy gamma irradiated and subsequently melted. GUR1020 and GUR1050 bar stock of varying irradiation doses were machined into compact tension specimens [4] with a notch depth of 17 mm and a blunt notch root radius of 0.25 mm, mimicking a geometry of a joint replacement component. Specimens were held in constant tension until failure; 3 to 5 different loads between 1 kN and 2.25 kN (n=3 samples per load per material) were tested. A video camera was focused on the face of the notch and took a picture every 10 seconds. The photos were reviewed to manually determine the crack initiation time (Fig 1). The time it took for the sample to completely fail – that is, shear into two separate pieces – was also recorded. Results. For all materials tested, the crack initiation time (Fig 2a,b) and the time to failure (Fig 2c,d) decreased as the applied load increased. The crack initiation time increased for the gamma sterilized materials when compared to the virgin materials while the time to failure decreased. The highly crosslinked, 91 kGy materials had crack initiation times and times to failure that were less than that of the virgin material. Post irradiation melting greatly diminished the fatigue strength of the material, yielding the lowest crack initiation time and time to failure. Discussion. The test yielded results consistent with current knowledge: that is, high-dose irradiation yields a slight drop in fatigue strength, and post-irradiation melting greatly reduces strength. This test was simple to set up and run and can be a good tool to determine the relative fatigue strengths of UHMWPE formulations for orthopaedic applications. For figures/tables, please contact authors directly.

Introduction. Tendon disease and rupture are common in patients with diabetes and these are exacerbated by poor healing. although nanoscale changes in diabetic tendon are linked to increased strength and stiffness. The resistance to mechanical damage of a tissue may be measured using fatigue testing but this has not been carried out in diabetic tendon, although the toughness of diabetic bone is known to be reduced. The aim of this study was to measure the static fatigue behaviour of tendons from a streptozotocin (STZ)-induced rat model of diabetes, hypothesising that diabetes causes tendon to show lower resistance to mechanical damage than healthy tendon. Materials and Methods. Diabetic (n=3, 12 weeks post-STZ) and age-matched control (n=3) adult male Sprague Dawley rats were culled, tails harvested and stored at −80ºC. Following defrosting, fascicles (5 per animal) were carefully dissected, mean diameter measured using an optical micrometer and mounted in a Bose Biodynamics test machine using custom grips in a PBS bath. Static fatigue testing at 30 MPa to failure enabled both elastic modulus (initial ramp) and steady state creep rate (gradient at creep curve inflexion) to be measured. Data are reported as median ± interquartile range and pw0.05 using a Mann-Whitney U test was taken as significant. Results. Confirming previous reports, tendon from diabetic rats showed significantly higher elastic modulus (201 ± 68 MPa) than healthy (151 ± 62 MPa). Strain at failure showed no differences between groups. Tendon from diabetic rats showed significantly slower steady state creep (71 ± 44 μstrain s. −1. ) than healthy (691 ± 1000 μstrain s. −1. ). Discussion. These preliminary data show an order of magnitude larger resistance to mechanical damage in diabetic tendons, possibly associated with the previously reported increased packing and decreased fibril diameters. Energy-storing flexor tendons, the most commonly affected in diabetics, and the positional tendons tested here show similar fatigue behaviour when tested at the same fraction of “stress-in-life”. Further investigation is required into the cell tissue repair response in diabetes in order to link reduced rates of mechanical damage with the clinically increased risk of disease and rupture in diabetic patients

Introduction. Total hip arthroplasty (THA) using short design stem is surging with increasing movement of minimally invasive techniques. Short stems are easier to insert through small incisions preserving muscles. We have used these types of short stems since 2010. Almost all of the patients have shown good clinical results. However, two patients developed fatigue fractures on femurs post operatively. We have reviewed the clinical and radiographic results of these patients. Patients and methods. From April 2010, we have performed 621 THAs with short design stems, Microplasty. R. , Biomet, using a muscle preservation approach, the Direct Anterior Approach (DAA). The age ranged from 31 to 88 years old. Case1: 56y.o. male, BMI 23.1kg/m. 2. Preoperative diagnosis was bilateral osteoarthritis. Simultaneous THAs were performed on bilateral hips. He was allowed to bear as much weight as he could tolerate using an assistive device immediately after surgery, and followed standard hip precautions for the first 3 weeks. He was discharged from hospital seven days after surgery and returned to his job two weeks after surgery. He noticed sudden left thigh pain three weeks after surgery without any obvious cause. Crutches were recommended to partially bear his weight. Six weeks after surgery, a fracture line became visible on the radiographs and new callus formation also became visible. Three months after surgery, he felt no pain and was able to walk without any crutches. Case2: 66y.o. female, BMI 27.5 kg/m. 2. Preoperative diagnosis was bilateral osteoarthritis. THAs were performed on the hips at a six month interval. The right hip was operated on first, followed by the left hip. She was discharged from hospital four days after surgery and returned to her job six weeks after surgery. Two months later after left hip surgery, she suddenly felt pain on her left femur without any obvious cause, and was unable to walk. Three weeks later, X-rays showed fatigue fracture lines and new callus formations. After two or three months using crutches, her pain improved and X-rays showed good callus formation and no stem subsidence. Discussions. Several reports showed insufficiency fractures of the pelvis following THA. But most of them occurred due to repetitive stress on fragile bones. But our cases showed no evidence of osteoporosis. They had no history of trauma. But they had some points in common, which were they were bilateral cases and their BMI were not low. The incident rate of fatigue fractures of femur with this short stem THAs was 0.3% in our cases. We suggested that one of the causes of these fatigue fractures was the shortness of the stems. The shortness of the stems concentrate the body weight to limited contact area of the femur, and the stress causes the fatigue fractures. We should consider the risk of fatigue fractures on the patients who are operated on bilaterally. However these two patients showed good callus formations and no stem subsidence after a few weeks of partial weight bearing

There is an increasing prevalence of haptic devices in many engineering fields, especially in medicine and specifically in surgery. The stereotactic haptic boundaries used in Computer Aided Orthopaedic Surgery Unicomparmental Knee Arthroplasty (CAOS UKA) systems for assistive milling control can lead to an increase in the force required to manipulate the device; this study presented here has seen a several fold increase in peak forces between haptic and non-haptic conditions of a semi-active preoperative image system. Orthopaedic Arthroplasty surgeons are required to apply forces ranging from large gripping forces to small forces for delicate manipulation of tools and through a large range of postures. There is also a need for surgeons to move around and position themselves to gain line of sight with the object of interest and to operate while wearing additional clothing such as the protective headwear and double gloves. These factors further complicate comparison with other ergonomic studies of other robotics systems. While robotics has been implemented to reduce fatigue in surgery one area of concern in CAOS is localised user muscle fatigue in high volume use. In order to create the conditions necessary for the generation of fatigue in a realistic user experience, but in the time available for the participants, an extended period of controlled and prolonged cutting and manipulation of the robotic arm was needed. This pragmatic test requirement makes the test conditions slightly artificial but does indicate areas of high potential for fatigue when interacting with the system in high volume instances. The surgeon-robotic system interaction was captured using 3 dimensional motion analysis and a force transducer embedded in the end effector of the robotic arm and modelled using an existing upper body model in Anybody software. The kinematic and force information allowed initial calculations of the interaction between the user and the Robotic system. Validation of the model was conducted using Electromyography assessment of activity and fatigue. Optimisation of the model sought to create an efficient cutting regime to reduce cutting time with reduced muscle force in an attempt to reduce users discomfort/fatigue while taking into account anthropometric variations in the users and minimising overall energy requirements, burr path length and maximum muscle force. From the assessment of a small group of three surgeons with experience of the Robotic system there was little to no experience of above normal localised fatigue during small volume use of the system. Observation of these surgeons operating the robot state otherwise with examples of reactions to discomfort. There is also anecdotal evidence that fatigue becomes more problematic in higher volume work loads

Total Hip Arthroplasty (THA) surgery is a physical and cognitive challenge for surgeons. Data on stress levels, cognitive and physical load of orthopaedic surgeons, as well as ergonomic impact, are limited. With and without the use of an automated impaction device, operational efficiency and the surgeon's ergonomic, mental, and physical load was investigated. In a total of thirty THA procedures, a standard manual technique was compared with an automated impaction device. Three computerized cognitive tasks (Simon, pattern comparison, and pursuit rotor) and five physical tests (isometric wall-sit, plank-to-fatigue, handgrip, supra-postural task, and shoulder endurance) were used to assess psychophysiological load of the surgeon. Surgeon's cortisol concentration was evaluated from saliva samples. Postural risk was assessed by Rapid Upper Limb Assessment (RULA) and Rapid Entire Body Assessment (REBA). Efficiency was assessed by timing surgical steps and instrumentation flow. Cognitive performances after automated impaction showed faster response times and lower error rates with a greater time-on-target (+1.5 s) and a lower mouse deviation from target (−1.7 pixels). Manual impaction showed higher physical exhaustion in the isometric wall-sit test (10.6% vs. 22.9%), plank-to-fatigue (2.2% vs. 43.8%), the number of taps in the supra-postural task (−0.7% vs. −7.7%), handgrip force production in the dominant (−6.7% vs. −12.7%) and contralateral hand (+4.7% vs. +7.7%), and in shoulder endurance (−15s vs. −56s). An increase of 38.2% in salivary cortisol concentration between the midday (1.31 nmol/l) and afternoon session (1.81 nmol/l) was observed with manual impaction. After using automated impaction, salivary cortisol concentration decreased (−51.2%). Manual broaching time was on average 6′20’’ versus 7’3’’ with automated impaction. RULA of manual impaction scored 6 for cup impaction and 5 for femoral broaching, versus 3 and 3 for automated impaction, respectively. REBA of manual impaction scored 9 for cup impaction and 5 for femoral broaching, versus 4 and 3 for automated impaction, respectively. Automated impaction lowers surgeons’ cognitive and physical fatigue and leads to reduced stress and improved ergonomics without loss of surgical efficiency

Summary Statement. Tendon micromechanics were investigated using 2 methods. When collagen deformation was measured directly, higher levels of inter-fibre sliding were observed than when tenocyte nuclei were tracked. This suggests that under high strain tenocytes become unattached from the collagen fibres. Introduction. Fibre extension and inter-fibre sliding have both been reported during tendon extension, but fibre sliding is believed to be the predominant mechanism in normal healthy tendon function. Fatigue damage is known to result in structural changes and reduced mechanical properties, but its influence on micromechanics is unknown. This work aimed:. 1. To investigate the effect of fatigue loading on bovine digital extensor fascicle micromechanics, comparing fibre extension and fibre sliding, hypothesising that the relative importance of these may change due to fatigue damage. 2. To compare two techniques for characterising micromechanics: bleaching of a grid to directly measure collagen deformation, and using the cells as fiducial markers of fibre movement. Methods. The tensional regions of healthy digital extensor tendons were removed within 24 hours of slaughter and frozen. Tendons were defrosted, hydrated and fascicles dissected and loaded into custom-designed chambers allowing the mechanical loading of fully hydrated tendon fascicles. Fascicles were loaded for 0, 300 or 900 cycles under creep conditions at a frequency of 1Hz and to a maximum applied stress of 25% of the mean UTS of the fascicles. Fascicles were stained using either Acridine Orange to stain the cell nuclei or DTAF solution to stain the collagen. After DTAF staining, a grid consisting of 4 squares of side 50 μm was photo-bleached using the FRAP system on a Leica TCS SP2 confocal scanning microscope. To investigate micromechanics, fascicles were secured in a uniaxial rig and strained in 2% increments to 10% total strain at a rate of 1%s. −1. Imaging was carried out at each increment and local strains calculated from grid deformation or nuclei movement. Results. No significant changes in micromechanics were observed with increasing numbers of creep cycles, as measured with either technique. This was despite quite significant matrix damage being observed particularly after 900 cycles. When using the grid deformation measure of strains, a continual increase in fibre sliding was seen above 4% applied strain, correlating with the levelling off of intra-fibre strains. This same move towards dominant fibre sliding was not observed with techniques using the nuclei as fiducial markers. Using the nuclei as markers consistently reported significantly lower levels of fibre sliding than those measured from grid deformation at strains of 6% and above, under all creep conditions. Discussion/Conclusion. The apparent absence of any effect of creep on the measured microstructural deformation may be a result of the localised nature of the measurement techniques. At sites where matrix structure broke down both the tracking of nuclei and the photo-bleaching of the grid proved problematic and it is these regions where the greatest degree of deformation would perhaps be expected, with remaining areas of the tissue stress-deprived. The smaller levels of fibre shear reported when measured through nuclei tracking suggests that the tenocytes may not be well adhered to the fibres and may be protected from some of the matrix deformation in response to loading

One method of reducing intra-operative complications in revision hip surgery is the cement-in-cement technique. Some concern exists regarding the retention of the existing fatigued cement mantle. It was hypothesised that leaving the existing fatigued cement mantle does not degrade the mechanical properties of the cement in cement revision construct. The aim of this research was to test this hypothesis using in vitro fatigue testing of analogue cement in cement constructs. Primary cement mantles were formed by cementing a large polished stem into sections of tubular stainless steel using polymethylmethacrylate with Gentamicin. At this stage, the specimen was chosen to be in the test group or the control group. If in the test group, it underwent a fatigue of 1 million cycles. This was carried out in a specifically designed rig and a fatigue testing machine. Into these fatigued and unfatigued primary mantles, the cement in cement procedure was carried out. Both groups underwent a fatigue of again 1 million cycles. Subsidence of the stems and their inducible displacement was recorded. A power calculation preceded testing. Completion of a Mann Whitney test on the endpoints of the subsidence curves revealed that there is no statistical difference between the data sets (means 0.51, 0.46, n=10 + 10, p = 0.496). This data was also calculated for the inducible displacement. Again, there was no statistical difference in the separate groups for this parameter (means 0.38, 0.36, p = 0.96). This methodology produces a complex 3 dimensional reconstruction of the cement in cement revision which replicates the in vivo structure. This reconstruction has undergone fatigue testing. Neither of these two aspects has been produced for the study of cement in cement revision before. A fatigued primary cement mantle does not appear to degrade the mechanical properties of the cement in cement revision construct

Representative pre-clinical analysis is essential to ensure that novel prosthesis concepts offer an improvement over the state-of-the-art. Proposed designs must, fundamentally, be assessed against cyclic loads representing common daily activities [Bergmann 2001] to ensure that they will withstand conceivable in-vivo loading conditions. Fatigue assessment involves:. –. cyclic mechanical testing, representing worst-case peak loads encountered in-vivo, typically for 10 million cycles, or. –. prediction of peak fatigue stresses using Finite Element (FE) methods, and comparison with the material's endurance limit. Cyclic stresses from gait loading are super-imposed upon residual assembly stresses. In thick walled devices, the residual component is small in comparison to the cyclic component, but in thin section, bone preserving devices, residual assembly stresses may be a multiple of the cyclic stresses, so a different approach to fatigue assessment is required. Modular devices provide intraoperative flexibility with minimal inventories. Components are assembled in surgery with taper interfaces, but resulting residual stresses are variable due to differing assembly forces and potential misalignment or interface contamination. Incorrect assembly can lead to incomplete seating and dissociation [Langdown 2007], or fracture due to excessive press-fit stress or point loading [Hamilton 2010]. Pre-assembly in clean conditions, with reproducible force and alignment, gives close control of assembly stresses. Clinical results indicate that this is only a concern with thick sectioned devices in a small percentage of cases [Hamilton 2010], but it may be critical for thin walled devices. A pre-clinical analysis method is proposed for this new scenario, with a case study example: a thin modular cup featuring a ceramic bearing insert and a Ti-6Al-4V shell (Fig. 1). The design was assessed using FE predictions, and manufacturing variability from tolerances, surface finish effects and residual stresses was assessed, in addition to loading variability, to ensure physical testing is performed at worst case:. –. assembly loads were applied, predicting assembly residual stress, verified by strain gauging, and a range of service loads were superimposed. The predicted worst-case stress conditions were analysed against three ‘constant life’ limits [Gerber, 1874, Goodman 1899, Soderberg 1930], a common aerospace approach, giving predicted safety factors. Finally, equivalent fatigue tests were conducted on ten prototype implants. Taking a worst-case size (thinnest-walled 48 mm inner/58 mm outer), under assembly loading the peak tensile stress in the titanium shell was 274 MPa (Fig. 2). With 5kN superimposed jogging loading, at an extreme 75° inclination, 29 MPa additional tensile stress was predicted. This gave mean fatigue stress of 288.5 MPa and stress amplitude of 14.5 MPa (R=0.9). Against the most conservative infinite life limit (Soderberg), the predicted safety factor was 2.40 for machined material, and 2.03 for forged material, or if a stress-concentrating surface scratch occurs during manufacturing or implantation (Fig. 3). All cups survived 10,000,000 fatigue cycles. This study employed computational modelling and physical testing to verify the strength of a joint prosthesis concept, under worst case static and fatigue loading conditions. The analysis technique represents an improvement in the state of the art where testing standards refer to conventional prostheses; similar methods could be applied to a wide range of novel prosthesis designs

Background and purpose: Back injury is a common complaint amongst rowers. With long training hours muscle fatigue is an inevitable consequence which may be a precursor to injury. This study aims to explore the effects of fatigue on iliocostalis lumborum (IL) and superficial multifidus (SM) whilst rowing on a Concept 2C rowing ergometer (C2CRE). Method: Nineteen male athletes from Cardiff University Rowing Club were recruited fulfilling specific inclusion criteria (mean age 22yrs ± 3). Ethical approval was obtained from the institutions ethical committee. With bilateral EMG electrodes (IL and SM) attached Maximum Voluntary Contractions were collected followed by a 10 minute warm up on a C2CRE. Subjects subsequently performed a 7 stroke power test (pre fatigue condition) (. Godfrey and Williams 2007. ). Subjects then rowed at a power rate of an average power rating from the 7 stroke power test. As soon as subjects power ratings fell below 85% of the average they stopped, and then immediately performed the 7 stroke power test whilst EMG data (IL and SM) was collected (post fatigue condition). Paired T tests reported differences between pre and post fatigue scores for IL and SM. Results: A non significant trend in IL between pre and post fatigue conditions (p=0.065) was noted with no significant difference in SM activity (p=0.196). Conclusion: This study has provided evidence that there is a difference in muscle activity between IL and SM following a fatiguing protocol, which may play an important role in the understanding of mechanisms leading to low back pain in rowers

Introduction: The regulation of balance during upright standing involves continuous muscular activity, associated with body sway. In single stance standing, the base of support is narrower compared to double stance, resulting in an increased body sway and emphasizing the role of individual muscles in regulating the sway motion. In this study, we investigated the effect of Tibialis Anterior (TA) fatigue on body sway during standing on one leg on ten able-bodied subjects. Methods: Foot ground reaction forces, goniometry of the ankle joint, and EMG of the TA were all measured simultaneously in two tests. Each test lasted 30 sec. During which the subjects were required to stand as still as possible with their dominant leg on a forceplate and the contralateral knee flexed upward at 90 deg approximately, and their hands resting on their waists. The tests were separated by a 4 min isotonic fatiguing effort of the TA, indicated by a significant decrease of the mean power frequency (MPF). Results: The EGM root mean square (RMS) started off at 45% MVC but, towards the end of the effort, significantly increased to 52% MVC, the latter determined in non-fatigue condition. Compared to the non-fatigue state, the following significant (p< 0.05) sway changes took place in the fatigue state: force RMS increased from 2.61 to 3.90 N and from 3.77 to 5.01 N in the mediolateral (ML) and vertical directions, respectively. The center of pressure (CoP). RMS in the ML direction increased from 0.57 to 0.68 cm. The EMG RMS in the TA increased from 4.15 to 5.58 and the MPF decreased from 107.6 to 96.7 Hz in the fatigued state. Discussion: An interesting finding was revealed by comparing the variations of the ankle angle to those of the center of pressure in the anterior-posterior direction taking place during standing. During the non-fatigue test the CoP moved gradually posteriorly, while the goniometer indicated an ankle change towards dorsiflexion. These obviously two opposing trends necessitate compensatory angular adjustments at the knee and/or hip joints. However, during the fatigue test, the posterior excursion of the CoP was accompanied by a consistent change in the ankle, towards plantar flexion. This seems to suggest that in the fatigue state the redundancy of the musculoskeletal system is reduced, increasing the degree of correction between ankle angle and CoP

Background: Neck pain is a growing problem which is linked to occupational factors that include work above shoulder height or sustained neck flexion. These activities may induce fatigue in the neck muscles impairing the muscles’ ability to provide reflex contractions that protect against tissue injury. The aim of this study was to investigate the effect of neck muscle fatigue on reflex activation of the neck muscles. Methods: Healthy volunteers were subjected to one of two loading protocols. Isometric contractions of neck extensors at 60% MVC were sustained to the endurance limit (n=30) to induce high level fatigue in these muscles. A similar protocol for neck flexors (n=21) was used to initiate low level contraction of the extensors which are co-activated to stabilise the cervical spine under such circumstances. Before and after each loading protocol, reflex activation of the trapezius muscle was assessed using skin surface electromyography (EMG) to measure the latency and amplitude of muscle activation in response to a sudden perturbation of the head. Results: Reflex latencies increased from 73±17ms to 93±27ms (p=0.0041), and from 72±12ms to 97±28ms (p< 0.0001) following low and high level extensor fatigue, respectively. Time to peak EMG also increased from 122±32ms to 148±39ms (p=0.0093), and from 113±15ms to 138±25ms (p< 0.0001), respectively, although no change in peak EMG amplitude was observed. Conclusions: Reflex activation of trapezius was substantially delayed following both loading protocols. These findings suggest that even low level postural loading in the workplace may impair neck muscle reflexes rendering the underlying tissues more vulnerable to strain injury. Conflicts of Interest: None. Source of Funding: BBSRC (Biotechnology and Biological Sciences Research Council, UK)