The most important issue in the assessment of fracture healing is to acquire information about the restoration of the mechanical integrity of bone. Many researchers have attempted to monitor stiffness either directly or indirectly for the purpose of assessing strength, as strength has been impossible to assess directly in clinical practice. The purpose of this study was thus to determine the relationship between bending stiffness and strength using mechanical testing at different times during the healing process. Unilateral, transverse, mid-tibial osteotomies with a 2-mm gap were performed in 28 rabbits. The osteotomy site was stabilized using a double-bar external fixator. The animals were divided into four groups (n=7/group/time point; 4, 6, 8 and 12 weeks). A series of images from micro-computed tomography of the gap was evaluated to detect the stage of fracture healing and a 4-point bending test was performed to measure stiffness and strength. Formation of cortex and medullary canal at the gap was seen in the 12-week group and would represent the remodeling stage. In addition, the relationship between stiffness and strength remained almost linear until at least 12 weeks. However, stiffness recovered much more rapidly than strength. Strength was not fully restored until the later stages of fracture healing. However, the current study demonstrated that stiffness could be monitored as a surrogate marker of strength until at least the remodeling stage.

The most important issue in the assessment of fracture healing is to acquire information about the restoration of the mechanical integrity of bone. Echo tracking (ET) can noninvasively measure the displacement of a certain point on the bone surface under a load. Echo tracking has been used to assess the bone deformation angle of the fracture healing site. Although this method can be used to evaluate bending stiffness, previous studies have not validated the accuracy of bending stiffness. The purpose of the present study is to ensure the accuracy of bending stiffness as measured by ET. A four-point bending test of the gap-healing model in rabbit tibiae was performed to measure bending stiffness. Echo tracking probes were used to measure stiffness, and the results were compared with results of stiffness measurements performed using laser displacement gauges. The relationship between the stiffness measured by these two devices was completely linear, indicating that the ET method could precisely measure bone stiffness.

Introduction

Spinal aBMD only explains 50–80% of vertebral strength, and the application of aBMD measurements in isolation cannot accurately identify individuals who are likely to eventually experience bone fracture, due to the low sensitivity of the test. For appropriate treatment intervention, a more sensitive test of bone strength is needed. Such a test should include not only bone mineral density, but also bone quality. Quantitative computed tomography-based finite element methods (QCT/FEM) may allow structural analyses taking these factors into consideration to accurately predict bone strength (PBS). To date, however, basic data have not been reported regarding the prediction of bone strength by QCT/FEM with reference to age in a normal population. The purpose of this study was thus to create a database on PBS in a normal population as a preliminary trial. With these data, parameters that affect PBS were also analyzed.

Introduction: Low-intensity pulsed ultrasound stimulation (LIPUS) can enhance bone regeneration and callus healing during fracture repair. However, whether a certain phase of the healing process in fracture repair in particular is infiuenced by LIPUS treatment remains unclear. In this investigation, the effect of LIPUS on callus remodeling in a gap healing model was evaluated by bone morphometric analyses using 3-dimensional (3D) quantitative micro computed tomography (μCT) at the healing site, providing information on the temporal sequence of mineralized remodeling events that characterize the gap healing.

Materials and Methods: The rabbit osteotomy model with 2-mm gap for the right tibia was immobilized with four pins fixed to an external fixator with double side bars. LIPUS was continued for both the treatment group (n=7/group/time point) and the control group (n=7/group/time point), for 20 min, six times/week, for 4, 6, or 8 weeks. The control group also received a sham inactive transducer under exactly the same condition as the LIPUS group. After the harvested tibia was scanned by μCT, region of interest was set at the callus healing area. It defined as a center of the osteotomy gap with a width of 1 mm. Morphometric parameters used for evaluation were mineralized callus volume (BV, cm³) and volumetric bone mineral density of mineralized tissue comprising the callus (mBMD, mBMD = BMC/ BV, mgHA/cm³). The whole ROI was measured and was subdivided into three zones. The periosteal callus zone (External), the medullary callus zone (Endosteal) and the remaining zone was the cortical gap zone (Intercortical). For each zone, BV and mBMD were measured. Data of the μCT evaluations were analyzed using a one-way ANOVA test. Statistically significant difference was set at p < 0.05.

Results: In the LIPUS groups, BV for the Endosteal zone was significantly lower for the 8-week group than for the 4-week group. Comparing results at the same time point, the LIPUS group at 8 weeks was significantly higher than that of the control group in the Intercortical zone. As for mBMD, in the LIPUS group, the 8-week group was significantly higher than the 4-week group for Total, External, Internal, and Endosteal zones, respectively. Comparing results at the same time point, mBMD was significantly higher for the LIPUS group at 8 weeks than for the control group in both External and Intercortical zones.

Discussion: The most striking finding in our study was that LIPUS accelerated bone formation in the Intercortical zone and callus resorption in the Endosteal zone. This suggests that LIPUS could shorten the time required for remodeling. However, the results of this study do not clarify whether an early phase in callus formation in particular is infiuenced by LIPUS.

Introduction: Low-intensity pulsed ultrasound stimulation (LIPUS) reportedly enhances restoration of strength at fracture healing sites. However, evaluation of strength by mechanical testing was limited to only one direction, with either bending or torsion. Quantitative micro computed tomography (μCT) scans allow us to calculate strength-related parameters such as cross-sectional moment (CSM) and cross-sectional moment of inertia (CSMI). Previous studies have performed 2-dimensional (2D) analyses, and 3-dimensional (3D) evaluations have not been described. The purpose of this study was thus to investigate the effects of LIPUS on osteotomy healing using 3D analyses of CSM and CSMI.

Materials and Methods: Bilateral, transverse, mid-tibial osteotomies with a 2-mm gap were performed in 42 rabbits. LIPUS was continued for both the treatment group (n=7/group/time point) and the control group (n=7/ group/time point), for 20 min, six times/week, for 4, 6, or 8 weeks. The control group also received a sham inactive transducer under the same condition as the LIPUS group. After the tibia was scanned by μCT, region of interest (ROI) was set at the center of the osteotomy gap with a width of 1 mm. Center of gravity for the ROI and the XYZ coordinate was calculated. An optional line (I) can be drawn in this coordinate. The angle of the Z axis (𝛉) was measured, and also the degree of angle of the X axis (φ) was measured. The 3D CSM [I (φ, 𝛉)] around this line was calculated using the following equation: I (φ, 𝛉) = ∫ r²dV (mm5), where r is the distance of a voxel to the center of gravity (mm) and dV is the area of a voxel (mm3). The axial CSM was defined as CSMx: I (0, 90), CSMy: I (90, 90), whereas the polar CSM was also defined as CSMp: I (any, 0). 3D CSMI weighted by density distribution was calculated using the following equation: I’ (φ, 𝛉) = ∫ r²dm = ∫ ρr²dV (mg.mm²), ρ is the measured volumetric callus mineral density. Likewise CSMIx, CSMIy and CSMIp were calculated. These data of the μCT evaluations were analyzed using a one-way ANOVA test (p< 0.05).

Results: When 3D CSMs at the same time point were compared, values for the LIPUS groups were significantly higher than those for control groups for CSMx at 6 weeks and CSMp at 8 weeks. As for comparison of 3D CSMIs at the same time point, values for the LIPUS groups were significantly higher than those of the control groups for CSMIx, CSMIy, and CSMIp at 6 and 8 weeks.

Discussion: Bone healing by 3D CSM and CSMI has not been described before. Our results demonstrate that these bone strength parameters improved with LIPUS during the early phases. However, whether the late phase of callus formation is infiuenced remains unclear.

Introduction: There is a clear need for the development of more sensitive risk assessment tools for clinical predictors of fractures. Bone densitometries are limited in the ability to account for complex geometry, architecture, and heterogeneity of bone. Quantitative computed tomography (QCT)-based finite element (FE) Methods: (QCT/FEM) are able to perform structural analyses taking these factors into consideration to accurately predict bone strength. However, no basic data have been available regarding predicted strength (PS) of the proximal femur by QCT/FEM with reference to age in a normal population. The purpose of this study was thus to create a database on PS in a normal population as a preliminary trial. With these data, parameters that affect PS were also analyzed.

Methods: Participants in this study comprised individuals who participated in a health checkup program with computed tomography (CT) at our hospital in 2008. Participants included 487 men and 237 women (age range, 40–87 years). Exclusion criteria were provided. Scan data of the proximal femur were isolated and taken from overall data from CT of each participant with simultaneous scans of a calibration phantom containing hydroxyapatite rods. A FE model was constructed from the isolated data using Mechanical Finder software. For each of the FE models, loading and boundary conditions as well as the definition of PS were exactly the same as described by Bessho et al. (Bone 2009). For each participant, height, weight, and abdominal circumference (AC) were measured. The analyses included linear regression analysis relating age and PS, one-way analysis of variance to compare average PS among the groups of participants who were divided into 5-year age brackets, and multiple regression analysis to determine how PS was affected by age, height, weight, and AC. Differences were considered significant for values of p< 0.05.

Result: The following results were obtained. First, average PS was lower in women than in men for all age ranges. Second, PS in men under stance configuration, and those in women under stance and fall configurations significantly decreased with age. Third, weight positively affected PS in both men and women.

Discussion: This was the first study to investigate changes in PS with age in a normal population. Whether PS by QCT/FEM correlates more closely with fracture risk for osteoporotic patients in comparison to other bone densitometries remains unclear, but the our results did not contradict any existing concept of risk factors for fragility fracture. More baseline data for PS in normal populations need to be accumulated by increasing the number of participants in studies like this.

We evaluated the effect of low-intensity pulsed ultrasound stimulation (LIPUS) on the remodelling of callus in a rabbit gap-healing model by bone morphometric analyses using three-dimensional quantitative micro-CT. A tibial osteotomy with a 2 mm gap was immobilised by rigid external fixation and LIPUS was applied using active translucent devices. A control group had sham inactive transducers applied. A region of interest of micro-CT was set at the centre of the osteotomy gap with a width of 1 mm. The morphometric parameters used for evaluation were the volume of mineralised callus (BV) and the volumetric bone mineral density of mineralised tissue (mBMD). The whole region of interest was measured and subdivided into three zones as follows: the periosteal callus zone (external), the medullary callus zone (endosteal) and the cortical gap zone (intercortical). The BV and mBMD were measured for each zone.

In the endosteal area, there was a significant increase in the density of newly formed callus which was subsequently diminished by bone resorption that overwhelmed bone formation in this area as the intramedullary canal was restored. In the intercortical area, LIPUS was considered to enhance bone formation throughout the period of observation. These findings indicate that LIPUS could shorten the time required for remodelling and enhance the mineralisation of callus.

Ring frames have the advantage of allowing progressive correction. However, the available frames for complex deformities are heavy and bulky leading to poor compliance by patients. Also, the mounting procedure requires considerable expertise and skill. On the other hand, a unilateral external fixator has the advantages of less bulk and a lighter weight. Thus, it causes less disability and can achieve better patient compliance even with bilateral application. However, previous unilateral fixators have had various limitations with respect to deformity correction, such as restricted placement of hinges, restricted correction planes, and a limited range of correction angles. In addition, it was impossible to achieve progressive correction while fixation was maintained. To overcome these disadvantages of existing unilateral fixators, we developed a new fixator for gradual correction of multi-plane deformities including translational and rotation deformities. This unilateral external fixator is equipped with a universal bar link system. The link is constructed from three dials and two splines that are connecting the dials. The pin clamps are able to vary the direction of a pin cluster in the three dimensional planes. The system allows us to correct angulation, translation, rotation, and the combination of the above. In addition, open or closed hinge technique is available because the correction hinge can be placed right on the center of rotational angulation (CORA), or at any desired location, by adjusting the length of the link spline. By increasing the spline length, the virtual hinge can also be set far from the fixator. Gradual correction can be performed by rotating the three dials using a worm gear goniometer that is temporarily attached. A 3D reconstructed image of the bone is generated preoperatively. Preoperative planning can be done using this image. Mounting parameters are determined by postoperative AP and lateral computed radiography images. These postoperative images are matched with the pre-operative 3D CT image by 2D and 3D image registration. Then, the fixator can be virtually fixed to the bone. By performing virtual correction, it is possible to plan the correction procedure. The fixator is manipulated by rotating each of the three dials to the predetermined angles calculated by the software. Static load testing disclosed that the fixator could bear a load of 1700 N. No breakage or deformation of the fixator itself was recognized. Mechanical testing demonstrated that this new fixator has sufficient strength for full weight bearing, as well as sufficient fatigue resistance for repeated or prolonged use. The results of clinical application in patients with multi-plane femoral deformities were excellent, and correction with very small residual deformity was achieved in each plane.

The most important issue in the assessment of fracture healing is to acquire information on the restoration of mechanical integrity of the bone. To measure bending stiffness at the healing fracture site, we focused on the use of echo tracking (ET) that was a technique measuring minute displacement of bone surface by detecting a wave pattern in a radiofrequency echo signal with an accuracy of 2.6 μ. The purpose of this study was to assure that the ET system could quantitatively assess the progress, retardation or arrest of healing by detecting bending stiffness at the fracture site.

With the ET system, eight tibial fractures in 7 patients with an average age of 37 years (range: 24–69) were measured. Two tibiae in 2 patients were treated conservatively with a cast, and 6 tibiae in 5 patients were treated with internal fixation (intramedullary nailing: 4, plating: 1, screw 1). Patients assumed supine position, and the affected lower leg was held horizontally with the antero-medial aspect faced upwards. The fibula head and the lateral malleolus were supported and held tight by a Vacufix ®. A 7.5 Hz ultrasound probe was placed on each antero-medial aspect of the proximal and distal fragments along its long axis. Each probe was equipped with a multi-ET system with 5 tracking points with each span of 10 mm. A load of 25 N was applied at a rate of 5 N/second using a force gauge parallel to the direction of the probe and these probes detected the bending angle between the proximal and distal fragments. An ET angle was defined as the sum of the inclinations of both fragments. In the patients treated with a cast, the contralateral side was also measured and served as a control. Fracture healing was assessed time sequentially with an interval of 2 or 3 weeks during the treatment.

None of the patients complained of pain, or no other complication related to this measurement occurred. In the patient (patient:M) treated with a cast, the ET angle exponentially decreased as time elapsed (y = 1.4035e-0.1053x, R = 0.9754) and the radiographic appearance showed normal healing. Including this case, in all patients with radiographic normal healing, the ET angle exponentially decreased. However, in patients with retarded healing (patient:N), the decrease of the angle was extremely slow(y = 0.2769e-0.0096x, R = 0.815). In patients with non union (patient:T), the angle stayed at the same level.

With this method, noninvasive assessment of bending stiffness at the healing site was achieved. Bending angle measured by ET diminished over time exponentially in patients with normal healing. On the contrary, in patients with healing arrest, no significant decrease of the bending angle was recognized. It was demonstrated that the echo tracking method could be applicable clinically to evaluate fracture healing as a versatile, quantitative and noninvasive technique.

Aims: The purpose of this study was to clarify how the mechanical characteristics of the lengthened bone changes with time by means of the analyses using the CT based finite element method. Methods: CT images were obtained from the bilateral tibiae of five patients who had undergone unilateral tibia. The average time interval from completion of lengthening to CT scanning was 30 months. There were two patients had CT examinations twice. The analyses were made using the Mechanical Finder®(Mitsubishi Space Software, Osaka, Japan). 3-D finite element models were made from axial CT images of the whole tibiae. The models were 3mm tetrahedron elements for a cancellous bone and 3 nodal-points shell elements with a thickness of 0.3 mm for a cortical bone. The uni-axial compressive load was applied on the tibial plateau, while the distal part of the tibia was fully restrained. The elastic moduli at the middle of the lengthened bones and the maximum principal strains were calculated using the elastic analysis. Results: The elastic moduli of the lengthened bones were significantly smaller than those of the contra-lateral bones, while the maximum principal strains of the lengthened bones tended to be larger. The ratios of the elastic modulus disparity between the lengthened bone and the paired contra-lateral bone to the elastic modulus of the contra-lateral bone decreased significantly with time. Likewise, the ratios of the maximum principal strains calculated as above decreased identically. Conclusions: The results indicated that the stiffness of the lengthened bone got closer to that of the contra-lateral with time, which means the lengthened bones were in the process of modeling during these follow up time intervals.

Pin clamp motion was continuously monitored using a displacement sensor as patients walked with a dynamic fixator applied. Patients with a shaft fracture, nonunion or lengthening of the tibia were monitored, all of whom were in the stage of dynamization. The Hifixator equipped with a ball bearing mechanism on the inner surface of its dynamic pin clamp was used as a dynamic external fixator. The aim of this study was to estimate the magnitude of movement and the type of deformation occurring at the fracture site or callus generated after distraction osteogenesis. The actual motion of the bone fragment has components with six degrees of freedom, which are transferred to the pin clamp. The magnitude of the displacement of the pin clamp along the shaft is expressed by an equation involving these six components. If the pin clamp has a sufficiently smooth sliding surface and a small clearance between it and the shaft, and the pin clusters are sufficiently rigid during walking, the amount of the displacement can be expressed by the linear combination of these components.

Accuracy of the measurement was evaluated using a bone model fixed with a Hifixator mounted with a displacement sensor, by performing dynamic loading tests with axial, bending and torsional forces The measured values agreed well with the theoretical values when the rigidity of the bone model was high. The displacement was recorded versus time during more than twenty cycles of walking with weight bearing of the patients. The rhythm of walking was controlled with a metronome set at 0.5 Hz. The displacement curve had an oscillatory component synchronized with a heel strike and a toe off, a time dependent component expressed by shifting of the baseline, and an irreversible component during a non-weight bearing period after walking. The three components were analyzed with a simple Voigt model.

In all patients, both the amplitude of the oscillatory component and the time dependent component expressed as retardation time decreased as healing proceeded, and by the time of fixator removal the irreversible component had disappeared. This method was useful for quantitatively evaluation the viscoelastoplascity of the healing site.

The purpose of this study is to elucidate the possibility of an ideal joint alignment after monofocal lengthening of tibia in achondroplastic patients. In 10 cases of the alignments of knee and ankle joints of tibias in which plane radiographs were examined.Unilateral fixators were applied to both tibias,after lengthening in the normal manner, deformity was corrected manually in a single procedure without anesthesia. In order to determine the amount of angle to be corrected, a line was first drawn on the radiograph from the center of the knee joint to the center of the ankle joint. (This line is named the Knee-ankle line: KAL).

Next we drew a line along the ankle joint and measured the angle between this line and KAL. We also drew a line across the tibial plateau and measured the medial angle between this line and KAL. We tried to align the ankle joint perpendicular to KAL and the medial angle between the tibial plateau and KAL at 87 degrees , instead of trying to align the axis of the tibial shaft perfectly straight. The medial angles between the line across the tibial plateau and KAL were corrected to 86 degrees in average, with a range from 84 to 90 degrees, and the medial angles between the line across the ankle joints were corrected to 87 degrees in average, ranging from 80 to 90 degrees in result.

In conclusion, joint alignments of tibias in achondro-plastic patients were able to be corrected successfully without any complications using our monofocal lengthening technique. And severe varus deformities of tibias can be corrected even with monofocal lengthening technique by trying to correct the alignments of knee and ankle joints rather than trying to straighten tibial shafts.