Timothy L. Norman

Cortical Bone Viscoelasticity and Fixation Strength of Press-Fit Femoral Stems: A Finite Element Model

Many cementless implant designs rely upon a diaphyseal press-fit in conjunction with a porous coated implant surface to achieve primary or short term fixation, thereby constraining interface micromotion to such a level that bone ingrowth and consequent secondary or long-term fixation, i.e., osseointegration, can occur. Bone viscoelasticity, however, has been found to affect stem primary stability by reducing push-out load. In this investigation, an axisymmetric finite element model of a cylindrical stem and diaphyseal cortical bone section was created in order to parametrically evaluate the effect of bone viscoelasticity on stem push-out while controlling coefficient of friction (mu = 0.15, 0.40, and 1.00) and stem-bone diametral interference (delta = 0.01, 0.05, 0.10, and 0.50 mm). Based on results from a previous study, it was hypothesized that stem-bone interference (i.e., press-fit) would elicit a bone viscoelastic response which would reduce the initial fixation of the stem as measured by push-out load. Results indicate that for all examined combinations of mu and delta, bone viscoelastic behavior reduced the push-out load by a range of 2.6-82.6% due to stress relaxation of the bone. It was found that the push-out load increased with mu for each value of delta, but minimal increases in the push-out load (2.9-4.9%) were observed as delta was increased beyond 0.10 mm. Within the range of variables reported for this study, it was concluded that bone viscoelastic behavior, namely stress relaxation, has an asymptotic affect on stem contact pressure, which reduces stem push-out load. It was also found that higher levels of coefficient of friction are beneficial to primary fixation, and that an interference threshold exists beyond which no additional gains in push-out load are achieved.

Age-related changes in porosity and mineralization and in-service damage accumulation

It has been proposed that bone damageability (i.e. bones susceptibility to formation of damage) increases with the elevation or suppression of bone turnover. Suppression of turnover via bisphosphonates increases local bone mineralization, which theoretically should increase the susceptibility of bone to microcrack formation. Elevation of bone turnover has also been proposed to increase bone microdamage through an increase in bone intracortical porosity and local stresses and strains. The goal of this paper was to investigate the above proposals, i.e., whether or not increases to mineral content and porosity increase bone in-service damageability. To do this, we measured in vivo diffuse damage area (Df.Dm.Ar, %) and microcrack density (Cr.Dn) (cracks/mm(2)) in the same specimen from human cortical bone of the midshaft of the proximal femur obtained from cadavers with an age range of eight decades and examined their relationships with porosity, mineralization and age. Results of this study showed that Cr.Dn and Df.Dm.Ar increased with a decrease in bulk mineralization. This finding does not appear to support the proposal that damage accumulation increases with low bone turnover that results in increases mineralization. It was proposed however that the negative correlation between damage accumulation and mineralization may be attributed to highly mineralized regions of bone existing with under-mineralized regions resulting in an overall decrease in average bone mineralization. It was also found that microdamage accumulates with increasing porosity which does appear to support the proposal that elevated bone turnover that results in increased porosity can accelerate microdamage accumulation. Finally, it was shown that linear microcracks and Df.Dm.Ar accumulate with age differently, but because they correlate with each other, one may be the precursor for the other.

Cortical Bone Viscoelasticity and Fixation Strength of Press-Fit Femoral Stems: An In-Vitro Model

Cementless total hip femoral components rely on press-fit for initial stability and bone healing and remodeling for secondary fixation. However, the determinants of satisfactory press-fit are not well understood. In previous studies, human cortical bone loaded circumferentially to simulate press-fit exhibited viscoelastic, or time dependent, behavior. The effect of bone viscoelastic behavior on the initial stability of press-fit stems is not known. Therefore, in the current study, push-out loads of cylindrical stems press-fit into reamed cadaver diaphyseal femoral specimens were measured immediately after assembly and 24 h with stem-bone diametral interference and stem surface treatment as independent variables. It was hypothesized that stem-bone interference would result in a viscoelastic response of bone that would decrease push-out load thereby impairing initial press-fit stability. Results showed that push-out load significantly decreased over a 24 h period due to bone viscoelasticity. It was also found that high and low push-out loads occurred at relatively small amounts of stem-bone interference, but a relationship between stem-bone interference and push-out load could not be determined due to variability among specimens. On the basis of this model, it was concluded that press-fit fixation can occur at relatively low levels of diametral interference and that stem-bone interference elicits viscoelastic response that reduces stem stability over time. From a clinical perspective, these results suggest that there could be large variations in initial press-fit fixation among patients.

Bone creep and short and long term subsidence after cemented stem total hip arthroplasty (THA).

Stem-cement and cement-bone interfacial failures as well as cement fractures have been noted in cemented total hip arthroplasty (THA) as the cause of aseptic loosening. Attempts to reduce the risk of femoral component loosening include improving the stem-cement interface by various coatings, using a textured or porous coated stem surfaces or by using a tapered stem having a highly-polished surface. The latter approach, often referred to as force-closed femoral stem design, would theoretically result in stem stabilization subsequent to debonding and taper-lock. Previous work using three-dimensional finite element analysis has shown a state of stress at the stem-cement interface indicative of taper-lock for the debonded stem and indicated that stem-cement interface friction and bone cement creep played a significant role in the magnitudes of stresses and subsidence of the stem. However, the previous analysis did not include the viscoelastic properties of bone, which has been hypothesized to permit additional expansion of the bone canal and allow additional stem subsidence (Lu and McKellop, 1997). The goal of this study was to investigate the effect of bone viscoelastic behavior on stem subsidence using a 3D finite element analysis. It was hypothesized that the viscoelastic behavior of bone in the hoop direction would allow expansion of the bone reducing the constraint on bone over time and permit additional stem subsidence, which may account for the discrepancies between predicted and clinical subsidence measurements. Analyses were conducted using physiological loads, average peak loads and high peak loads for normal patient and active patient (Bergmann et al., 2010) from which short and long term subsidence was predicted. Results indicated that bone creep does contribute to higher stem subsidence initially and after 10 years of simulated loading. However, it was concluded that the constraint upon the cement mantle is not mitigated enough to result in stem subsidence equivalent to that observed clinically.

Nicotine Increases Osteoblast Activity of Induced Bone Marrow Stromal Cells in a Dose-Dependent Manner: An in vitro Cell Culture Experiment

Previous studies by our group showed that nicotine delivered via a transdermal nicotine patch significantly enhanced posterior spinal fusion rates in rabbits. Nicotine transdermal patches provide a steady serum level; there may be a dose-dependent effect of nicotine on posterior spinal fusion. In an in vitro cell culture model of rabbit bone marrow–derived osteoblast-like cells, cells were exposed to different concentrations of nicotine (0, 20, 40, 80 ng/mL and 10, 100, 250 μg/mL). Wells were stained with an alkaline phosphatase (ALP) staining kit to determine ALP enzyme activity. Cells were stained with Von Kossa for mineralization. A two-way analysis of variance (ANOVA) using dose and time as variables showed significant differences among groups; post hoc analysis showed that the 100-μg/mL dose of nicotine significantly enhanced ALP activity over controls. A one-way ANOVA using dose as the variable showed that the 100- and 250-μg/mL doses had significantly greater mineralization than controls. Dose-response analysis revealed a statistically significant effect of nicotine dose on ALP activity and Von Kossa activity. The effects of nicotine on spinal fusion may be dose-dependent and due to stimulation of osteoblastic activity. Nicotine may not be responsible for the inhibited bone healing observed in smokers.

Effect of Serum Nicotine Level on Posterior Spinal Fusion in an In-vivo Rabbit Model

BACKGROUND CONTEXTnCigarette smoking has a deleterious effect on spinal fusion. Although some studies have implied that nicotine is primarily responsible for poor fusion outcomes, other studies suggest that nicotine may actually stimulate bone growth. Hence, there may be a dose-dependent effect of nicotine on posterior spinal fusion outcomes.nnnPURPOSEnThe purpose of this study was to determine if such a relationship could be shown in an in vivo rabbit model.nnnSTUDY DESIGN/SETTINGnThis is a prospective in vivo animal study.nnnMETHODSnTwenty-four adult male New Zealand white rabbits were randomly divided into four groups. All groups received a single-level posterolateral, intertransverse process fusion at L5-L6 with autologous iliac crest bone. One group served as controls and only underwent the spine fusion surgery. Three groups received 5.25-, 10.5-, and 21-mg nicotine patches, respectively, for 5 weeks. Serum nicotine levels were recorded for each group. All animals were euthanized 5 weeks postoperatively, and spinal fusions were evaluated radiographically, by manual palpation, and biomechanically. Statistical analysis evaluated the dose response effect of outcomes variables and nicotine dosage. This study was supported by a portion of a

The Relationships Between Femoral Cortex Geometry and Tissue Mechanical Properties

100,000 grant from the Orthopaedic Research and Education Foundation. Author financial disclosures were completed in accordance with the journals guidelines; there were no conflicts of interests disclosed that would have led to bias in this work.nnnRESULTSnThe average serum levels of nicotine from the different patches were 7.8±1.9 ng/mL for the 5.25-mg patch group; 99.7±17.7 ng/mL for the 10.5-mg patch group; and 149.1±24.6 ng/mL for the 21-mg patch group. The doses positively correlated with serum concentrations of nicotine (correlation coefficient=0.8410, p<.001). The 5.25-mg group provided the best fusion rate, trabeculation, and stiffness. On the basis of the palpation tests, the fusion rates were control (50%), 5.25 mg (80%), 10.5 mg (50%), and 21 mg (42.8%). Radiographic assessment of trabeculation and bone incorporation and biomechanical analysis of bending stiffness ratio were also greatest in the 5.25-mg group. Radiographic evaluation showed a significant (p=.0446) quadratic effect of nicotine dose on spinal fusion.nnnCONCLUSIONSnThe effects of nicotine on spinal fusion are complex, may be dose dependent, and may not always be detrimental. The uniformly negative effects of smoking reported in patients undergoing spinal fusion may possibly be attributed to the other components of cigarette smoke.

Direct Current Stimulation for Spine Fusion in a Nicotine Exposure Model

Bone tissue and geometry are constantly modified through modeling and remodeling at the periosteal, endosteal and intracortical envelopes. Results from several studies indicate that femoral bone geometry is a predictor of whole bone strength (e.g. femoral neck strength), however, it is not known whether there is a relationship between bone structural and material properties. Bone geometry can be determined from parameters based on plane X-ray radiogrammetry which are used to evaluate femoral bone quality for implant success. If there is a relationship between these parameters and tissue mechanical properties, this would have implications in the interpretation of such parameters for assessment of fracture risk and in further understanding of bone biology. Following measurement of radiogrammetric parameters from antero-posterior and medio-lateral X-rays (cortical thickness, bone diameter, bone area, moment of inertia, cortical index, Singh index), human femurs were machined into standard test specimens for assessment of tensile fracture toughness (GIc) of the tissue. Results indicated that tensile fracture toughness generally increased with increasing bone size. We also found that fracture toughness of the tissue was significantly related to radiogrammetric indices and that some of these indices explained a greater variability in toughness than porosity, age or gender.