Trevor J. Lujan

Locked plating of distal femur fractures leads to inconsistent and asymmetric callus formation.

Objectives: Locked plating constructs may be too stiff to reliably promote secondary bone healing. This study used a novel imaging technique to quantify periosteal callus formation of distal femur fractures stabilized with locking plates. It investigated the effects of cortex-to-plate distance, bridging span, and implant material on periosteal callus formation. Design: Retrospective cohort study. Setting: One Level I and one Level II trauma center. Patients: Sixty-four consecutive patients with distal femur fractures (AO types 32A, 33A-C) stabilized with periarticular locking plates. Intervention: Osteosynthesis using indirect reduction and bridge plating with periarticular locking plates. Main Outcome Measurement: Periosteal callus size on lateral and anteroposterior radiographs. Results: Callus size varied from 0 to 650 mm2. Deficient callus (20 mm2 or less) formed in 52%, 47%, and 37% of fractures at 6, 12, and 24 weeks postsurgery, respectively. Callus formation was asymmetric, whereby the medial cortex had on average 64% more callus (P = 0.001) than the anterior or posterior cortices. A longer bridge span correlated minimally with an increased callus size at Week 6 (P = 0.02), but no correlation was found at Weeks 12 and 24 postsurgery. Compared with stainless steel plates, titanium plates had 76%, 71%, and 56% more callus at Week 6 (P = 0.04), Week 12 (P = 0.03), and Week 24 (P = 0.09), respectively. Conclusions: Stabilization of distal femur fractures with periarticular locking plates can cause inconsistent and asymmetric formation of periosteal callus. A larger bridge span only minimally improves callus formation. The more flexible titanium plates enhanced callus formation compared with stainless steel plates.

Effects of Construct Stiffness on Healing of Fractures Stabilized with Locking Plates

The benefits of locked-plate fixation, which include improved fixation strength in osteoporotic bone1-3 and the ability to provide a more biologically friendly fixation construct4,5, have led to the rapid adoption of this technology. Biological fixation of comminuted fractures with locking plates relies on secondary fracture-healing by callus formation6,7, which is stimulated by interfragmentary motion in the millimeter range8,9. Secondary bone-healing can be enhanced by active or passive dynamization10,11. Conversely, bone-healing can be suppressed by rigid fracture fixation aimed at preventing interfragmentary motion12. Biomechanical studies have suggested that locked-plate constructs are stiff and suppress interfragmentary motion to a level that may be insufficient to reliably promote secondary fracture-healing1,13-15. Recent clinical studies substantiate the concern that the inherently high stiffness of locked-plate constructs suppresses callus formation, contributing to a nonunion rate of up to 19% seen with periarticular locking plates16,17. Deficient healing may also contribute to late hardware failures seen with locking plates18-20 since, in the absence of osseous union, constructs remain load-bearing and eventually fail by hardware fatigue or loss of fixation. This paper summarizes a line of research that addresses two questions of critical importance when using locked-plate constructs: 1. Does the high stiffness of locked-plate constructs suppress callus formation and fracture-healing? 2. Can a stiffness-reduced locked-plate technique, termed far cortical locking , improve fracture-healing, compared with standard locked plating, by providing flexible fixation and parallel interfragmentary motion? First, we will present the findings of biomechanical and clinical studies of the effect of construct stiffness on interfragmentary motion and fracture-healing with locking plates. Subsequently, studies that describe the function, benefits, and clinical application of far cortical locking are …

Contribution of glycosaminoglycans to viscoelastic tensile behavior of human ligament.

The viscoelastic properties of human ligament potentially guard against structural failure, yet the microstructural origins of these transient behaviors are unknown. Glycosaminoglycans (GAGs) are widely suspected to affect ligament viscoelasticity by forming molecular bridges between neighboring collagen fibrils. This study investigated whether GAGs directly affect viscoelastic material behavior in human medial collateral ligament (MCL) by using nondestructive tensile tests before and after degradation of GAGs with chondroitinase ABC (ChABC). Control and ChABC treatment (83% GAG removal) produced similar alterations to ligament viscoelasticity. This finding was consistent at different levels of collagen fiber stretch and tissue hydration. On average, stress relaxation increased after incubation by 2.2% (control) and 2.1% (ChABC), dynamic modulus increased after incubation by 3.6% (control) and 3.8% (ChABC), and phase shift increased after incubation by 8.5% (control) and 8.4% (ChABC). The changes in viscoelastic behavior after treatment were significantly more pronounced at lower clamp-to-clamp strain levels. A 10% difference in the water content of tested specimens had minor influence on ligament viscoelastic properties. The major finding of this study is that mechanical interactions between collagen fibrils and GAGs are unrelated to tissue-level viscoelastic mechanics in mature human MCL. These findings narrow the possible number of extracellular matrix molecules that have a direct contribution to ligament viscoelasticity.

Simultaneous Measurement of Three-Dimensional Joint Kinematics and Ligament Strains With Optical Methods

The objective of this study was to assess the precision and accuracy of a nonproprietary, optical three-dimensional (3D) motion analysis system for the simultaneous measurement of soft tissue strains and joint kinematics. The system consisted of two high-resolution digital cameras and software for calculating the 3D coordinates of contrast markers. System precision was assessed by examining the variation in the coordinates of static markers over time. Three-dimensional strain measurement accuracy was assessed by moving contrast markers fixed distances in the field of view and calculating the error in predicted strain. Three-dimensional accuracy for kinematic measurements was assessed by simulating the measurements that are required for recording knee kinematics. The field of view (190 mm) was chosen to allow simultaneous recording of markers for soft tissue strain measurement and knee joint kinematics. Average system precision was between +/-0.004 mm and +/-0.035 mm, depending on marker size and camera angle. Absolute error in strain measurement varied from a minimum of +/-0.025% to a maximum of +/-0.142%, depending on the angle between cameras and the direction of strain with respect to the camera axes. Kinematic accuracy for translations was between +/-0.008 mm and +/-0.034 mm, while rotational accuracy was +/-0.082 deg to +/-0.160 deg. These results demonstrate that simultaneous optical measurement of 3D soft tissue strain and 3D joint kinematics can be performed while achieving excellent accuracy for both sets of measurements.

A Computational Technique to Measure Fracture Callus in Radiographs

Callus formation occurs in the presence of secondary bone healing and has relevance to the fractures mechanical environment. An objective image processing algorithm was developed to standardize the quantitative measurement of periosteal callus area in plain radiographs of long bone fractures. Algorithm accuracy and sensitivity were evaluated using surrogate models. For algorithm validation, callus formation on clinical radiographs was measured manually by orthopaedic surgeons and compared to non-clinicians using the algorithm. The algorithm measured the projected area of surrogate calluses with less than 5% error. However, error will increase when analyzing very small areas of callus and when using radiographs with low image resolution (i.e. 100 pixels per inch). The callus size extracted by the algorithm correlated well to the callus size outlined by the surgeons (R2=0.94, p<0.001). Furthermore, compared to clinician results, the algorithm yielded results with five times less inter-observer variance. This computational technique provides a reliable and efficient method to quantify secondary bone healing response.

Effect of ACL Deficiency on MCL Strains and Joint Kinematics

The knee joint is partially stabilized by the interaction of multiple ligament structures. This study tested the interdependent functions of the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) by evaluating the effects of ACL deficiency on local MCL strain while simultaneously measuring joint kinematics under specific loading scenarios. A structural testing machine applied anterior translation and valgus rotation (limits 100 N and 10 N m, respectively) to the tibia of ten human cadaveric knees with the ACL intact or severed. A three-dimensional motion analysis system measured joint kinematics and MCL tissue strain in 18 regions of the superficial MCL. ACL deficiency significantly increased MCL strains by 1.8% (p<0.05) during anterior translation, bringing ligament fibers to strain levels characteristic of microtrauma. In contrast, ACL transection had no effect on MCL strains during valgus rotation (increase of only 0.1%). Therefore, isolated valgus rotation in the ACL-deficient knee was nondetrimental to the MCL. The ACL was also found to promote internal tibial rotation during anterior translation, which in turn decreased strains near the femoral insertion of the MCL. These data advance the basic structure-function understanding of the MCL, and may benefit the treatment of ACL injuries by improving the knowledge of ACL function and clarifying motions that are potentially harmful to secondary stabilizers.

Motion Predicts Clinical Callus Formation: Construct-specific Finite Element Analysis of Supracondylar Femoral Fractures

BACKGROUND Mechanotransduction is theorized to influence fracture-healing, but optimal fracture-site motion is poorly defined. We hypothesized that three-dimensional (3-D) fracture-site motion as estimated by finite element (FE) analysis would influence callus formation for a clinical series of supracondylar femoral fractures treated with locking-plate fixation. METHODS Construct-specific FE modeling simulated 3-D fracture-site motion for sixty-six supracondylar femoral fractures (OTA/AO classification of 33A or 33C) treated at a single institution. Construct stiffness and directional motion through the fracture were investigated to assess the validity of construct stiffness as a surrogate measure of 3-D motion at the fracture site. Callus formation was assessed radiographically for all patients at six, twelve, and twenty-four weeks postoperatively. Univariate and multivariate linear regression analyses examined the effects of longitudinal motion, shear (transverse motion), open fracture, smoking, and diabetes on callus formation. Construct types were compared to determine whether their 3-D motion profile was associated with callus formation. RESULTS Shear disproportionately increased relative to longitudinal motion with increasing bridge span, which was not predicted by our assessment of construct stiffness alone. Callus formation was not associated with open fracture, smoking, or diabetes at six, twelve, or twenty-four weeks. However, callus formation was associated with 3-D fracture-site motion at twelve and twenty-four weeks. Longitudinal motion promoted callus formation at twelve and twenty-four weeks (p = 0.017 for both). Shear inhibited callus formation at twelve and twenty-four weeks (p = 0.017 and p = 0.022, respectively). Titanium constructs with a short bridge span demonstrated greater longitudinal motion with less shear than did the other constructs, and this was associated with greater callus formation (p < 0.001). CONCLUSIONS In this study of supracondylar femoral fractures treated with locking-plate fixation, longitudinal motion promoted callus formation, while shear inhibited callus formation. Construct stiffness was found to be a poor surrogate of fracture-site motion. Future implant design and operative fixation strategies should seek to optimize 3-D fracture-site motion rather than rely on surrogate measures such as axial stiffness.

Imaging Techniques for the Assessment of Fracture Repair

Imaging of a healing fracture provides a non-invasive and often instructive reproduction of the fracture repair progress and the healing status of bone. However, the interpretation of this reproduction is often qualitative and provides only an indirect and surrogate measure of the mechanical stability of the healing fracture. Refinements of the available imaging techniques have been suggested to more accurately determine the healing status of bone. Plain radiographs provide the ability to determine the degree of bridging of the fracture gap and to quantify the amount of periosteal callus formation. Absorptiometric measures including dual X-ray absorptiometry and computed tomography provide quantitative information on the amount and the density of newly formed bone around the site of the fracture. To include the effect of spatial distribution of newly formed bone, finite element models of healing fracture can be employed to estimate its load bearing capacity. Ultrasound technology not only avoids radiation doses to the patients but also provides the ability to additionally measure vascularity in the surrounding soft tissue of the fracture and in the fracture itself.

Aryl Hydrocarbon Receptor Activation by TCDD Modulates Expression of Extracellular Matrix Remodeling Genes During Experimental Liver Fibrosis

The aryl hydrocarbon receptor (AhR) is a soluble, ligand-activated transcription factor that mediates the toxicity of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Increasing evidence implicates the AhR in regulating extracellular matrix (ECM) homeostasis. We recently reported that TCDD increased necroinflammation and myofibroblast activation during liver injury elicited by carbon tetrachloride (CCl4). However, TCDD did not increase collagen deposition or exacerbate fibrosis in CCl4-treated mice, which raises the possibility that TCDD may enhance ECM turnover. The goal of this study was to determine how TCDD impacts ECM remodeling gene expression in the liver. Male C57BL/6 mice were treated for 8 weeks with 0.5 mL/kg CCl4, and TCDD (20 μg/kg) was administered during the last two weeks. Results indicate that TCDD increased mRNA levels of procollagen types I, III, IV, and VI and the collagen processing molecules HSP47 and lysyl oxidase. TCDD also increased gelatinase activity and mRNA levels of matrix metalloproteinase- (MMP-) 3, MMP-8, MMP-9, and MMP-13. Furthermore, TCDD modulated expression of genes in the plasminogen activator/plasmin system, which regulates MMP activation, and it also increased TIMP1 gene expression. These findings support the notion that AhR activation by TCDD dysregulates ECM remodeling gene expression and may facilitate ECM metabolism despite increased liver injury.

Tissue swelling during extended material testing of ligaments

Material testing is often used to characterize the mechanical properties of biological tissue and to understand the specific effects of treatments and pathologies on mechanical behavior. To have confidence in results from material testing, it is important that the test environment is repeatable between samples and that tests are performed in an environment that mimics physiological conditions.Copyright