Fracture stiffness measurement in tibial shaft fractures: a non-invasive method

Investigation of load transfer process between external fixator and bone model by experimental and finite element methods

INTRODUCTION:

Unilateral external fixators are widely used in orthopedics to stabilize fractured bones and to treat limb deformities. One of the main problems is that it is difficult to detect healing status. In addition, whether load transfer progress between the fixator and bone model are the same under axial, torsional, and bending loads has not been studied.

METHODS:

Therefore the main purpose of this study was to detect the load transfer process between the fixator and a bone model by measuring strains on the fixator-bone system during four healing states using experimental and finite element methods. In the experimental method, 20 strain gauges were used to measure strain on the fixator and bone model under three load conditions. Polyacetal slice models with different material properties were used to simulate the callus model during four growth states.

RESULTS:

The results indicate that strain on the bone model increased and strain on the fixator parts decreased with maturation of the callus under axial, bending, and torsional loads. Although all curves showed a similar changing trend, they were slightly different under the three loads.

DISCUSSION AND CONCLUSIONS:

This study provides a useful method to monitor the fracture healing process, and identifies the healing endpoint, detects healing status, and provides useful information for the orthopedist.

Towards a Non-Invasive Technique for Healing Assessment of Internally Fixated Femur

The lack of a quantitative method to adequately assess fractured bone healing that has undergone fixation limits prognostic capabilities on patients' optimal return to work. This paper addresses the use of vibrational analysis to monitor the state of healing of a plate-screw fixated femur and supplement the current clinical radiographic assessment. This experimental study involves an osteotomised composite femur specimen enclosed by modelling clay to simulate the damping effect of overlying soft tissues. Epoxy adhesives are applied to the fractured region and to simulate the healing process. With the instrumentation described, the cross-spectrum and coherence are obtained and analysed in the frequency domain over a period of time. The results suggest that it is crucial to analyse the cross-spectrum and proposed healing index to quantitatively assess the stages of healing. The results also show that the mass loading effect due to modelling clay did not influence the proposed healing assessment technique. The findings indicate a potential non-intrusive technique to evaluate the healing of fractured femur by utilising the vibrational responses.

A finite element analysis for monitoring the healing progression of fixator-bone system under three loading conditions

BACKGROUND

Unilateral external fixators are widely used in orthopedics to stabilize fractured bones and in the treatment of limb deformities. The main value for evaluation of mechanical stability of the external fixator is fixator stiffness. The fixator stiffness is an important factor as it will influence the biomechanical environment to which fixator and regenerating tissues are exposed.

OBJECTIVE

The main objective of this work was to monitor the transmission of stress and the change of displacement generated in fixator-bone system under three loading conditions during healing process.

METHODS

In this study, a finite element model with changing Young's modulus of the callus is established, finite element analysis was used to investigating stress and deformation of fixator-bone system caused by axial load, torsional load and bending load during three healing stages.

RESULTS

The results reveal that at different healing stages, stress distribution between the fixator and fractured bone is different, the position of displacement is mainly concentrated in the fracture site and proximal bone and with the increase of healing time, the deformation decreased.

CONCLUSIONS

This work helps orthopedic doctors to monitor the progression of fracture healing and determine the appropriate time for removal of a fixation device and provide useful information.

A theoretical analysis and finite element simulation of fixator-bone system stiffness on healing progression

INTRODUCTION

The unilateral external fixator has become a quick and easy application for fracture stabilization of the extremities; the main value for evaluation of mechanical stability of the external fixator is stiffness. The stiffness property of the external fixator affects the local biomechanical environment of fractured bone.

METHODS

In this study, a theoretical model with changing Young's modulus of the callus is established by using the Castigliano's theory, investigating compression stiffness, torsional stiffness and bending stiffness of the fixator-bone system during the healing process. The effects of pin deviation angle on three stiffness methods are also investigated. In addition, finite element simulation is discussed regarding the stress distribution between the fixator and bone.

RESULTS

The results reveal the three stiffness evaluation methods are similar for the fixator-bone system. Finite element simulation shows that with increased healing time, the transmission of the load between the fixator and bone are different. In addition, the finite element analyses verify the conclusions obtained from the theoretical model.

CONCLUSIONS

This work helps orthopedic doctors to monitor the progression of fracture healing and determine the appropriate time for removal of a fixation device and provide important theoretical methodology.

Monitoring Healing Progression and Characterizing the Mechanical Environment in Preclinical Models for Bone Tissue Engineering

The treatment of large segmental bone defects remains a significant clinical challenge. Due to limitations surrounding the use of bone grafts, tissue-engineered constructs for the repair of large bone defects could offer an alternative. Before translation of any newly developed tissue engineering (TE) approach to the clinic, efficacy of the treatment must be shown in a validated preclinical large animal model. Currently, biomechanical testing, histology, and microcomputed tomography are performed to assess the quality and quantity of the regenerated bone. However, in vivo monitoring of the progression of healing is seldom performed, which could reveal important information regarding time to restoration of mechanical function and acceleration of regeneration. Furthermore, since the mechanical environment is known to influence bone regeneration, and limb loading of the animals can poorly be controlled, characterizing activity and load history could provide the ability to explain variability in the acquired data sets and potentially outliers based on abnormal loading. Many approaches have been devised to monitor the progression of healing and characterize the mechanical environment in fracture healing studies. In this article, we review previous methods and share results of recent work of our group toward developing and implementing a comprehensive biomechanical monitoring system to study bone regeneration in preclinical TE studies.

Monitoring the mechanical properties of healing bone

Fracture healing is normally assessed through an interpretation of radiographs, clinical evaluation, including pain on weight bearing, and a manual assessment of the mobility of the fracture. These assessments are subjective and their accuracy in determining when a fracture has healed has been questioned. Viewed in mechanical terms, fracture healing represents a steady increase in strength and stiffness of a broken bone and it is only when these values are sufficiently high to support unrestricted weight bearing that a fracture can be said to be healed. Information on the rate of increase of the mechanical properties of a healing bone is therefore valuable in determining both the rate at which a fracture will heal and in helping to define an objective and measurable endpoint of healing. A number of techniques have been developed to quantify bone healing in mechanical terms and these are described and discussed in detail. Clinical studies, in which measurements of fracture stiffness have been used to identify a quantifiable end point of healing, compare different treatment methods, predictably determine whether a fracture will heal, and identify factors which most influence healing, are reviewed and discussed.

Bone stiffness in children: part II. Objectives criteria for children to assess healing during leg lengthening

BACKGROUND

The decision when to remove the frame after limb lengthening through standard distraction osteogenesis remains a challenge. Multiple studies have attempted to find objective criteria to assess bone healing after fracture or bone lengthening. However, there is a paucity of such data for the pediatric population. The purpose of this study was to correlate data obtained after dual-energy x-ray absorptiometry (DXA) measurement and bending stiffness in children to find an end-point value for the safe removal of an external fixation device.

METHODS

We investigated 16 consecutive children aged between 5.5 and 16.7 years who had 22 lengthenings by callotasis. Twelve femurs and 10 tibiae were lengthened with a monoplane Orthofix external fixator. Fifty simultaneous measurements of bending bone stiffness measured with an Orthometer and DXA scans (bone mineral content [BMC], bone mineral density, volumetric bone mineral density, BMC/1 cm, Area/1 cm, BMC/1 cm, Area) were obtained during healing process. Four femoral fractures were reported after the removal of the external fixation device. Linear regression analysis was used to calculate the squared correlation coefficients for the relation between the DXA scans and the mechanical tests measuring bone stiffness.

RESULTS

The bone stiffness measurement of the intact bone was compared with consecutive measurements of the bone stiffness of the regenerate, and it was expressed as a percentage (coefficient). We compared the BMC of the regenerate with the same bone area of the opposite limb. The best correlation was observed for anteroposterior (AP) bone stiffness coefficient and BMC coefficient (R = 0.82). The linear equation was BMC coefficient = 0.5 x AP stiffness coefficient + 30. The end point of 75% of BMC of the regenerate corresponds to 75% of the AP stiffness on DXA scanning; this is the time when we should consider safe removal of the fixator.

CONCLUSIONS

Our method of comparing bone stiffness and DXA measurements gives an objective healing end point for every patient irrespective of his or her size. This method could allow noninvasive measurement of the end point and identified at-risk population of children, reducing regenerate fracture after bone lengthening.

Bone stiffness in children: part I. In vivo assessment of the stiffness of femur and tibia in children

Although there are many publications concerning the mechanical behavior of adult bone, there are few data about mechanical properties of children's bone. In vivo bone stiffness measurement with Orthometer device has been validated and extensively used in adults to assess bone healing after fracture or lengthening. We hypothesized that in vivo stiffness measurement with Orthometer was applicable in children and was correlated with age, height, body weight, and corpulence index. The purpose was to establish baseline stiffness values for femur and tibia in growing children.Sixteen bone measurements (7 femurs and 9 tibias) were obtained during application of an external fixator for leg lengthening in 11 children aged between 5.5 and 16.7 years. A 3-point bending test with an Orthometer was carried out on the intact bone (before osteotomy) under general anesthesia. The anteroposterior stiffness measurement was successful in all children of the series, aged from 5.5 to 16.7 years. A wide variation of femoral and tibial bone stiffness values were observed. The use of a unique value as in adults as the end point of bending stiffness during bone healing process is not possible for children. The anteroposterior bone stiffness was found to have linear correlation with children's height and body weight, but not with age and corpulence indexes. The original data obtained by this study will give a stiffness reference for height and weight and could be useful as reference values for monitoring of healing process after fracture or limb lengthening.

An ultrasound wearable system for the monitoring and acceleration of fracture healing in long bones

An ultrasound wearable system for remote monitoring and acceleration of the healing process in fractured long bones is presented. The so-called USBone system consists of a pair of ultrasound transducers, implanted into the fracture region, a wearable device and a centralized unit. The wearable device is responsible to carry out ultrasound measurements using the axial-transmission technique and initiate therapy sessions of low-intensity pulsed ultrasound. The acquired measurements and other data are wirelessly transferred from the patient-site to the centralized unit, which is located in a clinical setting. The evaluation of the system on an animal tibial osteotomy model is also presented. A dataset was constructed for monitoring purposes consisting of serial ultrasound measurements, follow-up radiographs, quantitative computed tomography-based densitometry and biomechanical data. The animal study demonstrated the ability of the system to collect ultrasound measurements in an effective and reliable fashion and participating orthopaedic surgeons accepted the system for future clinical application. Analysis of the acquired measurements showed that the pattern of evolution of the ultrasound velocity through healing bones over the postoperative period monitors a dynamic healing process. Furthermore, the ultrasound velocity of radiographically healed bones returns to 80% of the intact bone value, whereas the correlation coefficient of the velocity with the material and mechanical properties of the healing bone ranges from 0.699 to 0.814. The USBone system constitutes the first telemedicine system for the out-hospital management of patients sustained open fractures and treated with external fixation devices.

Stiffness, strength and healing assessment in different bone fractures--a simple mathematical model

External fixators can only be removed safely when fractures have healed sufficiently to restore mechanical integrity to the bone. A bending stiffness of 15 N m/ degrees has been suggested as a means of estimating mechanical integrity. To examine whether this end point stiffness value can be applied to all fractures, the present study examined the degree of variability in predicted stiffness and strength that arises from variations in bone dimensions. Results imply that there is no common value for the end-point of bending stiffness in different bones. At an end point value of 15 N m/degrees, the maturity of the fracture repair tissue (represented by its elastic modulus) can vary 500-fold between an adult femur with a 0.5-mm gap to a child's mid diaphyseal tibia with a 1.0-mm gap. Fortunately, the strength does not vary by as large an extent as the modulus. However, even though two fractures each have reached a stiffness of 15 N m/degrees, a fracture in a bone of 50 mm diameter may exhibit only 60% of the strength of repair in a bone of 30 mm diameter. Therefore, caution should be exercised when using the bending stiffness as an end point indicator for different bones.