Influence of the frequency of the external mechanical stimulus on bone healing: A computational study

Simulation study on parameter dependence of dynamic osteocyte response under low-magnitude high-frequency vibration

The dynamic response mechanism of osteocytes to whole-body low-amplitude high-frequency vibration (LMHFV) is investigated using numerical simulation. In this study, a finite element model of a single bone lacuna-osteocyte incorporating the cytoskeleton was established. The vibration parameter dependence characteristics (acceleration amplitude (a), frequency (f)) of the dynamic osteocyte response under LMHFV were simulated. The results demonstrate that the alternating positive and negative liquid pressure acted on the osteocyte under LMHFV protocols (0.01 g-0.05 g, 30 Hz) (g=gravitational acceleration, 1 g = 9.8 m/s2) and the fluid shear stress increase with the acceleration amplitude. Additionally, the absolute values of positive and negative liquid pressure are relatively higher in the parameters range (0.026 g-0.038 g, 30 Hz). The von Mises stress extreme value of the microtubules presents a non-linear variation with increasing vibration parameters. Moreover, cytoskeletons can generate higher stress under vibration protocols (0.02 g-0.03 g, 30-45 Hz), thus facilitating the transmission of mechanical signals while satisfying the mechanical strength conditions compared to other reasonable vibration parameter range (0.01 g-0.05 g, 30-45 Hz). In summary, LMHFV with appropriate parameters can improve the mechanical microenvironment of osteocytes and enhance cell bioactivity to some extent.

Significance of mechanical loading in bone fracture healing, bone regeneration, and vascularization

In 1892, J.L. Wolff proposed that bone could respond to mechanical and biophysical stimuli as a dynamic organ. This theory presents a unique opportunity for investigations on bone and its potential to aid in tissue repair. Routine activities such as exercise or machinery application can exert mechanical loads on bone. Previous research has demonstrated that mechanical loading can affect the differentiation and development of mesenchymal tissue. However, the extent to which mechanical stimulation can help repair or generate bone tissue and the related mechanisms remain unclear. Four key cell types in bone tissue, including osteoblasts, osteoclasts, bone lining cells, and osteocytes, play critical roles in responding to mechanical stimuli, while other cell lineages such as myocytes, platelets, fibroblasts, endothelial cells, and chondrocytes also exhibit mechanosensitivity. Mechanical loading can regulate the biological functions of bone tissue through the mechanosensor of bone cells intraosseously, making it a potential target for fracture healing and bone regeneration. This review aims to clarify these issues and explain bone remodeling, structure dynamics, and mechano-transduction processes in response to mechanical loading. Loading of different magnitudes, frequencies, and types, such as dynamic versus static loads, are analyzed to determine the effects of mechanical stimulation on bone tissue structure and cellular function. Finally, the importance of vascularization in nutrient supply for bone healing and regeneration was further discussed.

Influence of therapeutic grip exercises induced loading rates in distal radius fracture healing with volar locking plate fixation

BACKGROUND AND OBJECTIVE

Therapeutic exercises could potentially enhance the healing of distal radius fractures (DRFs) treated with volar locking plate (VLP). However, the healing outcomes are highly dependant on the patient-specific fracture geometries (e.g., gap size) and the loading conditions at the fracture site (e.g., loading frequency) resulted from different types of therapeutic exercises. The purpose of this study is to investigate the effects of different loading frequencies induced by therapeutic exercises on the biomechanical microenvironment of the fracture site and the transport of cells and growth factors within the fracture callus, ultimately the healing outcomes. This is achieved through numerical modelling and mechanical testing.

METHODS

Five radius sawbones specimens (Pacific Research Laboratories, Vashon, USA) fixed with VLP (VRP2.0+, Austofix) were mechanically tested using dynamic test instrument (INSTRON E3000, Norwood, MA). The loading protocol used in mechanical testing involved a series of cyclic axial compression tests representing hand and finger therapeutic exercises. The relationship between the dynamic loading rate (i.e., loading frequency) and dynamic stiffness of the construct was established and used as inputs to a developed numerical model for studying the dynamic loading induced cells and growth factors in fracture site and biomechanical stimuli required for healing.

RESULTS

There is a strong positive linear relationship between the loading rate and axial stiffness of the construct fixed with VLP. The loading rates induced by the moderate frequencies (i.e., 1-2 Hz) could promote endochondral ossification, whereas relatively high loading frequencies (i.e., over 3 Hz) may hinder the healing outcomes or lead to non-union. In addition, a dynamic loading frequency of 2 Hz in combination of a fracture gap size of 3 mm could produce a better healing outcome by enhancing the transport of cells and growth factors at the fracture site in comparison to free diffusion (i.e. without loading), and thereby produces a biomechanical microenvironment which is favourable for healing.

CONCLUSION

The experimentally validated numerical model presented in this study could potentially contribute to the design of effective patient-specific therapeutic exercises for better healing outcomes. Importantly, the model results demonstrate that therapeutic grip exercises induced dynamic loading could produce a better biomechanical microenvironment for healing without compromising the mechanical stability of the overall volar locking plate fixation construct.

The investigation of bone fracture healing under intramembranous and endochondral ossification

After trauma, fractured bone starts healing directly through bone union or indirectly through callus formation process. Intramembranous and endochondral ossification are two commonly known mechanisms of indirect healing. The present study investigated the bone fracture healing under intramembranous and endochondral ossification by developing theoretical models in conjunction with performing a series of animal experiments. Using experimentally determined mean bone densities in sheep tibia stabilized by the Locking Compression Plate (LCP) fixation system, the research outcomes showed that intramembranous and endochondral ossification can be described by Hill Function with two unique sets of function parameters in mechanical stimuli mediated fracture healing. Two different thresholds exist within the range of mechanical simulation index which could trigger significant intramembranous and endochondral ossification, with a relatively higher bone formation rate of endochondral ossification than that of intramembranous ossification. Furthermore, the increase of flexibility of the LCP system and the use of titanium LCP could potentially promote uniform bone formation across the fracture gap, ultimately better healing outcomes.

In silico dynamic characterization of the femur: Physiological versus mechanical boundary conditions

It is established that bone tissue adapts and responds to mechanical loading. Several studies have suggested an existence of positive influence of vibration on the bone mass maintenance. Thus, some bone regeneration therapies are based on vibration of bone tissue under circumstances of disease to stimulate its formation. Frequency of loading should be properly selected and therefore a correct characterization of the dynamic properties of this tissue may be critical for the success of such orthopedic techniques. On the other hand, many studies implement vibration techniques with in silico models. Numerical results are exclusively dependent on properties of bone tissue, i.e. geometry, density distribution and stiffness, as well as boundary conditions. In the present study, the influence of boundary conditions and material properties on the dynamic characteristics of bone tissue was explored in a human femur. Bone shape and density were directly reconstructed from computer tomographies, whereas natural frequencies and modes of vibration were obtained for different boundary conditions including physiological and mechanical ones. Results of this study show the moderate effect of material properties compared to the much substantial effect of boundary conditions. A factor of 2 in the natural frequency was obtained depending on imposed boundary conditions, highlighting the importance in the selection of appropriate conditions in the analysis of the bone organ.

Matrix architecture plays a pivotal role in 3D osteoblast migration: The effect of interstitial fluid flow

Osteoblast migration is a crucial process in bone regeneration, which is strongly regulated by interstitial fluid flow. However, the exact role that such flow exerts on osteoblast migration is still unclear. To deepen the understanding of this phenomenon, we cultured human osteoblasts on 3D microfluidic devices under different fluid flow regimes. Our results show that a slow fluid flow rate by itself is not able to alter the 3D migratory patterns of osteoblasts in collagen-based gels but that at higher fluid flow rates (increased flow velocity) may indirectly influence cell movement by altering the collagen microstructure. In fact, we observed that high fluid flow rates (1 µl/min) are able to alter the collagen matrix architecture and to indirectly modulate the migration pattern. However, when these collagen scaffolds were crosslinked with a chemical crosslinker, specifically, transglutaminase II, we did not find significant alterations in the scaffold architecture or in osteoblast movement. Therefore, our data suggest that high interstitial fluid flow rates can regulate osteoblast migration by means of modifying the orientation of collagen fibers. Together, these results highlight the crucial role of the matrix architecture in 3D osteoblast migration. In addition, we show that interstitial fluid flow in conjunction with the matrix architecture regulates the osteoblast morphology in 3D.

Clinical analysis of the rap stress stimulator applied for crus fracture after skeletal external fixation

INTRODUCTION

Open crus fracture is still difficult in clinical treatment because of the delayed fracture union and high rate of nonunion after the operation. A consensus has been reached that mechanical stress can promote fracture healing. We independently developed a stress stimulator, which can provide longitudinal pressure for the fixed fracture end of the lower legs to promote fracture healing. The purpose of this study is to explore the advantages and clinical effect of the rap stress stimulator applied for open crus fracture after skeletal external fixation.

MATERIAL AND METHODS

One hundred and sixty-five patients (183 limbs) who suffered from open tibia and fibula fracture received skeletal external fixation, of which 108 limbs were treated with the rap stress stimulator after external fixation and 75 limbs were treated with regular functional exercises of muscle contraction and joint activity only. Then the fracture healing time and rate of nonunion were compared between the two groups.

RESULTS

The mean fracture healing time and rate of nonunion in the group treated with the rap stress stimulator were 138.27 ±4.45 days and 3.70% respectively, compared to 153.43 ±4.89 days and 10.67% in the group treated without the stimulator.

CONCLUSIONS

The rap stress stimulator significantly shortened the fracture healing time and reduced the rate of nonunion for treating open tibia and fibula fractures.

Programmable mechanobioreactor for exploration of the effects of periodic vibratory stimulus on mesenchymal stem cell differentiation

A programmable bioreactor using a voice-coil actuator was developed to enable research on the effects of periodic vibratory stimulus on human and porcine mesenchymal stem cells (MSCs). We hypothesized that low frequency vibrations would result in a cartilage phenotype and higher frequency vibrations would result in a bone phenotype. The mechanical stimulation protocol is adjusted from a computer external to the incubator via a USB cable. Once programmed, the embedded microprocessor and sensor system on the bioreactor execute the protocol independent of the computer. In each test, a sinusoidal stimulus was applied to a culture plate in 1-min intervals with a 15-min rest following each, for a total of 15 h per day for 10 days. Frequencies of 1 and 100 Hz were applied to cultures of both human and porcine umbilical cord–derived MSCs. Chondrogenesis was determined by Alcian blue staining for glycosaminoglycans and an increased differentiation index (ratio of mRNA for collagen II and collagen I). Osteogenic differentiation was indicated with Alizarin red for calcium staining and increased bone morphogenetic protein 2 mRNA. One-hertz stimulation resulted in a cartilage phenotype for both human and porcine MSCs, while 100-Hz stimulation resulted in a bone phenotype.

Cyclic mechanical loading enables solute transport and oxygen supply in bone healing: an in vitro investigation

Bone healing is a complex process with an increased metabolic activity and consequently high demand for oxygen. In the hematoma phase, inflammatory cells and mesenchymal stromal cells (MSCs) are initially cut off from direct nutritional supply via blood vessels. Cyclic mechanical loading that occurs, for example, during walking is expected to have an impact on the biophysical environment of the cells but meaningful quantitative experimental data are still missing. In this study, the hypothesis that cyclic mechanical loading within a physiological range significantly contributes to oxygen transport into the fracture hematoma was investigated by an in vitro approach. MSCs were embedded in a fibrin matrix to mimic the hematoma phase during bone healing. Construct geometry, culture conditions, and parameters of mechanical loading in a bioreactor system were chosen to resemble the in vivo situation based on data from human studies and a well-characterized large animal model. Oxygen tension was measured before and after mechanical loading intervals by a chemical optical microsensor. The increase in oxygen tension at the center of the constructs was significant and depended on loading time with maximal values of 9.9%±5.1%, 14.8%±4.9%, and 25.3%±7.2% of normal atmospheric oxygen tension for 5, 15, and 30 min of cyclic loading respectively. Histological staining of hypoxic cells after 48 h of incubation confirmed sensor measurements by showing an increased number of normoxic cells with intermittent cyclic compression compared with unloaded controls. The present study demonstrates that moderate cyclic mechanical loading leads to an increased oxygen transport and thus to substantially enhanced supply conditions for cells entrapped in the hematoma. This link between mechanical conditions and nutrition supply in the early regenerative phases could be employed to improve the environmental conditions for cell metabolism and consequently prevent necrosis.

Manual khalifa therapy in patients with completely ruptured anterior cruciate ligament in the knee: first results from near-infrared spectroscopy

BACKGROUND

Manual Khalifa therapy has been practiced in Hallein, Austria, for more than 30 years; however, there are no scientific results available on the topic.

AIMS

The goal of the present study was to investigate possible acute effects of Khalifa therapy on regional oxygen saturation of knee tissues in patients with completely ruptured anterior cruciate ligament.

MATERIALS AND METHODS

We investigated 10 male patients (mean age ± standard deviation (SD) 35.9 ± 6.1 year) using a four-channel oximeter. The sensors were applied anterolaterally and anteromedially, beside the patella, on both the injured and the healthy (control) knee.

RESULTS

The results of the controlled study showed that values of oxygen saturation on the knee with the ruptured ligament were significantly increased (P < 0.001) immediately after Khalifa therapy, whereas the values on the control knee showed insignificant increases. Baselines values of the anterolateral side of the injured knee were significantly (P < 0.001) different from those of the anterolateral side of the control knee. The same effect was present on the anteromedial side; however, with a lower degree of significance (P < 0.05).

CONCLUSIONS

Khalifa therapy was clinically successful in all 10 patients. Further, investigations and analyzes are necessary to explain the underlying mechanism.

A finite element analysis of the vibration behaviour of a cementless hip system

An early diagnosis of aseptic loosening of a total hip replacement (THR) by plain radiography, scintigraphy or arthography has been shown to be less reliable than using a vibration technique. However, it has been suggested that it may be possible to distinguish between a secure and a loose prosthesis using a vibration technique. In fact, vibration analysis methods have been successfully used to assess dental implant stability, to monitor fracture healing and to measure bone mechanical properties. Several studies have combined the vibration technique with the finite element (FE) method in order to better understand the events involved in the experimental technique. In the present study, the main goal is to simulate the change in the resonance frequency during the osseointegration process of a cementless THR (Zweymüller). The FE method was used and a numerical modal analysis was conducted to obtain the natural frequencies and mode shapes under vibration. The effects were studied of different bone and stem material properties, and different contact conditions at the bone-implant interface. The results were in agreement with previous experimental and computational observations, and differences among the different cases studied were detected. As the osseointegration process at the bone-implant interface evolved, the resonance frequency values of the femur-prosthesis system also increased. In summary, vibration analysis combined with the FE method was able to detect different boundary conditions at the bone-implant interface in cases of both osseointegration and loosening.

Influence of high-frequency cyclical stimulation on the bone fracture-healing process: mathematical and experimental models

Mechanical stimulation affects the evolution of healthy and fractured bone. However, the effect of applying cyclical mechanical stimuli on bone healing has not yet been fully clarified. The aim of the present study was to determine the influence of a high-frequency and low-magnitude cyclical displacement of the fractured fragments on the bone-healing process. This subject is studied experimentally and computationally for a sheep long bone. On the one hand, the mathematical computational study indicates that mechanical stimulation at high frequencies can stimulate and accelerate the process of chondrogenesis and endochondral ossification and consequently the bony union of the fracture. This is probably achieved by the interstitial fluid flow, which can move nutrients and waste from one place to another in the callus. This movement of fluid modifies the mechanical stimulus on the cells attached to the extracellular matrix. On the other hand, the experimental study was carried out using two sheep groups. In the first group, static fixators were implanted, while, in the second one, identical devices were used, but with an additional vibrator. This vibrator allowed a cyclic displacement with low magnitude and high frequency (LMHF) to be applied to the fractured zone every day; the frequency of stimulation was chosen from mechano-biological model predictions. Analysing the results obtained for the control and stimulated groups, we observed improvements in the bone-healing process in the stimulated group. Therefore, in this study, we show the potential of computer mechano-biological models to guide and define better mechanical conditions for experiments in order to improve bone fracture healing. In fact, both experimental and computational studies indicated improvements in the healing process in the LMHF mechanically stimulated fractures. In both studies, these improvements could be associated with the promotion of endochondral ossification and an increase in the rate of cell proliferation and tissue synthesis.