Mechanical properties of compacted morselized cancellous bone graft using one-dimensional consolidation testing

[Influence of thermodisinfection on impaction of cancellous bone : An in vitro model of femoral impaction bone grafting]

BACKGROUND

The reconstruction of bony defects during endoprosthesis revision surgery using "impaction bone grafting" leads to the possibility of a longstanding osseous integration to achieve good clinical results. Native allogeneic cancellous bone is often used for the procedure. This study examines the influence of thermodisinfection on the impaction behaviour of cancellous bone of different geometries and on the cement distribution.

METHODS

The cancellous bone was obtained from the femoral heads of 7‑month old pigs. One half of the head was thermodisinfected while the other remained native. Bone chips with sizes of 3-5, 5-8 and 8-10 mm were produced. The impaction was performed in a cylinder model with an internal diameter of 30 mm and with standardized impaction force using an impactor with a weight of 1450 g. The best particle combination was used for the subsequent computer tomography examination of the cement distribution and the contact surface to the bone in different parts of the shaft in seven investigations. For statistic measurements two-dimensional variance analysis including repetitions of measurement and Bonferroni correction, the LSD post-hoc-zest and the Mann Whitney U Test were used. The error probability was set at α = 5%. The SPSS® for Windows software was used for the statistical analysis.

RESULTS

The distribution of the cancellous and compacted bone also along the shaft revealed no significant difference between thermodisinfected and native cancellous bone at different levels (p > 0.05). Impacted native cancellous bone showed less inclusion of air, which resulted in a better distribution of density compared with thermodisinfected bone overall (p < 0.001). In the distal shaft area the cement volume was significantly larger in conjunction with the native bone. The overall area of cement penetration appeared to be significantly larger for native cancellous bone (p < 0.001).

CONCLUSIONS

The impaction of thermodisinfected and native cancellous bone showed greater deformation of the processed bone without any significant difference in the maximum density reached at different levels. Cement volume and cement penetration were pronounced proximally in native and processed cancellous bone. The cement distribution was significantly more distal for the native bone. Distally, the stabilization of the shaft appears to be increasingly dependent on the density of the impacted spongiosa, while proximally, the penetration of the cement into cancellous bone seems to correlate with porosity.

Acetabular reinforcement ring with additional hook improves stability in three-dimensional finite element analyses of dysplastic hip arthroplasty

Background

The stability of acetabulum reconstructions using reinforcement rings and hooks is important for successful replacement surgery. The objective of this study was to biomechanically determine the effects of the hook on stress and the related micromotions of the acetabular reinforcement ring during the immediate postoperative period.

Methods

Acetabular reinforcement ring models were developed using a nonlinear, three-dimensional, finite element method. Using a pre-prepared template, we constructed without-hook and bone graft models of varying volumes and material properties.

Results

The stress on the inferior margin of the acetabulum was higher in the with-hook model than in the without-hook model, especially with increased bone graft volumes, and the stiffness of the bone graft material was decreased. Relative micromotions in the without-hook model were higher than in the with-hook models. The highest relative micromotion was observed in the model with increased bone graft volume and lower stiffness of bone graft material.

Conclusions

In biomechanical analyses, the hook effectively dispersed stress and improved the initial fixation strength of the acetabular reinforcement ring.

Finite element analysis of the tibial bone graft in cementless total knee arthroplasty

Background

Achieving stability of the tibial implant is essential following cementless total knee arthroplasty with bone grafting. We investigated the effects of bone grafting on the relative micromotion of the tibial implant and stress between the tibial implant and adjacent bone in the immediate postoperative period.

Methods

Tibial implant models were developed using a nonlinear, three-dimensional, finite element method. On the basis of a preprepared template, several bone graft models of varying sizes and material properties were prepared.

Results

Micromotion was larger in the bone graft models than in the intact model. Maximum micromotion and excessive stress in the area adjacent to the bone graft were observed for the soft and large graft models. With hard bone grafting, increased load transfer and decreased micromotion were observed.

Conclusions

Avoidance of large soft bone grafts and use of hard bone grafting effectively reduced micromotion and undue stress in the adjacent area.

Preparation of morselised bone for impaction grafting using a blender method

Impaction bone grafting is a method of restoring bone stock to patients suffering significant bone loss due to revision total hip surgery. The procedure requires morselised bone (MB) to be impacted into the site of bone loss in order to stabilise the prosthesis with the aim of the long term resorption and reintegration of the impacted bone graft. Currently, the method for producing MB requires the use of expensive surgical bone mills or manually-intensive rongeurs that can produce a limited variety of particle sizes and may have a low throughput. This study examines the potential to produce suitable MB using a domestic blender. The method produces a wide range of particle sizes without the need for an adjustment of the system. It was found through packing modelling that this particle distribution resulted in reduced initial graft porosity and thus a theoretical potential to increase the graft stiffness and ability of the graft to stabilise a prosthesis in comparison to a manually prepared roughly cut morselised bone samples. Mechanical testing confirmed the increased mechanical performance of the graft through both impaction testing and subsidence testing. The blended MB was found to exhibit greater graft stiffness under the same impaction conditions. The graft was also found to have subsided less in comparison to the rough cut, less well graded MB. Scanning electron imaging also confirmed the retention of the trabecular structure necessary for revascularisation and host bone ingrowth. In conclusion, the blender method offers a rapid and cheap way of obtaining morselised bone with favourable particle size distribution, particle morphology and mechanical properties with preservation of the bone trabecular structure.

The use of hardened bone cement as an impaction grafting extender for revision hip arthroplasty

Impaction bone grafting is a method of restoring bone stock to patients who have suffered significant bone loss due to revision total hip surgery. The procedure requires morsellised cancellous bone (MCB) to be impacted into the site of bone loss in order to stabilise the prosthesis with the aim of long term resorption and reintegration of the impacted bone graft. Due to financial cost and the potential to transmit disease, the use of supplementary material, known as an extender, is frequently used to increase the graft material volume. This study investigates the use of hardened Hydroset (Stryker Corp, MA, USA), an injectable bone cement (IBC), as an extender material and compares the performance of the IBC in different weight percent inclusions to a commercially available bone graft extender (GCP, BoneSave, Stryker Corp, MA, USA). The surgical impaction procedure was standardised and samples were evaluated in terms of graft stiffness and height. It was observed that 30wt% IBC extended samples had significantly improved graft stiffness (p = 0.02) and no significant different in height (p = 0.067) over a 100% MCB control sample. Cyclic loading, representative of gait, found that the IBC subsided similarly to the commercial bone substitute in wt% above 10%. Shear testing of the impacted grafts showed no significant differences between GCP and IBC with impaction forces determining the shear parameters of impacted grafts. The effects of the impaction and cyclical loading procedures on extender particle sizes was assessed via particle size analysis. It was found that the IBC extended samples demonstrated reduced friability, evident in the better retention of particle size as a result of both impaction and gait representative loading compared to that of the GCP samples. This indicates a potential reduction in issues arising from small particle migration to joint surfaces. Scanning electron microscopy of the MCB particles with both GCP and IBC as extenders showed retention of the porous trabecular structure post-testing which is essential for revascularisation and bone growth into the graft.

Effect of thermodisinfection on mechanic parameters of cancellous bone

Revision surgery of joint replacements is increasing and raises the demand for allograft bone since restoration of bone stock is crucial for longevity of implants. Proceedings of bone grafts influence the biological and mechanic properties differently. This study examines the effect of thermodisinfection on mechanic properties of cancellous bone. Bone cylinders from both femoral heads with length 45 mm were taken from twenty-three 6-8 months-old piglets, thermodisinfected at 82.5 °C according to bone bank guidelines and control remained native. The specimens were stored at -20 °C immediately and were put into 21 °C Ringer's solution for 3 h before testing. Shear and pressure modulus were tested since three point bending force was examined until destruction. Statistical analysis was done with non-parametric Wilcoxon, t test and SPSS since p < 0.05 was significant. Shear modulus was significantly reduced by thermodisinfection to 1.02 ± 0.31 GPa from 1.28 ± 0.68 GPa for unprocessed cancellous bone (p = 0.029) since thermodisinfection reduced pressure modulus not significantly from 6.30 ± 4.72 GPa for native specimens to 4.97 ± 2.23 GPa and maximum bending force was 270.03 ± 116.68 N for native and 228.80 ± 70.49 N for thermodisinfected cancellous bone. Shear and pressure modulus were reduced by thermodisinfection around 20 % and maximum bending force was impaired by about 15 % compared with native cancellous bone since only the reduction of shear modulus reached significance. The results suggest that thermodisinfection similarly affects different mechanic properties of cancellous bone and the reduction of mechanic properties should not relevantly impair clinical use of thermodisinfected cancellous bone.

The mechanical stability of allografts after a cleaning process: comparison of two preparation modes

In revision hip arthroplasty, bone loss can be compensated by impacting allograft material. Cleaning processes reduce the risk of bacterial and viral contamination. Cleaned allograft material was compared to native untreated allografts by using a uniaxial compression test. 30 measurements were performed for each group before and after compaction. Grain size distribution and weight loss were determined. A reduction in the amount of large bone fragments and a higher compaction rate were observed in the cleaned bone grafts. The cleaned bone chips presented with a better mechanical resistance to a compression force and a reduced flowability. The benefit of a cleaner and a mechanical stable graft material comes with the drawback that higher initial amounts of graft material are needed.

Mechanical properties of morcellised bone graft with the addition of hydroxyapatite

Mixtures of morcellised bone graft (MBG) and hydroxyapatite (HA) are frequently used in revision arthroplasty surgery. However, the changes in the mechanical properties from adding HA to MBG are unknown. This study used a uniaxial compression test to replicate impaction bone grafting and subsequent early postoperative weightbearing to investigate the effect of adding different proportion of HA to MBG. To achieve this aim, human MBG was subjected to increasing impaction forces and the apparent stiffness and creep for each stress level determined. Subsequently, increasing proportions porous and non porous HA were added to the MBG. The major findings were that the apparent stiffness for MBG increased and the associated creep decreased both with the application of increasing stress and with the addition of increasing proportions of HA. In conclusion, greater proportions of HA in the graft mixture improved the mechanical response compared with MBG impacted under the same force. This improvement replicated the properties of pure MBG under high axial stress. This study indicates that graft mixtures of MBG and HA can be tailormade for patients. The need for less impaction force in MBG:HA mixtures to obtain the same properties as pure MBG may decrease the risk of intraoperative fracture.

Effect of acetabular reinforcement ring with hook for acetabular dysplasia clarified by three-dimensional finite element analysis

The objective of this study was to biomechanically determine the effect of the severity of acetabular dysplasia, number and positions of screws and type of bone graft material used on the initial fixation strength of the acetabular reinforcement ring with hook (Ganz ring) using the finite element method. Relative micromotion increased as the severity of acetabular dysplasia increased and tended to decrease as the number of screws increased, but varied according to screw placement position. Increased strength of the bone graft material led to decreased relative micromotion. Biomechanically, the Ganz ring can be placed securely using 3 screws in patients with Crowe 1 dysplasia. However, in patients with Crowe 2 or higher dysplasia, it is necessary to spread at least 4 screws across an area of good host bone.

Morsellised sawbones is an acceptable experimental substitute for the in vitro elastic and viscoelastic mechanical characterisation of morsellised cancellous bone undergoing impaction grafting

Impaction grafting using morsellised bone chips is widely used during surgery to mitigate the effects of bone loss. The technique typically involves the packing of morsellised allograft cancellous bone into bone defects, and has found extensive application in revision hip and knee surgery. In the ideal situation, the presence of the bone graft prevents subsidence of the revised prosthesis in the short term, and integrates with the host bone in the longer term. However, the configuration of particles within the graft remains to be optimised, and is highly likely to vary across potential sites and loading conditions. Human bone, for use in experimental investigation, is often difficult to obtain with properties that are relevant from a clinical point of view. This study, therefore, has explored the mechanical response of a Sawbones based experimental substitute. An established confined compression technique was used to characterise the morsellised Sawbones material. Comparison of the results with published values for bovine and human bone indicate that the mechanical response of the morsellised Sawbones material map well onto the elastic and viscoelastic response of bone of a biological origin.

Optimizing the fat and water content of impaction bone allograft

Fresh morselized impacted bone graft usually fails due to shear forces. The presence of fat, water, and marrow particles act as interparticle lubricants, reducing the interlocking of particles and allowing the graft to move more freely. Furthermore, the presence of this incompressible fluid damps and resists compressive forces during impaction, preventing the graft particles from moving into a closer formation. We believe there exists an ideal concentration of fat and water that will maximize resistance to shear forces. We performed mechanical shear testing in vitro on morselized human femoral heads, varying the amount of fat and water to determine their optimum concentrations. Level of fat and water were determined that increased strength by 36% over unaltered bone graft. This is most closely approximated in an operating room by washing and subsequently squeezing the bone graft. Optimizing the fat and water content of bone graft produces a stronger graft that is more resistant to shear stresses, protecting the surgical construct until bone growth can occur.

The effect of the addition of hydroxyapatite graft substitutes upon the hoop strain and subsequent subsidence of a femoral model during impaction bone grafting

Impaction bone grafting using morcellised allograft can successfully restore bone stock in revision surgery. However, concerns exist regarding supply of bone and transmission of infection. Bone-graft extenders, such as tricalcium phosphate (TCP) and hydroxyapatite (HA), are used to minimise the use of donor bone. However, concerns exist around a reported increased risk of femoral fracture during impaction bone grafting with a 1:1 mixture of TCP/HA and morcellised bone graft (MBG) during impaction grafting in human cadaveric femora. Using a sawbones model, it was evaluated whether there was increased femoral cortical strain with a HA:MBG mixture during impaction grafting compared to MBG impacted at the same and a greater force. Subsequently the subsidence behaviour of the different graft mixes was compared by using a loaded femoral stem in an endurance test. It was demonstrated that the femora with the MBG:HA graft had greater cortical hoop stresses but improved subsidence behaviour compared to a graft composed of pure MBG impacted at the same force.

Impaction grafting of the acetabulum with a mixture of frozen, ground irradiated bone graft and porous synthetic bone substitute (Apapore 60)

The clinical and radiological results of 50 consecutive acetabular reconstructions in 48 patients using impaction grafting have been retrospectively reviewed. A 1:1 mixture of frozen, ground irradiated bone graft and Apapore 60, a synthetic bone graft substitute, was used in all cases. There were 13 complex primary and 37 revision procedures with a mean follow-up of five years (3.4 to 7.6). The clinical survival rate was 100%, with improvements in the mean Harris Hip Scores for pain and function. Radiologically, 30 acetabular grafts showed evidence of incorporation, ten had radiolucent lines and two acetabular components migrated initially before stabilising.

Acetabular reconstruction in both primary and revision surgery using a 1:1 mixture of frozen, ground, irriadiated bone and Apapore 60 appears to be a reliable method of managing acetabular defects. Longer follow-up will be required to establish whether this technique is as effective as using fresh-frozen allograft.

The consolidation behavior of silk hydrogels

Hydrogels have mechanical properties and structural features that are similar to load-bearing soft tissues including intervertebral disc and articular cartilage, and can be implanted for tissue restoration or for local release of therapeutic factors. To help predict their performance, mechanical characterization and mathematical modeling are the available methods for use in tissue engineering and drug delivery settings. In this study, confined compression creep tests were performed on silk hydrogels, over a range of concentrations, to examine the phenomenological behavior of the gels under a physiological loading scenario. Based on the observed behavior, we show that the time-dependent response can be explained by a consolidation mechanism, and modeled using Biot's poroelasticity theory. Two observations are in strong support of this modeling framework, namely, the excellent numerical agreement between increasing load step creep data and the linear Terzaghi theory, and the similar values obtained from numerical simulations and direct measurements of the permeability coefficient. The higher concentration gels (8% and 12% w/v) clearly show a strain-stiffening response to creep loading with increasing loads, while the lower concentration gel (4% w/v) does not. A nonlinear elastic constitutive formulation is employed to account for the stiffening. Furthermore, an empirical formulation is used to represent the deformation-dependent permeability.

Constitutive models for constrained compression of unimpacted and impacted human morselized bone grafts

Morselized corticocancellous bone (MCB) is widely used in revision surgery with and without impaction. In the current study material parameters for the nonlinear viscoelastic and plastic responses of impacted and unimpacted human MCBs were determined during constrained compression. These models may be useful in finite element analyses of surgical constructs involving impacted and unimpacted MCBs. MCB is impacted layer by layer in the femoral canal during revision surgery. The influence of different layers on the mechanical properties was therefore also examined by comparing the relaxation strength and elastic and plastic strains for bone pellets impacted in one and two layers during constrained compression of human MCB. The relaxation strength was found to increase significantly by 14% for two layer pellets compared to one layer pellets, and the plastic strains decreased significantly by 15%, while the elastic strains were similar.

Impaction grafting for femoral component revision in a goat model using washed morselized cancellous allograft

To determine whether washing morselized cancellous bone allograft in impaction grafting for revision hip arthroplasty would improve mechanical and biologic performance, left hip hemiarthroplasty with a collarless stem cemented into impacted morselized cancellous bone was performed in 22 goats. Washed allograft was used in the experimental group, and standard allograft was used in the control group. One of 11 experimental and 4 of 11 control implants were observed to be loose at 8 weeks. Washing allowed significantly more morselized cancellous bone to be placed in the experimental group compared to the control group (7.7+/-1.9 and 6.2+/-2.0 g, respectively, P<.05). Significantly less in vivo subsidence over the 8-week study period also was demonstrated in the experimental group compared to the control group (0.4+/-0.4 and 2.2+/-2.3 mm, respectively, P<.05). Angular motion during cyclic +/-1.5 Nm loading demonstrated significant differences between the 2 groups at time zero (2.67 degrees +/-1.02 degrees for the control group and 1.98 degrees +/-0.47 degrees for the experimental group, P<.05) and at 8 weeks (2.40 degrees +/-0.38 degrees for the control group and 1.74 degrees +/-0.55 degrees for the experimental group, P<.05). Histology showed little difference between the 2 groups, but there was a trend toward less inflammation in the experimental group.

Pressure during compaction of morsellised bone gives an increase in stiffness: An in vitro study

Morsellised bone impaction is used in joint prosthesis revision surgery to repair structural damage to the periarticular bone stock. The initial stiffness of the impacted bone is crucial for the survival of the revised hip joint. Impaction of morsellised bone in a femoral canal can cause fractures that may induce implant loosening in both femur and acetabulum. Alternative techniques to increase stiffness can therefore be of major interest. In this study we analyse whether applying a constant pressure during impaction can increase the stiffness of the morsellised bone. We constructed bone pellets by impaction with and without applying a constant pressure. The constrained stiffness and coefficient of secondary strain were determined by unidirectional load testing after construction of the pellets. A significant increase in constrained stiffness (P < 0.001) from 3.9 to 5.5 MPa and a decrease in the coefficient of secondary strain (P < 0.001) from 1.1 to 0.5 were found.

Cement penetration and primary stability of the femoral component after impaction allografting

This study explored the relationship between the initial stability of the femoral component and penetration of cement into the graft bed following impaction allografting.

Impaction allografting was carried out in human cadaveric femurs. In one group the cement was pressurised conventionally but in the other it was not pressurised. Migration and micromotion of the implant were measured under simulated walking loads. The specimens were then cross-sectioned and penetration of the cement measured.

Around the distal half of the implant we found approximately 70% and 40% of contact of the cement with the endosteum in the pressure and no-pressure groups, respectively. The distal migration/micromotion, and valgus/varus migration were significantly higher in the no-pressure group than in that subjected to pressure. These motion components correlated negatively with the mean area of cement and its contact with the endosteum.

The presence of cement at the endosteum appears to play an important role in the initial stability of the implant following impaction allografting.

Impaction grafting for femoral component revision using a non-polished bead-blasted chrome cobalt stem-average 8 1/2-year follow-up

Impaction grafting for femoral component revision in patients with significant bone loss has been reported using a tapered polished femoral component that is meant to subside. This study reports our results of femoral component revision using impaction grafting with a bead-blasted chrome cobalt stem designed not to subside. Forty-eight femoral component revisions using impaction grafting were retrospectively reviewed with a minimum 6 1/2-year follow-up. There were 2 failures due to aseptic loosening of the femoral component (4%). There were 22 total complications, and the overall failure rate was 21%. Impaction grafting for femoral component revision using a bead-blasted chrome cobalt stem in patients with a large femoral canal diameter has shown good results with respect to aseptic loosening with minimal subsidence.

The elastic properties of morsellised cortico-cancellous bone graft are dependent on its prior loading

Confined compression experiments were carried out on cortico-cancellous bone taken from bovine femoral condyles to assess the effect of prior loading on the elastic confined modulus, E(c) of morsellised cortico-cancellous bone (MCB). Measurements were taken to find the values of E(c) for MCB subjected to cyclic loading resulting in axial stresses in the range of 0.5-3.0 N mm(2). Two values of E(c) were considered: E(ic), the instantaneous modulus, and E(dc), the delayed modulus allowing for stress relaxation effects. It was found that the values of E(c) increased with increasing maximum axial stress. It was also found that for each stress level the values of E(c) increased as the number of load cycles increased. The dependence of E(c) on the maximum axial stress and the number of load cycles is seen to explain the wide range of values for the apparent modulus of MCB found in previous studies. Tests examining the stress relaxation behaviour of MCB are also discussed. The results indicate that a minimum of 10 compaction episodes are required for MCB to achieve around 90% of its predicted maximum stiffness for a given compaction force.

Factors affecting the cohesion of impaction bone graft

The role of bone-graft extenders in impaction revision surgery is becoming increasingly important. Tricalcium phosphate and hydroxyapatite have been shown to be both biocompatible and osteoconductive, yet many surgeons remain reluctant to use them. The difficulty in handling bone-graft extenders can be partly alleviated by using porous particles and adding clotted blood. In an in vitro model we measured the cohesive properties of various impaction graft mixes. Several factors were evaluated including the use of pure bone graft compared with mixes with extender, washing the bone and the addition of clotted blood. Our findings showed that pure allograft bone particles had significantly higher cohesion than when mixed with extender (p < 0.001). Washing had no effect on cohesion. The addition of clotted blood significantly increased the cohesion of both pure bone (p < 0.019) and mixes with pure bone and with porous graft extender (p < 0.044).

3D non-linear analysis of the acetabular construct following impaction grafting

The study investigates the short-term behaviour of the acetabular construct following revision hip arthroplasty, carried out using the Slooff-Ling impaction grafting technique; using 3D finite element analyses. An elasto-plastic material model is used to describe the constitutive behaviour of morsellised cortico-cancellous bone (MCB) graft, since it has been shown that MCB undergoes significant plastic deformation under normal physiological loads. Based on previous experimental studies carried out by the authors and others, MCB is modelled using non-linear elasticity and Drucker Prager Cap (DPC) plasticity. Loading associated with walking, sitting down, and standing up is applied to the acetabular cup through a femoral head using smooth sliding surfaces. The analyses yield distinctive patterns of migration and rotation due to different activities. These are found to be similar to those observed in the clinical setting.

Influence of water and fat content on compressive stiffness properties of impacted morsellized bone: an experimental ex vivo study on bone pellets

BACKGROUND

The initial stability of an exchanged hip arthroplasty is crucial for the survival of the revised joint. Several factors can affect the outcome. The amount of liquid in morsellized bone has a major influence on the constrained stiffness properties of impacted bone applied in revision joint surgery.

METHOD

To determine whether water or fat is the main contributing liquid, we performed an experimental study on impacted morsellized cortico-cancellous bovine bone to compare the constrained e-moduli in native bone and bone with modified water and fat content. The bone was impacted into bone pellets by a standardized method by which the construction procedure was monitored. Other stiffness properties were recorded during subsequent load testing.

RESULTS

Low water content significantly increased the constrained stiffness moduli during load, while high water content significantly reduced it. Low fat content increased stiffness significantly only during the initial phase of loading.

INTERPRETATION

Our findings indicate that the preparation and usage of morsellized bone in revision joint surgery should be performed under dry conditions to improve the initial stability of the revised prosthesis.

Factors affecting stiffness properties in impacted morsellized bone used in revision hip surgery: An experimentalin vitro study

When revising loosened joint prosthesis, impacted morsellized bone is frequently used as organic scaffolding. We studied the relative influence that different bone particle size, impaction energy, and liquid content had on impacted bone stiffness. Bovine bone was morsellized in a bone mill by three grinding drums to produce bone with different chip size distribution. Next, portions of bone chips of controlled sizes were produced by a five-leveled sieve. Layer by layer of bone are constructed into pellets by our experimental impaction method. This method allows us to vary one independent factor at a time in a controlled manner while keeping the other factors constant. Stiffness for all bone pellets were measured during impaction and loading. In earlier studies, we focused on how impaction force, number of impaction strokes, and bone liquid contents influence mechanical behavior. Here, we compare the outcome of all studies using general linear models. All five factors significantly contribute to stiffness of impacted morsellized bone. Changing bone moisture has major, while increasing the number of impaction strokes beyond five per layer has minor effect. Low water content is the main contributor to highest load stiffness. Optimal stability of impacted morsellized bone is achieved with dried and well-graded particles. The number of heavy impaction strokes can be restricted.

The effect of acetabular cup size on the short-term stability of revision hip arthroplasty: A finite element investigation

The study uses idealized two-dimensional finite element models to examine the behaviour of the acetabular construct following revision hip arthroplasty, carried out using the Slooff-Ling impaction grafting technique. The behaviour of bone graft was considered in detail, with non-linear elasticity and non-associated plasticity being adopted. Load was applied to the acetabular construct through a femoral head using smooth sliding surfaces. In particular, four models were subjected to two idealized cyclic load cases to investigate the effect of acetabular cup size on the short-term stability of the acetabular construct. The study suggests that benefits may be gained by using the largest practical size of acetabular cup.

Calcium phosphate cement composites in revision hip arthroplasty

Loosening of the femoral component in a total hip arthroplasty with concomitant bone loss can pose a problem for revision surgery due to inadequate structure in the remaining femur. While impaction allografting has shown promise, it has also shown serious complications, especially with moderate to severe bone loss. It may be possible to stabilize the graft layer with a bioresorbable cement to improve clinical results. This study examines the mechanical properties of a potential morsellized bone-bioresorbable composite. Morsellized bone was mixed with a commercially available bioresorbable cement (alpha-BSM, Etex Corp.) in compositions of 0%, 25%, 50% and 75% bone. Unconfined compression and diametral tensile and confined compression tests were performed to determine the composite mechanical properties. The composition containing 50% bone tended to exhibit the highest uniaxial strengths, as well as the highest confined compression modulus. The uniaxial compressive strength and stiffness of this composition was in the range of cancellous bone. Uniaxial compressive modulus decreased with increasing bone fraction whereas elongation exhibited the opposite trend. Bone fraction had a significant effect on compressive strength (p < 0.0001), compressive modulus (p < 0.0001), elongation (p < 0.01), tensile strength (p < 0.0001) and confined compressive modulus (p = 0.04). The addition of a bioresorbable cement to the allograft layer may improve the properties of the layer, preventing early subsidence seen in some clinical studies of impaction allografting, and therefore improving the clinical results. Further testing is required to evaluate the in vitro mechanical performance, as well as in vivo remodelling characteristics.

Constitutive models for impacted morsellised cortico-cancellous bone

Constitutive models are developed, based on the results of confined compression testing, to describe the visco-elastic, and non-linear elasto-plastic behaviour of morsellised cortico-cancellous bone (MCB). It is found that the elastic modulus, E of MCB can be expressed as a linear function of the applied pressure, p. E varied from 3 to 30N/mm(2) for pressures up to 1N/mm(2). The visco-elastic behaviour of MCB can be described using a fourth-order Prony series. The plastic behaviour of MCB can be described using a Drucker Prager Cap (DPC) yield criterion, in which consolidation behaviour is described using an exponential function. The developed relationships allow MCB to be included in a realistic manner in finite element models, for example of the acetabular construct, following revision hip arthroplasty, carried out using the Slooff-Ling impaction grafting technique.

A laboratory simulation for morselized bone graft fusion: apparent modulus under operatively based femoral impaction kinetics

The purpose of this study was to determine the apparent modulus changes accompanying a novel procedure for simulating in situ fusion of morselized cancellous bone femoral impaction grafts. An experienced surgeon's habitual intra-operative impaction grafting protocol was first quantified in human cadaver femurs, using a customized impulse force hammer. A corresponding standardized impaction procedure was then defined, and was used to prepare impaction grafts in axisymmetric metallic fixturing designed to replicate the nominal geometry of femoral canal confinement. Impaction graft fusion was simulated by mixing morselized cancellous bone with an amine-based epoxy adhesive before the impaction, then allowing the mixture to fuse after the impaction (J. Biomech. 34 (2001) 811). Force/deflection behavior of the unfused and fused impaction grafts was measured for both the (tapered) proximal and (untapered) distal portions of the grafts. Apparent modulus was then calculated from force/deflection stiffness. The impaction graft fusion simulation increased apparent modulus by an order of magnitude over the unfused state, for mixture parameters appropriate to have the fused graft apparent modulus be comparable to the compressive modulus of intact femoral cancellous bone.

Mechanical characteristics of the bone-graft-cement interface after impaction allografting

Impaction allografting is an attractive procedure for the treatment of failed total hip replacements. The graft-cement-host bone interface after impaction allografting has not been characterized, although it is a potential site of subsidence for this type of revision total hip reconstruction. In six human cadaveric femurs, the cancellous bone was removed proximally and local diaphyseal lytic defects were simulated. After the impaction grafting procedure, the specimens were sectioned in 6 mm transverse sections and push-out tests were performed. From the adjacent sections the percentage cement contact of the PMMA cement with the endosteal bone surface was determined. The host bone interface mechanical properties varied significantly along the femur largely due to different interface morphologies. The apparent host bone interface shear strength was highest around the lesser trochanter and lowest around the tip of the stem. A significant positive correlation was found between the percentage cement contact and the apparent host bone interface shear strength (r2 = 0.52). The sections failed in 69% of the cases through a pure host bone interface failure without cement or allograft failure, 19% failed with local cement failure, and 12% with a local allograft failure. The apparent host bone interface strength was on average 89% lower than values reported for primary total hip replacements and were similar to cemented revisions proximally and lower distally. This study showed that cement penetration to the endosteal surface enhanced the host bone-graft interface.

Impacted bone stiffness measured during construction of morsellised bone samples

Impacted morsellised bone is widely used for filling bone deficiencies during revision of total hip arthroplasties. However, the physical properties and mechanical behaviour of this bone material are still not well understood. In this study we recorded the increase of stiffness in pellets of morsellised bone during their construction. The construction of bone pellets was measured stroke-by-stroke to ascertain optimal stiffness. We have derived an impact-constrained module of elasticity, which represents the dynamic resistance in the granulated bone mass to impaction. Drop level of the impaction slap hammer increases constrained bone stiffness during impaction and load. However, increasing the number of impaction strokes at the highest drop level does not improve stiffness properties; no significant increase in stiffness was achieved after five strokes on each layer of morsellised bone.

Is hydroxyapatite cement an alternative for allograft bone chips in bone grafting procedures? A mechanical and histological study in a rabbit cancellous bone defect model

To evaluate in vivo performance of hydroxyapatite cement (HAC) as a porous bone graft substitute, HAC was mixed (1:1 ratio) with either porous calcium-phosphate granules (80% tricalcium phosphate, 20% hydroxyapatite) or defatted morsellized cancellous bone (MCB) allograft and implanted bilaterally in cylindrical drill holes in distal femurs of rabbits. Groups with empty defects and impacted MCB were used for reference. After 8 weeks, one femur from each pair was examined histologically. All contralateral specimens and Time-0 specimens were used for mechanical indentation tests. Histology showed that some empty defects were filled with newly formed osteopenic bone after 8 weeks. The impacted MCB showed remodeling into new vital bone. Incorporation of the HAC/MCB composite was incomplete, whereas minimal new bone ingrowth was found in the HAC/granule composites. Though not different from each other, both composites were significantly stronger than empty defects, incorporated impacted MCB, and intact cancellous bone. At Time 0, the mechanical behavior of impacted MCB was similar to both HAC composites. In conclusion, composites of HAC and porous biomaterials can maintain relatively high strength over 8 weeks in vivo, but their incorporation into a new bony structure is slower than impacted MCB. The HAC/MCB composite showed favorable incorporation behavior.

Impaction bone-grafting in revision joint replacement surgery

The standard graft material for impaction bone-grafting is fresh-frozen femoral head allograft morselized to a particle size as large as is practical to ensure stability and allow new bone formation. The graft must be sufficiently compacted to provide immediate mechanical stability; this requires containment of the graft and substantial impaction energy. Diaphyseal bone fracture and excessive implant migration are the most common complications of the operation. Impaction bone-grafting in revision total hip replacement has produced good medium-term results on both the acetabular and the femoral side. The use of compacted morselized bone graft is a relatively new technique in revision knee surgery and requires longer-term follow-up with larger numbers of patients to assess its value.

Impacted morselized cancellous bone: mechanical effects of defatting and augmentation with fine hydroxyapatite particles

Geotechnical engineering testing techniques were used to study the mechanical properties of morselized cancellous bone (MCB) and the effects of defatting and augmentation with fine hydroxyapatite (HA) particles. Bovine and human cancellous bone was morselized, rinsed, and manually squeezed to remove excess fluid, producing a standard surgical MCB sample that was also used as a control. Some of the MCB was defatted with heat and detergent and mixed with HA particles in ratios ranging from 0% to 100% HA. Compaction tests were used to determine the effects of moisture content and the amount of MCB that can be packed into a confined space. One-dimensional consolidation tests were used to determine the uniaxial strain behavior, confined modulus, and steady-state creep rate. The compaction tests demonstrated that defatting and adding HA particles significantly increased density. The one-dimensional consolidation tests showed that strain was decreased, modulus was increased and the creep rate was decreased by defatting and adding HA.

Cancellous and cortical morselized allograft in revision total hip replacement: A biomechanical study of implant stability

To restore femoral intramedullary bone stock loss in revision surgery of failed total hip arthroplasties, impacted morselized cancellous allograft is recommended. This study investigated the mechanical properties of both impacted cortical (group A) and cancellous (group B) morselized bone graft for reconstruction of femoral bones. Ten matched pairs of fresh frozen human femora were prepared by over-reaming to create a smooth-walled cortical shell. Each pair had one cortical and one cancellous impacted morselized allograft and cement. Stem subsidence was evaluated by a cyclic axial load, which was applied by a servohydraulic test. The stem subsidence was measured for initial subsidence (subsidence at the first 1000 cycles), the total axial subsidence (subsidence at the end of cycles under load) and the final axial subsidence (subsidence after the unloading phase). Torque test was measured by torsional loads through the prosthetic femoral heads. Total axial subsidence was significantly higher in group B (mean: 1.32+/-0.32 mm) compared to group A (mean: 0.94+/-0.26 mm) (P<0.01). There was no significant difference between the two groups in terms of initial subsidence (P=0.09) and final axial subsidence. The mean maximum torque before failure was 39.5+/-22.2 N-m for the cortical morselized allograft and 32.5+/-18.1N-m for cancellous. We concluded that impacted morselized cortical bone graft used for reconstruction of contained femoral bone loss in revision hip arthroplasty, may reduce the stem subsidence. Further animal experimentation for mechanical and histological evaluation of in vivo application is warranted.

Time-dependent mechanical properties of HA/TCP particles in relation to morsellized bone grafts for use in impaction grafting

In reconstructive surgery human bone defects are sometimes filled with the use of the impaction bone grafting technique. Currently different types of biomaterial particles are being developed as bone-substitute materials. Before these biomaterials can be applied their mechanical and biological behavior should be characterized. In this study the time-dependent mechanical behavior of biomaterial particles with different tri-calcium-phosphate/hydroxy-apatite (TCP:HA) ratios, particle sizes, and porosities is determined and compared to the behavior of human bone grafts, the latter being the standard material currently used to augment bone defects. The mechanical properties were assessed with the use of dynamic confined compression creep tests with a loading and unloading phase. Different graft material groups were tested, consisting of 100% human bone grafts, 100% biomaterial particles, and 50:50 weight mixtures of human grafts and biomaterial particles. No damage to the particles was observed by the impaction in the test chamber or by the dynamic load. Relative to the human graft material, the biomaterial particles hardly deformed under loading, were much stiffer, and showed almost no viscoelastic behavior. The mixtures showed intermediate results. Particle size and porosity influenced the behavior of the biomaterial particles. TCP:HA ratio did not have a great effect. The conclusion is that the application of these particles should be done with great care, as their mechanical behavior is drastically different than that of the human graft material. Mixing it with human bone grafts gave the material some biphasic, viscoelastic behavior that may be important for its biological response.

Tissue engineered microsphere-based matrices for bone repair: design and evaluation

The need for synthetic alternatives to conventional bone grafts is due to the limitations of current grafting materials. Our approach has been to design polymer-based graft substitutes using microsphere technology. The gel microsphere matrix and the sintered microsphere matrix were designed using the random packing of poly(lactide-co-glycolide) microspheres to create a three-dimensional porous structure. The evaluation of these methods dealt with analysis of effects of matrix composition and processing. Matrices were evaluated structurally by scanning electron microscopy and porosimetry, and biomechanically by compression testing. The evaluation revealed the high modulus of the gel microsphere matrix and the versatility of the sintered microsphere matrix. The gel microsphere matrix incorporated hydroxyapatite particles and had a Young's modulus of 1651 MPa, but structural analysis through SEM revealed a pore system less optimal for bone in-growth. The sintered microsphere matrices were fabricated without hydroxyapatite particles by thermally fusing polymeric microspheres into a three-dimensional array, possessing interconnectivity and a modulus range of 241 (+/-82)-349 (+/-89) MPa. The sintered microsphere matrix demonstrated a connected pore system and mechanical properties in the mid-range of cancellous bone. Porosimetry data indicated that matrix pore diameter varied directly with microsphere diameter, while pore volume was independent of microsphere diameter in the range of diameters examined. The microsphere-based matrices show promise as polymeric substitutes for bone repair.