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Dienes B, Bazsó T, Szabó L, Csernoch L. The Role of the Piezo1 Mechanosensitive Channel in the Musculoskeletal System. Int J Mol Sci 2023; 24:ijms24076513. [PMID: 37047487 PMCID: PMC10095409 DOI: 10.3390/ijms24076513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
Since the recent discovery of the mechanosensitive Piezo1 channels, many studies have addressed the role of the channel in various physiological or even pathological processes of different organs. Although the number of studies on their effects on the musculoskeletal system is constantly increasing, we are still far from a precise understanding. In this review, the knowledge available so far regarding the musculoskeletal system is summarized, reviewing the results achieved in the field of skeletal muscles, bones, joints and cartilage, tendons and ligaments, as well as intervertebral discs.
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Kague E, Medina-Gomez C, Boyadjiev SA, Rivadeneira F. The genetic overlap between osteoporosis and craniosynostosis. Front Endocrinol (Lausanne) 2022; 13:1020821. [PMID: 36225206 PMCID: PMC9548872 DOI: 10.3389/fendo.2022.1020821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/08/2022] [Indexed: 11/29/2022] Open
Abstract
Osteoporosis is the most prevalent bone condition in the ageing population. This systemic disease is characterized by microarchitectural deterioration of bone, leading to increased fracture risk. In the past 15 years, genome-wide association studies (GWAS), have pinpointed hundreds of loci associated with bone mineral density (BMD), helping elucidate the underlying molecular mechanisms and genetic architecture of fracture risk. However, the challenge remains in pinpointing causative genes driving GWAS signals as a pivotal step to drawing the translational therapeutic roadmap. Recently, a skull BMD-GWAS uncovered an intriguing intersection with craniosynostosis, a congenital anomaly due to premature suture fusion in the skull. Here, we recapitulate the genetic contribution to both osteoporosis and craniosynostosis, describing the biological underpinnings of this overlap and using zebrafish models to leverage the functional investigation of genes associated with skull development and systemic skeletal homeostasis.
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Affiliation(s)
- Erika Kague
- School of Physiology, Pharmacology and Neuroscience, Biomedical Sciences, University of Bristol, Bristol, United Kingdom
- *Correspondence: Erika Kague,
| | - Carolina Medina-Gomez
- Department of Internal Medicine, Erasmus Medical Center (MC), University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Simeon A. Boyadjiev
- Department of Pediatrics, University of California, Davis, Sacramento, CA, United States
| | - Fernando Rivadeneira
- Department of Oral and Maxillofacial Surgery, Erasmus Medical Center (MC), University Medical Center Rotterdam, Rotterdam, Netherlands
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Qin L, He T, Chen S, Yang D, Yi W, Cao H, Xiao G. Roles of mechanosensitive channel Piezo1/2 proteins in skeleton and other tissues. Bone Res 2021; 9:44. [PMID: 34667178 PMCID: PMC8526690 DOI: 10.1038/s41413-021-00168-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/16/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022] Open
Abstract
Mechanotransduction is a fundamental ability that allows living organisms to receive and respond to physical signals from both the external and internal environments. The mechanotransduction process requires a range of special proteins termed mechanotransducers to convert mechanical forces into biochemical signals in cells. The Piezo proteins are mechanically activated nonselective cation channels and the largest plasma membrane ion channels reported thus far. The regulation of two family members, Piezo1 and Piezo2, has been reported to have essential functions in mechanosensation and transduction in different organs and tissues. Recently, the predominant contributions of the Piezo family were reported to occur in the skeletal system, especially in bone development and mechano-stimulated bone homeostasis. Here we review current studies focused on the tissue-specific functions of Piezo1 and Piezo2 in various backgrounds with special highlights on their importance in regulating skeletal cell mechanotransduction. In this review, we emphasize the diverse functions of Piezo1 and Piezo2 and related signaling pathways in osteoblast lineage cells and chondrocytes. We also summarize our current understanding of Piezo channel structures and the key findings about PIEZO gene mutations in human diseases.
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Affiliation(s)
- Lei Qin
- Department of Orthopedics, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, Guangdong, China
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Tailin He
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Sheng Chen
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, Guangdong, China
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Dazhi Yang
- Department of Orthopedics, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Weihong Yi
- Department of Orthopedics, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, Guangdong, China.
| | - Huiling Cao
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, Guangdong, China.
| | - Guozhi Xiao
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, Guangdong, China.
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Qin L, Fu X, Ma J, Lin M, Zhang P, Wang Y, Yan Q, Tao C, Liu W, Tang B, Chen D, Bai X, Cao H, Xiao G. Kindlin-2 mediates mechanotransduction in bone by regulating expression of Sclerostin in osteocytes. Commun Biol 2021; 4:402. [PMID: 33767359 PMCID: PMC7994671 DOI: 10.1038/s42003-021-01950-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 03/03/2021] [Indexed: 12/16/2022] Open
Abstract
Osteocytes act as mechanosensors in bone; however, the underlying mechanism remains poorly understood. Here we report that deleting Kindlin-2 in osteocytes causes severe osteopenia and mechanical property defects in weight-bearing long bones, but not in non-weight-bearing calvariae. Kindlin-2 loss in osteocytes impairs skeletal responses to mechanical stimulation in long bones. Control and cKO mice display similar bone loss induced by unloading. However, unlike control mice, cKO mice fail to restore lost bone after reloading. Osteocyte Kindlin-2 deletion impairs focal adhesion (FA) formation, cytoskeleton organization and cell orientation in vitro and in bone. Fluid shear stress dose-dependently increases Kindlin-2 expression and decreases that of Sclerostin by downregulating Smad2/3 in osteocytes; this latter response is abolished by Kindlin-2 ablation. Kindlin-2-deficient osteocytes express abundant Sclerostin, contributing to bone loss in cKO mice. Collectively, we demonstrate an indispensable novel role of Kindlin-2 in maintaining skeletal responses to mechanical stimulation by inhibiting Sclerostin expression during osteocyte mechanotransduction.
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Affiliation(s)
- Lei Qin
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, China
| | - Xuekun Fu
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, China
| | - Jing Ma
- Department of Biomedical Engineering, Southern University of Science and Technology, Shenzhen, China
| | - Manxia Lin
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, China
| | - Peijun Zhang
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, China
| | - Yishu Wang
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, China
| | - Qinnan Yan
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, China
| | - Chu Tao
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, China
| | - Wen Liu
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, China
| | - Bin Tang
- Department of Biomedical Engineering, Southern University of Science and Technology, Shenzhen, China
| | - Di Chen
- Research Center for Human Tissues and Organs Degeneration, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Xiaochun Bai
- Department of Cell Biology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Huiling Cao
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, China.
| | - Guozhi Xiao
- Department of Biochemistry, School of Medicine, Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research, Shenzhen Key Laboratory of Cell Microenvironment, Southern University of Science and Technology, Shenzhen, China.
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Rummler M, Ziouti F, Bouchard AL, Brandl A, Duda GN, Bogen B, Beilhack A, Lynch ME, Jundt F, Willie BM. Mechanical loading prevents bone destruction and exerts anti-tumor effects in the MOPC315.BM.Luc model of myeloma bone disease. Acta Biomater 2021; 119:247-258. [PMID: 33130307 DOI: 10.1016/j.actbio.2020.10.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/05/2020] [Accepted: 10/27/2020] [Indexed: 02/08/2023]
Abstract
Bone continually adapts to changing external loading conditions via (re)modeling (modeling and remodeling) processes. While physical activity is known to beneficially enhance bone mass in healthy individuals, little is known in how physical stimuli affect osteolytic bone destruction in patients suffering from multiple myeloma bone disease. Multiple myeloma (MM) is caused by malignant plasma cells in the bone marrow, shifting the balance in bone remodeling towards massive resorption. We hypothesized that in vivo tibial mechanical loading has anabolic effects in mice with locally injected MOPC315.BM.Luc cells. Conventional microCT analysis revealed enhanced cortical bone mass and microstructure in loaded compared to nonloaded mice. State-of-the-art time-lapse microCT based image analysis demonstrated bone (re)modeling processes at the endosteal and periosteal surfaces as the underlying causes of increased bone mass. Loading prevented the progression and development of osteolytic destruction. Physical stimuli also diminished local MM cell growth and dissemination evidenced by quantification of MM cell-specific immunoglobulin A levels in the serum of mice and by bioluminescence analysis. These data indicate that mechanical loading not only rescues the bone phenotype, but also exerts cell-extrinsic anti-myeloma effects in the MOPC315.BM.Luc model. In conclusion, the use of physical stimuli should be further investigated as an anabolic treatment for osteolytic bone destruction in patients with MM.
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Pacharne S, Livesey M, Kadmiel M, Wang N, Caron KM, Richards GO, Skerry TM. Accelerated Development With Increased Bone Mass and Skeletal Response to Loading Suggest Receptor Activity Modifying Protein-3 as a Bone Anabolic Target. Front Endocrinol (Lausanne) 2021; 12:807882. [PMID: 35095771 PMCID: PMC8790142 DOI: 10.3389/fendo.2021.807882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/01/2021] [Indexed: 11/13/2022] Open
Abstract
Knockout technologies provide insights into physiological roles of genes. Studies initiated into endocrinology of heteromeric G protein-coupled receptors included deletion of receptor activity modifying protein-3, an accessory protein that alters ligand selectivity of calcitonin and calcitonin-like receptors. Initially, deletion of Ramp3-/- appeared phenotypically silent, but it has emerged that mice have a high bone mass phenotype, and more subtle alterations to angiogenesis, amylin homeostasis, and a small proportion of the effects of adrenomedullin on cardiovascular and lymphatic systems. Here we explore in detail, effects of Ramp3-/- deletion on skeletal growth/development, bone mass and response of bone to mechanical loading mimicking exercise. Mouse pups lacking RAMP3 are healthy and viable, having accelerated development of the skeleton as assessed by degree of mineralisation of specific bones, and by microCT measurements. Specifically, we observed that neonates and young mice have increased bone volume and mineralisation in hindlimbs and vertebrae and increased thickness of bone trabeculae. These changes are associated with increased osteoblast numbers and bone apposition rate in Ramp3-/- mice, and increased cell proliferation in epiphyseal growth plates. Effects persist for some weeks after birth, but differences in gross bone mass between RAMP3 and WT mice lose significance in older animals although architectural differences persist. Responses of bones of 17-week old mice to mechanical loading that mimics effects of vigorous exercise is increased significantly in Ramp3-/- mice by 30% compared with WT control mice. Studies on cultured osteoblasts from Ramp3-/- mice indicate interactions between mRNA expression of RAMPs1 and 3, but not RAMP2 and 3. Our preliminary data shows that Ramp3-/- osteoblasts had increased expression β-catenin, a component of the canonical Wnt signalling pathway known to regulate skeletal homeostasis and mechanosensitivity. Given interactions of RAMPs with both calcitonin and calcitonin-like receptors to alter ligand selectivity, and with other GPCRs to change trafficking or ligand bias, it is not clear whether the bone phenotype of Ramp3-/- mice is due to alterations in signalling mediated by one or more GPCRS. However, as antagonists of RAMP-interacting receptors are growing in availability, there appears the likelihood that manipulation of the RAMP3 signalling system could provide anabolic effects therapeutically.
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Affiliation(s)
- Suruchi Pacharne
- Department of Oncology and Metabolism, School of Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Matthew Livesey
- Department of Oncology and Metabolism, School of Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Mahita Kadmiel
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Ning Wang
- Department of Oncology and Metabolism, School of Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Kathleen M. Caron
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Gareth O. Richards
- Department of Oncology and Metabolism, School of Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Tim M. Skerry
- Department of Oncology and Metabolism, School of Medicine, University of Sheffield, Sheffield, United Kingdom
- *Correspondence: Tim M. Skerry,
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van Tol AF, Schemenz V, Wagermaier W, Roschger A, Razi H, Vitienes I, Fratzl P, Willie BM, Weinkamer R. The mechanoresponse of bone is closely related to the osteocyte lacunocanalicular network architecture. Proc Natl Acad Sci U S A 2020; 117:32251-9. [PMID: 33288694 DOI: 10.1073/pnas.2011504117] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The explanation of how bone senses and adapts to mechanical stimulation still relies on hypotheses. The fluid flow hypothesis claims that a load-induced fluid flow through the lacunocanalicular network can be sensed by osteocytes, which reside within the network structure. We show that considering the network architecture results in a better prediction of bone remodeling than mechanical strain alone. This was done by calculating the fluid flow through the lacunocanalicular network in bone volumes covering the complete cross-sections of mouse tibiae, which underwent controlled in vivo loading. The established relationship between mechanosensitivity and network architecture in individual animals implies possibilities for patient-specific therapies. A new connectomics approach to analyze lacunocanalicular network properties is necessary to understand skeletal mechanobiology. Organisms rely on mechanosensing mechanisms to adapt to changes in their mechanical environment. Fluid-filled network structures not only ensure efficient transport but can also be employed for mechanosensation. The lacunocanalicular network (LCN) is a fluid-filled network structure, which pervades our bones and accommodates a cell network of osteocytes. For the mechanism of mechanosensation, it was hypothesized that load-induced fluid flow results in forces that can be sensed by the cells. We use a controlled in vivo loading experiment on murine tibiae to test this hypothesis, whereby the mechanoresponse was quantified experimentally by in vivo micro-computed tomography (µCT) in terms of formed and resorbed bone volume. By imaging the LCN using confocal microscopy in bone volumes covering the entire cross-section of mouse tibiae and by calculating the fluid flow in the three-dimensional (3D) network, we could perform a direct comparison between predictions based on fluid flow velocity and the experimentally measured mechanoresponse. While local strain distributions estimated by finite-element analysis incorrectly predicts preferred bone formation on the periosteal surface, we demonstrate that additional consideration of the LCN architecture not only corrects this erroneous bias in the prediction but also explains observed differences in the mechanosensitivity between the three investigated mice. We also identified the presence of vascular channels as an important mechanism to locally reduce fluid flow. Flow velocities increased for a convergent network structure where all of the flow is channeled into fewer canaliculi. We conclude that, besides mechanical loading, LCN architecture should be considered as a key determinant of bone adaptation.
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Pilawski I, Tulu US, Ticha P, Schüpbach P, Traxler H, Xu Q, Pan J, Coyac BR, Yuan X, Tian Y, Liu Y, Chen J, Erdogan Y, Arioka M, Armaro M, Wu M, Brunski JB, Helms JA. Interspecies Comparison of Alveolar Bone Biology, Part I: Morphology and Physiology of Pristine Bone. JDR Clin Trans Res 2020; 6:352-360. [PMID: 32660303 DOI: 10.1177/2380084420936979] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Few interspecies comparisons of alveolar bone have been documented, and this knowledge gap raises questions about which animal models most accurately represent human dental conditions or responses to surgical interventions. OBJECTIVES The objective of this study was to employ state-of-the-art quantitative metrics to directly assess and compare the structural and functional characteristics of alveolar bone among humans, mini pigs, rats, and mice. METHODS The same anatomic location (i.e., the posterior maxillae) was analyzed in all species via micro-computed tomographic imaging, followed by quantitative analyses, coupled with histology and immunohistochemistry. Bone remodeling was evaluated with alkaline phosphatase activity and tartrate-resistant acid phosphatase staining to identify osteoblast and osteoclast activities. In vivo fluorochrome labeling was used as a means to assess mineral apposition rates. RESULTS Collectively, these analyses demonstrated that bone volume differed among the species, while bone mineral density was equal. All species showed a similar density of alveolar osteocytes, with a highly conserved pattern of collagen organization. Collagen maturation was equal among mouse, rat, and mini pig. Bone remodeling was a shared feature among the species, with morphologically indistinguishable hemiosteonal appearances, osteocytic perilacunar remodeling, and similar mineral apposition rates in alveolar bone. CONCLUSIONS Our analyses demonstrated equivalencies among the 4 species in a plurality of the biological features of alveolar bone. Despite contradictory results from older studies, we found no evidence for the superiority of pig models over rodent models in representing human bone biology. KNOWLEDGE TRANSFER STATEMENT Animal models are extensively used to evaluate bone tissue engineering strategies, yet there are few state-of-the-art studies that rigorously compare and quantify the factors influencing selection of a given animal model. Consequently, there is an urgent need to assess preclinical animal models for their predictive value to dental research. Our article addresses this knowledge gap and, in doing so, provides a foundation for more effective standardization among animal models commonly used in dentistry.
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Affiliation(s)
- I Pilawski
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - U S Tulu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - P Ticha
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - P Schüpbach
- Schupbach Ltd, Service and Research Laboratory, Thalwil, Switzerland
| | - H Traxler
- Center of Anatomy and Cell Biology, Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | - Q Xu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - J Pan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - B R Coyac
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - X Yuan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Y Tian
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Y Liu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - J Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Y Erdogan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - M Arioka
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA.,Department of Clinical Pharmacology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - M Armaro
- Nobel Biocare Services AG, Zürich-Flughafen, Switzerland
| | - M Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - J B Brunski
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - J A Helms
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
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Shah FA, Ruscsák K, Palmquist A. Transformation of bone mineral morphology: From discrete marquise-shaped motifs to a continuous interwoven mesh. Bone Rep 2020; 13:100283. [PMID: 32577436 PMCID: PMC7305389 DOI: 10.1016/j.bonr.2020.100283] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/17/2020] [Indexed: 12/24/2022] Open
Abstract
Continual bone apposition at the cranial sutures provides the unique opportunity to understand how bone is built. Bone harvested from 16-week-old Sprague Dawley rat calvaria was either (i) deproteinised to isolate the inorganic phase (i.e., bone mineral) for secondary electron scanning electron microscopy or (ii) resin embedded for X-ray micro-computed tomography, backscattered electron scanning electron microscopy, and micro-Raman spectroscopy. Interdigitated finger-like projections form the interface between frontal and parietal bones. Viewed from the surface, bone mineral at the mineralisation front is comprised of nanoscale mineral platelets arranged into discrete, ~0.6–3.5 μm high and ~0.2–1.5 μm wide, marquise-shaped motifs that gradually evolve into a continuous interwoven mesh of mineralised bundles. Marquise-shaped motifs also contribute to the burial of osteoblastic–osteocytes by contributing to the roof over the lacunae. In cross-section, apices of the finger-like projections resemble islands of mineralised tissue, where new bone apposition at the surface is evident as low mineral density areas, while the marquise-shaped motifs appear as near-equiaxed assemblies of mineral platelets. Carbonated apatite content is higher towards the internal surface of the cranial vault. Up to 4 μm from the bone surface, strong Amide III, Pro, Hyp, and Phe signals, distinct PO43− bands, but negligible CO32– signal indicate recent bone formation and/or delayed maturation of the mineral. We show, for the first time, that the extracellular matrix of bone is assembled into micrometre-sized units, revealing a superstructure above the mineralised collagen fibril level, which has significant implications for function and mechanical competence of bone. The mineralisation front at cranial sutures of 16-week-old rats was investigated Interdigitated finger-like projections extend between frontal and parietal bones Micrometre-sized, marquise-shaped motifs of bone apatite at the mineralisation front Distinct motifs evolve into interwoven mesh of mineralised bundles Cranial bones are more mineralised at the internal surface (towards the dura mater)
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Affiliation(s)
- Furqan A Shah
- Department of Biomaterials, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Krisztina Ruscsák
- Department of Biomaterials, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Palmquist
- Department of Biomaterials, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Fleck C, Burke M, Ganzosch G, Müller C, Currey JD, Zaslansky P. Breaking crown dentine in whole teeth: 3D observations of prevalent fracture patterns following overload. Bone 2020; 132:115178. [PMID: 31816420 DOI: 10.1016/j.bone.2019.115178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 11/04/2019] [Accepted: 11/26/2019] [Indexed: 12/19/2022]
Abstract
Teeth with intact crowns rarely split or fracture, despite decades of cyclic loading and occasional unexpected overload. This is largely attributed to the presence of dentine, since cracking and fracture of enamel have been frequently reported. Dentine is similar to bone, comprising mineralised collagen fibres as a main constituent. Unlike cortical bone, however, where microcracking and damage arrest are essential for re/modelling and healing, dentine can neither remodel nor regenerate. This raises questions regarding the evolutionary benefits of toughening, leading to uncertainty whether cracks actually appear in dentine in situ. Here we study the notion that circumpulpal dentine is usually protected against, rather than damaged by severe overloads, even though it is not much more massive or stronger than it needs to be. To address this, we examined hydrated teeth still within whole jawbones of freshly-slaughtered skeletally mature pigs, mechanically loaded until fracture. Force displacement curves, optical and electron microscopy combined with 3D microstructural analysis by conventional micro-computed tomography (μCT) revealed mostly brittle fracture paths in circumpulpal crown dentine. Once overload cracks reach this mass of dentine they propagate rapidly along straight paths often parallel to the enamel flanks of the oblong shovel shaped premolars. We find infrequent signs of active toughening mechanisms with minimal crack diversion, ligament bridging and microcracking. When such toughening is seen, it mainly appears in softer dentine in the root, or near the dentine-enamel-junction (DEJ) in mantle dentine. We observed shear bands in overloaded circumpulpal dentine, due to mutual gliding of upper and lower segments. These shear bands are formed as periodic arrays of rotated dentine fragments. The 3D data consistently demonstrate the importance of the layered tooth structure, containing a stiff outer enamel shell, a soft sub-DEJ interlayer and a stiff circumpulpal dentine bulk, for deflecting cracks from splitting the tooth.
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Affiliation(s)
- Claudia Fleck
- Technische Universität Berlin, Chair of Materials Science and Engineering, Institute of Materials Science and Technologies, Str. des 17. Juni 136 - Sekr. EB13, 10623 Berlin, Germany.
| | - Martin Burke
- Technische Universität Berlin, Chair of Materials Science and Engineering, Institute of Materials Science and Technologies, Str. des 17. Juni 136 - Sekr. EB13, 10623 Berlin, Germany; Charité - Universitätsmedizin Berlin, Department for Operative and Preventive Dentistry, Aßmannshauser Str. 4-6, 14297 Berlin, Germany
| | - Gregor Ganzosch
- Technische Universität Berlin, Institute of Mechanics, Chair of Continuum Mechanics and Materials Theory, Einsteinufer 5 - Sekr. MS2, 10587 Berlin, Germany
| | - Cecilia Müller
- Technische Universität Berlin, Chair of Materials Science and Engineering, Institute of Materials Science and Technologies, Str. des 17. Juni 136 - Sekr. EB13, 10623 Berlin, Germany
| | - John D Currey
- The University of York, Department of Biology, Wentworth Way, York YO10 5DD, United Kingdom
| | - Paul Zaslansky
- Charité - Universitätsmedizin Berlin, Department for Operative and Preventive Dentistry, Aßmannshauser Str. 4-6, 14297 Berlin, Germany.
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11
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Willie BM, Zimmermann EA, Vitienes I, Main RP, Komarova SV. Bone adaptation: Safety factors and load predictability in shaping skeletal form. Bone 2020; 131:115114. [PMID: 31648080 DOI: 10.1016/j.bone.2019.115114] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/06/2019] [Accepted: 10/17/2019] [Indexed: 02/09/2023]
Abstract
Much is known about skeletal adaptation in relation to the mechanical functions that bones serve. This includes how bone adapts to mechanical loading during an individual's lifetime as well as over evolutionary time. Although controlled loading in animal models allows us to observe short-term bone adaptation (epigenetic mechanobiology), examining an assemblage of extant vertebrate bones or a group of fossils' bony structures can reveal the combined effects of long-term trends in loading history and the effects of natural selection. In this survey we examine adaptations that take place over both time scales and highlight a few of the extraordinary insights first published by John Currey. First, we provide a historical perspective on bone adaptation control mechanisms, followed by a discussion of safety factors in bone. We then summarize examples of structural- and material-level adaptations and mechanotransduction, and analyze the relationship between these structural- and material-level adaptations observed in situations where loading modes are either predictable or unpredictable. We argue that load predictability is a major consideration for bone adaptation broadly across an evolutionary timescale, but that its importance can also be seen during ontogenetic growth trajectories, which are subject to natural selection as well. Furthermore, we suggest that bones with highly predictable load patterns demonstrate more precise design with lower safety factors, while bones that experience less predictable loads or those that are less capable of repair and adaptation are designed with a higher safety factor. Finally, exposure to rare loading events with high potential costs of failure leads to design of structures with very high safety factor compared to everyday loading experience. Understanding bone adaptations at the structural and material levels, which take place over an individual's lifetime or over evolutionary time has numerous applications in translational and clinical research to understand and treat musculoskeletal diseases, as well as to permit the furthering of human extraterrestrial exploration in environments with altered gravity.
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Affiliation(s)
- Bettina M Willie
- Research Centre, Shriners Hospital for Children-Canada, Montreal, Canada; Department of Pediatric Surgery, McGill University, Montreal, Canada.
| | - Elizabeth A Zimmermann
- Research Centre, Shriners Hospital for Children-Canada, Montreal, Canada; Department of Pediatric Surgery, McGill University, Montreal, Canada
| | - Isabela Vitienes
- Research Centre, Shriners Hospital for Children-Canada, Montreal, Canada; Department of Pediatric Surgery, McGill University, Montreal, Canada
| | - Russell P Main
- Department of Basic Medical Sciences and Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA
| | - Svetlana V Komarova
- Research Centre, Shriners Hospital for Children-Canada, Montreal, Canada; Faculty of Dentistry, McGill University, Montreal, Canada
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12
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Wang N, Niger C, Li N, Richards GO, Skerry TM. Cross-Species RNA-Seq Study Comparing Transcriptomes of Enriched Osteocyte Populations in the Tibia and Skull. Front Endocrinol (Lausanne) 2020; 11:581002. [PMID: 33071985 PMCID: PMC7543096 DOI: 10.3389/fendo.2020.581002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/21/2020] [Indexed: 12/17/2022] Open
Abstract
Local site-specific differences between bones in different regions of the skeleton account for their different properties and functions. To identify mechanisms behind these differences, we have performed a cross-species study comparing RNA transcriptomes of cranial and tibial osteocytes, from bones with very different primary functions and physiological responses, collected from the same individual mouse, rat, and rhesus macaque. Bioinformatic analysis was performed to identify 32 genes changed in the same direction between sites and shared across all three species. Several well-established key genes in bone growth and remodeling were upregulated in the tibias of all three species (BMP7, DKK1, FGF1, FRZB, SOST). Many of them associate or crosstalk with the Wnt signaling pathway. These results suggest Wnt signaling-related candidates for different control of regulatory mechanisms in bone homeostasis in the skull and tibia and indicate a different balance between genetically determined structure and feedback mechanisms to strains induced by mechanical loading at the different sites.
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Affiliation(s)
- Ning Wang
- Department of Oncology and Metabolism, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, United Kingdom
| | - Corinne Niger
- Department of Oncology and Metabolism, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, United Kingdom
| | - Nan Li
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, United Kingdom
| | - Gareth O. Richards
- Department of Oncology and Metabolism, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, United Kingdom
| | - Tim M. Skerry
- Department of Oncology and Metabolism, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, United Kingdom
- *Correspondence: Tim M. Skerry
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13
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Abstract
Stress fractures (SF) are one of the most common and potentially serious overuse injuries. PURPOSE This study aimed to develop a computational biomechanical model of strain in human tibial bone that will facilitate better understanding of the pathophysiology of SF. METHODS The MRI of a healthy, young male was used for full anatomical segmentation of the calf tissues, which considered hard-soft tissues biomechanical interactions. From the undeformed coronal MR images, the geometry of bones, muscles, connecting ligaments, and fat were reconstructed in three dimensions and meshed to a finite element model. A force that simulated walking was applied on the tibial plateaus. The model was then analyzed for strains in the tibia under various conditions: unloaded walking, walking with a load equivalent to 30% of bodyweight, and walking under conditions of muscular fatigue. In addition, the effect of tibia robustness on strain was analyzed. RESULTS The model showed that the tibia is mostly loaded by compression, with maximal strains detected in the distal anterior surface: 1241 and 384 microstrain, compressive and tensile, respectively. Load carriage resulted in ~30% increase in maximal effective strains. Muscle fatigue has a complex effect; fatigued calf muscles (soleus) reduced the maximal effective strains up to 9%, but fatigued thigh muscles increased those strains by up to 3%. It had also been shown that a slender tibia is substantially prone to higher maximal effective strains compared with an average (22% higher) or robust tibia (39% higher). CONCLUSIONS Thigh muscle fatigue, load carriage, and a slender tibia were detected as factors that may contribute to the development of SF. The methodology presented here is a novel tool for investigating the pathophysiology of SF.
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Affiliation(s)
- Amir Hadid
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, ISRAEL
| | - Yoram Epstein
- Heller Institute of Medical Research, Sheba Medical Center, Tel Hashomer, ISRAEL.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, ISRAEL
| | - Nogah Shabshin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Amit Gefen
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, ISRAEL
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Birkhold AI, Razi H, Duda GN, Checa S, Willie BM. Tomography-Based Quantification of Regional Differences in Cortical Bone Surface Remodeling and Mechano-Response. Calcif Tissue Int 2017; 100:255-270. [PMID: 27999894 DOI: 10.1007/s00223-016-0217-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/02/2016] [Indexed: 01/27/2023]
Abstract
Bone has an adaptive capacity to maintain structural integrity. However, there seems to be a heterogeneous cortical (re)modeling response to loading at different regions within the same bone, which may lead to inconsistent findings since most studies analyze only one region. It remains unclear if the local mechanical environment is responsible for this heterogeneous response and whether both formation and resorption are affected. Thus, we compared the formation and resorptive response to in vivo loading and the strain environment at two commonly analyzed regions in the mouse tibia, the mid-diaphysis and proximal metaphysis. We quantified cortical surface (re)modeling by tracking changes between geometrically aligned consecutive in vivo micro-tomography images (time lapse 15 days). We investigated the local mechanical strain environment using finite element analyses. The relationship between mechanical stimuli and surface (re)modeling was examined by sub-dividing the mid-diaphysis and proximal metaphysis into 32 sub-regions. In response to loading, metaphyseal cortical bone (re)modeled predominantly at the periosteal surface, whereas diaphyseal (re)modeling was more pronounced at the endocortical surface. Furthermore, different set points and slopes of the relationship between engendered strains and remodeling response were found for the endosteal and periosteal surfaces at the metaphyseal and diaphyseal regions. Resorption was correlated with strain at the endocortical, but not the periosteal surfaces, whereas, formation correlated with strain at all surfaces, except at the metaphyseal periosteal surface. Therefore, besides mechanical stimuli, other non-mechanical factors are likely driving regional differences in adaptation. Studies investigating adaptation to loading or other treatments should consider region-specific (re)modeling differences.
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Affiliation(s)
- Annette I Birkhold
- Julius Wolff Institute, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Continuum Biomechanics and Mechanobiology Research Group, Institute of Applied Mechanics, University of Stuttgart, Stuttgart, Germany
| | - Hajar Razi
- Julius Wolff Institute, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Max Planck Institute of Colloids and Interfaces, Potsdam, Germany
| | - Georg N Duda
- Julius Wolff Institute, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sara Checa
- Julius Wolff Institute, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Bettina M Willie
- Julius Wolff Institute, Charité - Universitätsmedizin Berlin, Berlin, Germany.
- Department of Pediatric Surgery, McGill University, Research Centre, Shriners Hospital for Children-Canada, 1003 Decarie Blvd, Montreal, H4A 0A9, Canada.
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15
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Knabe C, Mele A, Kann PH, Peleska B, Adel-Khattab D, Renz H, Reuss A, Bohner M, Stiller M. Effect of sex-hormone levels, sex, body mass index and other host factors on human craniofacial bone regeneration with bioactive tricalcium phosphate grafts. Biomaterials 2017; 123:48-62. [PMID: 28160669 DOI: 10.1016/j.biomaterials.2017.01.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/23/2016] [Accepted: 01/27/2017] [Indexed: 12/16/2022]
Abstract
Little is known regarding the associations between sex-hormone levels, sex, body mass index (BMI), age, other host factors and biomaterial stimulated bone regeneration in the human craniofacial skeleton. The aim of this study was to elucidate the associations between these factors and bone formation after sinus floor augmentation procedures (SFA) utilizing a bioactive tricalcium phosphate (TCP) bone grafting material. We conducted a prospective study in a human population in which 60 male and 60 female participants underwent SFA and dental implant placement using a staged approach. BMI as well as levels of serum estradiol (E2), total testosterone (TT), and the free androgen index (FAI) were measured by radioimmunoassay and electrochemoluminescent-immunoassay. At implant placement, 6 months after SFA, bone biopsy specimens were harvested for hard tissue histology, the amount of bone formation was evaluated by histomorphometry and immunohistochemical analysis of osteogenic marker expression. The Wilcoxon rank-sum U test, Spearman correlations and linear regression analysis were used to explore the association between bone formation and BMI, hormonal and other host factors. BMI and log E2 were significantly positively associated with bone formation in male individuals (p < 0.05). Histomorphometry revealed trends toward greater bone formation and osteogenic marker expression with non-smokers compared to smokers. In male patients, higher E2 levels and higher BMI enhanced TCP stimulated craniofacial i.e. intramembranous bone repair.
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Xu C, Silder A, Zhang J, Hughes J, Unnikrishnan G, Reifman J, Rakesh V. An Integrated Musculoskeletal-Finite-Element Model to Evaluate Effects of Load Carriage on the Tibia During Walking. J Biomech Eng 2016; 138:2537122. [DOI: 10.1115/1.4034216] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Indexed: 11/08/2022]
Abstract
Prior studies have assessed the effects of load carriage on the tibia. Here, we expand on these studies and investigate the effects of load carriage on joint reaction forces (JRFs) and the resulting spatiotemporal stress/strain distributions in the tibia. Using full-body motion and ground reaction forces from a female subject, we computed joint and muscle forces during walking for four load carriage conditions. We applied these forces as physiological loading conditions in a finite-element (FE) analysis to compute strain and stress. We derived material properties from computed tomography (CT) images of a sex-, age-, and body mass index-matched subject using a mesh morphing and mapping algorithm, and used them within the FE model. Compared to walking with no load, the knee JRFs were the most sensitive to load carriage, increasing by as much as 26.2% when carrying a 30% of body weight (BW) load (ankle: 16.4% and hip: 19.0%). Moreover, our model revealed disproportionate increases in internal JRFs with increases in load carriage, suggesting a coordinated adjustment in the musculature functions in the lower extremity. FE results reflected the complex effects of spatially varying material properties distribution and muscular engagement on tibial biomechanics during walking. We observed high stresses on the anterior crest and the medial surface of the tibia at pushoff, whereas high cumulative stress during one walking cycle was more prominent in the medioposterior aspect of the tibia. Our findings reinforce the need to include: (1) physiologically accurate loading conditions when modeling healthy subjects undergoing short-term exercise training and (2) the duration of stress exposure when evaluating stress-fracture injury risk. As a fundamental step toward understanding the instantaneous effect of external loading, our study presents a means to assess the relationship between load carriage and bone biomechanics.
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Affiliation(s)
- Chun Xu
- Telemedicine and Advanced Technology Research Center, Department of Defense Biotechnology High Performance Computing Software Applications Institute, U.S. Army Medical Research and Materiel Command, Fort Detrick, MD 21702-5012
| | - Amy Silder
- Department of Bioengineering, Stanford University, Stanford, CA 94305-6175
| | - Ju Zhang
- Auckland Bioengineering Institute, University of Auckland, Auckland 1010, New Zealand
| | - Julie Hughes
- U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760-5007
| | - Ginu Unnikrishnan
- Telemedicine and Advanced Technology Research Center, Department of Defense Biotechnology High Performance Computing Software Applications Institute, U.S. Army Medical Research and Materiel Command, Fort Detrick, MD 21702-5012
| | - Jaques Reifman
- Telemedicine and Advanced Technology Research Center, Department of Defense Biotechnology High Performance Computing Software Applications Institute, U.S. Army Medical Research and Materiel Command, MCMR-TT, 504 Scott Street, Fort Detrick, MD 21702-5012 e-mail:
| | - Vineet Rakesh
- Telemedicine and Advanced Technology Research Center, Department of Defense Biotechnology High Performance Computing Software Applications Institute, United States Army Medical Research and Materiel Command, Fort Detrick, MD 21702-5012
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Ireland A. What is new in neuro-musculoskeletal interactions? From brains to babies. J Musculoskelet Neuronal Interact 2016; 16:1-3. [PMID: 26944816 PMCID: PMC5089448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 02/20/2016] [Indexed: 11/17/2022]
Affiliation(s)
- A. Ireland
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
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