Breast implants and cancer: causation, delayed detection, and survival

Concern for many women with breast implants has been focused on three topics: cancer (both breast and other cancers), delayed detection of breast cancer, and increased breast cancer recurrence or decreased length of survival. In this study, a qualitative review of the literature on these subjects was conducted, coupled with a meta-analysis of the risk for breast cancer or other cancers (excluding that of the breast). Researchers have consistently found no persuasive evidence of a causal association between breast implants and any type of cancer. The meta-analysis results obtained by combining the epidemiology studies support the overall conclusion that breast implants do not pose any additional risk for breast cancer (relative risk, 0.72; 95% confidence interval, 0.61 to 0.85) or for other cancers (relative risk, 1.03; 95% confidence interval, 0.87 to 1.24). This analysis suggests that breast implants may confer a protective effect against breast cancer. Women with implants should be reassured by the consistency of scientific studies which have uniformly determined that, compared with women without implants, they are not at increased risk for cancer, are not diagnosed with later-stage breast malignancies, are not at increased risk for breast cancer recurrence, and do not have a decreased length of survival.

Shear stress distribution in the trabeculae of human vertebral bone

The statistical distribution of von Mises stress in the trabeculae of human vertebral cancellous bone was estimated using large-scale finite element models. The goal was to test the hypothesis that average trabecular von Mises stress is correlated to the maximum trabecular level von Mises stress. The hypothesis was proposed to explain the close experimental correlation between apparent strength and stiffness of human cancellous bone tissue. A three-parameter Weibull function described the probability distribution of the estimated von Mises stress (r2>0.99 for each of 23 cases). The mean von Mises stress was linearly related to the standard deviation (r2=0.63) supporting the hypothesis that average and maximum magnitude stress would be correlated. The coefficient of variation (COV) of the von Mises stress was nonlinearly related to apparent compressive strength, apparent stiffness, and bone volume fraction (adjusted r2=0.66, 0.56, 0.54, respectively) by a saturating exponential function [COV = A + B exp(-x/C)]. The COV of the stress was higher for low volume fraction tissue (<0.12) consistent with the weakness of low volume fraction tissue and suggesting that stress variation is better controlled in higher volume fraction tissue. We propose that the average stress and standard deviation of the stress are both controlled by bone remodeling in response to applied loading.

Human vertebral body apparent and hard tissue stiffness

Cancellous bone apparent stiffness and strength are dependent upon material properties at the tissue level and trabecular architecture. Microstructurally accurate, large-scale finite element (LS-FE) models were used to predict the experimental apparent stiffness of human vertebral cancellous bone and to estimate the trabecular hard tissue stiffness. Twenty-eight LS-FE models of cylindrical human vertebral cancellous bone specimens (8 mm in diameter, 9.5 mm in height, one each from twenty-eight individuals) were generated directly from microcomputed tomography images and solved by a special purpose iterative finite element program. The experimental apparent stiffness and strength of the specimens were determined by mechanical testing to failure in the infero superior direction. Morphometric measurements including bone volume fraction (BV/TV), three eigenvalues of the fabric tensor and average P(L) were also calculated. The finite element estimate of apparent stiffness explained much of the variance in both experimental apparent stiffness (r2=0.89) and experimental apparent strength (r2=0.87). Stepwise linear regression analysis demonstrated that the LS-FE estimated apparent stiffness was the only significant predictor of experimental apparent stiffness and strength when it was included with all measured morphometric values. Hard tissue stiffness was quite variable between individuals (mean, 5.7 GPa; S.D. 1.6 GPa), but was not significantly related to age, sex, race, weight or morphometric measures for this sample.

Effect of fatiguing exercise on longitudinal bone strain as related to stress fracture in humans

Muscular fatigue in the training athlete or military recruit has been hypothesized to cause increased bone strain that may contribute to the development of a stress fracture. Under normal circumstances, muscles exert a protective effect by contracting to reduce bending strains on cortical bone surfaces. In vivo strain studies in dogs show that muscle fatigue following strenuous exercise elevates bone strain and changes strain distribution. However, a similar experiment has yet to be performed in humans. The purpose of this work was to test the hypothesis in humans that strenuous fatiguing exercise causes an elevation in bone strain. It was also hypothesized that this elevation is greater in younger people than in older people due to the decline in muscle strength and endurance that normally occurs with age. To test these hypotheses, strain in the tibiae of seven human volunteers was measured during walking before and after a period of fatiguing exercise. Neither hypothesis was sustained. Post-hoc analysis of the strain data suggests that strain rate increases after fatigue with a greater increase in younger as opposed to older persons. Although not conclusive, this suggests that it is strain rate, rather than strain magnitude, that may be causal for stress fracture.

The interosseous membrane affects load distribution in the forearm

The role of the interosseous membrane in load sharing was defined by simultaneously quantitating loads in the distal radius and ulna and in the proximal radius and ulna with an axial load to the wrist, before and after transecting the interosseous membrane. With the interosseous membrane intact, the load at the proximal ulna was greater than at the distal ulna and the load at the proximal radius was less than at the distal radius, suggesting that force was transferred from the radius distally to the ulna proximally. The average percentage of the total load in each bone in supination was as follows: distal radius, 68%; distal ulna, 32%; proximal radius, 51%; proximal ulna, 49%. After interosseous membrane division, the proximal and distal load values became equal in each bone, in all forearm positions, demonstrating that without the membrane there was no load transfer between the radius and ulna. The interosseous membrane transfers load from the wrist to the proximal forearm, via fibers that run from the proximal radius to the distal ulna and exert a proximally directed pull on the ulnar shaft.

A method suitable for in vivo measurement of bone strain in humans

Strain gages are the gold-standard for measurement of bone strains in vivo. The use of strain gages in humans, however, is limited by the need for surgery to implant them and by the use of cyanoacrylate adhesives to bond them to bone. Cyanoacrylate adhesives are not FDA approved for implantation in humans, making it difficult to justify their use in experimental procedures. To surmount this difficulty, a method was developed to bond strain gages to bone using an approved substance: polymethylmethacrylate (PMMA). The technique and the validating experiments are presented. The PMMA bonding method gave strain gage readings within an average of 0.25% (range 0-5%) of those found using cyanoacrylate bonding in a side by side comparison on cast acrylic. On bone, the PMMA bonding method produced results comparable to extensometer readings. This method of strain gage application is accurate and straightforward. It is currently being successfully used for in vivo strain measurements in both humans and animals for up to several days following gage application.

Decrease in canine proximal femoral ultimate strength and stiffness due to fatigue damage

Fractures of the proximal femur represent a significant health concern especially in the elderly. Fatigue damage and microfractures have been implicated in the etiology of hip fractures; however, the extent to which these factors are sufficient to bring about significant reductions in proximal femur strength and stiffness is unknown. This study examined the hypothesis that fatigue loading of the proximal femur results in highly correlated decreases in bone stiffness and strength through the accumulation of bone microdamage. One canine femur from each of 10 pairs was monotonically loaded to failure to determine the ultimate strength. The contralateral femur was then cyclically loaded at 50% of the ultimate load value for either 3600 cycles or until a 40% reduction in stiffness was achieved. This femur was then monotonically loaded to failure. For two additional femur pairs, the fatigued femur was histologically processed to reveal bone microdamage. In support of the hypothesis, the data demonstrated a linear relationship between strength loss and stiffness loss (Adj. R2 = 0.79, p < 0.0004) with significant decreases in residual whole bone strength (p < 0.004) following cyclic loading. In addition, damage (microcracks) in the cortical bone and broken trabeculae were observed in the neck and head region of the femur fatigued until its stiffness was reduced by 40% but not fractured subsequent to cyclic loading.

Human vertebral cancellous bone surface distribution

The three-dimensional distribution of bone surface and the bone volume fraction (BV/TV) of 110 human vertebral cancellous bone specimens from seven individuals were measured using a three-dimensional radiographic method (microcomputed tomography). The ratios of the three principal projections of bone surface per total volume were found to be relatively constant for specimens examined in this study. The constancy of the projected surface ratios means that the fraction of the total bone surface oriented in any direction does not change markedly with BV/TV. Bone volume fraction was a good predictor of bone surface per total volume (BS/TV) for a one-parameter nonlinear model (r2 = 0.92). The results of this pilot study suggest that the changes in surface distribution which occur during age-related bone loss are largely predetermined rather than adaptive. The results are also consistent with the idea that cancellous bone tends to maintain a constant ratio of trabecular number for the principal directions. If these inferences from the data are correct, the morphogenetic processes which create the initial adult trabecular pattern become of primary interest. A model was developed which explained the strong relationship between BS/TV and BV/TV. The model was used to demonstrate the importance of morphogenetic processes.