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Fatigue crack propagation resistance and high-cycle S-N fatigue life of cortical bone allograft tissue are both negatively impacted in a radiation dose-dependent manner from 0 to 25 kGy. The standard radiation sterilization dose of 25-35 kGy has been shown to induce cleavage of collagen molecules into smaller peptides and accumulation of stable crosslinks within the collagen matrix, suggesting that these mechanisms may influence radiation-induced losses in cyclic fracture resistance. The objective of this study was to determine the radiation dose-dependency of collagen chain fragmentation and crosslink accumulation within the dose range of 0-25 kGy. Previously, cortical bone compact tension specimens from two donor femoral pairs were divided into four treatment groups (0 kGy, 10 kGy, 17.5 kGy, and 25 kGy) and underwent cyclic loading fatigue crack propagation testing. Following fatigue testing, collagen was isolated from one compact tension specimen in each treatment group from both donors. Radiation-induced collagen chain fragmentation was assessed using SDS-PAGE (n = 5), and accumulation of pentosidine, pyridinoline, and non-specific advanced glycation end products were assessed using a fluorometric assay (n = 4). Collagen chain fragmentation increased progressively in a dose-dependent manner (p < 0.001). Crosslink accumulation at all radiation dose levels increased relative to the 0 kGy control but did not demonstrate dose-dependency (p < 0.001). Taken together with our previous findings on fatigue crack propagation behavior, these data suggest that while collagen crosslink accumulation may contribute to reduced notched fatigue behavior with irradiation, dose-dependent losses in fatigue crack propagation resistance are mainly influenced by radiation-induced chain fragmentation.

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BACKGROUND: Pediatric patients with isolated femoral diaphyseal fractures are difficult to assess for nonaccidental trauma (NAT). The purpose of this study was to determine (1) if there are any demographic features of isolated femoral diaphyseal fractures associated with suspected NAT and (2) if there are clinical signs associated with isolated femoral diaphyseal fractures associated with suspected NAT. METHODS: All patients with femoral diaphyseal fractures from January 2010 to June 2018 were reviewed. We included patients younger than 4 years old with isolated femoral diaphyseal fractures. We excluded patients 4 years old and older, polytraumas, motor vehicle collisions, and patients with altered bone biology. Diagnosis of suspected NAT was determined by review of a documented social work assessment. We recorded fracture characteristics including location along femur as well as fracture pattern and presence of associated findings on NAT workup including the presence of retinal hemorrhage, subdural hematoma, evidence of prior fracture, or cutaneous lesions. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these associated findings were calculated. RESULTS: Totally, 144 patients met the inclusion criteria. Social work was consulted on 50 patients (35%). Suspected NAT was diagnosed in 27 patients (19%). The average age of patients with suspected NAT was 0.82 and 2.25 years in patients without NAT ( P <0.01). The rate and type of skin lesions present on exam were not different between the 2 groups. Patients with suspected NAT had no findings of retinal hemorrhage or subdural hematoma, but 5 of 27 patients (19%) had evidence of prior fracture on skeletal survey. The sensitivities of retinal hemorrhage, subdural, and skeletal survey were 0%, 0%, and 19% and the specificities of all were 100%. The NPVs were 39%, 27%, and 63%, respectively. The PPV of skeletal survey was 100%. Since there were no patients in this study with positive findings of retinal hemorrhage or subdural hematoma, the PPV for these could not be assessed. CONCLUSIONS: In the current study, signs of NAT such as skin lesions, retinal hemorrhage, subdural hematoma, and evidence of prior fracture on skeletal survey may not be helpful to diagnosis suspected NAT in patients with an isolated femoral diaphyseal fracture. LEVEL OF EVIDENCE: Level III-diagnostic study.

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Computational models of mature bone have been used to predict fracture; however, analogous study of immature diaphyseal fracture has not been conducted due to sparse experimental mechanical data. A model of immature bone fracture may be used to aid in the differentiation of accidental and non-accidental trauma fractures in young, newly ambulatory children (0-3 years). The objective of this study was to characterize the evolution of tissue-level mechanical behavior, composition, and microstructure of maturing cortical porcine bone with uniaxial tension, Raman spectroscopy, and light microscopy as a function of maturation. We asked: 1) How do the monotonic uniaxial tensile properties change with maturation and displacement rate; 2) How does the composition and microstructure change with maturation; and 3) Is there a correlation between composition and tensile properties with maturation? Elastic modulus (p < 0.001), fracture stress (p < 0.001), and energy absorption (p < 0.014) increased as a function of maturation at the quasistatic rate by 110%, 86%, and 96%, respectively. Fracture stress also increased by 90% with maturation at the faster rate (p = 0.001). Fracture stress increased as a function of increasing displacement rate by 28% (newborn p = 0.048; 1-month p = 0.004; 3-month p= < 0.001), and fracture strain decreased by 68% with increasing displacement rate (newborn p = 0.002; 1-month p = 0.036; 3-month p < 0.001). Carbonate-to-phosphate ratio was positively linearly related to elastic modulus, and fracture stress was positively related to carbonate-to-phosphate ratio and matrix maturation ratio. The results of this study support that immature bone is strain-rate dependent and becomes more brittle at faster rates, contributing to the foundation upon which a computational model can be built to evaluate immature bone fracture.

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PURPOSE: The purpose of this study was to evaluate the effect of bioabsorbable interference screw diameter on the pullout strength and failure mode for femoral tunnel fixation in primary anterior cruciate ligament reconstruction (ACLR) at time zero fixation using bone-patellar tendon-bone (BTB) autograft in a cadaveric model. METHODS: Twenty-four fresh-frozen cadaveric knees were obtained from 17 different donors. Specimens were allocated to three different treatment groups (n = 8 per group) based on interference screw diameter: 6 mm, 7 mm, or 8 mm biocomposite interference screw. All specimens underwent dual energy X-ray absorptiometry (DEXA) scanning prior to allocation to ensure no difference in bone mineral density among groups (n.s.). All specimens underwent femoral-sided ACLR with BTB autograft. Specimens subsequently underwent mechanical testing under monotonic loading conditions to failure. The load to failure and failure mechanism were recorded. RESULTS: The mean pullout force (N) at time zero for each group was 309 ± 213 N, 518 ± 313 N, and 541 ± 267 N for 6 mm, 7 mm, and 8 mm biocomposite interference screw diameter, respectively (n.s.). One specimen in the 6 mm group, two specimens in the 7 mm group, and one specimen in the 8 mm group failed by screw pullout. The remainder in each group failed by graft failure (n.s.). CONCLUSION: Biocomposite interference screw diameter did not have a significant influence on fixation pullout strength or failure mode following femoral tunnel fixation using BTB autograft at time zero. A 6 mm interference screw can improve preservation of native bone stock, increase potential for biologic healing, and decrease the risk of damage to the graft during insertion without significantly compromising fixation strength. This study supports the use of smaller 6 mm interference screw diameter options for femoral tunnel fixation in ACLR.

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Background: The Epoch FullCoat Hip Stem (Zimmer) was an isoelastic composite femoral stem developed to address stem stiffness concerns. Purpose: We sought to evaluate the long-term bone mineral density (BMD) of a cohort of patients who underwent total hip arthroplasty (THA) using the Epoch isoelastic stem and having more than 2-decade follow-up. Methods: We conducted a retrospective chart review of all patients who were study subjects at our institution in a multicenter prospective trial for the Food and Drug Administration of the Epoch implant in the mid-1990s. Through this, we identified 16 patients who had dual-energy X-ray absorptiometry (DEXA) scans, with which we could determine BMD preoperatively and at 3 points postoperatively. Of these, 5 agreed to participate in the study (the others were deceased, unable or declined to participate, or were lost to follow-up) with mean follow-up of 22 years. These participants underwent clinical and radiographic evaluation consisting of a Harris hip score, anteroposterior (AP) pelvis and AP and lateral hip X-rays, and DEXA evaluation of both hips. BMD in the 7 Gruen zones at last follow-up was compared with immediate postoperative and 2-year follow-up. Results: At last follow-up, all stems were well-fixed with signs of extensive osteointegration. In proximal Gruen zones 1 and 7, patients underwent a decrease in BMD with more modest losses in Gruen zone 1. All patients demonstrated an increase in BMD in zones 2 through 6 at latest follow-up, except for 1 patient in Gruen zone 6. BMD changes were not limited to the first 2 years of follow-up. Conclusion: This small follow-up cohort study found excellent long-term clinical results, no plain radiographic signs of notable stress shielding, and general maintenance of BMD at a follow-up of over 20 years for this isoelastic stem. Long-term bone remodeling after implantation of the isoelastic stem resulted in increased BMD in Gruen zones 2 through 6, suggesting that composite implant designs may still have a role in THA.

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Cortical bone allograft sterilized with a standard γ-radiation dose of 25-35kGy has demonstrated reduced static and cyclic fracture resistance compared with unirradiated bone. To mitigate radiation damage, we recently observed a dose-dependent response of high-cycle fatigue behavior of human cortical bone from 0 to 25 kGy, with lower doses exhibiting logarithmically longer fatigue lives. The objectives of this study were as follows: (1) to determine whether fracture toughness, work-to-fracture, and fatigue crack propagation resistance of human cortical bone are also radiation dose-dependent, and (2) to determine the associations of radiation dose and a Raman biomarker for collagen disorder with fracture properties. Compact tension specimens were machined from two donor femoral pairs and allocated to four treatment groups: 0 (unirradiated control), 10, 17.5, and 25 kGy. Fracture toughness specimens were monotonically loaded to failure and the critical stress intensity factor (KC ) was determined. Work-to-fracture was calculated from the load versus displacement integral up to fracture. Fatigue crack propagation specimens were cyclically loaded under constant room-temperature irrigation and fatigue crack growth rate (da/dN) and cyclic stress intensity (∆K) were calculated. Fracture toughness, work-to-fracture, and fatigue crack propagation resistance decreased 18%, 33%, and 15-fold from 0 to 25 kGy, respectively (p < 0.05). Radiation dose was more predictive of fracture properties than collagen disorder. These findings support that quasi-static and fatigue fracture properties of cortical bone are radiation dose-dependent within this dose range. The structural alterations arising from irradiation that cause these losses in fracture resistance remain to be elucidated.

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BACKGROUND: Structural cortical bone allografts are a reasonable treatment option for patients with large cortical bone defects caused by trauma, tumors, or complications of arthroplasty. Although structural cortical bone allografts provide the benefit of an osteoconductive material, they are susceptible to fatigue failure (fracture) and carry a risk of disease transmission. Radiation-sterilization at the recommended dose of 25 kGy decreases the risk of disease transmission. However, previous studies demonstrated that radiation sterilization at this dose can negatively impact the high cycle-fatigue life of cortical bone. Although the effects of higher doses of radiation on cortical bone allografts are well described, the effects of lower doses of radiation on a high-cycle fatigue life of cortical bone are poorly understood. QUESTIONS/PURPOSES: (1) Does the cycle-fatigue life of human cortical allograft bone vary with gamma radiation dose levels of 0 (control), 10 kGy, 17.5 kGy, and 25 kGy? (2) What differences in Raman spectral biomarkers are observed following varying doses of gamma radiation exposure? METHODS: The high-cycle fatigue behavior of human cortical bone specimens was examined at different radiation sterilization doses under physiologic stress levels (35 MPa) and in a 37° C phosphate-buffered saline bath using a custom-designed rotating-bending fatigue device. Six human femora from three donors were obtained for this study (two male, 63 and 61 years old, respectively, and one female, 48 years old). Test specimens were allocated among four treatment groups (0 kGy [control], 10 kGy, 17.5 kGy, and 25 kGy) based on donor and anatomic location of harvest site (both length and cross-sectional quadrant of femoral diaphysis) to ensure equal variation (n = 13 per group). Specimens underwent high-cycle fatigue testing to failure. The number of cycles to failure was recorded. Raman spectroscopy (a noninvasive vibrational spectroscopy used to qualitatively assess bone quality) was used to detect whether any changes in Raman spectral biomarkers occurred after varying doses of gamma radiation exposure. RESULTS: There was a decrease in the log-transformed mean high-cycle fatigue life in specimens irradiated at 25 kGy (5.39 ± 0.32) compared with all other groups (0 kGy: 6.20 ± 0.50; 10k Gy: 6.35 ± 0.79; 17.5 kGy: 6.01 ± 0.53; p = 0.001). Specimens irradiated at 25 kGy were also more likely to exhibit a more brittle fracture surface pattern than specimens with more ductile fracture surface patterns irradiated at 0 kGy, 10 kGy, and 17.5 kGy (p = 0.04). The Raman biomarker for the ratio of the relative amount of disordered collagen to ordered collagen showed a decrease at the 10 kGy radiation level from 1.522 ± 0.025 preirradiation to 1.489 ± 0.024 postirradiation (p = 0.01); no other detectable changes in Raman biomarkers were observed. CONCLUSION: The high-cycle fatigue life of cortical bone undergoes a nonlinear, dose-dependent decrease with an increase in gamma radiation sterilization in a clinically relevant dose range (0-25 kGy). Importantly, a notable drop-off in the high-cycle fatigue life of cortical bone appeared to occur between 17.5 kGy and 25 kGy, correlating to a sixfold decrease in mean cycles to failure. We speculate that the decrease in the Raman biomarker for disordered collagen at 10 kGy with no loss in high-cycle fatigue life may be caused by an increased amount of nonenzymatic crosslinking of the collagen backbone relative to collagen chain-scission (whereas the benefits of crosslinking may be outweighed by excess scission of the collagen backbone at higher radiation doses), but future studies will need to ascertain whether this in fact is the case. CLINICAL RELEVANCE: Radiation sterilization at the industry standard of 25 kGy has a substantial negative impact on the high-cycle fatigue life of cortical bone. Given these findings, it is possible to provide a meaningful increase in the high-cycle fatigue life and improve the overall functional lifetime of cortical bone allografts by lowering the radiation-sterilization dose below 25 kGy. Future work on radiation-sterilization methods at these clinically relevant doses is warranted to aid in preserving the high cycle fatigue life of cortical bone allografts while maintaining sterility.

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BACKGROUND: A uniquely designed, non-heat-treated moderately cross-linked acetabular polyethylene liner used in total hip arthroplasty (THA) demonstrated excessive wear during routine follow-up, prompting an evaluation of the linear wear rate. METHODS: All THAs were performed by the senior author. The study group included 38 THAs using the uniquely designed polyethylene in question, compared to a control group of 21 THAs using another moderately cross-linked polyethylene with good 10-year outcomes. Two-dimensional linear head penetration wear measurements were obtained using the Martell Hip Analysis Suite, and retrieval analysis was performed on two liners. RESULTS: The study group had a significantly higher average penetration rate of 0.089 mm/y than the control group average rate of 0.047 mm/y (P = .04). Forty-five percent of the study group had a wear rate above the osteolysis threshold (0.1 mm/y), compared to 24% in the control group. Macroscopic analysis of two retrieved liners validated the radiographic findings. CONCLUSION: The data suggest unexpectedly higher wear rates for a moderately cross-linked polyethylene design, with nearly half of the study group at risk for osteolysis. Further registry or database analyses of this particular moderately cross-linked polyethylene are warranted.

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The whole bone geometry, microstructure, and mechanical properties of mature human bone are widely reported; however, immature bone (0-18 years) has not been similarly robustly characterized. There is an interest in analyzing and predicting the mechanical loading conditions associated with long bone diaphyseal fractures attributed to trauma in children. Thus, understanding the mechanical properties of immature bone in a temporal reference frame is an essential first step to understand diaphyseal fractures of pediatric long bones. The purpose of this systematic review was to ask, what is the state of knowledge regarding the 1) evolution of whole bone geometry and microstructure of immature pediatric bone as a function of maturation and 2) cortical bone density and experimental quasi-static mechanical properties at the tissue level in the diaphyseal region of immature pediatric long bones? The systematic search yielded 36 studies of the whole bone geometry, microstructure, and mechanical properties of immature pediatric long bones. The elastic modulus, yield stress, and ultimate stress were shown to generally increase with maturation, whereas the yield strain was approximately invariant; however, the specific year-to-year progression of these properties could not be characterized from the limited studies available. The results of this systematic search indicate there is a dearth of knowledge associated with the biomechanics of cortical bone from immature pediatric long bones; it also provides a basis for computational studies of immature human long bones. Additional biomechanical studies of immature human bone are necessary to develop a robust catalogue, which can be used in broad applications to understand fracture mechanics, bone pathologies, and athletic injury in the pediatric setting.

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Microarchitectured materials achieve superior mechanical properties through geometry rather than composition. Although ultralightweight microarchitectured materials can have high stiffness and strength, application to durable devices will require sufficient service life under cyclic loading. Naturally occurring materials provide useful models for high-performance materials. Here, we show that in cancellous bone, a naturally occurring lightweight microarchitectured material, resistance to fatigue failure is sensitive to a microarchitectural trait that has negligible effects on stiffness and strength-the proportion of material oriented transverse to applied loads. Using models generated with additive manufacturing, we show that small increases in the thickness of elements oriented transverse to loading can increase fatigue life by 10 to 100 times, far exceeding what is expected from the associated change in density. Transversely oriented struts enhance resistance to fatigue by acting as sacrificial elements. We show that this mechanism is also present in synthetic microlattice structures, where fatigue life can be altered by 5 to 9 times with only negligible changes in density and stiffness. The effects of microstructure on fatigue life in cancellous bone and lattice structures are described empirically by normalizing stress in traditional stress vs. life (S-N) curves by √ψ, where ψ is the proportion of material oriented transverse to load. The mechanical performance of cancellous bone and microarchitectured materials is enhanced by aligning structural elements with expected loading; our findings demonstrate that this strategy comes at the cost of reduced fatigue life, with consequences to the use of microarchitectured materials in durable devices and to human health in the context of osteoporosis.

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BACKGROUND: Structural bone allografts are an established treatment method for long-bone structural defects resulting from such conditions as traumatic injury and sarcoma. The functional lifetime of structural allografts depends on resistance to cyclic loading (cyclic fatigue life), which can lead to fracture at stress levels well below the yield strength. Raman spectroscopy biomarkers can be used to non-destructively assess the 3 primary components of bone (collagen, mineral, and water), and may aid in optimizing allograft selection to decrease fatigue fracture risk. We studied the association of Raman biomarkers with the cyclic fatigue life of human allograft cortical bone. METHODS: Twenty-one cortical bone specimens were machined from the femoral diaphyses of 4 human donors (a 63-year old man, a 61-year-old man, a 51-year-old woman, and a 48-year-old woman) obtained from the Musculoskeletal Transplant Foundation. Six Raman biomarkers were analyzed: collagen disorganization, mineral maturation, matrix mineralization, and 3 water compartments. The specimens underwent cyclic fatigue testing under fully reversed conditions (35 and 45 MPa), during which they were tested to fracture or to 30 million cycles ("runout"), simulating 15 years of moderate activity. A tobit censored linear regression model for cyclic fatigue life was created. RESULTS: The multivariate model explained 60% of the variance in the cyclic fatigue life (R = 0.604, p < 0.001). Increases in Raman biomarkers for disordered collagen (coefficient: -2.74×10, p < 0.001) and for loosely collagen-bound water compartments (coefficient: -2.11×10, p < 0.001) were associated with a decreased cyclic fatigue life. Increases in Raman biomarkers for mineral maturation (coefficient: 3.50×10, p < 0.001), matrix mineralization (coefficient: 2.32×10, p < 0.001), tightly collagen-bound water (coefficient: 1.19×10, p < 0.001), and mineral-bound water (coefficient: 3.27×10, p < 0.001) were associated with an increased cyclic fatigue life. Collagen disorder accounted for 44% of the variance in the cyclic fatigue life, mineral maturation accounted for 6%, and all bound water compartments accounted for 3%. CONCLUSIONS: Increasing baseline collagen disorder was associated with a decreased cyclic fatigue life and had the strongest correlation with the cyclic fatigue life of human cortical donor bone. This model should be prospectively validated. CLINICAL RELEVANCE: Raman analysis is a promising tool for the non-destructive evaluation of structural bone allograft quality for load-bearing applications.

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