Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 469 | Issue 8 | Aug, 2011

Methods for Assessing Bone Quality: A Review

Eve Donnelly PhD

Bone mass, geometry, and tissue material properties contribute to bone structural integrity. Thus, bone strength arises from both bone quantity and quality. Bone quality encompasses the geometric and material factors that contribute to fracture resistance.

Whole Bone Mechanics and Bone Quality

Jacqueline H. Cole PhD, Marjolein C. H. Meulen PhD

The skeleton plays a critical structural role in bearing functional loads, and failure to do so results in fracture. As we evaluate new therapeutics and consider treatments to prevent skeletal fractures, understanding the basic mechanics underlying whole bone testing and the key principles and characteristics contributing to the structural strength of a bone is critical.

Functional Interactions Among Morphologic and Tissue Quality Traits Define Bone Quality

Karl J. Jepsen PhD

Advances in diagnostic and treatment regimens that aim to reduce fracture incidence will benefit from a better understanding of how bone morphology and tissue quality define whole-bone mechanical properties.

Raman Assessment of Bone Quality

Michael D. Morris PhD, Gurjit S. Mandair PhD

Progress in the diagnosis and prediction of fragility fractures depends on improvements to the understating of the compositional contributors of bone quality to mechanical competence. Raman spectroscopy has been used to evaluate alterations to bone composition associated with aging, disease, or injury.

Infrared Assessment of Bone Quality: A Review

Eleftherios P. Paschalis PhD, Richard Mendelsohn PhD, Adele L. Boskey PhD

Bone strength depends on both bone quantity and quality. The former is routinely estimated in clinical settings through bone mineral density measurements but not the latter. Bone quality encompasses the structural and material properties of bone. Although its importance is appreciated, its contribution in determining bone strength has been difficult to precisely quantify partly because it is multifactorial and requires investigation of all bone hierarchical levels. Fourier transform infrared spectroscopy provides one way to explore these levels.

High-resolution Computed Tomography for Clinical Imaging of Bone Microarchitecture

Andrew J. Burghardt BS, Thomas M. Link MD, Sharmila Majumdar PhD

The role of bone structure, one component of bone quality, has emerged as a contributor to bone strength. The application of high-resolution imaging in evaluating bone structure has evolved from an in vitro technology for small specimens to an emerging clinical research tool for in vivo studies in humans. However, many technical and practical challenges remain to translate these techniques into established clinical outcomes.

Diseases Affecting Bone Quality: Beyond Osteoporosis

Aasis Unnanuntana MD, Brian J. Rebolledo BA, M. Michael Khair MD, Edward F. DiCarlo MD, Joseph M. Lane MD

Bone quantity, quality, and turnover contribute to whole bone strength. Although bone mineral density, or bone quantity, is associated with increased fracture risk, less is known about bone quality. Various conditions, including disorders of mineral homeostasis, disorders in bone remodeling, collagen disorders, and drugs, affect bone quality.

The Effect of Antiresorptives on Bone Quality

Robert R. Recker MD, Laura Armas MD

Currently, antiresorptive therapy in the treatment and prevention of osteoporosis includes bisphosphonates, estrogen replacement, selective estrogen receptor modulators (raloxifene), and denosumab (a human antibody that inactivates RANKL). The original paradigm driving the development of antiresorptive therapy was that inhibition of bone resorption would allow bone formation to continue and correct the defect. However, it is now clear increases in bone density account for little of the antifracture effect of these treatments.

Anabolic Agents and Bone Quality

Tarek Sibai MD, Elise F. Morgan PhD, Thomas A. Einhorn MD

The definition of bone quality is evolving particularly from the perspective of anabolic agents that can enhance not only bone mineral density but also bone microarchitecture, composition, morphology, amount of microdamage, and remodeling dynamics.

Short-term and Long-term Orthopaedic Issues in Patients With Fragility Fractures

Susan V. Bukata MD, Stephen L. Kates MD, Regis J. O’Keefe MD, PhD

Patients with impaired bone quality who suffer a fragility fracture face substantial challenges in both their short- and long-term care. In addition to poor bone quality, many of these patients have multiple medical comorbidities that alter their surgical risk and affect their ultimate functional recovery. Some medical issues can contribute to the altered bone quality and must be addressed to prevent future fractures.

Surgical Treatment Options in Patients With Impaired Bone Quality

Norman A. Johanson MD, Jody Litrenta MD, Jay M. Zampini MD, Frederic Kleinbart MD, Haviva M. Goldman PhD

Bone quality should play an important role in decision-making for orthopaedic treatment options, implant selection, and affect ultimate surgical outcomes. The development of decision-making tools, currently typified by clinical guidelines, is highly dependent on the precise definition of the term(s) and the appropriate design of basic and clinical studies. This review was performed to determine the extent to which the issue of bone quality has been subjected to this type of process.

Bone Quality: Educational Tools for Patients, Physicians, and Educators

Junaid Shams BA, Allison B. Spitzer BA, Ann M. Kennelly BA, Laura L. Tosi MD

Defining bone quality remains elusive. From a patient perspective bone quality can best be defined as an individual’s likelihood of sustaining a fracture. Fracture risk indicators and performance measures can help clinicians better understand individual fracture risk. Educational resources such as the Web can help clinicians and patients better understand fracture risk, communicate effectively, and make decisions concerning diagnosis and treatment.

History and Systematic Review of Wear and Osteolysis Outcomes for First-generation Highly Crosslinked Polyethylene

Steven M. Kurtz PhD, Heather A. Gawel MS, Jasmine D. Patel PhD

Highly crosslinked polyethylene (HXLPE) was introduced to reduce wear and osteolysis in total joint arthroplasty. While many studies report wear and osteolysis associated with HXLPE, analytical techniques, clinical study design and followup, HXLPE formulation and implant design characteristics, and patient populations differ substantially among investigations, complicating a unified perspective.

Do First-generation Highly Crosslinked Polyethylenes Oxidize In Vivo?

Daniel MacDonald BS, Ashlyn Sakona BS, Allyson Ianuzzi PhD, Clare M. Rimnac PhD, Steven M. Kurtz PhD

Highly crosslinked and thermally treated polyethylenes were clinically introduced to reduce wear and osteolysis. Although the crosslinking process improves the wear performance, it also introduces free radicals into the polymer that can subsequently oxidize. Thermal treatments have been implemented to reduce oxidation; however, the efficacy of these methods with regard to reducing in vivo oxidative degradation remains to be seen. Polyethylene oxidation is a concern because it can compromise the ultimate strength and ductility of the material.

Vitamin E-stabilized UHMWPE for Total Joint Implants: A Review

Pierangiola Bracco MD, Ebru Oral PhD

Osteolysis due to wear of UHMWPE limits the longevity of joint arthroplasty. Oxidative degradation of UHMWPE gamma-sterilized in air increases its wear while decreasing mechanical strength. Vitamin E stabilization of UHMWPE was proposed to improve oxidation resistance while maintaining wear resistance and fatigue strength.

Europium Stearate Additives Delay Oxidation of UHMWPE for Orthopaedic Applications: A Pilot Study

Luis A. Gallardo MS, Ilenia Carpentieri PhD, Michel P. Laurent PhD, Luigi Costa PhD, Markus A. Wimmer PhD

Ultrahigh-molecular-weight polyethylene (UHMWPE) is used as an articulating surface in prosthetic devices. Its failure under various mechanisms after oxidation is of utmost concern. Free radicals formed during the sterilization process using high-energy irradiation result in oxidation. Europium, an element of the lanthanide family, has a unique electron configuration with an unusual lack of preference for directional bonding and notable bonding to oxygen. Because of this, it currently is used in studies for stabilization of polymers such as polyvinyl chloride.

Crack Propagation Resistance Is Similar Under Static and Cyclic Loading in Crosslinked UHMWPE: A Pilot Study

Jevan Furmanski PhD, Clare M. Rimnac PhD

Recent work suggests crack phenomena (eg, crack initiation and propagation) in UHMWPE do not depend on cyclic damage mechanisms. Materials for which crack phenomena occur in static (noncyclic) mode should exhibit similar crack propagation behavior under static and cyclic loading conditions.

Do Tissues From THA Revision of Highly Crosslinked UHMWPE Liners Contain Wear Debris and Associated Inflammation?

Ryan M. Baxter MS, Theresa A. Freeman PhD, Steven M. Kurtz PhD, Marla J. Steinbeck PhD

Polyethylene wear debris is a major contributor to inflammation and the development of implant loosening, a leading cause of THA revisions. To reduce wear debris, highly crosslinked ultrahigh-molecular-weight polyethylene (UHMWPE) was introduced to improve wear properties of bearing surfaces. As highly crosslinked UHMWPE revision tissues are only now becoming available, it is possible to examine the presence and association of wear debris with inflammation in early implant loosening.

Does Texturing of UHMWPE Increase Strength and Toughness?: A Pilot Study

Frédéric Addiego PhD, Olivier Buchheit PhD, David Ruch PhD, Said Ahzi PhD, Abdesselam Dahoun PhD

Crosslinked UHMWPE as a bearing surface in total joint arthroplasty has higher wear resistance than conventional UHMWPE but lower strength and toughness. To produce crosslinked UHMWPE with improved mechanical properties, the material can be treated before crosslinking by tension to induce molecular alignment (texture).

Cartilage-mimicking, High-density Brush Structure Improves Wear Resistance of Crosslinked Polyethylene: A Pilot Study

Masayuki Kyomoto PhD, Toru Moro MD, Yoshio Takatori MD, Hiroshi Kawaguchi MD, Kazuhiko Ishihara PhD

In natural synovial joints under physiologic conditions, fluid thin-film lubrication by a hydrated layer of the cartilage is essential for the smooth motion of the joints. The considerably less efficient lubrication of artificial joints of polyethylene is prone to wear, leading to osteolysis and aseptic loosening and limiting the longevity of THA. A nanometer-scale layer of poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) with cartilage-mimicking brushlike structures on a crosslinked polyethylene (CLPE) surface may provide hydrophilicity and lubricity resembling the physiologic joint surface.

Reduced Wear of Cross-linked UHMWPE Using Magnesia-stabilized Zirconia Femoral Heads in a Hip Simulator

Marcel E. Roy PhD, Leo A. Whiteside MD, Mark E. Magill MD, Brian J. Katerberg BS

To reduce wear, the ideal bearing surface in joint arthroplasty should be smooth and hydrophilic. Ceramics generally offer better wettability than metals and can be polished to a smoother finish. However, clinical studies have found no reduction in liner wear when using yttria-stabilized zirconia (Y-TZP) instead of cobalt chromium alloy (CoCr) femoral heads.

Internal Rotation of the Tibial Component is Frequent in Stiff Total Knee Arthroplasty

Martin Bédard MD, FRCS(C), Kelly G. Vince MD, FRCS(C), John Redfern MD, Stacy R. Collen MS

Stiffness complicating TKA is a complex and multifactorial problem. We suspected internally rotated components compromised motion because of pain, patellar maltracking, a tight medial flexion gap, and limited femoral rollback on a conforming lateral tibial condyle.

Does Fresh Osteochondral Allograft Transplantation of Talar Osteochondral Defects Improve Function?

Gregory C. Berlet MD, Christopher F. Hyer DPM, Terrence M. Philbin DO, Jodi F. Hartman MS, Michelle L. Wright MPH

Fresh osteochondral allograft transplantation can be used to replace talar osteochondral defects (OCDs) with single bulk osteochondral graft. While limited studies report improvement of function, improvement in quality of life and radiographic durability is unknown.

Simultaneous Nailing of Skeletal Metastases: Is the Mortality Really that High?

Bryan Moon MD, Patrick Lin MD, Robert Satcher MD, PhD, Valerae Lewis MD

The risk of death during simultaneous nailing of pathologic and impending fractures in patients with metastatic disease is believed to be so high that some authors have advocated a staged approach, especially for impending fractures. However, there are limited data to either support or refute the appropriateness of staging of multiple impending or pathologic fractures.

The Use of an Algorithm for Classifying Acetabular Fractures: A Role for Resident Education?

Thuan V. Ly MD, Michael D. Stover MD, Stephen H. Sims MD, Mark C. Reilly MD

The Letournel and Judet classification system is commonly used for classifying acetabular fractures. However, for orthopaedic surgeons with less experience with these fractures, correct classification can be more difficult. A stepwise approach has been suggested to enhance the inexperienced observer’s ability to properly classify acetabular fractures, but it is unclear whether this actually improves one’s ability.

Is Noncontact ACL Injury Associated with the Posterior Tibial and Meniscal Slope?

R. Hudek MD, B. Fuchs MD, PhD, F. Regenfelder MD, P. P. Koch MD

The risk of noncontact ACL injury reportedly is increased in patients with a greater posterior tibial slope (PTS), but clinical data are inconsistent. It is unclear whether the medial and lateral PTSs have a different impact on this connection. It also is unknown whether the meniscal slope (MS) is associated with ACL injury.

Case Report: Pseudotendon Formation after a Type III Flexor Digitorum Profundus Avulsion

Nick Pappas MD, A. Nicolas Gay MD, Nancy Major MD, David Bozentka MD

Avulsion of the flexor digitorum profundus tendon is a common injury to the hand that virtually always requires surgical repair for restoration of normal finger function.

Emerging Ideas: Can Erythromycin Reduce the Risk of Aseptic Loosening?

Weiping Ren MD, PhD, David C. Markel MD

Persistent inflammatory reaction to wear debris causes periprosthetic osteolysis and loosening. Some authors have advocated pharmaceutical approaches to reduce the inflammatory reaction. Erythromycin has antiinflammatory effects independent of its antimicrobial properties. Although oral erythromycin reportedly inhibits periprosthetic tissue inflammation in patients with aseptic loosening, long-term systematic erythromycin treatment is not recommended owing to its side effects. Therefore, it would be advantageous to restrict erythromycin delivery to the inflammatory periprosthetic tissue without causing side effects.

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