Fracture Non Union

[Biomechanics & Union] Page | 1
Fracture Biomechanics
• Bone can be considered as a biphasic composite material, mineral as one phase, and
collagen and ground substance as the other
• The combined substances are stronger for their weight than either substance alone
• Cortical bone is stiffer than cancellous bone and more brittle, withstanding less strain before
failure than cancellous bone
o Fracture occurs in cortical bone in vitro at strains of only 2%
o Fracture occurs in cancellous bone in vitro at strains of > 75%
• Bone is VISCOELASTIC (= time dependent property where the deformation of the material is
related to the rate of loading, hysteresis, creep, stress relaxation)
• Load deformation curve for bone compared to other materials = the elastic portion of the graph
has a slight curve in bone.
• Bone stiffness compared to other materials:
Bone behaviour under various loading modes

• Bone is ANISOTROPIC (i.e it has different mechanical properties when loaded along different
axes). This is ð structure of bone is dissimilar in the transverse and longitudinal directions
• Adult cortical bone is stronger in compression than tension and weakest in shear.
• Most fractures occur as a result of several loading modes
1- Tension
• At the microscopic level, the failure mechanism for bone loaded in tension is mainly
debonding at the cement lines and pulling out of the osteons
• The type of fracture occurring in tension is a transverse fracture
• Tension #s tend to occur in areas with a large proportion of cancellous bone eg calcaneum,
5th metatarsal
2- Compression
• At the microscopic level the failure mechanism for bone tissue in compression is mainly
oblique cracking of the osteons
• The type of fracture that occurs in compression is an oblique fracture at an angle of 30
degrees as shear forces at this angle are responsible for the failure.
• There are few fractures which occur purely due to compression
• These fractures tend to occur in the metaphyses of bones where there is more cancellous
bone which is weaker.
3- Bending
• In bending there is a combination of
compression and tension. Tensile stresses and
strains on one side of the neutral axis and
compressive stresses and strains on the other
side. Because bone is assymmetrical, the
compressive and tensile stresses may not be
equal
• Bending causes transverse fractures as failure
on the tension side progresses transversely
across the bone and the neutral axis shifts.
Three point bending- three forces act on a structure produce 2 equal moments, each being the
product of one of the two peripheral forces and the distance to the axis of rotation (the point at
which the middle force is applied. If loading continues to yield point assuming the structure is
2 | Page [Biomechanics & Union]
homogenous and symmetrical, it will break at the point of application of the middle force. Fracture
begins on the tension side in adult bone as bone is weaker in tension than compression. Examples
include skiboot fractures of the tibia. In immature bone it may fail by compression causing buckling
on the compression side
Four point bending- Two force couples acting on a structure produce two equal moments. The
magnitude of the bending moment is the same throughout the area between the two force
couples. The structure will break at its weakest point between them. Eg a previous unhealed
fracture.
4- Compression and bending combined

• A combination of fracture type occurs. Bending produces a transverse crack on the tensile
side of the bone, compression causes an oblique fracture on the other side. Where they
meet a butterfly segment results
5- Torsion
• A load is placed on a structure so that twisting occurs about an axis. A torque or moment is
produced within the structure.
• Maximal shear stresses act in planes parallel and perpendicular to the neutral axis
• Maximal tensile and compressive forces act on planes diagonal to the neutral axis
• The fracture for a bone loaded in torsion is a spiral fracture.
• It begins é failure in shear, with the formation of a crack parallel to neutral axis of the bone
• Followed by failure in tension along the line of maximal tensile stress at a diagonal to the axis
6- Shear
• A structure subjected to shear loading deforms internally in an angular manner, right
angles on a plane surface within the structure become obtuse or acute.
• Whenever a structure is subject to compressive or tensile loading, shear stress is also
produced
• The value for the stiffness of a material under shear loading is known as the shear modulus,
not elastic modulus
• Shear fractures tend to occur in cancellous bone eg. Femoral condyles, tibial plateau.
Bone strength
Compression Strongest
Tension Weak
Shear Weakest
Bone type Load type Elastic modulus (109 N/m2) Ultimate stress (106 N/m2 )
Cortical Compression 15.1 - 19.7 156 - 212
Tension 11.4 - 19.1 107 - 146
Shear 73 - 82
Cancellous Compression 0.1 - 3 1.5 - 50
Tension 0.2 - 5 3 - 20
Shear 6.6
Influence of muscle activity & loading on stress distribution in bone

1- When bone is loaded in vivo, simultaneous contraction of surrounding muscles act to oppose
these loads, so that it can withstand higher loads.
Wolff's Law (Julius Wolff, 1884)
• 'form follows function'.
• Bone has the ability to adapt, by changing its size, shape, and structure, to the mechanical
demands placed on it.
• Bone is laid down where needed and resorbed where not needed.
• The remodelling may be either external (a change in the external shape of the bone) or
internal (a change in the porosity, mineral content, and density of bone).
Rate dependency in bone

• Because bone is viscoelastic, its biomechanical behaviour varies with the rate of application
of forces
• Bone is stiffer and more brittle and can sustain a higher load to failure when loads are
applied at higher rates [Graph]
• Bone also stores more energy to failure before failure at high loading rates. When a bone
fractures the stored energy is released. At a low loading rate the energy can dissipate
through formation of a single crack. At a high loading rate, the greater energy stored
cannot be dissipated rapidly enough through a single crack and comminution and
extensive soft tissue damage result
Fatigue fracture of bone
• Caused by repeated applications of a load below the ultimate strength/stress of the bone
• The fatigue process in living bone is affected by the amount of load, the number of
repetitions and the frequency of loading. Fatigue fracture only occurs when the rate of
remodelling is outpaced by the fatigue process.
• Fatigue fractures tend to occur during continuous strenuous physical activity causing the
muscles to fatigue and reduces their ability to contract and counteract the imposed loading.
Influence of bone geometry on biomechanical behaviour

In tension and compression,
• The load to failure and stiffness are proportional to the cross sectional area of the bone
In bending,
• The load to failure and the stiffness are proportional to the ‘area moment of inertia.’ This is a
figure which takes into account the cross sectional area and the distribution of bone about
the neutral axis.
• The area moment of inertia for a rectangular block= BxH3/ 12 (B = width H = height)
• Block III is more resistant to bend than block I and II.

• Bones increase their area moment of inertia by distributing most of the bone tissue in the
periphery, away from the neutral axis
• In bending, the load to failure and stiffness is also inversely proportional to the length of the
bone. The longer the bone is, the bigger the bending moment produced for the same force.
• For a tubular structure / cylinder the further the material is from the neutral axis, the stiffer
the construct under a given loads = Second Moment of Area (I)
4
o Circle: I = [pi.r ] /4 (hollow: r= outer radius-inner rad.)
o Bending Stiffness = E.I (where E is Youngs Modulus)
o The region of a bone/nail with the smallest I is subjected to the largest deformation
under load & will fail first
o Indirect bone healing (thick periosteum) -> incr. I -> incr. stiffness & strength.
In Torsion:
• The load to failure and stiffness are proportional to the Polar Moment of Inertia(J)
• This takes into account the cross sectional area and the distribution of bone tissue around
the neutral axis
• J = [pi/2]x[Ro4-Ri4] = 2.I; T/ø = JG/L (T/ø= torsional stiffness, T= torque, ø= angle of twist, G=
shear modulus, L= length of shaft)
In bone healing:
• Callus formation around the periphery of a fracture increases the Second Moment of Area
(I) and the Polar Moment of Inertia(J) of a bone, thus maximising the strength and stiffness
of the bone in bending and torsion during healing.
Bone remodelling
• Wolff’s law – Bone is laid down where needed and resorbed where not needed
• Thus disuse leads to supperiosteal and periosteal bone resorption, reducing its stiffness and
strength.
• Stress protection of bone- is a phenomenon whereby an implant, by sharing the imposed
load can cause resorption of the underlying/surrounding bone as this bone carries less load
than normal.
• Bone hypertrophy can also occur at implant attachment sites, eg. Around screws.
• Laying down of bone can occur as a result of strenuous exercise, or resorption can occur in
prolonged weightlessness or inactivity.
Strain Theory of Fracture Healing
• The theory of interfragmentary strain hypothesis is that the type of tissue formed in a
healing gap depends on the strain that it experiences
• If the strain is between:
o 10%-100% granulation tissue can be expected to form
o 2%-10% fibrocartilage will form
o < 2% bone will form
Effect of movement on bone healing

Kenwright et al studied osteotomies with a gap of 3mm and subjected them to movement. They
showed that when compared to a rigidly held osteotomy there was:
• Increased bone mineral content in the gap with movement of 0.5mm (16% strain)
• Decreased bone mineral content in the gap with movement of 2.0mm (66% strain)
It is important to note that it is not compressive load but strain, whether compressive or tensile that
increases bone mineralisation
Other Factors Affecting Bone Strength

Effects of use and disuse
Rubin and Laynon in an avian model (turkey ulna):
Disuse
• 42 days without functional load decreased bone mineral content to 88% of normal
• Bone is lost from the endosteal surface
Use
• Controlled cyclical loading (as low as 36 cycles per day) produced a hypertrophic response
with an increase of between 140%-150% of normal bone mineral content
• Bone is deposited on the periosteal surface
Effects of holes on bone strength

• The strength of bone is effected by the size and shape of holes
• Holes with sharp corners will reduce the torsional strength of bone to a greater extent than
those with smooth edges due to the stress riser effect associated with sharp corners
• 4 point bending strength decreased to 80% of normal for a hole diameter of 10% of the
diameter of the bone
• Torsional strength is affected when the hole size is greater than 10% of the diameter of the
bone
• 20% size hole would reduce the torsional strength to 67% of normal
Changes in bone associated with aging

• Progressive loss of bone density occurs with age
• Young bone is more ductile /less brittle than older bone, so more strain before breakage is
allowed in young bone.
Fracture Healing
1- HEMATOMA FORMATION
2- INFLAMMATORY RESPONSE ........................... WITHIN 24-72 hours
• Injured tissues and platelets release vasoactive mediators,
growth factors and other cytokines.
• These cytokines influence cell migration, proliferation,
differentiation and matrix synthesis.
• Growth factors recruit fibroblasts, mesenchymal cells &
osteoprogenitor cells to the fracture site.
• Macrophages, PMNs & mast cells (48hr) arrive at the fracture
site to begin the process of removing the tissue debris.
Important cytokines in bone healing:

BMP Osteoinductive, induces metaplasia of mesenchymal cells into osteoblasts
Target cell for BMP is the undifferentiated perivascular mesenchymal cell
TGFβ ⊕ UMC to produce type II collagen and proteoglycans
⊕ osteoblasts to produce collagen
PDGF Attracts inflammatory cells to the fracture site
FGF ⊕ fibroblast proliferation
IGF-II Stimulates type I collagen production, cartilage matrix synthesis and cellular proliferation
IL-1 Attracts inflammatory cells to the fracture site
IL-6 Attracts inflammatory cells to the fracture site
3- REPARATIVE RESPONSE ................................. WITHIN 2 weeks

a. Vasoactive substances (Nitric Oxide & Endothelial Stimulating Angiogenesis Factor) cause
neovascularisation & local vasodilation
b. Undifferentiated mesenchymal cells migrate to the fracture site and have the ability to form cells
which in turn form cartilage, bone or fibrous tissue.
c. The fracture haematoma is organised and fibroblasts and chondroblasts appear between the bone
ends and cartilage + Type II collagen are formed (SOFT CALLUS)
d. Endochondral ossification takes place and the soft callus is turned Into (HARD CALLUS)
e. The amount of callus formed is inversely ∝ to the amount of immobilisation of the fracture.
• In fractures that are fixed with rigid compression plates there can be primary bone healing with little
or no visible callus formation.
Types of callus:
External (bridging) callus From the # haematoma Æ endochondral ossification Æ woven bone
Periosteal callus from inner cambium layer Æ intramembranous ossification Æ woven bone
Internal (medullary) callus Forms more slowly and occurs later
4- REMODELLING:
– Middle of repair phase up to 7 years
• Remodelling of woven bone depends on mechanical forces applied (W
WOLFF’S LAW - 'form follows function')
• Fracture healing is complete when there is repopulation of the medullary canal
• Cortical bone
o Remodelling occurs by invasion of an osteoclast “cutting cone” which is then followed by
osteoblasts which lay down new lamellar bone (osteon)
• Cancellous bone
o Remodelling occurs on the surface of the trabeculae ώ causes trabeculae to become thicker
Bone Remodeling
The BMU remodeling sequence
Phase Factors Description
1- Origination (+) PTH, IGF, IL-1, IL-6, After microdamage to the bone, following
PGE, calcitriol, TNF, mechanical stress, following exposure to some
NO cytokines, or at random, a BMU will originate. The
(-) estrogen lining cells become active and change from a
pancake-like to a cuboidal shape.
2- Osteoclast (+) RANK-ligand, M- Lining cells that have been activated by IL-1, PTH,
recruitment CSF calcitriol, etc (but not IL-6) will then secrete RANK-
(-) osteoprotegerin ligand, which may remain bound to the cell surface.
(OPG), GM-CSF Osteoblast precursors also secrete RANK-ligand. Pre-
osteoclasts have membrane receptors called RANK.
When RANK-ligand activates these receptors the cells
fuse and differentiate into mature multinucleared
osteoclasts which develop a ruffled border and resorb
bone. Meanwhile, OPG is a free-floating decoy
receptor, related to the TNF family, which can bind
the RANK-ligand and prevent it from activating the
RANK.
3- Resorption (+) Integrins, some The mature osteoclasts resorb bone. As the BMU
interleukins, acidosis, wanders, new osteoclasts are continuously activated
vitamin A and then start resorption. At any one spot on the
(-) estrogen, surface the resorption lasts about two weeks. The
calcitonin, interferon, osteoclasts then undergo programmed cell death or
TGF, other apoptosis, which is delayed by estrogen deficiency.
interleukins, sFRP-1
4- Osteoblast (+) Wnt, BMPs, IGF, Osteoblasts are derived from marrow stromal cells,
recruitment FGFs, PDGFs, CSF, which can differentiate into either adipocytes or
PTH, calcitriol, Runx2, osteoblasts; the transcription factor Runx2 (previously
GST-RANK-Ligand, named Cbfa1) is necessary for osteoblastic
TGF-beta differentiation. Osteoblasts are probably attracted by
(-) ? leptin bone-derived growth factors. Wnt-signalling and
bone morphogenic proteins are important.
5- Osteoid (+) TGF-beta, BMPs, The active, secreting osteoblasts then make layers of
formation IGF osteoid and slowly refil the cavity. They also secrete
(-) FGFs, PDGFs, growth factors, osteopontin, osteocalcin, and other
glucocorticoids proteins.
6- Mineralization (+) calcium, When the osteoid is about 6 microns thick, it begins
phosphate to mineralize. This process, also, is regulated by the
(-) pyrophosphate osteoblasts.
7- Mineral Other ions For months after the cavity has been filled with bone,
maturation the crystals of mineral are packed more closely and
the density of the new bone increases.
8- Quiescence The final osteoblasts turn into lining cells which

participate in the minute-to-minute release of calcium
from the bones. Some of the osteoblasts also turn into
osteocytes which remain in the bone, connected by
long cell processes which can sense mechanical
stresses to the bones.
Factors influencing bone healing
Systemic Local
Age Degree of local trauma &vascular injury
Hormones Degree of bone loss
Functional activity Local pathological condition
Nerve function Type of bone fractured
Nutrition Immobilization
Drugs (NSAID) Infection
Hormonal influences on bone healing

Hormone Effect Mechanism
Cortisone z Decreased callus production
Calcitonin y Unknown
TH/PTH y Bone remodelling
GH y Increased callus volume
Androgens y Increased callus volume
Type of immobilization and Healing

Implant Type of Healing
Cast Periosteal bridging callus + endochond ossification
DCP Primary cortical healing (cutting cone)
IMN Early ......... as cast
Late .......... Medullary callus
External Fixator z rigid ..... Periosteal Callus
y rigid ..... Primary cortical healing
Inadequate immobilization + Hypertrophic non union (ytype II collagen)
adequate blood supply
Inadequate immobilization + Atrophic non union
Inadequate blood supply
Fracture displacement Oligotrophic nonunion
Electricity and fracture healing

• Stress generated potentials serve as signals that modulate cellular activity. Piezoelectric effect and
streaming potentials are examples of stress generated potentials
1. Piezoelectric effect: charges in tissues are changed secondary to mechanical forces
2. Streaming potentials: occur when electrically charged fluid is forced over a tissue (cell
membrane) with a fixed charge
• Transmembrane potentials: generated by cellular metabolism
• Fracture Healing
1. Direct current inflammatory response
2. Alternating current repair phase collagen synthesis and calcification
3. Pulsed Electro Magnetic Field remodeling & calcification of fibrocartilage
Ultrasound
• Can decrease the time to clinical healing and radiological union
IMPLANTS FOR FRACTURE SURGERY
1. BONE SCREWS
There are two types of screws = Machine screws & Wood screws.
Bone screws are machine screws.
1. A wood screw is inserted into a small pilot hole. The screw threads compress the wood,
which is less stiff than the screw, resulting in an elastic force.
2. A machine screw is inserted into a pre-drilled & pre-tapped hole. The screw itself deforms
plastically when inserted into metal.
Screw Head
• = attachment for screwdriver
• Countersink = conical area under head
• Hexagonal head recess design is most popular because:
1. it avoids slippage of screwdriver & thus head distortion
2. it allows for better directional control during screw insertion
3. the torque is spread between 6 points of contact
Screw Shaft
• = smooth link betw. head & thread.
• The 'Run out' is the transitional area between shaft & thread. This is the area screws break.
Screw Thread
• The standard orthopaedic screw has a single thread (more threads increase the rate of advancement,
but produces less compression for the same energy)
• Core/root diameter = the narrowest diameter.
o The cube of the root diameter is proportional to the torsional strength of the screw.
• Outer/thread diameter = across the maximum thread width.
o The larger the outer diameter the greater the resistance to screw pullout.
• Pitch= the distance between adjacent threads.
o Cortical screws have small pitch & cancellous screws have large pitch
o The stronger the bone the smaller the pitch
• Lead= the distance the screw advances with each turn.
o The smaller the lead the greater the mechanical advantage of the screw.
o Cortical screws have a smaller lead than cancellous screws
• Pitch & lead = incline of a ramp. A barrel travels a shorter distance on a steeper incline before it gets
to the top, but it is harder to push it up the ramp.
• Thread design:
o 'V' profile - produces shear + compression forces
o Buttress profile - produces compression forces only
o shear forces promote bone resorption, reducing pullout strength.
• Thread length:
o Partially threaded screws are designed for lagging cancellous bone.
o 80% of the screw's grip is determined by the thread on the near cortex & 20% on the
purchase at the far cortex.
Screw Tip
1. Blunt tip of self-tapping screw - cortical
• fluted to act as a cutting edge & transport bone
chips away.
• the sharpness, number & geometry of flutes
determines its effectiveness.
2. Blunt tip of non-self-tapping screw - cortical
• the rounded tip allows for more accuracy &
direction into a pre-tapped hole.
• More 'effective torque' is obtained from pre-
tapping -> increased interfragmentary
compression.
3. Corkscrew tip - cancellous screw
• compresses trabecular bone & produces
compression by overshooting the pre-drilled hole.
4. Trocar tip -
• doesn't have a flute, thus displaces bone as it advances.
SCREW INSERTION
Drilling:
Heat Generation:
1. Bone heated to >45ºC leads to osteocyte necrosis, deactivation of alkaline phosphatase &
degradation of collagen-hydroxyapatite bone. This results in permanent alterations in the
mechanical properties.
2. Causes:
1. dull drill bit - also causes crushing of bone & small local fractures.
2. Time
3. Thick bone
4. Excessive thrust & speed
5. Dry bone
6. No drill sleeve -> drill wandering
3. Good drilling practice:
1. straight, sharp drill bit with 3 flutes & cutting angle of >70o
2. Clean the tip frequently
3. start slowly & maintain the drilling angle
4. Use a drill sleeve
5. Simultaneous saline irrigation
Tapping:
1. Allows precision placement when placing screw obliquely (lag)
2. Less torque lost in overcoming friction at the bone-screw interface.
3. Less force required. = less likelihood of losing # position.
Self-Tapping Screws => quicker, less instruments, tight fit, same holding power as pre-tapped screw.
Lag Screws:
• = involves placement of one or more screws across a fracture or osteotomy site to produce
interfragmentary compression.
• achieved by overdrilling the near cortex.
• The ideal position is perpendicular to line of fracture, but this does not provide axial or rotational
stability. Therefore, should try & use more than one screw with the other screw perpendicular to the
long axis of the shaft.
• LAG SCREW EXERTS 3000 N INTERFRAGMENTARY EVEN COMPRESSIVE FORCE FROM WITHIN THE
FRACTURE
2. PLATES:
Benefits:
• Anatomical reduction of the fracture with open techniques
• Stability for early function of muscle-tendon units and joints
Disadvantages:
• Risk of bone refracture after their removal
• Stress protection and osteoporosis beneath a plate
• Plate irritation
Types/ Techniques of Plates:
1) Compression Plate(DCP):
• Applied to the tensile surface; under compression Æ tension within plate & compression on bone.
• Compression produced by the DCP = 600 N, and not even (either on the compression side in prestressed
plates, or one the tension side in the contoured plates)
• Fracture edges resorb after 72hrs Æ z stresses in plate & bone -> improved apposition.
• Plate resists bending moment by its tension.
2) Neutralisation Plate (semitubular plate usually):
• applied at right angles to the above.
• If apposition is poor this arrangement is more rigid.
• But screws are subject to bending & torsional forces.
• Plate is centred at the neutral axis rather than the extreme fibre.
3) Buttress
4) Bridging
5) Tension-band
6) Double plates
• y torsional rigidity.
7) LC-DCP (Titanium)
• less disturbance of periosteal blood supply, reduces bone resorption under plate
• Prebending plates -> prevents gapping of cortex opp. to plate -> more uniform compression.
8) LCP locked Compression Plate:
• Best for osteoporotic patients
AO PLATES & SCREWS SIZES
BASIC LAG DCP CANCELLOUS
Drill 3.2 & 4.5 3.2 3.2/4.5
Tap 4.5 4.5 6.5
Screw 4.5 4.5 cort. 6.5 spong.
SMALL LAG DCP/Tub. CANCELLOUS
Drill 2.5 & 3.5 2.5 2.5
Tap 3.5 3.5 4.0
Screw 3.5 3.5 4.0
MINI LAG
Drill 1.5 & 2.0 OR 2.0 & 2.7
Tap 2.0 OR 2.7
Screw 2.0 OR 2.7
Max. Screw-Plate Angle:

• DCP = 25º in horizontal plane & 7º in transverse plane
• Third Tubular = 50º
• DCP EXERTS 600 N AXIAL UNEVEN COMPRESSIVE FORCE
LAG COMPRESSION DCP COMPRESSION

FORCE 3000 N 600 N (prestressing & eccentric fix)
DISTRIBUTION EVEN FROM WITHIN # UNEVEN
DIRECTION INTER-FRAGMENTARY AXIAL
BEST SUIT SMALL POROUS BONE LARGE DENSE BONE
3. INTRAMEDULLARY NAILS
Nail Length:
• The working length is defined as the length of a nail bet the
most proximal point of fixation in the distal fragment and the
most distal point of fixation in the proximal fragment = the
unsupported portion of nail between the bone fragments. More
important than actual length
• Torsional stiffness 1/working length
2
• Bending stiffness 1/working length
• Femoral bow forces the nail to contact the medullary wall Æ z
working length Æ y torsional & bending stiffness
Nail Diameter & Area moment of inertia:
• = The principal factor that alters BENDING stiffness (and shape
also)
• Distribution of material in cross section (SECOND MOMENT OF AREA) is a crucial factor to
bending
• Wider diameter hollow tube is stiffer than solid smaller dr tube é the same amount of
material.
• This is why bones have a medullary canal
• Tubes with a wall thickness/radius < 1/8 Æ behave as curved sheets rather than tubes.
These thin-walled tubes are subject to buckling. (Bone is thick-walled).
Slot:
• = The principal factor that alters TORSIONAL stiffness (POLAR MOMENT OF INERTIA)
• Non-slotted nail is 40 times stiffer in Torsion.
• A slot reduces torsional stiffness by 98% -> quicker healing with callus.
• Disadvantages: y torsional stress during insertion Æ z material around the screw holes
Locking:
Dynamic Static
Deformation control Bending & rotational Axial, bending, & rotational
Load Sharing Bearing
Used in Axially stable # Comminuted unstable #
Reaming Effects on Blood flow & union:
Normally bone has centrifugal blood flow, from centre (endosteal) outwards.
Callus is largely independent of endosteal blood supply.
1. Reaming y periosteal bl flow. (not dependent on nutrient artery), -> z endosteal bl flow.
2. 2wk: reaming markedly y blood flow.
3. 6wks flow in cortical bone recovers to normal & periosteal blood flow is still high.
Reason= centrifugal flow is reversed. (law of compensation, Treute)
4. y Reaming products = fibroblasts, bone, mesenchymal cells Æ NBF.
5. union is quicker in reamed fractures (Hooper, 1991)
Reamed vs Unreamed:
Reamed Unreamed
Larger, stiffer nail Suitable for contaminated fractures
y area of bone-nail contact
y stability of locking bolts Does not disturb the endosteal blood vessels
initial bone devascularization delayed union (due to excessive motion at # site).
y local pressure less pressure
microthrombi Æ PE less microthrombi
thermal necrosis nil
Compartment Pressures:
• Compartment pressures: yin bone (up to 300mmHg), but no change in compartmental pressure
Intramedullary Nails vs. Plates
IM NAIL PLATE & SCREWS
Load sharing Load Bearing
zendosteal circ. z periosteal circ.
Indirect reduction Direct reduction
Preserves soft tissue Destroys soft tissue
Allows # motion Rigid fixation
Early union-callus Slow union- no callus
Rare anat. Reduction Frequent anat. Red.
Failure at crossbolts Failure at plate
For segmental #'s For intraarticular #'s
For shaft #'s For juxtaarticular #'s
4. EXTERNAL FIXATION:
Advantages:
• Apply quickly
• Technically easy to perform
• Adjust later
• Soft tissues not disturbed
• Access to wounds
• Joints can be mobilized
• Can dynamize
• Easy removal
• Reconstruction surgery
Disadvantages:
1- Pin tract infection
2- Malunion
3- Patient compliance required
Types:
• Rod
1- Uniplanar
2- Biplanar
• Circular
• Hybrid
Factors affecting construct stiffness
Useful for:
1- Any fracture
2- Bone transport
3- Limb lengthening
4- Angular correction
5- Soft tissue reconstruction
6- Contractures
ILIZAROV EXTERNAL FIXATOR
1- wires= 1.5mm in adults & children; 1.8mm in adult femur.
2- wire types= smooth & olives (for stability/translation)
3- Insertion= Push-Drill-Tap
4- Aim for wires at 90deg. to each other & 4-5 wires per segment
5- Bring the ring to the wire- Not the wire to ring -Tether through muscles in joint extension
6- Wire Tension= 1.2mm-90kg; 1.5mm-110kg; 1.8mm-150kg
7- Focus = fracture / non-union site
8- Segments = bone fragments
Removal of Internal Fixation Devices:

Usually remove 12 to 18 months following insertion.
There is a very high incidence of refracture and of neurological complication following removal
of forearm plates.
Implant Failure
Definition:
• It is failure of an implant (Standard alloy) to satisfy the specific function for which it is
implanted or inserted.
• In the past, there were different improper implants not of a quality good enough to
withstand bone stresses.
• Nowadays, due to the evolution in metallurgy & biomechanics, we have (standard alloy)
which is a metal , if inserted accurately & properly, will mostly achieve the aims of its
application
Types:
This depends on Two factors:

1- Implant material choice
o Implant material
o Implant design
o Implant biochemical activity (inert or not)
2- Implant application:
o Implant type size shape
o Application technique.
Types of implant.
1) Implants for fracture fixation e.g. Plating.
2) Arthroplasty.
3) Artificial ligaments.
4) Silastic implants e.g. Bead sadius & MP Joints.
Biomechanics of implant
YOUNG’S MODULUS OF ELASTICITY : (measure of stiffness) = stress / strain.
MODULUS OF RESILIENCE: energy/vol. a material can absorb éout yielding (=area below the elastic
curve)
MODULUS OF TOUGHNESS: energy/vol. a material can absorb till breakage (=area below the curve)
AMOUNT OF DEFLECTION = measure of rigidity or stiffness of implant.
YIELD STRESS: the max stress a metal éstand éout plastic deformation
ULTIMATE TENSILE STRENGTH = the max stress a metal éstand éout # é a single peek load
7
FATIGUE STRENGTH = the maximum cyclic load a metal éstand éout # é 10 cyclic loads.
ENDURANCE (Fatigue Limit) = the cyclic load limit below fatigue will not occur
FATIGUE: failure 2ry to cyclic loading
FRACTURE: failure 2ry to bending stresses into > 2 parts
BUCKLING: failure 2ry to compression of a thin walled tube
CORROSION: failure 2ry to electrochemical action
WEAR: failure 2ry to mechanical deterioration of solid surface
CREEP & deformation
LOOSENING: failure 2ry to a biologic response of colonizing bacteria or wear particles (septic or aseptic)
Implant Failure
1. CORROSION
• MATERIAL DETERIORATION ð ELECTROCHEMICAL ACTION
• It requires a GALVANIC CELL = 2 diff electrically conducting solids + conducting pathway +
electrolytes in-between
• PASSIVATION is the formation of an oxide layer on the surface to prevent corrosion
• Types:
1) GALVANIC: between metals é different electrochemical potentials
2) FRETTING: surface breakdown 2ry to motion & loads between metal surfaces
3) CREVICE: motion bet metals depassivate their surfaces
4) PITTING: surface abrasion galvanic corrosion
5) STRESS: load generated crack galvanic corrosion Æ y the crack, and so on
6) MICRO-BIOLOGIC: micro-org secrete corrosive metabolite
7) INTERGRANULAR: corrosion at weld points & not the metal Æ structure failure (weld decay)
• Corrosion can be minimised by
o Choosing a corrosion resistant material
o Treating the surface with a passivating layer prior to use
o Not using combinations of metals in close proximity
o Careful operating technique to reduce surface scratching
o Using non modular implants.
2. FATIGUE-
• PROGRESSIVE MATERIAL DETERIORATION 2RY TO CYCLIC STRESSES BELOW THE ULTIMATE TENSILE STRESS CAUSING
CRACK PROPAGATION.
• Crack usually starts at a STRESS RISER:
o Scratch
o Hole
o Corner
o Change in cross section
o Fretting
• The stress concentration factor (ratio of maximum stress at the surface irregularity to the
average stress in the same direction depends on the geometry of the surface. Stress at a
large distal interlocking hole of an IM nail is < small hole, but the stress concentration factor
is higher é the large hole because the surface area of the metal left in that plane will be less.
• S-N CURVE relates stress applied to number of cycles to failure
• ENDURANCE, FATIGUE LIMIT is the maximum cyclic loads below fatigue will not occur. However,
it is best to consider all orthopaedic implants as having no fatigue limit as there is the
potential for damage during insertion, and the corrosive environment of the human body
and the variability of the stresses applied are difficult to control.
• Reduction of fatigue failure can be achieved by
o Appropriate design of implants, avoiding sudden changes in geometry
o Surface treatments of implant, e.g. peening, polishing
o zfretting corrosion
o Correct insertion of implants, e.g. avoiding distraction of fractures, so that bone heals
and can share the loads with the implant.
o z early WB until fracture is healing.
3- BUCKLING:
• sudden material deterioration 2ry to compression of a thin walled tube (diameter < 1/8 its length)
4. WEAR
• MECHANICAL DETERIORATION OF SOLID SURFACE
• Types: (the main are the 1st two types)
1]. ABRASIVE: the harder grooves the softer material
2]. ADHESIVE: the softer material adheres on the harder surface
3]. FATIGUE, in which repetitive loading Æ subsurface delaminate Æ lost from the surface
4]. THIRD-BODY WEAR implies the retention of debris bet. sliding surfaces Æ abrasive wear.
5]. BACK SIDE WEAR: bet PE & the metal backing
6]. RUN IN WEAR: is the accelerated wear that occur in the 1st few millions of cycling
• Effects of wear most predominant in joint prostheses. Particles produced by wear
(metal/PE/PMMA) are phagocytosed by osteoclasts Æ osteolysis Æ loosening + material loss
5. SEPTIC LOOSENING
RACE FOR SURFACE THEORY
When a total joint prosthesis is placed into the
human body, the body's cells & bacteria (usually
skin bacteria) hurry to get hold on the
prosthesis surface &colonize.
If bacteria win, thet evolve the capability to adhere
to surfaces for their survival, by secretion of a
surface glycoprotien called GLYCOCALYX:
i. Very strong adhesive
ii. Mask the bacterial antigens
iii. Colonize inside this biofilm away from
immune system
iv. Invite other types of bacteriae to trick the immune system
v. When they adhere to the inert implant surface, bacteria are protected by the
antiphagocytic effect of biomaterial. All these Æ powerful resistance 100-1000 times
against AB & immune system.
MATERIALS USED IN FRACTURE FIXATION

Stainless steel
1]. Stiff
2]. Cheap
3]. Ductile; so it is useful in contouring of plates and wires during operative procedures.
4]. Relatively inert
5]. Chromium passivate when dipped in nitric acid Æ z corrosion
6]. Can still undergo corrosion if carbon gets to the surface.
7]. y Young’s modulus - 200 Pascals (10x that of bone) Æ y stress shielding Æ bone resorption
• Used in plates, screws, external fixators, I.M. nails.
• Stainless Steel Composed of:
o Iron ................................................. 60% (cold forged or annealed to y strength)
o Chromium .................................... 20% (major corrosion protection after passivation)
o Nickel ............................................. 15% (corrosion resistance)
o Molybdenum ............................... 3% (protects against pitting corrosion)
o Carbon .......................................... 0.03% (y stiffness)
o Mg, Si, P, S .................................... 2%
Titanium and its alloys
1]. Inert
2]. Less stiff: less stress shielding & stress risers at the tip of the implant (modulus ≈ ½ of SS)
3]. More expensive than stainless steels
4]. More wear (not good for bearing surfaces)
5]. Less ductile < stainless steel, but ductile titanium alloys being produced
• Used in plates, screws, I.M. nails, external fixators, & halos.
Adhesives
• Not common in orthopaedics but potentially useful in small fragment fixation, controversial
• Prerequisits:
i. Sufficient bond strength
ii. Able to bond to moist surfaces
iii. Permit healing across the bond line
iv. Sterilizable.
Bone cement does not count as an adhesive.
CYANOACRYLATE: has poor results
FIBRIN: is the only suitable adhesive for fracture provided that it has an inherent stability or NWB
Biodegradable polymers
• Potential advantages
o Hardware removal not necessary, reducing morbidity and cost.
o Stiffness of polymer decreases as stiffness of fracture callus increases.
o Can be used in future for controlled release of antibiotics or stimulants to healing
• Requirements
o Adequate mechanical stability
o Sufficient strength over a sufficient period of time
o Degradability into products those are not harmful.
• Examples
o Polyglycolic acid
o Polylactic acid
o Copolymers
• Only about 1/20 the stiffness and strength of stainless steel
• Used in ankle fractures with poor results
• Used in phalangeal fractures with better results
Summary Of Implant Properties
Steel Titanium alloy Ceramic Composite

Stiffness ++ + +++ +
Hardness ++ + +++ +
Corrosion Resistance + ++ +++ ++
Wear Resistance + - +++ +
Ultimate Strength ++ + ++ ++
Yield Strength + +++ - +
Ductility + ++ - +
Cost ++ - -- +
Perfect Material =
1]. Stiff .................................................... resist deformation
2]. Hard ................................................. resist surface abrasion
3]. Inert .................................................. resist corrosion
4]. Tough .............................................. resist breakage
5]. Ductile ............................................. able to deform before breakage
6]. Adapt to loading
7]. Regenerate (reduce failure) = a composite = Bone (a ceramic phase (calcium
hydroxyapatite), dispersed in a collagen-based matrix).
Fracture Non-Union
Pseudoarthrosis
Definition:
• Arrest of bony fracture repair process, Short of osseous bridging of the defect between the
fracture fragments, where fibrous or cartilaginous tissue will interpose.
• Pseudoarthrosis is the final status of non-union é formation of a synovial lining & joint fluid.
Causes of non union:
General factors:
Age. Nutrition. Radiation
Burns Hyperpara Drugs: anticoagulants, steroids
Local:
1- Biological:
[1]. Individual bone succeptibility:
Scaphoid.
Neck femur
Lower 1/3 tibia. (no surrounding ms & depend on vessels)
[2]. Injury to:
Soft tissue
Vascular inj: severe injury, periosteal stripping, reaming Æ poor revascularization
[3]. Infection
Necrosis & bone devitalization bl. Supply.
Osteolysis gaps
Motion instability.
2- Mechanical:
[4]. Improper fracture coaption (gap):
Loss of bone substance
Soft tissue interposition
Distraction, Displacement, or overriding
[5]. Insufficient immobilization:
Moving fracture fragments.
[6]. Abnormal mechanics:
Shearing, torsional & bending stresses counteract the biological repair process,
e.g. Vertical fr. Neck femur Æ Shearing stresses.
Pathology non union:

Stage I ..................................................................... ( 3-6 months)
• Bone ends are covered by fibrocartilage & enclosed in a fibrous capsule
• The centre of the callus shows:
1- Amorphous fibrinoid degeneration
2- Hyaline degeneration.
Stage II ....................................................................... (2 Years)
• Bone ends become highly sclerotic
• Mechanical disturbance of the fracture Æ Cleavage of the amorphous area & formation of
extra-cellular fluid containing mucin.
Stage III ...................................................................... (2-5 years):
• Mature pseudo-arthrosis is formed:
1- Cavity filled with highly viscous fluid.
2- Lining synovial like membrane
• Callus osteogenesis never ceases, but never bridges the gap
• Proximally it is saucered concave cavity to receive the rounded distal end
• Over growth of bone around the bone ends.
• Continued fibrinoid degeneration of callus
Classification non union:
I. ACCORDING TO CALLUS FORMATION (WEBER)
A. Hypervascular (Hypertrophic)
1- ELEPHANT FOOT:
i) Rich in callus
ii) Caused by:
• insecure fixation.
• Premature W.B.
2- HORSE HOOF:
i) Poor in callus.
ii) Caused by moderately unstable
plate & screw fixation.
3- OLIGOTROPHIC:
i) Absent callus
ii) Caused by:
• Fracture displacement
• Fragment distraction
B. Avascular (Atrophic).
1- TORSION WEDGE: z Intermediate fragment
vascularity Æ unites to one end
2- COMMINUTED:
• One fragment, became necrotic
• No callus formation
• Usually complicated by plate break
3- DEFECT non-union: lost diaph fragment
4- ATROPHIC non-union:
• Lost diaphyseal fragment + atrophic ends
• After sequestrectomy, tumor excision
II. ACCORDING TO TIME OR DEGREE :
A. Delayed union: healing has not advanced at the
average rate for the site & type of fracture (usually 3-6
mo). It needs immobilization, osteoinduction, PEMF,….
B. Non-union: either é mobile gap or immobile gap
C. Synovial pseudo-arthrosis.
III. ACCORDING LOCATION:
A. Diaphyseal.
B. Metaphyseal
C. Intra-articular
IV. ACCORDING TO INFECTIONS.
A. Non-infected (felsitic).
B. Infected (static)
1. Draining.
2. Non-draining (Dry) 3 months
V. CLINICAL & RADIOGRAPHIC PALY CLASSIFICATION.
A. Type A (with bone loss < 1 cm)
1. A1 : mobile deformity.
2. A2 : stiff .
- A2.1 eout deformity
- A2.2 é fixed deformity
B. Type B (with bone loss > 1 cm).
1. B1 : with bony defect.
2. B2 : with loss of bone length.
3. B3 : with both
Diagnosis of non union:
A) History:
1. Mechanism of inj 4. Excessive traction. 7. Other # & their healing
(high or low energy) 5. Long immobilization. 8. Skin grafts or muscle
2. History of infection 6. Implant removal. transfers.
3. History of operation
B) Clinical examination, (S.&S.):
1. Pain 6. Sinus 10. joint pain, contraction.
2. Swelling 7. Limb vascularity. 11. Skin condition.
3. ROM 8. Limp. 12. Limb sensations
4. Tenderness 9. ms. Weakness. 13. Malrotation
5. Colour charges.
C) Investigations :
1. X-rays (for both sides): AP, Lateral, Obliques (rt & lt according to type of non.)
o The entire bone in diaphyseal non-union.
o Leg-length film in L.L. frs (shortening, rotation).
2. CT & Tomogram (AP, lat) , esp in metaph non- unions.
3. Arthrography or arthroscopy (to check state of cartilage in metaph non-unions).
4. Siniogram (M.blue)
5. Culture & Sensitivity test.
6. MRI.
7. EMG & nerve conduction test.
8. Arteriogram if limb circulation is doulotfull.
9. Tc99, Ga67, In111: hot zone = biologically active non-union. Cold zone = pseudoarthrosis.
1- Non-Operative Treatment
Objectives
1. Union of the bone in a reasonable time.
2. Correction of shortening, angulation or notation.
3. Mobilization of the adjacent stiff joint(s).
4. Eradication of infection.
Modalities:
1- Functional cast bracing with weight-bearing (tibia).
2- Functional cast bracing after osteotomy of intact or united fibula.
3- Electric stimulation by: invasive, semi-invasive, non-invasive
Indications:
1- Gaps > 1 cm
2- Synovial pseudoarthrosis
3- Metaphyseal non-union
4- Difficult control of # motion; e.g. proximal femur & proximal humerus
Disadvantages
1. Does not correct shortening or malposition
2. Requires long POP NWB immobilize. Æ stiffness, porosis & loss of function.
3. Usually does not suffice alone, so used as an adjuvant to operative treatment.
Principle:
Cathodal electrodes convert fibrous union to fibrocartilage endochondral ossification
2- Operative
Principles
1. REDUCTION OF THE FRAGMENTS : (provides axial compression with mechanical stability) .
• When in good position, do not dissect the fibrous tissue surrounding the periosteum
• Callus and fibrous tissue preserves the fragment's circulation Æ they ossify ofter a
bridging graft unites with the fracture fragments .
• Necrotic bone acts as a scaffold for union.
2. GRAFTING BONE Æ Induction of ostergenesi cortical .
• Bridge gaps with bone graft:
o cancellous.
o cortico-cancellous.
• Types:
A. Onlay, sliding , inlay.
B. Autogemnous, allograft.
C. Vascularized, non – vascularized.
• Also, bone covering by skin of flaps is essential.
3. CORRECTION OF BIOMECHANICAL FACTORS e.g. By osteotomy: Shearing , torsion or bending
stresses should be eliminated by e.g. McMurray medial osteotomy & Schanz Osteotomy.
4. STABILIZING THE FRAGMENTS , by a compressive device: e.g. plate & screws or Ilizarov
• External support should be for many months to guard against fatigue failure.
5. ERADICATION OF INFECTION:
• Excision of non-union site.
• Sequestrectomy.
6. EXCISION OF SYNOVIAL PSEUDOARTHROSIS.
7. PROSTHETIC REPLACEMENT : in Old patients .
8. AMPUTATION: When the anticipated results of ttt are inferior to that after amputation.
NOTES
Operative rationale:
The rationale for treatment of non-unions is to reverse the causative factors:
1]. If excess motion Æ stable internal or external fixation.
2]. If there is a gap Æ obliterating or diminishing the space by compression or bone grafting.
3]. IF there is poor blood supply.
• start early active exercise of adjacent joints.
• Shingling & cancellous bone gr Æ bone stim, induct. & revasc.
• Drilling or petalling avasc. Cortices Æ revascularization them.
N.B: SHINGLING: both sides of non union, by using sharp chisel to decorticate bone with fine asteopertosteal
fragments attached to peritoneum and muscle , assuring their vascularity, and increasing surface area of
fracture. This is usually followed by cancellous bone grating of the pocket between shingles and bone.
Principles of treatment:
1]. Know the local pathology; non-union vs delayed–union, by history, examination, PXR & Tc
2]. Correct biomechanical factors e.g. Transposition osteotomy
3]. Provide stability: by internal or external fixation.
4]. BG
5]. Excessive synovial pseudoarthrosis "When Tc shows hot zone, with central cold zone".
6]. Bridge gaps
7]. Decortications "SSHINGLING" procedure of Dunn, to elevate periosteum & ⊕ periosteal NBF
8]. Eradicate infection by
• Excision of non-unions
• Antibiotics
• Sequestrectomy
9]. Plan surgical approach to ensure skin covering.
N.B:
When large gaps are present.
OR
When a shortened extremity requires lengthening prior to the above proc.
⇓
• Vascularized fibular, iliac or rib graft. (By microvasc. Anast.)
• Continue with the external fixator till healing occurs. Encourage early joint motion.
• Don't accept mal position or shortening. It is mandatory to achieve a final mechanically neutral
position of the limb. Unacceptable major shortening is corrected by preliminary lengthening
with the Wagner apparatus before definitive fixation
• Lengthening of lesser degrees (up to l inch) is usually done as are procedure with the müller
distractor, Wagner apparatus or external fixator rods in bilateral frame configuration, at the
time of internal fixation.
Treatment of specific types of Non-union:
1- Hypertrophic vital non-union (Elephant's foot callus):
1]. Non – displaced diaphyseal
2]. Corectable diaph. Non –unions.
⇓
a]. External fixators.
b]. Closed I.M.N. (é reaming) + I.M. BG (through chest tube) ILN (if not Instability)
c]. Open I.M.N.
d]. Tension band plating.
• BG is not necessary, as hypertrophic callus provides > enough BG for healing.
• Some prefer removing excess callus Æ small fragments & use it as BG Æ y heal. Potent.
• Some prefer shingling :
a]. y surface area.
b]. Induce local bone formation
• To control rotational instability either by: Lag screw fixation, Cerclage wire.
• Before correction of deformity, insert k- wires in the proximal & distal fragments at the
exact angle & rotation to be corrected.
3]. Open displaced diaphyseal non-union
a]. Shingling
b]. Excise pseudarthrosis.
c]. Mobilize the non-union.
d]. Correct the deformity.
e]. ORIF either by: Plate, T.band, I.M.N.
2- Atrophic Non-unions:
1]. Stable fixation (plates, lag screws, I.M.N…)
2]. Shingling (or decortications).
3]. Bone graft inserted between the shingled osteoperiosteal fragments & the cortex.
1,2,3 Æ to reactivate the dormant bone healing" switch.
When the cortex is osteoporotic:

1]. With plate & screws Æ petalling instead of shingling.
2]. With IMN Æ no much reaming.
• Reinforce the screws with liquid PMMA bone cement, injected with a syringe into
the loose screw holes. Tighten! Screws only after setting cement.
• Avoid cement entesing into the fracture site.
• Use cancellous bane graft liberally.
• External hinged plaster post – operative is recommended.
3- Metaphyseal articular Non-unions : (The most difficult).

1]. Arthrotomy Æ see articular surface, realign fragments, lyse adhesions, release contractures,
remove loose bodies or fragments, gently manipulate the joint.
2]. Reconstruct the articular surface (k.wires, screws, ).
3]. Attach the reconstructed articular Block to the metaph. Or. Shaft Æ straight, blade, T,L,
spoon. Plates, with compr.
4]. Start early active motion after prelimin splinting, depend on ligam. Repair or release, or
immediately, via a C.P.M. machine.
5]. Weight bearing is late, with brace or hinged cast brace, when fr. Is uniting.
4- Synovial pseudarthrosis: (PXR, Clinical: motion at fr. Site, Tc: cold cleft)
1]. Reaming the medullary Cavity.
2]. Excision of pseudarthrosis tissue.
3]. Opening the medullary Canal.
4]. Fracture reduction.
5]. Internal fix Æ plates, IMN.
6]. Shingling.
7]. Bone grafting in atrophic types or in presence of gaps.
5- Infected non- draining non-unions:

1]. If dry for at least months Æ as non-infected, but they should be debrided of any potent
infected fibrous as granulation tissue.
2]. Shingling & bone grafting Æ if avascular bone is present.
3]. Excision of Sequestra.
4]. Internal fixation: Plates & screws / IMN with reaming.
5]. Proper antibiotics & triple antibiotics for irrig. Intra-oper.
6- Infected draining non-union:

1]. If hardware is still holding and giving stability to the fracture, leave it in situ.
2]. If hardware is loose and ineffective Æ Remove it + :
a]. Incision & drainage.
b]. Debridement.
c]. Sequestrectomy.
d]. Open packing or closed suction irrigatioin.
e]. Antibiotic- Impregnated PMMA. Beads may be used to fill the dead space till healthy
granulation tissue develops (usually 1-3 wks.)
f]. Healing the non-union:
• Tibia bypass fibula pro-tibia operatio, through posterolat app. At fr. Level or by a
proximal & distal tibial. Bl. Synastosis using cancel bonegralf & screw fix.
• Ext fixation frames Æ Unit or bil.
g]. Following successful bypass. Bridging (usually months. Etadicate the infection.
a. Saucerization sequestrectomy.
b. Radjcal cxcistion of infected sinuses.
c. Excl of fibrurs & granul tissue with the addution of another bone PMMA
anthbiotic beads.
MANAGEMENT OF INFECTED NONUNION
1. Conventional treatment:
• The object is to convert an infected draining nonunion to one that has not drained for
several months and then promote healing of the nonunion by bone grafting.
• Disadvantage: needs a long time (one or more years) and may lead to joint stiffness.
• The skin requires three operations:
1]. Wound saucarization and debridement to provide a vascular bed.
• Correct major overlap or displacement and attempt to fix the fracture:
• Plates and screws usually lead to persistent drainage.
• Pins in prox & distal fragments are incorporated in a cast may be used (less secure)
• After 4-7 days when the granulation tissue covers the wound
2]. Split thickness skin graft. After 4 wks.
3]. Full thickness pedicled graft. .
• BG is delayed until the skin graft is stabilized.
• Reconstructive operations are delayed until at least 6 mo till infection is gone
2. Active treatment:
• The object is to obtain early bone union and thus shorten the period of convalescence and
preserve motion in the adjacent joints.
• This is done in the following steps:
1]. Restore bone continuity. This takes absolute priority over treatment of infection.
Expose the nonunion through the old scar and sinuses decorticate the ends of the
bones forming small osteoperiosteal grafts (detached grafts are discarded).
2]. Remove all devitalized infected bone and soft tissue.
3]. Align the fragment and stabillze by an external fixator while applying compression
across the nonunion if possible. A plate may be used when drainage have stopped.
4]. Apply cancellous bone graft.
5]. Close as much of the wound as possible and apply suction. Give AB.
3. Ilizaroy method:
4. PEMF
ELECTRO-STIMULATION OSTEOGENESIS
Electricity and fracture healing
1]. PIEZOELECTRIC EFFECT: charges in tissues are changed secondary to mechanical forces, so the
compression side has the negatively charged potentials & the tension side has he positively charges
2]. STREAMING POTENTIALS: occur as electrically charged fluid is forced over a cell membrane
3]. TRANSMEMBRANE POTENTIALS: generated by cellular metabolism
Fracture Healing
1]. DC (Direct Current) ...................................... inflammatory response (constant better than pulsed)
2]. AC (Alternating current) ............................ repair phase collagen synthesis and calcification
3]. PEMF (Pulsed Electro Magnetic Field) ........ remodeling & calcification of fibrocartilage
RESPONSE OF BONE TO DIRECT CURRENT:
1]. Bone forms at the cathode, whereas cell necrosis occurs around the anode.
2]. Resistance rapidly y between the electrodes Æ z in current; and so further increase in the
voltage is required to keep the amperage at the optimum level.
3]. Electrically induced osteogenesis exhibits a dose –response curve:
A) Current < 5 μAmp .................... do not produce ostegenesis.
B) Current = 5-20 μAmp ............... Produce y amount of bone formation and.
C) Current levels > 20 μAmp ....... Show NBF giving way to cell necrosis.
4]. Electricity # healing & NBF, but the cathodes must be at the fracture site.
5]. Reaction at cathode Æ consumption of O2 Æ hydroxyl radicals: 2 H2O + 4e - + O2 = 4 OH-.
RESPONSE OF BONE TO ELECTROMAGNETIC FIELDS:

• Pulsed electromagnetic fields (PEMF) induce electric potentials, The polarity of these potentials
changes as the magnetic field y & z Æ alternating current in the tissue.
• The PEMF – induced currents modify cell behavior in bone, cartilage and other tissues, Thus,
by properly programming the electrical events about the mesenchymal cells, a sequence of
histologic changes can be induced. For example, the calcium contont of chondrocytes can be
y or z, cAMP, collagen & proteoglycans can be modified & DNA synthesis can be changed.
MECHANISM OF ELECTRICALLY INDUCED OSTEOGENESIS:
1]. Cathode y local O2 consumption Æ relative hypoxia Æ NBF. It is known that bone
follows a predominantly anaerobic metabolic pathway.
2]. The electric impulses realign the collagen molecules Æ initiating calcification.
3]. cAMP by electrical stimulation has also been suggested.
Methods Used For Application Of Electricity:

Invasive Semi-Invasive Non Invasive
Idea • Totally implantable electrical • Insertion of cathodes • PEMF induce electric
stimulator of three parts: indirectly into nonunion potentials ώ change
polarity as the magnetic
1. Power unit Æ DC of 20 1. The power source. field y and z, ώ Æ AC in
μamp regardless of bone the tissues.
tissue resistance Changes.
Some use a pulsed direct
current freq of 20 Hz. • Pair of coils mounted on
2. 1-4 titanium cathodes to be 2. The cathode is a Teflon the surface of the cast.
implanted in the nonunion coated stainless steel k- They should be // to each
site whether it is a single or wires percutaneously. other & centered over the
multiple fracture sites. # site
3. One anode that is placed in 3. The anode.
the soft tissues adjacent to
the generator.
Results >85% within 12-36 weeks

Cons 1. It is portable é minimal 1- High success rate, 1- Can be used in OM.
postop discomfort. 2- No need for operations. 2- No surgery needed
2. Short hospital stay. 3- z infection 3- No risk of infection
3. No pt coop needed 4- z postop pain.
5- Portable
Pros 1. Need minor op for insert & 1- Patient remains NWB for 3 1- It is not portable.
removal mo to z cathode break 2- Should be used daily for
2. Not é acute OM. 2- Not é acute OM. at least 10 hours,
3- Not é motion at # site 3- Prolonged NWB POP.
4- Pin tract infection,
5- cathodes breaking
6- Recurrence of the OM.
7- Cathode dislodgement.
Bone Graft
Definition
• Replacing missing bone, adding to existing bone, or stimulation of the existing bone to
produce adequate structural and functional support
Classification:
Indications
1. To provide structural stability (cortical bone best)
2. To provide linkage, i.e. replace missing bone:
Congenital deficiencies
Traumatic deficiencies: best to be applied at the compression side
Infections after debridement: e.g. ca sulphate granules
Tumors after excisions
3. To stimulate osteogenesis and bone healing
Non united fractures
Osteoporotic fractures
Revision surgeries
Spine fusions (TCP) & Kyphoplasty (ceramic cement)
Contraindications:
1. Infections: (can use ca sulphate bone substitutes)
Wound infection
Open fractures
2. Non-viable surrounding bone Æ not capable of supporting and anchoring the implant
3. Bone disorders that hinders BG incorporation
Inflammatory bone disease.
Metabolic bone disease é altered calcium metabolism.
Immunologic abnormalities.
Systemic disorders é poor wound healing over the implant site.
Types according to structure

1. Cortical:
• Strong immediate structural support
• Slow incorporation Æ initially weakens the graft
• ~ 50% weaker than normal bone from 6 wks - 6 mo Æ returns to normal 1-2 y after
2. Cancellous:
• Revascularised more quickly
• Osteoblasts lay NBF down on old trabeculae which is later remodelled
• Only surface cells remain viable by diffusion.
3. Cortico-cancellous:
• Produce both structural stability & quick incorporation
4. Osteochondral
• For tumour surgery
• Osteochondral graft survival enhanced by immersion in glycerol
5. Bone marrow & bioactive inductive substances:
• BMAT; has osteoprogenitor cells
• BMP; impregnated ceramics
Types According to Source
1. Autografts
• From the same person, most still dies
• No immunogenicity
• Highest osteogenic and osteoinductive capacity
• Revascularized more quickly than allograft
• Donor site morbidity (20%) with hematoma, pain, fracture, wound infection
• Limited supply
• Best reserved for area of large bone loss or irradiated tissues
• No resorption at either ends of BG, segment heals as a fracture
2. Isograft:
• Same as allograft but from genetically identical twin Æ not immunogenic
3. Allograft
• Donor bone from another person
• No donor site morbidity
• Large amounts available
• Not osteogenic
• Incorporation:
o Qualitatively similar to that for autografts
o Delayed (μß ð collagen alteration after irradiation)
o Less extensive
o Biologically inferior
• Immunological response and less reliable incorporation
• Infection 10% Æ 80% clinical failure
• Transmission of HIV, Hep B, Hep C
4. Xenograft
• From a different species i.e. porcine, bovine
• Similar to allograft bone after freezing and irradiation.
5. Synthetic Grafts / Ceramics (see later)

1]. Allograft matrix
2]. Polylactic & Polyglycolic matrix
3]. Hyaluronic acid
4]. Collagen
5]. Ceramics
Types according to fuction
1- OSTEOINDUCTIVE: = BIO-ACTIVE POLY-PEPTIDES THAT BONE FORMATION
I. Bone Morphogenetic Proteins (BMP.s):
• Recruit & progenitor cells of osteoblast lineage
• bone collagen synthesis.
II. Insulin-Like Growth Factor (IGF):
• It plays a critical role in growth, whether it plays a role in bone healing is less certain.
III. Platelet-Derived Growth Factor (PDGF):
• Potent mitogen for UMC
• DNA synthesis, cell replication, and production of collagen
IV. Transforming Growth Factor-ß (TGF-ß):
• Mesenchymal cell growth and differentiation
• Collagen synthesis
• y fibroblasts and macrophages chemotaxis
• TGF-ß y osteoinductive activities of BMP.s.
V. Fibroblast Growth Factors (FGF.s):
• Mesenchymal cell growth and differentiation
• The most studied members are aFGF and bFGF
2- OSTEOGENIC: = ACTIVE CELLS CAPABLE OF BONE PRODUCTION

I. Unfractionated Fresh Bone Marrow: BMAT
• Harvested from the iliac crest and immediately transplanted to skeletal repair
• Simple procedure that is inexpensive and can be done on an outpatient basis.
• Limited source of osteoprogenitor cells
• Complications of harvesting
II. Connective Tissue Progenitors:
• Able to replication without differentiation, & has multilineage developmental
potential.
• C.T. progenitors are expanded in number without undergoing differentiation.
III. Differentiated Osteoblasts & Chondrocytes
• Difficult to obtain > osteoprogenitor cells & has limited capacity for proliferation
• Mature osteoblasts could be generated from culture expanded progenitor cells
IV. Genetically Modified Cells:
• In this new technique, gene therapy is used for treatment of bone cells, using a
delivery vehicle to transmit the genetic material coding for osteoinductive stimuli
3- OSTEOCONDUCTIVE (scaffolds) = materials that attachment, migration, and distribution

of cells responsible for bone-healing
I. ALLOGRAFT BONE MATRICES:
• Although allograft bone lacks any viable cells that might contribute to NBF
• Allograft matrix is highly OSTEOCONDUCTIVE é some osteoinductive properties.
• Drawbacks; less satisfactory results < autograft, disease transfer, & immunogenic reaction
II. COLLAGEN: (delivery system)
• Collagen is conductive to bone formation
• Surface contains sites for deposition of mineral
• Binds the non-collagen proteins, which provides sites for cell attachment
III. HYALURONAN:
• Hyaluronan is not osteoconductive, but it is useful tissue engineering substrate
IV. POLYLACTIC AND POLYGLYCOLIC POLYMERS:
• Degradable polymers have little osteoconductive potential
• Highly biocompatible so it is used also a successful substrate in tissue engineering
V. CERAMIC MATRICES:
A. HA from corals: = HYDROXYAPATITE:
• Derived from coral ca carbonate, PORITES as cortical bone & GENIPORA as cancellous
• Slowly resorbed & low porosity
B. Calcium Sulfate Matrices:
• Can be used in presence of infection, & is the cheapest
• Two forms, with or without AB.
C. Tricalcium phosphate:
• The porosity ≈ 35%, with pores ranging from 100-300 μM.
• Greater solubility >HA, and as a result implants are reabsorbed more rapidly.
D. Injectable Ceramic Cements : These Injectable cements are usually composed of α-TCP,
dicalcium and tetra calcium phosphate monoxide.
• Cements can be injected into # sites or bone defects
E. Ultraporous β-tricalcium Phosphate:
• A newly developed β-TCP é higher porosity & faster resorption.
• Larger surface area is exposed to cells and nutrients.
• Ultraporous β-TCP seeded é autologous BM could act as autograft
COLLECTION OF DONOR BONE (Femoral Heads)

• Blood tests (HIV, Hep B, VDRL, Rhesus)
• Swabs are taken form cut site & acetabulum
• Head placed in 2 sterile bags, sterile container & un-sterile bag
• 2.5 MRad of γ radiation
• Stored in (-70°C) ultra cold freezer
Preservation & transplantation:
1- FRESH - requires no preservation. No test for disease or sterility. There is y immune response.
The application of fresh allograft is limited to joint resurfacing.
2- FROZEN < (-60°C) Æ enzyme degradation Æ z immunogenicity + intact mech. Properties
3- LYOPHILIZED (Freeze-Dried):
• Removing water + vacuum packing + freezing + storage up to 5y
• z antigenicity
• Osteoconductive only
• Biomechanical alteration on rehydration.
4- IRRADIATED:
• Powerful sterilizing method
• z antigenicity
• Biomechanical alteration
Graft Healing
STAGE DESCRIPTION
1- Haemorrhage
2- Inflammation Chemotaxis stimulated by necrotic debris
3- Revascularisation
4- Creeping Substitution Replacement of necrotic host tissue by donor NBF
along the invasive host Bl. v v.
1]. Osteoblast differentiation ............... From Precursors
2]. Osteoinduction ................................... Osteoblast and clast function
3]. Osteoconduction .............................. New bone formation over a scaffold
5- Remodelling Continues for years
Factors adversely affecting healing
1- General:
o Mal nutrition
o Debility
o Extreme ages
o Drugs: NSAID’s, diphosphonates
2- Local:
o Severe soft tissue laceration & devitalization
o z Vascularity
o Infection
o Foreign Material
Immunogenicity
In general bone and cartilage ................. weakly immunogenic
Fresh allografts .............................................. most immunogenic
Freeze dried (lyophilized) ................................... least immunogenic; but BMP is depleted + low structural
integrity
Irradiation ....................................................... alter its structural strength
Advantages of grafts:
1]. Decrease cost: by seeking new definitive treatments (e.g. Osteoarthritis).
2]. Solve many reconstructive problems
3]. Good results as regard management of delayed and non union
4]. Multiple & variable sources
5]. Allo & synthetic grafts avoid autograft harvesting & donor site morbidity
Disadvantages:
1]. Disease transmission e.g. xeno & allografts
2]. Unavailable technology for the recombinant and genetically modified options
3]. Decreased osteogenic efficacy as compared é autografts
4]. Cell expansion & differentiation still under trials
5]. Osteoconductive matrices are still expensive
Properties of Bone Graft Materials

Material Osteoinductive Osteogenic Osteoconductive Integrity
AUTOGENOUS CANCELLOUS BONE ++ +++ +++ -
AUTOGENOUS CORTICAL BONE + + + ++
VASCULARIZED AUTOGRAFT + + + +++
ALLOGRAFT "+/-" - + +
BONE MARROW + + + -
DBM + - ++ -
COLLAGEN - - + +
CERAMICS - - + +
BMP "++" - - -
"+ = Moderate" " ++ = Marked " " - = None" " +/- = Some "
Cartilage Substitutes
• No consistently reliable means to regenerate joint cartilage currently exists.
• As with bone tissue engineering we have three basic elements for cartilage:
1- Growth Factors.
2- Chondorogenic cells.
3- Matrices ( Scaffolds).
1- GROWTH FACTORS
a. INSULIN-LIKE GROWTH FACTOR (IGF) :

• IGF.s, beside their effect on osteoblasts, known to be differentiative and mitogenic for
cartilage tissue. Their importance lies with their role in osteoarthritis.
b. BONE MORPHOGENETIC PROTEINS (BMP.S):
• BMP.s based on their variable functional expression, are able to modulate
chondrogenesis
• Theoretically, BMP.s are optimal growth factors to recruit undifferentiated stem cells
for the repair of full-thickness articular cartilage defects as they are unique in that they
can initiate the formation of cartilage by a process similar to the endochondral
ossification that occurs in the growth plate..
c. HEPATOCYTES GROWTH FACTOR (HGF):
• HGF has been reported to have mitogenic effects on chondrocytes, meniscal cells, and
ligament cells.
d. BASIC FIBROBLAST GROWTH FACTOR (BFGF):
• Several reports have shown that bFGF is capable of inducing repair of superficial or
partial thickness articular cartilage defects when injected intraarticularly..
e. TRANSFORMING GROWTH FACTOR-β (TGF-β):
• TGF-β is produced by articular chondrocytes and remains in the cartilage in a latent
form. It has been reported to influence the proliferation of human articular
chondrocytes.
2- CHONDROCYTES AND UNDIFFERENTIATED MESENCHYMAL CELLS
• Produce a new cartilage matrix.
• Selective transfer of gene expression to chondrocytes or chondroprogenitor cells may
be preferable to synovial cell transfer. These studies are encouraging for the future use
of ex vivo gene transfer to chondrocytes to treat cartilaginous defects.
3- ARTIFICIAL MATRICES
• y ingrowth of new cells
• y matrix formation
• Protective
• Different methods for holding matrices and cells in articular cartilage lesions may
include GLUES, FLAPS, PINS….etc.
• Intra-Articular Inj of Hyaluronan is an example of matrices in cartilage tissue engineering
Medically appropriate administration
1- Osteoarthritis of knee is documented with radiographic evidence: and
2- Osteoarthritic knee pain that interferes with functional activities such as; ambulation,
prolonged standing , etc.; and
3- Lack of functional improvement following a trial of at least three months of conservative
therapy; and/or Inability to tolerate NSAID therapy
4- Failure of at least one injection of a steroid product into the knee resulting in unsatisfactory
relief or relief that lasted less than three months.
• Repetition of a cycle (3 to 5 injections) every 6mo, if symptomatic relief from the previous
course of ttt has been confirmed and documented, is considered MEDICALLY APPROPRIATE.
Medically Inappropriate administration

1- Active inflammatory joint disease or synovitis affecting the knee (e.g., crystal synovitis,
rheumatoid arthritis)
2- Presence of infection of the target joint or skin surrounding the proposed site of injection
3- Allergy to birds, feather, eggs etc
4- Pregnancy.
• Repetition of treatment cycles (3 to 5 injections), more frequently than every six months, is
considered NOT MEDICALLY APPROPRIATE.
Terminology:
1- AUTOGRAFT: is tissue transplanted from one area to another in the same individual.
2- ALLOGRAFT: is tissue transplanted from one individual to another.
3- XENOGRAFT: is tissue transplanted between animals of different species.
4- ORTHOPTIC: anatomically appropriate graft.
5- HETEROTOPIC: anatomically inappropriate graft.
6- OSTEOGENESIS: bone formation with no indication of cellular origin. This may be graft or host
origin (i.e. osteogenesis refers to augmentation of bone formation).
7- OSTEOINDUCTION: refers to recruitment from the surrounding bed of mesenchymal-type cells,
which then differentiate into cartilage forming and bone forming cells. Osteoinduction is
mediated by graft-derived factors.
8- OSTEOCONDUCTION: refers to the three-dimensional process of ingrowth of sprouting capillaries,
perivascular tissue and osteoprogenitor cells from the recipient bed into the structure of the
graft. Simply, the graft functions as a scaffold, for the ingrowth of new host bone.
9- BIOMATERIAL: A non-viable material used in a medical device, intended to interact with
biological systems.
10- BIOCOMPATIBILITY: The ability of a material to perform with an appropriate host response in a
specific application.
11- BIOINERT: No host response to the material.
12- IMPLANT: An object made from non living material that is inserted into the human body where
it is intended to remain for a significant period of time in order to perform a specific function.
13- POLYMER BONE GRAFT: nonviable engineered materials formed from polylactic acid and/or
polyglycolic acid, nylon, animal derived collagen and other materials. Depending on the
material it degrades through inflammatory or metabolic processes. In some formulations its
mechanical properties allow it to be used as a resorpable plate or screw.
14- CERAMIC BONE GRAFT: nonviable brittle dense engineered material, solid or with formed or
natural porosity, generally available in powders, granules or standard geometric shapes such
as blocks and wedges. Most formulations degrade very slowly with some newer formulations
being reported to degrade more rapidly.
Zobad
Topic: Definition Notes
Load Is the force applied (newton)
Stress(ð) (nominal, F/A= N/m²= Pa= the force applied True stress (ðt) uses true csa instead of original csa (as
engineering) over a surface unit area. (measure with nominal stress).; ðt= [F/original csa] x [1+ nominal
of the force on an object) strain].; ðt>>ðn because of lower csa ('Necking')
Strain (ε) L-Lo/Lo = a ratio between the true strain= ln(1+ nominal strain).
change of length : original length
= how far atoms are displaced apart
Strain types 1]. Bending:
o 3 points bending
o 4 points bending
o Cantilever bending
2]. Compressive buckling
3]. Shearing
4]. Torsion
Stress Shielding Is the stress by pass from the less stiff material to the more stiff one when they are fixed
together
HOOKE’S Law Stress is directly proportionate to strain till the yield point (Robert Hooke, 1678)
Yield stress Is the stress beyond which the material will express plastic deformation (yield point= elastic
limit)
Tensile Strength Max stress the material can resist without breaking when exposed to a single load, beyond ώ
continuous deformation occur even with decrease of the stress
Failure Strength Max stress beyond which the material eventually fail
Fatigue strength Max cyclic loads the material can resist without breakage when exposed to 107 cyclic loads
Endurance Max cyclic loads below fatigue will not occur (theoretical for ortho implants)
(Fatigue Limit)) Polished steel endurance = ½ the tensile strength
YOUNGS Modulus measure of STIFFNESS of a material. =stress/strain. Usually the same in tension & compression
of elasticity (E)
Strain Energy(U) The increase in energy associated with the deformation of a structure, as a result of the
(Joules) application of a slowly increasing load. = Area under load-extension curve.
Strain Energy Energy associated é deformation of Strain energy density obtained by loading to rupture
Density (u) (J/m³) a structure, eliminating the effects MODULUS OF RESILIENCE= energy per unit volume that
of the structures size. =area under the material can absorb without yielding (= area under
stress-strain curve. u= stress²/2x elastic portion of stress-strain curve).
Modulus.
Strain y yield strength, z ductility & toughness, unchanged modulus(stiffness).
Hardening
Toughness Ability of a material to resist Toughness measurements:;
breaking (i.e. absorb energy & deform a. MODULUS OF TOUGHNESS =The area under the
plastically) = energy/unit volume a curve up to the breaking point
material can absorb before failure. b. Impact Tests- Charpy
Tough material has yductility & yyield
stress & withstands ystresses & c. Fracture toughness: ability to resist crack propogation
ystrains.
Stiffness Ability of a material to resist 1]. Axial Stiffness(A) = [pi/4]x [Do-Di];
deformation. Measured as Elastic 2]. Bending Stiffness= Area Moment of Inertia(I)
Modulus. 3]. Torsional Stiffnes= Polar Moment of Inertia(J)
Hardness Measure of a materials resistance to Hardness Tests: ; 1. Brinell- 10mm steel ball,
abrasion or indentation. Hardness is HB=F/½piD[D-sq.rt(D²-d²)]; 2. Vickers- pyramid-shaped
proportional to Tensile Strength. diamond, HD=1.854F/d²; 3. Rockwell
Ductility/ Is the ability of a materials to deform Measures of Ductility
Brittleness before they break (elastic & plastic) / 1. Percentage Elongation
2. Percentage Reduction in cross-sectional area
Is the resistance to plastic 3. Bend tests;
deformation before breakage 4. Cupping tests(Erichson);
5. Impact test(Charpy) - ductile absorb yenergy till #
SOURCIL Subchondral bone condensation at superomedial acetabulum (R is maximum at this point)
GOTHIC ARCH Remodeled bone at the acetabular roof above the sourcil
Euler's Column Determines critical load for scoliosis. Pcrit = C.(E.I/L²); Pcrit = critical load, C=end conditions, E
Law = modulus, I = moment of inertia, L =column length.
Definitions Kinematics= Analysis of motion w/out reference to forces.;
Kinetics= Analysis of motion under the action of given forces or moments. (= static /
dynamic); Statics= study of forces & moments acting on a body in equilibrium (at rest or
constant speed)
Dynamics= study of forces & moments acting on a body (accelerating/ decelerating)
Failure When a material lost its ability to Types(7):
satisfy the original design function. 1].FFATIGUE: failure 2ry to cyclic loading
FRACTURE: failure 2ry to bending stresses into > 2 parts
2].F
3].BBUCKLING: 2ry to compression of a thin walled tube
4].CCORROSION: 2ry to electrochemical action
5].WWEAR: mechanical deterioration of solid surface
6].CCREEP & deformation
7].LLOOSENING: septic & aseptic
Failure Ductile metals may fail in a brittle manner at; low temps, thick sections, at high strain rates or
where there are flaws.
Fatigue The z of strength by the application Low cycle fatigue = max. stress in a cycle > yield stress.
of cyclic loads below the tensile High cycle fatigue = max. stress in a cycle < yield stress.
strength of the material. This z by surface scratches.; PEENING= light hammering of
the surface with a round-nosed hammer Æ y Fatigue Life by
inducing residual compressive stresses in material
Fatigue Fracture Occurs in 3 steps:;
1]. Nucleation of a crack- occurs at locations of highest stress & lowest local strength. These are
usually at or near the surface & include surface defects, such as scratches or pits, sharp
corners, inclusions, grain boundaries or dislocation concentrations.;
2]. Propagation of a crack- towards lower stress regions. The crack propagates a little bit
further each cycle, until the load-carrying capacity of the metal is approached
3]. Catastrophic failure- in a brittle manner; implant buckles into 2 or more parts when the load
is changed during service.
Endurance Is the cyclic load limit below fatigue will not occur (theoretical for ortho implants)
(Fatigue Limit)) Polished steel endurance = ½ the tensile strength
Corrosion Destruction of metal by electrochemical action
Corrosion 1) GALVANIC: between metals é different electrochemical potentials
Mechanism 2) FRETTING: surface breakdown 2ry to motion & loads between metal surfaces
3) CREVICE: motion bet metals depassivate their surfaces
4) PITTING: surface abrasion galvanic corrosion
5) STRESS: load generated crack galvanic corrosion
6) MICRO-BIOLOGIC: micro-org secrete corrosive metabolite
7) INTERGRANULAR: corrosion at welding points &not the metal Æ structure failure (weld decay)
Corrosion z by o PASSIVATION (surface oxidation) ○ Implants é one metal type
o PEENING (light surface hammering) ○ Implants é non modular components
o POLISHING ○ Implants é inert metal
o Heat treatment
o Good surgical treatment technique to z abrasions
Types of Material 1]. ISOTROPIC= has same properties in all directions.;

2]. ANISOTROPIC= different properties in diff. directions.;
3]. ORTHOTROPIC= has same properties in a particular direction throughout the material
4]. BRITTLE = has linear stress strain curve till failure; i.e. zaffinity for plastic deformation
5]. DUCTILE = has great affinity for plastic deformation before failure
6]. VISCOELASTIC = has time-rate dependant stress strain curve (e.g. bone and ligament)
Creep Continuous deformation under constant stress.
It is stress, time & temp. dependent (fatigue is stress & time dependent only).
Stress Relaxation Decrease stress under constant strain over time.
Hysteresis Viscoelastic phenomenon that exhibits a different loading & unloading patterns of stress-strain
curve when subjected to cyclic loading,
ENERGY (JOULES) The ability to do work. Potential E=MGH (static energy);
Kinetic E=½mw² (motion energy)a, w=angular velocity
Energy cannot be created or destroyed.

Tribology concept 1]. Wear
2]. Friction
3]. Lubrication
1]. Wear Material shedding from solid surfaces as a consequent of the mechanical action.
1. ABRASIVE: the harder grooves the softer material
2. ADHESIVE: the softer material adheres on the harder surface
3. FATIGUE, in which repetitive loading Æ subsurface delaminate Æ lost from the surface
4. THIRD-BODY WEAR implies the retention of debris bet. sliding surfaces Æ abrasive wear.
5. BACK SIDE WEAR: bet PE & the metal backing.
6. RUN IN WEAR: is the accelerated wear that occur in the 1st few millions of cycling
2]. Friction The undesirable effect when two F=μR (μ= coefficient of friction) (frictional force, F, is
surfaces move in contact with each proportional to the normal component of the reaction
other. force, R); μ=tanø (ø is the critical angle on an incline
when motion starts to occur= 'angle of friction')
Coefficient of the resistance encountered in Normal joints= 0.008-0.02; metal-on-metal= 0.8; metal-
Friction moving one object over another. UHMWPE= 0.02; metal-bone= 0.1-0.2; ceramic-ceramic=
v. low; ceramic-UHMWPE= v. low; metal-ceramic= v. high
Coulombs Law of The shear stress is always parallel to the relative velocity & equal to the product of the contact
Friction pressure & the dynamic friction coefficient as determined from measurements on particular
combinations of materials. [Shear Stress= Compressive stress × Coefficient of Friction]
Torque Rotational Force [Newton X T= I x α; [I = Mass Moment of Inertia (Nm.sec²); α = angular
Meters(Nm)] acceleration (radian/sec²)]
Frictional Torque Is the force transmitted from head-PE interface to bone interface through out the motion arc
3]. Lubrication 1]. ELASTOHYDRODYNAMIC = the bearing materials deform elastically; friction is determined
by the complete lubricant film that separate the bearing surfaces
2]. BOUNDARY LUBRICATION = the bearing surfaces come much closer together & friction is
determined by the coefficient of friction of the non-deformable material surface (lubricant
partially separate the surfaces)
3]. BOOSTED LUBRICATION = the bearing surfaces are partially separated by pools of lubricant
ώ is trapped by areas of bearing surfaces
4]. HYDRODYNAMIC LUBRICATION = the load & motion influence the lubricant film between
the bearing surfaces.;
5]. WEEPING LUBRICATION = in which fluid shifts from cartilage to loaded areas
Wetability Is the affinity of a material to a Depends on the surface tension of the material = the
lubricant material angle of contact bet the material and a lubricant drop
Velocity the rate of change of the position of = a Vector (has magnitude, direction & sense). Speed is
the body. scalar (only has direction).
0.1% Proof Stress the stress which results in a 0.1% Line drawn on force-elongation/ stress-strain graph
plastic strain. For materials where parallel to the linear part of graph & passing through the
the yield stress is not easily 0.1% strain value(=0.1% gauge length).
identified (aluminium). (proof stress
not usually quoted for polymers)
Annealing Process involving heating to & Results in a softened state (more ductile), to facilitate
holding at a temp. high enough for cold-working, improved machine-ability and mechanical
recrystallization to occur and then properties.; eg. Orthop. wires (stainless steel 316L,
cooling slowly. annealed)
BOYLE'S Law Pressure= Force/Area
BARBA'S Law Takes into consideration the effect % Elong.= {[a x sq.rt.(csa)/gauge length] + b} x100
of csa on % elongation in Tensile
testing.
Bone Fracture Bone fails in TENSION. Shear failure is a tension failure, but crack propagates in spiral because of
the ANISOTROPY of bone.; *Haversion canals help to prevent crack propagation.
Brittle Fracture Break a material, & the broken ends fit together perfectly (i.e. no reduction in csa).
Solid 1]. METALS: High tensile strength & modulus of elasticity, medium hardness, can be ductile, poor
materials resistance to corrosion, high electrical & thermal conductivity.
ALLOYS-
• Mild steel= iron & carbon;
• Stainless steel- Fe, chromium, carbon & manganese (C y strength, Cr y R to corrosion)
• Vitallium= chromium, cobalt & molybdenum alloy (historical).
2]. POLYMERS:
1]. Thermosets= decompose when heated. Bakelite.
2]. Thermoplastics= soften when heated.
POLY-ETHYLENE. Low modulus of elasticity; low hardness; medium tensile strengths; ductile;
low densities; high corrosion resistance; low electrical & thermal conductivities; tend to creep;
properties depend on temp. Can withstand high strains, not high stresses.;
3]. CERAMICS:
1]. Brittle (Can withstand high stresses, not high strains)
2]. Hard
3]. High modulus of elasticity
4]. Stronger in compression than in tension
5]. Low electrical conductivity.
4]. COMPOSITES: two different materials bonded together. More expensive to produce.
Alloy A substance containing two or more metals mixed in ! liquid phase.
Ceramics A substance chemically comprised Properties determined by ionic bonds, stronger than
of metallic and non-metal covalent bonds of polymers & metallic bonds of metal.;
elements/molecules (eg. ZnO, SiO, 1]. High chemical resistance.
TiO2)) 2]. High Elastic Modulus.
3]. Highly Crystalline -> Brittle.
4]. Hard -> High wear resistance.
5]. Inert (eg. calcium hydroxyapatite).
6]. Can éstand high stresses, but cannot produce
high strain
NB- because of high melting point large ceramics are
prepared by compressing small powder particles Æ this
always has small defects Æ stress risers + Brittle Æ WEAK.
Composites = a multiphase material. The Types:;
constituents must be chemically 1]. PARTICLE REINFORCED:
dissimilar & seperated by a distinct a. Large particle (concrete)
interface. (matrix & dispersed b. Dispersion strenthened (atomic);
phases). It should provide distinctive 2]. FIBER REINFORCED: whisker, fiber, wire; continuous,
properties that cannot be obtained by discontinuous; aligned(anisotropic),random(isotropic);
the individual components alone.
High strength to weight ratio.
3]. STRUCTURAL:
a. Laminar(wood)
b. Sandwich panels.
Finite = The ability to model structures of The main requirement is to have, for a range of elements of
Element complex geometry as an assemblage varying shapes, solutions of the governing differential
Modelling/An of simple elements. equations for arbitrary boundary conditions.
alysis (FEM)
Instant centre It is the point about which the joint rotates
of rotation
Free Body The segment of the body of interest. The segment is assumed to be in equilibrium.
Diagram
IM Nails *Tubes é a wall thickness:radius ratio of < 1/8 tend to behave as curved sheets rather than tubes.
These thin- tubes are subject to buckling. (Bone is thick-walled).; *A wider diameter hollow tube is stiffer than a
solid smaller diameter tube with the same amount of material. A slot/slit Æ z torsional stiffness by 98% ->
quicker healing with callus.
Topic: Def: Notes:

PE - Glossary • BASE RESIN - The PE granules or powder; the raw source polymer.
• MEDICAL-GRADE PE is a very small percentage of the worldwide production of PE. Only ultra-
high molecular weight material is used in the manufacturing of components for total joint
replacement.
• CALCIUM STEARATE - A compound mixed with the PE powder (in some grades of the
material) before it is formed into a solid. The calcium stearate serves as a scavenger of residual
acid. In ram extrusion, it also acts as a lubricant, and has been shown to help prolong the life
of the manufacturing equipment. It also results in the poly ethylene having a whiter color.
However, some reports have indicated that fusion defects are more common in PE that
contains calcium stearate. Fusion defects may make the component more susceptible to crack
initiation and propagation. Consequently, many manufacturers now use grades of PE that do
not contain calcium stearate. However, the quantitative effects of calcium stearate on the
wear properties of PE components are a subject of ongoing debate. ; In several retrieval
studies, components manufactured from 1900 PE resin have shown significantly lower levels
of oxidation following sterilization by gamma irradiation in air. The reason(s) for this have not
been clearly identified.
• CHAIN SCISSION - Breakage of the long chains of PE into shorter molecules. Extensive chain
scission can substantially increase the crystallinity, density, stiffness and brittleness of the PE,
weakening the material. Oxidation is a primary cause of chain scission in PE.
• COMPRESSION MOLDING - A consolidation method that subjects the PE powder to high
temperature and pressure, fusing it into a solid form, either into bulk stock for subsequent
machining, or into net-shape components.
• CONSOLIDATION - The fusing of PE powder into a solid form by application of heat and
pressure. The two principal methods of consolidation are compression molding and ram
extrusion.
• CROSS SHEAR - The particular type of stress applied to the surface of the PE component due to
the crossing-path motion of the femoral ball. Crossing-path motion is also present, albeit to a
lesser extent, in some designs of knee prostheses. Studies have shown that PE wear is 10 to
100 times greater with crossing path motion than with simple linear reciprocating motion.
• CROSSLINKING - The process by which chemical bonds link carbon atoms in adjacent PE
molecules by combining two free radicals. Cross linking has been shown in laboratory wear
simulators (both hip and knee) to markedly y the wear resistance of PE.
• ELECTRON BEAM IRRADIATION - Also known as E-beam, the PE is bombarded with high-
energy electrons which induce crosslinking. Because there is more attenuation of an electron
beam than gamma rays, a high beam energy (e.g., 10 MeV) is used to produce crosslinking in
the PE. Residual free radicals generated by the electron beam can be extinguished by an
appropriate post-crosslinking thermal treatment to avoid long-term oxidative degradation; EtO
sterilization - A sterilization method that utilizes ethylene oxide gas (EtO). EtO does not induce
free radicals or oxidation; it also does not induce crosslinking. To eliminate the toxic gas,
components must be outgassed for a sufficient period prior to being implanted.
• FREE RADICAL - An electron on an atom that is a potential reaction site for oxidation or cross-
linking.
• GAMMA IRRADIATION - Irradiation by exposure to a radioactive cobalt source, which emits
gamma rays. Gamma radiation (in air) has been the predominant method used to sterilize
prosthetic joint components for more than two decades, with free radical production,
oxidation and crosslinking being unintentional by-products. Only recently has gamma
radiation been used to intentionally crosslink PE to improve its wear resistance.
• GAS PLASMA STERILIZATION - A non-irradiation sterilization method in which a device is
exposed to energized O2, nitrogen and argon gas particles and a peracetic acid gas in
alternating cycles. The plasma sterilizes the product by inactivating microorganisms. As with
EtO sterilization, gas plasma does not generate free radicals, induce oxidation or crosslinking.
• INERT GAS PACKAGING - Sealing the PE component in a package flushed with an inert gas,
such as argon or nitrogen, to remove the O2 present during sterilization and subsequent shelf
storage.
• ISOSTATIC MOLDING - A multi-step process that begins é manufacture of a cylindrical compact
of UHMWPE powder from ώ most of the air is expelled. Subsequently, the compacted rods are
sintered in a hot isostatic pressure (HIP) in an argon-filled pouch to z oxidative degradation of
the UHMWPE. Finished implants are then made by either turning or milling operations.
Topic: Def: Notes:
PE (cont.) • O2 LESS PACKAGING - PE components are sealed in a package in an atmosphere é minimal O2
during sterilization and subsequent shelf storage. Current versions include combinations of
inert gases partial vacuum, and enclosing a packet containing an O2 scavenger.
• OXIDATION - Reaction of an O2 molecule with a free radical on the PE molecule. This typically
leads to chain scission, indirectly increasing the crystallinity, density and stiffness of the
polymer and reducing its resistance to fracture and wear.
• RAM EXTRUSION - A consolidation process in which a ram is used to force the PE powder
through a heated nozzle, resulting in a fused bar as large as six inches in diameter. Careful
control of the processing variables (principally, the extrusion rate and the nozzle temperature)
is required to produce a fully and uniformly consolidated material (e.g., containing minimal
fusion defects).
• THERMAL STABILIZATION - Heating the PE to neutralize residual free radicals and, thereby,
stabilize it against long-term oxidation. Bulk PE (molded blocks or extruded bars) can be
heated above the melting temperature (about 150° C), held there for a number of hours, and
then cooled ("remelting") to extinguish the free radicals before being machined into a final
component. ; In contrast, if radiation crosslinking is applied to the finished components, they
cannot be remelted, but they can be heated to below the melt temperature and held at that
temperature for a number of days ("annealing") to substantially reduce the residual free
radicals. Because annealing occurs with the PE still in a semi-crystalline state (i.e., below the
melting temperature), it is not as effective as remelting in eliminating the residual free radicals.
• VACUUM PACKAGING - Typically, the PE components are placed in a barrier package, flushed
with an inert gas (i.e., nitrogen) and then evacuated to minimize the O2 present during
radiation, sterilization and subsequent shelf storage.
Polymers (Plastics) made up of long-chain molecules *viscoelastic (deformation time & stress dependent);
based on carbon & hydrogen. *Hysteresis
Power (watts) The rate of doing work. P=W/t
Slip =plastic deformation in metals, one Dislocations are faults or distorted regions. (types of
layer or plane of atoms gliding over dislocations= edge & screw dislocations); Material
another. Slip occurs step by step with deformation occurs by slip or 'twinning'.
the movement of 'dislocations' within
the crystal.
Mechanical = a form of Deformation where atoms in each succesive plane within a block will move different
Twinning distances, with the effect of altering the direction of the lattice so that each half of the crystal
becomes a mirror image of the other half. As compared to 'slip' where all atoms in one block
move the same distance.
Moment of Represents the resistance a structure 1]. MASS MOMENT OF INERTIA= R to angular acceleration
Inertia has to acceleration 2]. AREA MOMENT OF INERTIA= resistance to Bending.
3]. POLAR MOMENT OF INERTIA= resistance to Torsion.
Polar Moment of Measure of the Torsional Stiffness of a J = [pi/2]x[Ro4-Ri4] = 2.I; T/ø = JG/L (T/ø= torsional
Inertia (J) column/ shaft stiffness, T= torque, ø= angle of twist, G= shear modulus,
L= length of shaft)
Second Moment A property which measures the The further the material is from the neutral axis, the
of Area/ Area distribution of the material around stiffer the construct under a given load.; Circle: I = [pi.r4]
Moment of the cross section. (a measure of /4 (hollow: r= outer radius-inner rad.);
Inertia (I). bending stiffness) Bending Stiffness = E.I (where E is Youngs Modulus)
Rectangle: I= w×h³ ÷12;
The region of a bone/nail with the smallest I is subjected
to the largest deformation under load & will fail first.;
Indirect bone healing (thick periosteum) -> incr. I -> incr.
stiffness & strength.
Momentum Linear momentum= m.v
Angular momentum= I.w (I=mass moment of inertia)
Newton's Laws of 1]. A body will remain at rest or continue moving with a constant velocity along a straight line,
Motion unless a resultant external force acts on it.;
2]. The acceleration of a body is proportional to the resultant force acting on it and is in the
direction of this force. (F=ma);
3]. To every action there is an equal but opposite reaction.

Passivity Conditions existing on a metal Methods:;
surface because of the presence of a 1]. Surface Treatment- with a highly oxidizing solution
protective film that markedly lowers (nitric acid).;
the rate of corrosion. 2]. Some alloys & metals spontaneously form a passive film
(Type 316 stainless steel, Titanium).;
3]. Altered environment by incr. passivating/ oxidizing
agents (chromate, nitric acid);
4]. Applying a current (anodic protection)
Poiseuille's Law Rate of flow of fluid through a pipe/vessel is proportional to the fourth power of the radius, &
inversely proportional to the length.
Poisson's Ratio The lateral/transverse compressive v(mu)= lat. strain/longit. strain.; It may take on values
strain is proportional to the betw. 0(a fully compressible material) and 0.5(a material
longitudinal tensile strain, within the which maintains a constant volume during deformation).
elastic range of a material. Values >0.5 imply expansion of vol during deformation.
Titanium vs. Ultimate Strength(failure): Stainless Steel > Titanium; Yield Strength(permanent deformation):
Stainless Steel Titanium > Stainless Steel
Implant fixation 1]. Interference Fit: (Press fit): depends on formation of fibrous tissue interface
2]. Interlocking fit (PMMA): Grout that allow for gradual transfer of stresses to bone = Microinterlock
3]. Biological Fit (Porous coating): bone ingrowth into the implant
Work Work is done by a force when the W=Fs ; W=Frø=Mø (for angular motion)
(Joules=N.m) point of application of the force
moves in the line of action of that
force.
Perfect Material =
1]. Stiff ............................................................. resist deformation
2]. Hard ........................................................... resist surface abrasion
3]. Inert ........................................................... resist corrosion
4]. Tough ....................................................... resist breakage
5]. Ductile ....................................................... able to deform before breakage
6]. Adapt to loading
7]. Regenerate (reduce failure) = a composite = Bone (a ceramic phase (calcium
hydroxyapatite), dispersed in a collagen-based matrix).

Fracture Non Union

Hochgeladen von

Dokumentinformationen

Originalbeschreibung:

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Fracture Non Union

Hochgeladen von

Copyright:

Verfügbare Formate

[Biomechanics & Union] Page | 1

Bone behaviour under various loading modes

• Most fractures occur as a result of several loading modes

on the compression side

4- Compression and bending combined

Influence of muscle activity & loading on stress distribution in bone

Rate dependency in bone

Influence of bone geometry on biomechanical behaviour

• Block III is more resistant to bend than block I and II.

Effect of movement on bone healing

Other Factors Affecting Bone Strength

Effects of holes on bone strength

Changes in bone associated with aging

Important cytokines in bone healing:

3- REPARATIVE RESPONSE ................................. WITHIN 2 weeks

8- Quiescence The final osteoblasts turn into lining cells which

Hormonal influences on bone healing

Type of immobilization and Healing

Electricity and fracture healing

Max. Screw-Plate Angle:

LAG COMPRESSION DCP COMPRESSION

Removal of Internal Fixation Devices:

This depends on Two factors:

MATERIALS USED IN FRACTURE FIXATION

Summary Of Implant Properties

Steel Titanium alloy Ceramic Composite

Pathology non union:

When the cortex is osteoporotic:

3- Metaphyseal articular Non-unions : (The most difficult).

5- Infected non- draining non-unions:

6- Infected draining non-union:

RESPONSE OF BONE TO ELECTROMAGNETIC FIELDS:

Methods Used For Application Of Electricity:

Results >85% within 12-36 weeks

Types according to structure

Types According to Source

5. Synthetic Grafts / Ceramics (see later)

2- OSTEOGENIC: = ACTIVE CELLS CAPABLE OF BONE PRODUCTION

3- OSTEOCONDUCTIVE (scaffolds) = materials that attachment, migration, and distribution

COLLECTION OF DONOR BONE (Femoral Heads)

Properties of Bone Graft Materials

a. INSULIN-LIKE GROWTH FACTOR (IGF) :

Medically Inappropriate administration

Types of Material 1]. ISOTROPIC= has same properties in all directions.;

Topic: Definition Notes

Topic: Def: Notes:

Topic: Definition Notes

Das könnte Ihnen auch gefallen