Professional Documents
Culture Documents
Introduction
Osteonecrosis
Etiology
Cellular Bone Injury
Repair of Osteonecrotic Bone
Structural Sequelae
Clinical Effects
Bone Repair and Regeneration
Biomechanics of Fractures
Fracture Healing Responses
Stages of Fracture Healing
Vascular Response
Biochemistry of Fracture Healing
Biomechanical Properties of
Fracture Callus
Biology and Biomechanics of
Fracture Fixation
Compression Plating
External Fixation
Circular External Fixation
Intramedullary Nails
Comparison of Fixation Methods
Plate Fixation Versus
Intramedullary Fixation
Plate Fixation Versus
External Fixation
Factors Influencing Fracture Repair
Host Factors
Local Factors
Augmentation of Fracture Healing
Osteogenic Methods
Cortical Grafts
Autogenous Bone Marrow
Osteoconductive Methods
Osteoinductive Methods
Electromagnetic Fields
Chapter 14
Bone Injury,
Regeneration,
and Repair
Susan M. Day, MD
Robert F. Ostrum, MD
Edmund Y.S. Chao, PhD
Clinton T. Rubin, MD
Hannu T. Aro, MD
Thomas A. Einhorn, MD
Low-Intensity Ultrasound
Summary
This chapter discusses the form and function of bone and covers
a broad range of material from the basic structure of bone and its
biomechanical properties to bone homeostasis and diseases processes.
Introduction
Injury to bone can occur by a multitude of causes. In addition to physical injury (trauma), infection, tumor, genetic
disorders, and many other conditions can produce changes
in bone that could be considered injurious. Bone injury
from any cause must be viewed in terms of its effect on the
cellular content of bone, the ability of such cells to produce
extracellular matrix, and the structure and organization of
the organic and inorganic components of bone itself. This
chapter describes those injuries to bone caused by circulatory loss and physical injury. Such injuries jeopardize cell
viability and structural integrity. Injury to one affects the
other; loss of cell viability will directly and indirectly affect
the structural organization of bone. Similarly, structural
repair necessitates cellular changes. In the strictest sense,
bone repair is a regenerative process that brings about
changes in all aspects of the organ system. In this chapter,
bone injury is discussed along with the ways in which the
organ system as a whole responds to injury.
Depending on the nature of the injury and the proposed
method of repair, certain aspects of the process play a predominant role, but the underlying reactions and principles
remain the same and need to be understood if normal functioning bone is to be maintained.
One or more of the authors or the department with which they are
affiliated has received something of value from a commercial or
other party related directly or indirectly to the subject of this article.
Osteonecrosis
Osteonecrosis can arise from a variety of disorders. The
term itself, defined as the death of a segment of bone in
situ, actually refers to the death of the cells within bone
from lack of circulation, not from disease. Unless secondary
effects occur, the organic and inorganic matrices of the
structural components of bone are not affected; dead bone
refers to dead cells. Such cells include osteocytes, whether
they are in cortical or cancellous bone, and usually include
the cells of the hematopoietic and fatty marrow contents as
well. The term osteonecrosis is preferred to such commonly used terms as avascular necrosis and aseptic necrosis
because (1) it is the most appropriate description of the
histopathologic process seen, and (2) it doesnt suggest any
specific etiology.
Etiology
Osteonecrotic bone is not avascular; the vessels are still
present. However, in all causative mechanisms of
osteonecrosis, the circulation within the vessels is compromised. Such compromise may be grouped into 4 possible
mechanisms: (1) mechanical disruption of the vessels; (2)
postulated that the fat emboli arise from a fatty liver, from
plasma lipoproteins, or directly from marrow fat. There is
experimental evidence supporting this mechanism, but
whether it is the cause of osteonecrosis in a significant percent of humans is not known. A popular explanation for
idiopathic osteonecrosis, especially that seen in the femoral
head, is intraosseous hypertension. The theory is that the
intraosseous vessels are occluded secondary to excessive
pressure within the medullary space. The cause of the suspected intraosseous hypertension is not known. Although
measurement of the intraosseous pressure of bones with
early osteonecrosis reveals increased pressure, it is not clear
whether this pressure is a cause or an effect. The only conclusion that should be made is that the cause of osteonecrosis in the majority of cases still is not adequately understood.
Figure 1
Schematic representation of 3 mechanisms potentially capable of producing intraosseous fat embolism and triggering a process leading to focal
intravascular coagulation and osteonecrosis. (Reproduced with permission
from Jones JP Jr: Fat embolism and osteonecrosis. Clin Orthop
1985;16:595-633.)
373
Figure 2
T1-weighted (A) and T2-weighted
(B) magnetic resonance images of
osteonecrotic bone in the femoral
head.
Figure 3
Photomicrograph showing a cortical cutting cone.
Figure 4
Photomicrograph of a cancellous bone graft undergoing creeping substitution. Note lamellar bone with empty lacunae and the presence of woven
bone with basophilic staining osteoblasts which appears to be creeping
on this dead bone.
Structural Sequelae
Necrotic bone initially has no alteration in its mechanical
properties; osteonecrosis directly affects only the cells, and
structurally the bone functions normally. If, however, the
osteonecrosis involves the subchondral bone, the eventual
fracture and collapse of the bone leads to irregularities in
the articular surface and, subsequently, to degenerative
arthritis. All evidence indicates that this scenario is a secondary mechanical phenomenon that occurs over time as a
result of the absence of cells to respond to the effects of the
continuation of normal daily activities. The fracture and
collapse appear to be the result of multiple fatigue fractures
that are caused by repetitive loading of the bone and cannot
be repaired. They seem to be initiated in areas of bone
where: (1) the remaining avascular subchondral trabeculae
oriented perpendicular to the joint surface lack the means
to repair small microfractures; (2) the resorption of the subchondral bone at the periphery, where there is vascular
invasion of the necrotic bone, results in osteoporotic, weakened bone; or (3) the junction of increased bone density at
the front of revascularization results in a stress riser
between it and adjacent avascular bone. Prior to complete
fracture and collapse, the microfractures can elicit a pain
response. If functional activities are reduced, viable bone
within or surrounding the osteonecrotic bone area undergoes a reduction in bone mass. The relative increased density of unresorbed necrotic bone compared to the adjacent
viable osteoporotic bone permits the recognition of necrotic bone on plain radiographs. When the necrotic bone collapses, leading to loss of subchondral support, the result is
the appearance of the crescent sign. In the talus, Hawkins
sign the subchondral radiolucency seen in the talar bone,
represents the resorption of necrotic bone and suggests
that the bone is revascularized. When subchondral radiolucency is not seen, the bone is not being resorbed and
vascularization is not present.
Clinical Effects
The severity and significance of the clinical syndrome in
osteonecrosis depends on the size and site of its occurrence. If the lesion is small enough and the area can be
revascularized, then it is likely no effect will be seen. If the
area of involvement is large and blood supply cannot be
restored, then the area remains necrotic, fracture within the
necrotic area can occur and the result is progressive collapse. When the area becomes incongruous, joint destruction results. Bones that are often affected include the
Biomechanics of Fractures
Fractures can be classified according to the characteristics
of the force that causes them. A fracture may arise from
forces of low magnitude that are cyclicly repeated over a
long period of time or from a force having sufficient magnitude to cause failure after a single application. The susceptibility of bone to fracture under fluctuating forces or stresses of low magnitude is related to its crystal structure and
collagen orientation, which reflect the viscoelastic properties of the bone. Cortical bone is vulnerable to both tensile
and compressive fluctuating stresses. Under each cycle of
loading, a small amount of strain energy may be lost
through microscopic cracks along the cement lines. Fatigue
load under certain strain rates can cause progressive accumulation of microdamage in cortical bone. When such a
process is prolonged, bone may eventually fail through
fracturecrack propagation. However, bone is a living tissue
and can undertake a repair process simultaneously.
Periosteal callus and new bone formation near the microscopic cracks can arrest crack propagation by reducing the
high stresses at the tip of the crack. This phenomenon is
375
Figure 5
The 9 main fracture groups; fractures are classified according to degree of comminution and etiology. (Reproduced with permission from Johner R, Wruhs
O: Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop 1983;178:7-25.)
377
Vascular Response
The healing of a fracture is greatly dependent on blood flow
to the injured area throughout the healing process. The 3
major blood supplies to the long bone are the nutrient
artery, the metaphyseal arteries, and the periosteal arteries
(Fig. 6). The nutrient arteries penetrate the cortex of the
shaft and then divides into ascending and descending
medullary arteries. These endosteal blood vessels are the
ones that are destroyed during introduction of a reamed
intramedullary nail. The metaphyseal arteries supply blood
to the metaphysis and anastomose with the medullary
Figure 6
Diagrammatic representation of the
major components of the afferent
vascular system of a normal mature
long bone, based on differences in
the type of blood vessel observed
experimentally to enter the external
cortical surface at sites of heavy fascial attachment and at sites of tenuous periosteum beneath bellies of
muscle. Components 1, 2, and 3 constitute the total nutrient supply to
the diaphyseal cortex. Arrows indicate the direction of blood flow. (Reproduced with permission from Rhinelander FW: Circulation in bone, in
Bourne G (ed): The Biochemistry and
Physiology of Bone, ed 2. New York,
NY, Academic Press, 1972, vol 2.)
Figure 7
Blood flow rate at a fracture site as determined by a 125I-labeled 4-iodoantipyrine washout technique.
379
Figure 8
Changes in oxygen tension at fracture site.
Biomechanical Properties
of Fracture Callus
The mechanical properties of a healing fracture depend on
both the material and geometric properties of the uniting
callus. The restoration of fracture strength and stiffness is
related to the amount of new bone connecting the fracture
fragments. The stiffness (hardness) of the fracture callus
closely correlates with its calcium content (Fig. 9). The tensile strength of the fracture site during callus formation correlates to the ratio of callus/cortical bone area (Fig. 10). The
change from a low stiffness, rubbery quality to a hard tissue
type of resiliency occurs during a rather short period of
time and progresses through 4 distinct stages (Outline 1).
Figure 9
Compressive behavior (hardness) of fracture cells. (Adapted with permission from Aro HT, Wipperman BW, Hodgson SF, et al: Prediction of properties of fracture callus by measurement of mineral density using micro-bone
densitometry. J Bone Joint Surg 1989;71A:1020-1030.)
Figure 10
Breaking strength of fracture callus in tensile stressing. (Adapted with
permission from Chao EYS, Aro HT: Biomechanics of fracture fixation, in
Mow VC, Hayes WC (eds): Basic Orthopaedic Biomechanics. New York, NY,
Raven Press, 1991, pp 293-335.)
Outline 1
The Four Biomechanical Stages of Fracture Repair
Stage I
Stage II
Stage III
Stage IV
381
Compression Plating
Rigid compression plating of an osteotomy inhibits callus
formation; the bone ends unite directly by haversian
remodeling. This type of healing has been referred to as
contact healing in contact areas and as gap healing in noncontact areas. It is considered primary bone healing in contradistinction to the previously described secondary fracture healing, which includes callus formation and the 5
stages of fracture union. The haversian remodeling seen in
primary fracture healing has 2 main functions: the revascularization of necrotic fracture ends and reconstitution of
the intercortical union. The 3 requirements for haversian
remodeling across the fracture site are the performance of
an exact reduction, the production of stable fixation, and
the existence of a sufficient blood supply.
When a dynamic compression plate is applied to an
osteotomy in bone, the compression at the osteotomy site
diminishes slowly over a period of time, and it is reduced by
approximately 50% within 2 months. This same phenomenon also is seen when there is no osteotomy and a dynamic compression plate is applied to an intact bone. Therefore,
this slow decrease in compression is not caused by shortening of the fragments and resorption, but instead is a result
of haversian remodeling under the plate and screws.
The use of a dynamic compression plate in an osteotomy
model has been shown to lead to primary bone healing.
When there are no gaps and the fracture fragments are
rigidly held together, there is no ingrowth of mesodermal
cells from the periosteum or endosteum. Active haversian
remodeling is seen at approximately the fourth week of fixation via proliferation of haversian canals along the longitudinal axis of the bone. If a gap exists, which often is seen
opposite the plate even if there is rigid fixation, new blood
vessels and osteoblasts deposit osteoid into this gap in the
first 8 days of fixation. The lamellar bone that is formed in
this gap is oriented 90 to the longitudinal axis. Axially oriented osteons then bridge across this perpendicularly oriented osteoid by haversian remodeling. The growth of these
secondary osteons starts 4 weeks after fracture fixation in
the dog and later in humans; thus, there is always a lag period before the activation of haversian remodeling. This delay
in activation has been postulated to be related to the clearance of damaged tissue at the fracture site.
The growth of secondary osteons from one fracture fragment to another does not occur only at sites of macroscopic
gaps; it will occur in areas that seem to have intimate contact between the fracture fragments. After reduction and
compression plating, incongruencies remaining at the fracture site will result in small gaps. Within weeks after fracture,
these gaps are filled by direct lamellar or woven bone formation; that is, appositional bone formation. Woven bone
formed within the gap acts as a spacer but does not unite the
fracture ends. Secondary osteons use the gap tissue as a
scaffold to grow from one fragment to another.
Although primary bone healing refers to union without
callus formation and secondary bone healing to union by
means of callus formation, this distinction represents an
oversimplification that is not always seen in vivo. The production of a small amount of callus opposite a dynamic
compression plate indicates that there is sufficient interfragmentary motion opposite the plate to allow for a slight
amount of callus healing. If this motion is excessive or continues so that bony union is not achieved, the plate will fail
through cyclic loading. However, a small amount of motion
and subsequent callus formation opposite the plate can be
advantageous, leading to earlier and stronger union. Fractures also exist that heal without callus formation and, nevertheless, go through the stages previously described for
secondary bone healing, which include both endochondral
and intramembranous bone formation. Examples include
fractures of the scaphoid and talus, which are not heavily
endowed with periosteum.
When applying a plate for fixation, the appropriate number of screws must be used to minimize stresses and
achieve optimal results. A plate with less than adequate fixation and a decreased working length is at risk for failure.
Recommendations are for at least 6 cortices on each side
for the forearm and 6 to 8 cortices on each side at the
humerus. For the tibia and femur, 8 or more cortices on
each side are preferred. Such screws traversing the
medullary cavity do not significantly disturb the circulation; medullary vessels curve closely around tight screws.
By 1 week after fracture fixation, the arterioles and capillaries of the medullary canal cross an osteotomy site, thereby
effecting a medullary osseous union. At 6 weeks after tight
plate application, vascularization of the cortex under the
plate is greatly reduced.
External Fixation
Although primary bone healing can be seen with plate fixation, it can also be seen with external fixation. In a study of
osteotomies in canine tibias held in place with half-frame
external fixators placed in the mediolateral plane, compression was applied across the osteotomy site in one group
and not in another. Both groups showed a significantly
greater amount of periosteal new bone formation in the
anteroposterior plane than in the mediolateral plane where
there was more rigidity. Primary bone healing of both the
contact and gap type was seen in both groups. However, the
existence of primary bone healing with external fixation
does not indicate that it is the preferred method of healing.
Less rigid fixation has been shown to lead to controlled
interfragmentary motion and, therefore, to more periosteal
callus and new bone formation, which may produce equally good union.
383
Intramedullary Nails
Circular external fixation configurations have become popular for the treatment of fractures, posttraumatic deformities, osteomyelitis, and congenital anomalies. Circular rings
Outline 2
Key Factors in Increasing the Rigidity of
External Fixation
Increased pin diameter
Increased pin number
Decreased bond-rod distance
Increased pin group separation
Half pins separated > 45
Table 1
Types of Axial Stimulation at the Fracture Site Under External Fixation
Type
Passive dynamization
Description
Load transmission through fracture site due to pin bending under weightbearing (rigid side-bar)
Removal of additional site-bar or pins results in reduction of axial, torsional, and bending stiffness, proportionally
Load transmission through fracture site under weightbearing without pin bending (telescoping side-bar)
Relaxation of the axial constraint in the fixator does not affect the torsional and bending stability of the fixation
Controlled axial micromovement Load transmission through fracture site using controlled force/displacement actuator (telescoping side-bar)
between the nail and the cortical wall for more stable fixation. In the 1970s, Klemm and Schellmann added interlocking to the nail, which broadened indications for its use and
allowed treatment of nonmidshaft fractures by closed nailing techniques. Closed intramedullary nailing with interlocking is currently the treatment of choice for fractures
from the lesser trochanter to the supracondylar area of the
femur. In addition, modification of the intramedullary tibial nail to allow interlocking has led to its use for fractures of
the tibia that go from just below the plateau to just above
the supramalleolar region.
With the addition of a loosefitting intramedullary rod into
the medullary canal, the endosteal circulation is able to
regenerate rapidly and completely where space has been
left between the nail and the endosteal surface. When
reaming is used for placement of an intramedullary nail,
the results are different. The damage following reaming is
similar to an experimental situation in which there is simultaneous ligation of the nutrient artery and interruption of
the metaphyseal blood supply. Because of the anatomy of
the medullary blood supply, the essential damage is caused
by the first reaming, and there is necrosis of the inner 50%
to 70% of the cortex. Subsequent reaming has little effect on
cortical vascularity; therefore, the amount of reaming actually performed is of minor importance. After reaming and
the application of a tight-fitting intramedullary nail at the
4-week stage of repair, there appear to be 3 paths for blood
supply: (1) through a regenerative endosteal membrane; (2)
through the external callus at its junction with the cortex;
and (3) through the substance of the cortex itself. Six weeks
after medullary reaming and tight nailing, the significant
regenerative blood supply to all the bony tissue appears by
microangiography to be endosteal. Thus, the overall regenerative blood supply at 6 weeks follows the same 3 pathways as it did at 4 weeks, with a notable increase in the size
of the posterior intracortical (from the nutrient artery)
arteries.
It has been suggested that reaming, with its concomitant
increase in intraosseous pressure, is responsible for the
generation of medullary content emboli, and should, therefore, be avoided in traumatized patients with pulmonary
contusion. However, a recent study found that in a sheep
model, most pulmonary emboli occurred when the
medullary canal is first opened, and there was no substantial difference in the outcome of animals that had undergone reaming and those that did not.
Revascularization of the necrotic cortex comes from 2
sources. One is the regenerative medullary circulation
through small arterioles in the new endosteal membrane
that has been able to form within the crevices around the
intramedullary nail. The other is a new extraosseous circulation supplied by large arteries derived from the surrounding soft tissues with branches traversing the full thickness
of the external callus to support the osteoclastic removal of
the necrotic cortex. This periosteal blood supply is not the
Comparison of
Fixation Methods
Plate Fixation Versus
Intramedullary Fixation
When plate fixation was compared with intramedullary rod
fixation in dogs, blood flow reached higher levels and
remained elevated longer in osteotomies that were fixed
with the rods than those fixed with the plates (Fig. 11). Rodfixed osteotomies healed by periosteal callus, whereas
platefixed osteotomies showed predominantly endosteal
callus formation (Fig. 12). There were no significant differences in bone porosity between the fixation methods. The
plated osteotomies displayed higher torsional stiffness values than the rodfixed osteotomies at 90 days, but this difference was no longer apparent at 120 days.
These data show that bone heals by different mechanisms
with different types of fixation. Rigid plate fixation promoted early recovery of mechanical properties, although this
method inhibited periosteal callus formation. The time
needed for return of normal strength and stiffness was,
however, the same for both methods, indicating that the
end result of the different healing patterns was the same.
385
Figure 11
Figure 12
Fracture site clearance: mean values. (Adapted with permission from Rand
JA, An KN, Chao EY, Kelly PJ: A comparison of the effect of open
intramedullary nailing and compression-plate fixation on fracture site
blood flow and fracture union. J Bone Joint Surg 1981;63A:427-442.)
Callus formation in rod- and plate-fixed osteotomies. (Adapted with permission from Chao EYS, Aro HT: Biomechanics of fracture fixation, in Mow
VC, Hayes WC (eds): Basic Orthopaedic Biomechanics. New York, NY, Raven
Press, 1991, pp 293-335.)
Factors Influencing
Fracture Repair
When bony bridging does not progress at an expected pace,
the patient is said to have a delayed union or nonunion, depending on time since fracture and other factors such as the
site and severity of the injury, and host and/or local factors.
Host Factors
Common host factors implicated in delayed fracture healing
include diabetes mellitus, smoking, and nutritional status.
Although the pathophysiology has not been well explained,
diabetes has been associated with defects in collagen, with
most studies reporting a decrease in total collagen content,
defects in collagen crosslinking, or alterations in collagen
ratios. In an experimental animal model, streptozotocininduced diabetes led to decreased collagen in fracture
callus, which negatively influenced fracture healing.
The deleterious effect of cigarette smoking on fracture
healing and bone graft incorporation is well known,
although the mechanism of this effect is not. Cigarette
smoke has been shown to directly interfere with osteoblastic function. In addition, nicotine has vasoconstrictive
properties that may diminish blood flow at the fracture site.
Although good basic science research in this area is lacking,
the fact that tobacco use has been found to be associated
Local Factors
Local factors that may impede fracture healing include
extensive injury to the bone or surrounding soft tissue,
interruption of the local blood supply, imposition of soft
tissue between fracture fragments, inadequate reduction
and/or immobilization, and bone death caused by avascularity, radiation, thermal or chemical bums, or infection.
In general, if there is motion at the fracture site, callus will
form. The larger the stress, the greater the amount of callus.
If the motion is excessive, however, the increased strain
may result in tissue proliferation but may also damage the
vascularization, resulting in delayed union or nonunion.
Intermittent hydrostatic compression across the fracture
site and poor vascularity may result in a fibrocartilaginous
callus. Intermittent shear stresses are thought to encourage
ossification (Fig. 13).
Augmentation of
Fracture Healing
When fracture healing is delayed (arbitrarily from 3 to 9
months), spontaneous healing may occur, with time, for a
certain percentage of patients or intervention may be
Figure 13
Influence of intermittent stresses and vascularity on differentiation of mesenchymal tissue. (Adapted with permission from Carter DR, Blenman PR,
Beaupr GS: Correlations between mechanical stress history and tissue differentiation in initial fracture healing. J Orthop Res 1988;6:736-748.)
387
Osteogenic Methods
Osteogenic methods to enhance fracture healing include
the use of naturally-occurring materials, such as autogenous or allogeneic bone grafts or autogenous bone marrow
grafts, that have been shown to induce or support the formation of bone.
Tissue obtained from and implanted within the same
individual is an autograft. Tissue obtained from a donor of
the same species is an allograft. Tissue obtained from a
donor of a different species is a xenograft. An orthotopic
transplantation is implantation of tissue into an identical
anatomic site; implantation into a distant anatomic site is
called a heterotopic transplantation. Cancellous and cortical grafts are currently in common clinical use as autografts
or allografts.
Autogenic bone usually is used as a fresh graft. Allogeneic
bone usually is stored frozen, lyophilized, or chemically
sterilized; no viable cells remain. Each of these storage procedures substantially decreases the immunogenicity of
allogeneic bone. The biologic host response is also different
between autogenic and allogeneic bone and, as in
osteonecrosis, is different depending on whether the graft
is composed of cancellous or cortical bone. Therefore, it is
important to understand the biologic process of revascularization and graft incorporation not only as it relates to the
type of bone needing to be regenerated but also to the
source of the graft material.
The incorporation of a bone graft, whether it is autogenic
or allogeneic in origin, involves a partnership between the
Cancellous Grafts
For nonvascularized autogenous cancellous bone grafts,
graft repair or regeneration is similar to that noted in
osteonecrosis of cancellous bone. The first phase is vascular ingrowth and progenitor mesenchymal cell invasion. In
a dog model, this occurs during the first 3 weeks after
implantation (Fig. 14, top). The second phase, which occurs
in the dog model between 3 and 12 weeks after implantation, is a combination of osteoblastic appositional new
bone formation onto the dead trabeculae of the graft and
osteoclastic resorption of the graft trabeculae (Fig. 14, middle). The third phase, between 3 and 6 months after implantation, is that of remodeling and reorientation of the trabeculae to a mature pattern. This phase is influenced by the
mechanical factors acting on the host bed. In this animal
model, the process of remodeling becomes quiescent at 1
year after grafting (Fig. 14, bottom).
In a canine model, fresh cancellous bone allogeneic grafts
(allografts), which do not cross major histocompatibility
barriers, progress through the same sequence of incorporation steps, but twice as slowly (Fig. 15). The initial phase,
which consists of hemorrhage and necrosis corresponding
to the surgical placement of the graft, is identical to that for
the autograft. The fibrin clot develops and the same inflammatory response ensues. As in the autograft, increased vascularity in the adjacent tissues, dilation of the blood vessels,
transudation, and exudation are noted, but perhaps are
greater in extent and degree.
At this point, however, the response appears to differ. The
fibrin clot, clearly of great importance to the system, breaks
down, and the loosely structured granulation tissue that
serves as a source of cellular elements for repair becomes
filled with chronic inflammatory cells rather than fibroblasts and blood vessel elements. The numbers of lymphocytes, plasma cells, and mononuclear elements markedly
increase. The major portion of the delay appears to occur in
osteoclastic resorption and new bone formation. Final graft
incorporation with remodeling may remain incomplete.
The use of these data in the clinical setting of patient care
must be done with caution. In humans, clinical data and
occasional histologic evaluation of cancellous grafts suggest that the same sequence of steps occurs, but the process
osteochondral segments has resulted in incomplete remodeling and incorporation of subchondral allogeneic bone as
late as 7 years after implantation.
Cortical Grafts
There are 3 major differences in incorporation of autogenous nonvascularized cortical bone in animal models as
compared to that of cancellous bone grafts. First, the vascularization of cortical grafts is much slower, taking 8 weeks
for completion. Second, osteoclastic resorption must precede the osteoblastic new bone formation. In a manner
similar to the repair or regeneration in osteonecrosis,
creeping substitution occurs. Osteoclasts form cutting
cones within the donor bone and new bone is formed
behind the cutting cones. Third, during the process, autogenous cortical grafts generally do not demonstrate complete substitution with viable bone and, thus, are an admixture of necrotic graft bone and viable new host bone. The
healing process begins at the hostgraft cortical junction,
with bridging external endochondral bone formation from
the host tissue during the first 4 to 6 weeks, followed by
interstitial cortical osteoclasis and creeping substitution.
An allograft functions as an osteoconductive system. Similarly, with allogeneic tissues, the transplanted bone graft
acts as a trellis or scaffold for bony ingrowth of the host tissues. The function of either type of graft as a stimulator of
host bone formation by the process of osteoinduction,
however, is poorly understood.
Allograft cortical bone undergoes the same qualitative
sequence of steps during graft incorporation as does autograft cortical bone. The length of time for creeping substitution is greatly prolonged when allogeneic cortical bone is
Figure 14
Figure 15
389
used. The factors that stimulate host blood vessels to proliferate, invade the graft, and develop into cutting cones
appear to be diminished, absent, or severely suppressed.
Recruitment and differentiation of cellular elements to
become both vascular invaders and the osteoblastic and
osteoclastic elements essential to creeping substitution are
reduced in extent and degree. Replacement of tissue by
host bone is slow, and the stimulatory effect exerted on the
host is virtually absent. New bone formation in either the
host or the donor part is limited in degree, and repair of the
hostdonor junction site is prolonged when compared to the
use of autogenous bone. Healing of a delayed or nonunion
site in the host bone may respond to the mechanical
aspects of the insertion of the graft, but most authorities
consider that the allogeneic donor part contributes little in
the form of osteoinduction. The proportion of necrotic graft
bone to viable host bone is much greater in allogeneic
grafts, and the active process of graft substitution may last
several years.
On rare occasions, 2 special patterns of healing, or the
lack thereof, are encountered after implantation of an allogeneic graft. Under well-defined circumstances, the host
soft tissues wall off the allogeneic part for an extended period of time, possibly years, and the tissues show little or no
vascular proliferation or attempt at invasion of the graft.
Under other conditions, presumably immune-directed, the
graft is surrounded by inflammatory cells, invaded rapidly
by numerous blood vessels, and destroyed. Following such
a dissolution, the donor site may show no remnants of the
implanted graft.
Figure 16
The quantitative temporal interrelationships between the physical integrity and the biologic processes of repair within a segmental autogenous cortical bone transplant. (Reproduced with permission from Burchardt H:
Biology of cortical bone graft incorporation, in Friedlaender GE, Mankin
HJ, Sell KW (eds): Osteochondral Allografts. New York, NY, Little, Brown,
1981.)
Osteoconductive Methods
Osteoconduction is a process that supports the ingrowth of
capillaries, perivascular tissues, and osteoprogenitor cells
from the recipient host bed into the 3-dimensional structure of an implant or graft. The rationale for use of osteoconductive materials is that normal osteoblastic or
osteoblast-like cells have the ability to form bone on an
appropriate surface. Such a surface is able to support the
attachment, spreading, division, and differentiation of cells
and is also able to support the growth, vascularization, and
remodeling of bone. Examples of osteoconductive materials include ceramic materials, bioactive glasses, and synthetic polymers.
Ceramics
Most ceramics are calcium phosphate-based and are composed of hydroxyapatite, tricalcium phosphate, or a combination of the two substances, which is usually used because
each has its own advantages. Biodegradation is dependent
on the chemical composition and porosity of the compound. Tricalcium phosphate is resorbed and remodeled
more quickly than hydroxyapatite.
The first calcium phosphate-based bone graft substitute
to be approved for use was Interpore (Interpore International, Irvine, CA). Interpore, composed predominantly of
hydroxyapatite biomatrix, is formed by the conversion of a
marine coral calcium phosphate to crystalline hydroxyapatite. This substrate becomes a template for host bone, sustains living tissues, and has been shown to be as efficacious
as autogenous bone graft. Collagraft (Collagen Corporation,
Palo Alto, CA) is a mixture of hydroxyapatite, tricalcium
phosphate, and fibrillar collagen. It is to be used in conjunction with autogenous bone marrow as a composite
bone graft substitute. Collagraft has been shown to be as
effective as autogenous bone graft in augmentation of fracture healing.
Recently, a process has been developed for the in situ formation of the mineral phase of bone. This involves the
combination of inorganic calcium and phosphate to form
Norian SRS (Norian Corporation, Cupertino, CA) a paste
that can be injected into the site of a fracture. Under physiologic conditions, the material begins to harden within
minutes, forming the mineral dahllite. After 12 hours, the
dahllite formation is nearly completed, giving the material
an ultimate compressive strength of 55 mPa. As a result,
treatment of certain fractures with this calcium-phosphate
material can augment the fixation that is achieved with a
cast or surgically. Studies of animals have shown that the
material is remodeled in vivo and in many cases is completely resorbed and replaced by host bone.
Bioactive Glasses
Bioactive glasses are silicophosphatic chains that may bond
ionically to compounds. These compounds can undergo
ionic translocations, allowing an exchange of ions with the
physiologic milieu. This property may make these substances useful as delivery systems for growth factors.
Synthetic Polymers
Synthetic polymers of the family of polyhydroxy acids such
as polylactic acid (PLA) and polyglycolic acid (PGA) have
been used for many years as suture material, and are now
used as resorbable plates and screws. Use of these compounds as delivery systems for growth factors has been
explored. Biodegradation of the polyhydroxy acids has been
found in the past to be unpredictable, which in turn may
result in inconsistent delivery.
Osteoinductive Methods
Osteoinduction is a process that supports the mitogenesis
of undifferentiated perivascular mesenchymal cells, leading to the formation of osteoprogenitor cells with the
capacity to form new bone. Unlike osteoconductive materials, osteoinductive substances lead to the formation of
bone at extraskeletal sites, and the osteoinductive capacity
of a specific molecule may be potentiated by other factors
that influence cellular responses, such as those that
enhance cellular proliferation, migration, attachment to
extracellular matrix molecules, and differentiation.
Osteoinductive substances, because of this ability to regulate cellular activity, are being intensely investigated as
potential adjuncts to fracture healing.
Growth-Promoting Proteins
Growth factors are osteoinductive signaling molecules that
have the capacity to initiate the cascades of cellular events
that are critical to fracture healing. Several growth factors
that have been associated with healing fractures include
the TGF- family, bone morphogenetic protein (BMP),
insulin-like growth factors (IGFs), fibroblastic growth factors (FGFs), and PDGFs.
TGF-, which exists in 3 mammalian isoforms, is found in
the fracture hematoma as early as 24 hours after fracture
has occurred. TGF- is present in platelets, mesenchymal
cells, osteoblasts, and young and mature chondrocytes in
the callus, as well as in hypertrophic chondrocytes adjacent
to the ossification front. This factor induces the synthesis of
cartilage-specific proteoglycans and type II collagen by
mesenchymal cells, and stimulates collagen synthesis and
proliferation by osteoblasts. Based on the high concentrations found in bone, its effect on protein synthesis by chondrocytes and osteoblasts in vitro, and its release into the
fracture hematoma by platelets, TGF- may be responsible
for regulating cartilage and bone formation in the fracture
callus. TGF- has a broad range of activity, including cellu-
391
Systemic Approaches
It has been demonstrated that direct or indirect injury to
bone marrow enhances osteogenesis at distant skeletal
sites. While the mechanism remains unknown, this
response suggests the possibility that a systemic factor may
enhance fracture healing.
IGF-I, a low molecular weight polypeptide, is produced by
the liver in response to growth hormone (GH), and circulates bound to a carrier protein. IGF-I is known to have an
important regulatory effect on endochondral ossification at
the growth plate and it is therefore presumed to have a similar effect on fracture healing. Animal studies have shown
an enhancement of intramembranous bone formation;
however, endochondral bone formation has yet to be
demonstrated. Because IGF-I production is GH-dependent,
it has been hypothesized that GH could stimulate fracture
repair. This has never been proven, however, with some
studies demonstrating an enhancement and others failing
to show any effect.
IGF-II is closely related to IGF-I and is one of the most
prevalent growth factors in bone. Although it is found in
higher concentrations, IGF-II binds with a lower affinity
than IGF-I to the IGF receptor. In vitro studies have demonstrated that IGF-II stimulates bone cell proliferation and
cartilage matrix production in a dose-dependent manner.
IGF-II also stimulates type I collagen and type I procollagen
mRNA. IGF-II is produced by bone cells derived from a
number of species, including humans. Parathyroid hormone (PTH) and 1,25 dihydroxy vitamin D3 (1,25 (OH)2 vitamin D3) stimulate production of IGF-II in vitro cultures.
There are studies to suggest that PTH and parathyroid
hormone related peptide (PTHrP) may improve fracture
healing. In a rat model, it has been demonstrated that PTH
increases the concentration of IGF-I and TGF- in bone. It
is possible that these growth factors mediate the effect of
PTH on fracture healing. In vitro studies have shown that
PTHrP induces IL-6 production by human osteoblastic cells
and plays a role in chondrocyte differentiation.
An important class of compounds that may eventually be
used in the systemic enhancement of fracture healing is the
prostaglandins. Prostaglandins have several functions in
bone, and at times these functions may seem contradictory. When prostaglandins are released from traumatized
bone and soft tissues, they increase intracellular cyclic
adenosine monophosphate (cAMP) and stimulate production of IGF. Several in vitro studies have shown that they
stimulate type I collagen synthesis. However, their effect on
regulating the fracture callus in the presence of nonsteroidal anti-inflammatory agents is still unclear.
Indomethacin has been reported to inhibit prostaglandin
synthesis, thereby producing fracture callus weakness.
Contrary to these findings, ibuprofen has been shown to
have no effect on fracture healing despite being a potent
inhibitor of prostaglandin synthesis.
Electromagnetic Fields
The potential role of electricity in the regulation of bone tissue was first considered over 40 years ago with the report of
electric currents being generated with the loading of dry
bone. The discovery of loadinduced piezoelectric potentials
in bone provided a means by which stress or strain could
intrinsically alter the biophysical environment of the bone
cell, and thus influence proliferation and differentiation.
This mechanoelectric hypothesis became even more
attractive when it was demonstrated that, in wet bone, 2
sources of electrical current existed in parallel: piezoelectric
currents induced by the deformation of collagen, and the
relatively large electrokinetic currents (streaming potentials) produced by the strain-induced flow of charged constituents of extracellular fluids flowing past the mineral
phase of the matrix.
The interdependence of electric fields and functional load
bearing is critical in establishing a physiologic justification
for exogenously inducing fields in the absence of strain.
Measurement of the electric potentials generated by functional levels of strain shows the average field intensities in
bone are quite small, on the order of 1 V/e (1 microvolt
per microstrain). Considering the adult skeleton is seldom
subject to strains exceeding 4,000 microstrain, if endogenous fields are to influence bone morphology they must do
so at field intensities below 4 mV/cm. This field intensity, in
and of itself, is certainly sufficient to perturb a membrane
potential of an osteoblast to the point of having some biologic effect. However, a large percentage of bone tissue is
rarely subject to strains greater than 500 microstrain, yet
bone mass is retained in these areas. Therefore, if each cell
at each site of the bone is responsible for its own assessment of the physical milieu in its adjacent matrix, fields of
500 V/cm, 50% below the 1 mV/cm threshold often considered the low end of biologic relevance, must represent
some regulatory role. It is important to keep these biophysical thresholds in mind when considering the intensities of
the biophysical interventions currently available.
When exogenously applied, microamperes, direct electrical currents, capacitively coupled electrical fields, and
alternating, pulsed electromagnetic fields (PEMF) affect
bone cell activity in various ways in culture, in living bone
tissue, and clinically, in fracture nonunion. In addition,
PEMFs appear to affect endochondral bone formation,
connective tissue repair, osteoporosis, and a variety of
other conditions. At the same time, negative results of electromagnetic stimulation tested on several animal models
have been reported, and there is the continuing question of
how specific waveform characteristics affect the biologic
results. It is important to emphasize that the use of electricity in the clinic remains extremely controversial, with some
physicians strongly in support of its use and many who
remain unconvinced of its benefit. Principal issues in the
393
Low-Intensity Ultrasound
The sole intervention approved by the FDA to augment the
healing of fresh fractures is lowintensity ultrasound.
Although the approval was largely based on 2 double-blinded, placebo-controlled trials, substantive evidence at the
basic science level shows that ultrasound has a strong influence on biologic activity. Ultrasound, a form of mechanical
energy that can be transmitted in biologic organisms as
high-frequency acoustic pressure waves, has been widely
used in medicine as a therapeutic, surgical, and diagnostic
tool. Therapeutic ultrasound and some surgical ultrasound
use intensities as high as 1 to 3 W/cm2, and can cause considerable heating in living tissues. Use of ultrasound as a
surgical instrument employs even higher intensity levels (5
to 300 W/cm2), to fragment caliculi, ablate diseased tissues
such as cataracts, and even to remove methylmethacrylate
cement during revision of total joints.
Much lower magnitudes of ultrasound (1 to 50 mW/cm2)
are used to drive diagnostic devices that noninvasively
image vital organs, fetuses, peripheral flow, ophthalmic
echography, and even osteoporosis. This intensity level, 5
orders of magnitude below that used in surgery, studiously
avoids the energy levels that cause heating of tissues, and is
augment the fracture healing process (histologically, radiographically, and biomechanically) in various animal models. However, the greatest test of ultrasound must be at the
clinical level. The clinical evaluation of ultrasound has been
done via a series of doubleblinded, placebo-controlled
multicenter trials. In the first such study, which focused on
cortical bone, 67 closed or grade I open tibial fractures were
evaluated by Heckman and associates (1994). Ultrasound
treatment of 20 minutes per day at 30 mW/cm2 led to a significant (24%) reduction in the time of clinical healing (86
5.8 days in the active treatment group compared with 114
10.4 days in the control group; p = 0.01). Using both clinical
and radiographic criteria, a 38% decrease in the time to
overall healing was apparent (96 4.9 days in the active
treatment group compared with 154 13.7 days in the control group; p = 0.0001). This study also reported that the
patients compliance with the daily use of the ultrasound
device was excellent, and that there were no serious complications related to its use. Importantly, this study also
showed that several of the untreated patients went on to
delayed union, while no patients who were treated suffered
this complication, suggesting that ultrasound exposure not
only accelerates healing, but helps to ensure healing.
In the second study, to determine the efficacy of ultrasound to heal fractures in areas that consist primarily of
trabecular bone, a multicenter, prospective, randomized,
doubleblinded, placebocontrolled clinical trial of 61 dorsally angulated fractures of the distal radius was performed.
This 1997 study performed by Kristiansen and colleagues
showed that the time to union was 38% shorter for the
ultrasound-treated fractures (61 3 days) as compared to
those treated with placebo (98 5 days: p < 0.0001). In addition to the accelerated rate of healing, this study showed
that ultrasound treatment was associated with a significantly
smaller loss of reduction (20% 6% for active compared with
43% 8% obtained with the placebo treatment), an important
criteria in return to function of many fracture sites.
Because of the nature of the study design, the type of
injury that is going to be treated must be rigorously defined.
Therefore, the 2 studies described above excluded many
patients because their injuries did not meet the classification (for example, open type II fracture versus type I fracture), or because the patients had extenuating circumstances such as diabetes that might have hindered the
healing process. Ironically, it is just these patients that are
often the ones in greatest need of intervention.
Although healing may be optimized in the young healthy
patient with a closed fracture and a normal healing
response, it is more likely that the real benefit of biotechnology and/or bioengineering will be seen in those patients
in whom the healing response is overwhelmed, such as in
those with severe injuries, or in those patients in whom the
healing response is normally impaired, such as in those
who smoke. A recent study by Cook and associates (1997)
compared the effects of low-intensity ultrasound in the
395
Summary
Bone fracture union may follow any one of many combinations of pathways. Clinical factors such as the patients
expectations, compliance with treatment, degree of tolerance, the physicians experience, and other socioeconomic
considerations are likely to play important roles in the
selection of fixation methods. The best treatment modality
and fixation device must be selected according to the fracture morphology and the clinical condition of the patient. A
thorough knowledge of the devices biomechanical function and expected biologic response will optimize its effectiveness. Understanding the role of cell mediators and biophysical factors in the healing process may ultimately allow
the modulation of fracture healing regardless of the fixation
technique used.
Selected Bibliography
Osteonecrosis
Boettcher WG, Bonfiglio M, Hamilton HH, Sheets RF, Smith K:
Non-traumatic necrosis of the femoral head: I. Relation of altered
hemostasis to etiology. J Bone Joint Surg 1970;52A:312321.
Catto M: Pathology of aseptic bone necrosis, in Davidson JK (ed):
Aseptic Necrosis of Bone. Amsterdam, The Netherlands, Excerpta
Medica, 1976, pp 3100.
Chryssanthou CP: Dysbaric osteonecrosis: Etiological and pathogenetic concepts. Clin Orthop 1978;130:94106.
Cruess RL: Osteonecrosis of bone: Current concepts as to etiology
and pathogenesis. Clin Orthop 1986;208:3039.
Fisher DE: The role of fat embolism in the etiology of corticosteroidinduced avascular necrosis: Clinical and experimental results. Clin
Orthop 1978;130:6880.
Glimcher MJ, Kenzora JE: The biology of osteonecrosis of the human
femoral head and its clinical implications: I. Tissue biology. Clin
Orthop 1979;138:284309.
Glimcher MJ, Kenzora JE: The biology of osteonecrosis of the human
femoral head and its clinical implications: II. The pathological
changes in the femoral head as an organ and in the hip joint. Clin
Orthop 1979;139:283312.
Glimcher MJ, Kenzora JE: The biology of osteonecrosis of the human
femoral head and its clinical implications: III. Discussion of the etiology and genesis of the pathological sequelae: Comments on treatment. Clin Orthop 1979;140:273312.
Hawkins LG: Fractures of the neck of the talus. J Bone Joint Surg
1970;52A:9911002.
Hungerford DS, Lennox DW: The importance of increased
intraosseous pressure in the development of osteonecrosis of the
femoral head: Implications for treatment. Orthop Clin North Am
1985;16:635654.
Jones JP Jr: Fat embolism and osteonecrosis. Orthop Clin North Am
1985;16:595633.
Jones JP Jr: Concepts of etiology and early pathogenesis of
osteonecrosis, in Schafer M (ed): Instructional Course Lectures 43.
Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994,
pp 499512.
Steinberg ME: Early diagnosis, evaluation, and staging of
osteonecrosis, in Schafer M (ed): Instructional Course Lectures 43.
Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994,
pp 513518.
Smith SR, Bronk JJ, Kelly PJ: Effect of fracture fixation on cortical
bone blood flow. J Orthop Res 1990;8:471478.
External Fixation
Hart MB, Wu JJ, Chao EY, Kelly PJ: External skeletal fixation of canine
tibial osteotomies: Compression compared with no compression.
J Bone Joint Surg 1985;67A:598605.
Kummer FJ: Biomechanics of the Ilizarov external fixator. Bull Hosp
Jt Dis Orthop Inst 1989;49:140147.
397
Lewallen DG, Chao EY, Kasman RA, Kelly PJ: Comparison of the
effects of compression plates and external fixators on early bonehealing. J Bone Joint Surg 1984;66A:10841091.
Weber BG: On the biomechanics of external fixation, in Weber BG,
Magerl F (eds): The External Fixator: AO/ASIF-Threaded Rod System
Spine-Fixator. Springer-Verlag, Berlin, Germany, 1985, pp 2753.
Wu JJ, Shyr HS, Chao EY, Kelly PJ: Comparison of osteotomy healing
under external fixation devices with different stiffness characteristics.
J Bone Joint Surg 1984;66A:12581264.
Osteoconduction
Hollinger JO, Brekke J, Gruskin E, Lee D: Role of bone substitutes.
Clin Orthop 1996;324:5565.
Gazdag AR, Lane JM, Glaser D, Forster RA: Alternatives to autogenous bone graft: Efficacy and indications. J Am Acad Orthop Surg
1995;3:18.
Osteoinduction
Beck LS, Ammann AJ, Aufdemorte TB, et al: In vivo induction of bone
by recombinant human transforming growth factor beta 1. J Bone
Miner Res 1991;6:961968.
Bolander ME: Regulation of fracture repair by growth factors. Proc
Soc Exp Biol Med 1992;200:165170.
Bostrom MP, Lane JM, Berberian WS, et al: Immunolocalization and
expression of bone morphogenetic proteins 2 and 4 in fracture healing. J Orthop Res 1995;13:357367.
Centrella M, McCarthy TL, Canalis E: Transforming growth factorbeta and remodeling of bone. J Bone Joint Surg 1991;73A:14181428.
Goldring MB, Goldring SR: Skeletal tissue response to cytokines. Clin
Orthop 1990;258:245278.
Goldring SR, Goldring MB: Cytokines and skeletal physiology. Clin
Orthop 1996;324:1323.
Horowitz MC: Cytokines and estrogen in bone: Anti-osteoporotic
effects. Science 1993;260:626627.
Joyce ME, Jingushi S, Bolander ME: Transforming growth factor-beta
in the regulation of fracture repair. Orthop Clin North Am 1990;21:
199209.
Joyce ME, Roberts AB, Sporn MB, Bolander ME: Transforming
growth factor-beta and the initiation of chondrogenesis and osteogenesis in the rat femur. J Cell Biol 1990;110:21952207.
Joyce ME, Terek RM, Jingushi S, Bolander ME: Role of transforming
growth factor-beta in fracture repair. Ann N Y Acad Sci 1990;593:
107123.
Khouri RK, Koudsi B, Reddi H: Tissue transformation into bone in
vivo: A potential practical application. JAMA 1991;266:19531955.
Mohan S, Baylink DJ: Bone growth factors. Clin Orthop 1991;
263:3048.
Mustoe TA, Pierce GF, Thomason A, Gramates P, Sporn MB, Deuel TF:
Accelerated healing of incisional wounds in rats induced by transforming growth factor-beta. Science 1987;237:13331336.
Noda M, Camilliere JJ: In vivo stimulation of bone formation
by transforming growth factor-beta. Endocrinology 1989;124:
29912994.
Kristiansen TK, Ryaby JP, McCabe J, Frey JJ, Roe LR: Accelerated healing of distal radial fractures with the use of specific, low-intensity
ultrasound: A multicenter, prospective, randomized, double-blind,
placebo-controlled study. J Bone Joint Surg 1997;79A:961973.
Trippel SB, Coutts RD, Einhorn TA, Mundy GR, Rosenfeld RG:
Growth factors as therapeutic agents. J Bone Joint Surg 1996;78A:
12721286.
Yasko AW, Lane JM, Fellinger EJ, Rosen V, Wozney JM, Wang EA: The
healing of segmental bone defects, induced by recombinant human
bone morphogenetic protein (rhBMP-2): A radiographic, histological, and biomechanical study in rats. J Bone Joint Surg 1992;74A:
659670.
Biophysical Enhancement
Bassett CA: Fundamental and practical aspects of therapeutic uses of
pulsed electromagnetic fields (PEMFs). Crit Rev Biomed Eng
1989;17:451529.
Otter MW, Palmieri VR, Wu DD, Seiz KG, MacGinitie LA, Cochran GV:
A comparative analysis of streaming potentials in vivo and in vitro.
J Orthop Res 1992;10:710719.
Pilla AA, Mont MA, Nasser PR, et al: Non-invasive low-intensity
pulsed ultrasound accelerates bone healing in the rabbit. J Orthop
Trauma 1990;4:246253.
Pilla AA, Schmukler RE, Kaufman JJ, Rein G: Electromagnetic modulation of biological processess: Consideration of cell-waveform
interactions, in Chiabrera A, Nicolini C, Schwan HP (eds): Interactions Between Electromagnetic Fields and Cells. New York, NY,
Plenum Press, 1985.
Cochran GV, Pawluk RJ, Bassett CA: Electromechanical characteristics of bone under physiologic moisture conditions. Clin Orthop
1968;58:249270.
Wang S-J, Lewallen DG, Bolander ME, Chao EY, Ilstrup DM, Greenleaf JF: Low intensity ultrasound treatment increases strength in a rat
femoral fracture model. J Orthop Res 1994;12:4047.
Colson DJ, Browett JP, Fiddian NJ, Watson B: Treatment of delayedand non-union of fractures using pulsed electromagnetic fields. J
Biomed Eng 1988;10:301304.
Cook SD, Ryaby JP, McCabe J, Frey JJ, Heckman JD, Kristiansen TK:
Acceleration of tibia and distal radius fracture healing in patients
who smoke. Clin Orthop 1997;337:198207.
Duarte LR: The stimulation of bone growth by ultrasound. Arch
Orthop Trauma Surg 1983;101:153159.
Fukada E, Yasuda I: On the piezoelectric effect of bone. J Phys Soc
Japan 1957;10:11581162.
Heckman JD, Ryaby JP, McCabe J, Frey JJ, Kilcoyne RF: Acceleration
of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound. J Bone Joint Surg 1994;76A:2634.
399