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F Guilak

Publications and source records attributed to F Guilak.

At least 37 records · Page 2Linked to original sources

Longitudinal characterization of synovial fluid biomarkers in the canine meniscectomy model of osteoarthritis.

Damage to the meniscus can lead to posttraumatic osteoarthritis. Early markers of joint injury and tissue disease may be useful in developing and administering clinical treatment. We investigated the effects of total medial meniscectomy on biomarkers measured serially in synovial lavage fluid each month for 3 months. Following meniscectomy in dogs, four biomarkers were evaluated: cartilage oligomeric matrix protein, keratan sulfate epitope (5D4), the 3B3(-) neoepitope of chondroitin-6-sulfate, and the 3B3(+) chondroitinase-generated epitope of chondroitin-6-sulfate. Meniscectomy led to statistically significant elevations of all four biomarkers, with levels peaking at 4 weeks. By 12 weeks, the level of the 5D4 epitope returned to the preoperative baseline level whereas that of cartilage oligomeric matrix protein, 3B3(-), and 3B3(+) remained above the baseline. Concentrations of these biomarkers in the knees not operated on did not change significantly from the baseline. The levels of cartilage oligomeric matrix protein and 3B3(-) relative to 3B3(+) remained constant in all knees. In contrast, the level of 5D4 relative to 3B3(+) declined over time in the knee operated on but remained constant in the knee not operated on. These results demonstrate a quantitative change in the molecular components of synovial fluid after meniscectomy, as well as a qualitative change evinced by an alteration in the relative proportions of these epitopes. Extensive analyses showed a strong correlation between serum levels of 3B3(-) from the femoral and cephalic veins; however, serum 3B3(-) was not correlated with synovial fluid 3B3(-). These findings support the hypothesis that the concentrations of select cartilage biomarkers in synovial fluid are altered following meniscectomy and are promising tools for objectively monitoring the induction of osteoarthritis in this model system.

Animals↗

Simultaneous changes in the mechanical properties, quantitative collagen organization, and proteoglycan concentration of articular cartilage following canine meniscectomy.

The mechanical properties and microstructure of articular cartilage from the canine tibial plateau were studied 12 weeks after total medial meniscectomy. The organization of the birefringent collagen network was measured with quantitative polarized light microscopy to determine the thickness and the degree of organization of the superficial and deep zones. The zonal concentration of sulfated glycosaminoglycan was quantified with digital densitometry of safranin-O staining. Equilibrium compressive and shear properties, as well as dynamic shear properties, were measured at sites adjacent to those of microstructural analysis. The results evinced significant loss of cartilage function following meniscectomy, with decreases of 20-50% in the compressive and shear moduli. There was no evidence of alterations in the degree of collagen fibrillar organization, although a complete loss of the surface zone was seen in 60% of the samples that underwent meniscectomy. Meniscectomy resulted in a decreased concentration of sulfated glycosaminoglycan, and significant positive correlations were found between the equilibrium compressive modulus and the glycosaminoglycan content. Furthermore, the shear properties of cartilage correlated directly with collagen fibrillar organization measured at the superficial zone of corresponding sites. These findings demonstrate that meniscectomy leads to impaired mechanical function of articular cartilage, with significant evidence of quantitative correlations between cartilage microstructure and mechanics.

Animals↗

Viscoelastic properties of chondrocytes from normal and osteoarthritic human cartilage.

The deformation behavior and mechanical properties of articular chondrocytes are believed to play an important role in their response to mechanical loading of the extracellular matrix. This study utilized the micropipette aspiration test to measure the viscoelastic properties of chondrocytes isolated from macroscopically normal or end-stage osteoarthritic cartilage. A three-parameter standard linear solid was used to model the viscoelastic behavior of the cells. Significant differences were found between the mechanical properties of chondrocytes isolated from normal and osteoarthritic cartilage. Specifically, osteoarthritic chondrocytes exhibited a significantly higher equilibrium modulus (0.33 +/- 0.23 compared with 0.24 +/- 0.11 kPa), instantaneous modulus (0.63 +/- 0.51 compared with 0.41 +/- 0.17 kPa), and apparent viscosity (5.8 +/- 6.5 compared with 3.0 +/- 1.8 kPa-s) compared with chondrocytes isolated from macroscopically normal, nonosteoarthritic cartilage. The elastic moduli and relaxation time constant determined experimentally in this study were used to estimate the apparent biphasic properties of the chondrocyte on the basis of the equation for the gel relaxation time of a biphasic material. The differences in viscoelastic properties may reflect alterations in the structure and composition of the chondrocyte cytoskeleton that have previously been associated with osteoarthritic cartilage. Coupled with earlier theoretical models of cell-matrix interactions in articular cartilage, the increased elastic and viscous properties suggest that the mechanical environment of the chondrocyte may be altered in osteoarthritic cartilage.

Adult↗

Functional tissue engineering: the role of biomechanics.

"Tissue engineering" uses implanted cells, scaffolds, DNA, protein, and/or protein fragments to replace or repair injured or diseased tissues and organs. Despite its early success, tissue engineers have faced challenges in repairing or replacing tissues that serve a predominantly biomechanical function. An evolving discipline called "functional tissue engineering" (FTE) seeks to address these challenges. In this paper, the authors present principles of functional tissue engineering that should be addressed when engineering repairs and replacements for load-bearing structures. First, in vivo stress/strain histories need to be measured for a variety of activities. These in vivo data provide mechanical thresholds that tissue repairs/replacements will likely encounter after surgery. Second, the mechanical properties of the native tissues must be established for subfailure and failure conditions. These "baseline data" provide parameters within the expected thresholds for different in vivo activities and beyond these levels if safety factors are to be incorporated. Third, a subset of these mechanical properties must be selected and prioritized. This subset is important, given that the mechanical properties of the designs are not expected to completely duplicate the properties of the native tissues. Fourth, standards must be set when evaluating the repairs/replacements after surgery so as to determine, "how good is good enough?" Some aspects of the repair outcome may be inferior, but other mechanical characteristics of the repairs and replacements might be suitable. New and improved methods must also be developed for assessing the function of engineered tissues. Fifth, the effects of physical factors on cellular activity must be determined in engineered tissues. Knowing these signals may shorten the iterations required to replace a tissue successfully and direct cellular activity and phenotype toward a desired end goal. Finally, to effect a better repair outcome, cell-matrix implants may benefit from being mechanically stimulated using in vitro "bioreactors" prior to implantation. Increasing evidence suggests that mechanical stress, as well as other physical factors, may significantly increase the biosynthetic activity of cells in bioartificial matrices. Incorporating each of these principles of functional tissue engineering should result in safer and more efficacious repairs and replacements for the surgeon and patient.

Biocompatible Materials↗

An axisymmetric boundary integral model for incompressible linear viscoelasticity: application to the micropipette aspiration contact problem.

The micropipette aspiration test has been used extensively in recent years as a means of quantifying cellular mechanics and molecular interactions at the microscopic scale. However, previous studies have generally modeled the cell as an infinite half-space in order to develop an analytical solution for a viscoelastic solid cell. In this study, an axisymmetric boundary integral formulation of the governing equations of incompressible linear viscoelasticity is presented and used to simulate the micropipette aspiration contact problem. The cell is idealized as a homogeneous and isotropic continuum with constitutive equation given by three-parameter (E, tau 1, tau 2) standard linear viscoelasticity. The formulation is used to develop a computational model via a "correspondence principle" in which the solution is written as the sum of a homogeneous (elastic) part and a nonhomogeneous part, which depends only on past values of the solution. Via a time-marching scheme, the solution of the viscoelastic problem is obtained by employing an elastic boundary element method with modified boundary conditions. The accuracy and convergence of the time-marching scheme are verified using an analytical solution. An incremental reformulation of the scheme is presented to facilitate the simulation of micropipette aspiration, a nonlinear contact problem. In contrast to the halfspace model (Sato et al., 1990), this computational model accounts for nonlinearities in the cell response that result from a consideration of geometric factors including the finite cell dimension (radius R), curvature of the cell boundary, evolution of the cell-micropipette contact region, and curvature of the edges of the micropipette (inner radius a, edge curvature radius epsilon). Using 60 quadratic boundary elements, a micropipette aspiration creep test with ramp time t* = 0.1 s and ramp pressure p*/E = 0.8 is simulated for the cases a/R = 0.3, 0.4, 0.5 using mean parameter values for primary chondrocytes. Comparisons to the half-space model indicate that the computational model predicts an aspiration length that is less stiff during the initial ramp response (t = 0-1 s) but more stiff at equilibrium (t = 200 s). Overall, the ramp and equilibrium predictions of aspiration length by the computational model are fairly insensitive to aspect ratio a/R but can differ from the half-space model by up to 20 percent. This computational approach may be readily extended to account for more complex geometries or inhomogeneities in cellular properties.

Biomechanical Phenomena↗

Cell mechanics.

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Biomechanical Phenomena↗

The deformation behavior and viscoelastic properties of chondrocytes in articular cartilage.

Chondrocytes in articular cartilage utilize mechanical signals in conjunction with other environmental factors to regulate their metabolic activity. However, the sequence of biomechanical and biochemical events involved in the process of mechanical signal transduction has not been fully deciphered. A fundamental step in determining the role of various factors in regulating chondrocyte activity is to characterize accurately the biophysical environment within the tissue under physiological conditions of mechanical loading. Microscopic imaging studies have revealed that chondrocytes as well as their nuclei undergo shape and volume changes in a coordinated manner with deformation of the tissue matrix. Through micromechanical experiments, it has been shown that the chondrocyte behaves as a viscoelastic solid material with a mechanical stiffness that is several orders of magnitude lower than that of the cartilage extracellular matrix. These properties seem to be due to the structure of the chondrocyte cytoskeleton, and in part, the viscoelastic properties of the cell nucleus. The mechanical properties of the pericellular matrix that immediately surrounds the chondrocyte significantly differ from those of the chondrocyte and the extracellular matrix, suggesting that the pericellular matrix plays an important role in defining the mechanical environment of the chondrocyte. These experimentally measured values for chondrocyte and cartilage mechanical properties have been used in combination with theoretical constitutive modeling of the chondrocyte within articular cartilage to predict the non-uniform and time-varying stress-strain and fluid flow environment of the cell. The ultimate goal of these studies has been to elucidate the sequence of biomechanical and biochemical events through which mechanical stress influences chondrocyte activity in both health and in disease.

Animals↗

The mechanical environment of the chondrocyte: a biphasic finite element model of cell-matrix interactions in articular cartilage.

Mechanical compression of the cartilage extracellular matrix has a significant effect on the metabolic activity of the chondrocytes. However, the relationship between the stress-strain and fluid-flow fields at the macroscopic "tissue" level and those at the microscopic "cellular" level are not fully understood. Based on the existing experimental data on the deformation behavior and biomechanical properties of articular cartilage and chondrocytes, a multi-scale biphasic finite element model was developed of the chondrocyte as a spheroidal inclusion embedded within the extracellular matrix of a cartilage explant. The mechanical environment at the cellular level was found to be time-varying and inhomogeneous, and the large difference ( approximately 3 orders of magnitude) in the elastic properties of the chondrocyte and those of the extracellular matrix results in stress concentrations at the cell-matrix border and a nearly two-fold increase in strain and dilatation (volume change) at the cellular level, as compared to the macroscopic level. The presence of a narrow "pericellular matrix" with different properties than that of the chondrocyte or extracellular matrix significantly altered the principal stress and strain magnitudes within the chondrocyte, suggesting a functional biomechanical role for the pericellular matrix. These findings suggest that even under simple compressive loading conditions, chondrocytes are subjected to a complex local mechanical environment consisting of tension, compression, shear, and fluid pressure. Knowledge of the local stress and strain fields in the extracellular matrix is an important step in the interpretation of studies of mechanical signal transduction in cartilage explant culture models.

Biomechanical Phenomena↗

Viscoelastic properties of intervertebral disc cells. Identification of two biomechanically distinct cell populations.

STUDY DESIGN: A combined experimental and theoretical biomechanical study to quantify the mechanical properties of living cells of the porcine intervertebral disc. OBJECTIVES: To quantify zonal variations in the mechanical properties and morphology of cells isolated from the intervertebral disc. SUMMARY OF BACKGROUND DATA: Cellular response to mechanical stimuli is influenced by the mechanical properties of cells and of the extracellular matrix. Significant zonal variations in intervertebral disc matrix properties have been reported. No information is currently available on the corresponding regional variations in the mechanical properties of intervertebral disc cells, despite evidence of significant differences in cellular phenotype and biologic response to loading. METHODS: The micropipette aspiration test was used in combination with a three-parameter viscoelastic solid model to measure the mechanical properties of cells isolated from the anulus fibrosus, transition zone, and nucleus pulposus. RESULTS: Intervertebral disc cells exhibited viscoelastic solid behaviors. Highly significant differences were observed in the morphology, cytoskeletal arrangement, and biomechanical properties of the nucleus pulposus cells as compared with anulus fibrosus or transition zone cells. Cells of the nucleus pulposus were approximately three times stiffer and significantly more viscous than cells of the anulus fibrosus or transition zone. CONCLUSIONS: The findings of this study provide new evidence for the existence of two biomechanically distinct cell populations in the intervertebral disc. These differences in mechanical behavior may be related to observed differences in the cytoskeletal architecture between these cells, and may further play an important role in the development, maintenance, and degeneration of the intervertebral disc.

Animals↗

Comparison of several digital and stereological methods for estimating surface area and volume of cells studied by confocal microscopy.

BACKGROUND: The implementation of different methods for estimating the surface area and volume of cells studied by confocal microscopy was developed. The methods were compared from the point of view of their precision, applicability and efficiency. METHODS: Interactive stereological methods (spatial grid method, fakir method, Cavalieri principle) as well as automatic digital methods (digital Crofton method, voxel counting, triangulation method, iso-intensity contouring method) were considered. The methods were tested on model geometrical solids and on real volume images consisting of a stack of serial sections encompassing entire tobacco BY-2 cells or cell chains. RESULTS: It is shown that many of the studied methods are very precise when applied to cells of simple or moderately complex shapes. The automatic digital methods are fast and precise but their applicability is limited by the necessity to segment automatically the object surface and to find an optimal resolution. This limitation is not present in stereological methods which are applied interactively and thus are more time-consuming. CONCLUSIONS: The presented implementations of the fakir method and the Cavalieri principle enable interactive, unbiased and efficient estimation of the cell surface area and volume. The recommended steps for measuring the surface area and/or volume of objects studied by confocal microscopy are described.

Cell Line↗

Compressive and shear properties of alginate gel: effects of sodium ions and alginate concentration.

The equilibrium and viscoelastic properties of alginate gel crosslinked with Ca2+ were determined as a function of alginate concentration and duration of exposure to physiologic concentrations of NaCl. Compressive and shear stress relaxation tests and oscillatory shear tests were performed to measure the material properties at two time periods after storage in NaCl compared to no NaCl exposure. The effect of concentration was determined by testing 1-3% alginate gel in a bath of physiological NaCl and CaCl2. After 15 h of exposure to NaCl, the compressive, equilibrium shear, and dynamic shear moduli decreased by 63, 84, and 90% of control values, respectively. The material properties exhibited no further changes after 7 days of exposure to NaCl. The loss angle and amplitude of the relaxation function in the shear also decreased, indicating less viscous behaviors in both dynamic and transient configurations. All moduli, but not the loss angle, significantly increased with increasing alginate concentration. The observed decrease in compressive and shear stiffness for alginate gel after exposure to Na+ was significant and indicated that physiological conditions will soften the gel over a time period of up to 7 days after gelation. The alginate gel retains significant solid-like behaviors, however, as measured by a loss angle of approximately 3 degrees. This study provides the first available data for material properties of alginate gel tested in physiological saline.

Alginates↗

Mechanically induced calcium waves in articular chondrocytes are inhibited by gadolinium and amiloride.

Chondrocytes in articular cartilage utilize mechanical signals from their environment to regulate their metabolic activity. However, the sequence of events involved in the transduction of mechanical signals to a biochemical signal is not fully understood. It has been proposed that an increase in the concentration of intracellular calcium ion ([Ca2+]i) is one of the earliest events in the process of cellular mechanical signal transduction. With use of fluorescent confocal microscopy, [Ca2+]i was monitored in isolated articular chondrocytes subjected to controlled deformation with the edge of a glass micropipette. Mechanical stimulation resulted in an immediate and transient increase in [Ca2+]i. The initiation of Ca2+ waves was abolished by removing Ca2+ from the extracellular media and was significantly inhibited by the presence of gadolinium ion (10 microM) or amiloride (1 mM), which have previously been reported to block mechanosensitive ion channels. Inhibitors of intracellular Ca2+ release (dantrolene and 8-diethylaminooctyl 3,4,5-trimethoxybenzoate hydrochloride) or cytoskeletal disrupting agents (cytochalasin D and colchicine) had no significant effect on the characteristics of the Ca2+ waves. These findings suggest that a possible mechanism of Ca2+ mobilization in this case is a self-reinforcing influx of Ca2+ from the extracellular media, initiated by a Ca2+-permeable mechanosensitive ion channel. Our results indicate that a transient increase in intracellular Ca2+ concentration may be one of the earliest events involved in the response of chondrocytes to mechanical stress and support the hypothesis that deformation-induced Ca2+ waves are initiated through mechanosensitive ion channels.

Amiloride↗

Tensile properties of articular cartilage are altered by meniscectomy in a canine model of osteoarthritis.

Loss of or damage to the meniscus alters the pattern of loading in the knee joint and frequently leads to cartilage degeneration and osteoarthritis. The mechanical properties of articular cartilage have been shown to reflect the extent of cartilage degeneration in human osteoarthritis and in experimental models of joint disease, but there is little experimental data documenting changes in cartilage mechanics following meniscectomy. We hypothesized that the tensile properties of the surface zone of articular cartilage are altered following total medial meniscectomy. Twelve mongrel dogs underwent complete resection of the medial meniscus in the right knee, and the femoral cartilage was studied 12 weeks after the operation. We performed uniaxial, tensile stress-relaxation tests to determine the equilibrium tensile modulus of surface-zone cartilage. Water and glycosaminoglycan content were also measured at site-matched locations. The tensile moduli of the cartilage decreased significantly following meniscectomy. The linear region modulus decreased by 40%, from 25.5 +/- 7.7 to 15.3 +/- 7.2 MPa. There was a weak (r = -0.45), but significant, correlation between the linear region modulus and the gross morphological grade for cartilage damage. Water and glycosaminoglycan content did not change following meniscectomy. Composition was not correlated with mechanical properties or morphological grade, suggesting that cartilage structure may play a more important role than composition in determining the mechanical properties. The observed decrease in cartilage material properties provides a quantitative measure of the loss of cartilage function following meniscectomy and reflects a pattern of change that is consistent with damage to the collagen-proteoglycan solid network.

Animals↗

Alterations in the Young's modulus and volumetric properties of chondrocytes isolated from normal and osteoarthritic human cartilage.

The mechanical environment of the chondrocyte is an important factor that influences the maintenance of the articular cartilage extracellular matrix. Previous studies have utilized theoretical models of chondrocytes within articular cartilage to predict the stress-strain and fluid flow environments around the cell, but little is currently known regarding the cellular properties which are required for implementation of these models. The objectives of this study were to characterize the mechanical behavior of primary human chondrocytes and to determine the Young's modulus of chondrocytes from non-osteoarthritic ('normal') and osteoarthritic cartilage. A second goal was to quantify changes in the volume of isolated chondrocytes in response to mechanical deformation. The micropipette aspiration technique was used to measure the deformation of a single chondrocyte into a glass micropipette in response to a prescribed pressure. The results of this study indicate that the human chondrocyte behaves as a viscoelastic solid. No differences were found between the Young's moduli of normal (0.65+/-0.63 kPa, n = 44) and osteoarthritic chondrocytes (0.67+/-0.86 kPa, n = 69, p = 0.93). A significant difference in cell volume was observed immediately and 600 s after complete aspiration of the cell into the pipette (p < 0.001), and the magnitude of this volume change between normal (11+/-11%, n = 40) and osteoarthritic (20+/-11%, n = 41) chondroctyes was significantly different at both time points (p < 0.002). This finding suggests that chondrocytes from osteoarthritic cartilage may have altered volume regulation capabilities in response to mechanical deformation. The mechanical and volumetric properties determined in this study will be of use in analytical and finite element models of chondrocyte-matrix interactions in order to better predict the mechanical environment of the cell in vivo.

Adult↗

The deformation behavior and mechanical properties of chondrocytes in articular cartilage.

INTRODUCTION: Chondrocytes in articular cartilage utilize mechanical signals to regulate their metabolic activity. A fundamental step in determining the role of various biophysical factors in this process is to characterize the local mechanical environment of the chondrocyte under physiological loading. METHODS: A combined experimental and theoretical approach was used to quantify the in-situ mechanical environment of the chondrocyte. The mechanical properties of enzymatically-isolated chondrocytes and their pericellular matrix (PCM) were determined using micropipette aspiration. The values were used in a finite element model of the chondron (the chondrocyte and its PCM) within articular cartilage to predict the stress-strain and fluid flow microenvironment of the cell. The theoretical predictions were validated using three-dimensional confocal microscopy of chondrocyte deformation in situ. RESULTS: Chondrocytes were found to behave as a viscoelastic solid material with a Young's modulus of approximately 0.6 kPa. The elastic modulus of the PCM was significantly higher than that of the chondrocyte, but several orders of magnitude lower than that of the extracellular matrix. Theoretical modeling of cell-matrix interactions suggests the mechanical environment of the chondrocyte is highly non-uniform and is dependent on the viscoelastic properties of the PCM. Excellent agreement was observed between the theoretical predictions and the direct measurements of chondrocyte deformation, but only if the model incorporated the PCM. CONCLUSIONS: These findings imply that the PCM plays a functional biomechanical role in articular cartilage, and alterations in PCM properties with aging or disease will significantly affect the biophysical environment of the chondrocyte.

Biomechanical Phenomena↗

Biomechanical factors in tissue engineered meniscal repair.

Damage to the meniscus after trauma or injury is associated with detrimental changes in joint function that can lead to pain, disability, and degenerative joint changes. Recently, tissue engineering strategies for meniscal repair have been suggested including using biocompatible grafts as a substrate for regeneration, and cellular supplementation to promote remodeling and healing. Little is known, however, about the contributions of these novel repair strategies to restoration of normal meniscal function. Biomechanical factors play a role in the design and synthesis of tissue engineered biomaterials and bioreactors, and also are important for evaluating the efficacy of these new strategies for restoring normal meniscal function. In this report, an overview is presented of biomechanical factors that are critical to meniscal function followed by a review of biomechanical considerations for the design and evaluation of tissue engineered strategies for meniscal repair. Recommendations for future study of biomechanical factors in tissue engineered meniscal repair also are provided.

Animals↗

Incompressibility of the solid matrix of articular cartilage under high hydrostatic pressures.

The objective of this study was to test the hypothesis that the organic solid matrix of articular cartilage is incompressible under physiological levels of pressure. Due to its anisotropic swelling behavior, an anisotropic version of the biphasic theory was used to predict the deformation and internal stress fields. This theory predicts that, under hydrostatic loading of cartilage via a pressurized external fluid, a state of uniform hydrostatic fluid pressure exists within the tissue regardless of the anisotropic nature of the solid matrix. The theory also predicts that if the solid matrix is intrinsically incompressible, the tissue will not deform under hydrostatic loading conditions. This prediction, i.e., no deformation, was experimentally tested by subjecting specimens of normal bovine articular cartilage to hydrostatic pressures. A new high pressure hydrostatic loading chamber was designed and built for this purpose. It was found that normal bovine articular cartilage, when subject to hydrostatic pressures up to 12 M Pa, does not deform measurably. This experimental finding supports one of the fundamental assumptions of the biphasic theory for cartilage, i.e., the organic solid matrix of the tissue is intrinsically incompressible when loaded within the normal physiologic range of pressures. Hydrostatic loading has often heen used in cartilage explant cultures for tissue metabolism studies. The findings of this study provides an accurate method to calculate the states of stress acting on the fluid and solid phases of the tissue in these hydrostatically loaded explant culture experiments, and suggest that tissue deformation will be minimal under pure hydrostatic pressurization.

Algorithms↗

The effect of hip stem material modulus on surface strain in human femora.

Human femora were used to compare the changes in bone surface strain resulting from decreasing the material modulus of a collarless hip stem to determine whether a highly elastic stem increased bone loading. Three substrate materials were tested: titanium (modulus of elasticity 110 GPa), carbon fiber composite (modulus of elasticity 52 GPa), and polymethylmethacrylate (PMMA, modulus of elasticity of 1.9 GPa). Two separate analyses were performed in which femora were implanted randomly with one of the three stem types. Results showed that assembly strains did not differ significantly among different materials. There was a large strain reduction in the proximal region of the femora for all stem substrates relative to the intact femur. Although there was statistically greater surface shear strain as the material modulus decreased, the PMMA stem did not substantially increase bone loading.

Adult↗