Chapter 3

Biomechanics – Part I
Sudheer Reddy, Michele Dischino, and Louis J. Soslowsky

Abstract Biomechanics is the science of the action of forces, internal or external, on the living body. It includes the fields of statics, dynamics, and kinetics. This section will discuss some basic terminology used in biomechanics and also discuss the mechanical properties of some tissues and biomaterials that are important in orthopedic practice. Keywords Stress–Strain curve • Newton’s law • Young’s modulus of elasticity • Hooke’s law • Wolff’s law

one to analyze what forces are acting upon a bone or joint. An example would be lifting a weight with your arm such that the weight would exert a downward force on the hand and forearm while the biceps would be exerting an upwards force from its insertion on the radius.

Joint Biomechanics
Definitions

Definitions
Biomechanics is the science of the action of forces, internal or external, on the living body. Statics is the study of the action of forces on bodies at rest (in equilibrium). Dynamics is the study of bodies in motion and the forces related to producing motion. The field of kinetics relates the effects of forces to the motion of bodies, while kinematics is the study of motion (displacement, velocity, and acceleration) without reference to the forces causing the motion.

Newton’s Laws (Brief Summary)
Central to understanding the principles of biomechanics and how they affect the skeletal system are Newton’s three laws governing forces. The first law, the law of inertia, is simply stated as follows: if the net external force acting on a body is zero, the body will remain at rest or move uniformly (zero acceleration). This allows for static analysis of the forces acting upon a body via the equation SF = 0. The second law, the law of acceleration, is the principle that the net force acting on an object is the product of the object’s mass and its acceleration. Newton’s third law, the law of reactions, states that there is an equal and opposite reaction. An understanding of these forces allows one to analyze the action of forces on bodies (free body analysis). Free body analyses are useful for understanding stresses in bone and bone remodeling in response to these stresses. They are useful in that they allow
J.S. Khurana (ed.), Bone Pathology, DOI 10.1007/978-1-59745-347-9_3, © Humana Press a part of Springer Science+Business Media, LLC 2009

Degrees of Freedom: Joint motion is described as rotations and translations occurring in the x, y, and z planes, requiring six parameters or degrees of motion (freedom to function). It is important to note that not all joints exhibit 6 degrees of freedom (abduction, adduction, flexion, extension, internal rotation, and external rotation) due to anatomic constraints to motion. Hip: The hip is a joint that does exhibit 6 degrees of freedom and is termed a ball and socket joint. The stability of the joint is largely based upon the ball and socket design. The bone of the hip is also designed to withstand the significant stress that is placed upon it during daily activities. The reactive force of the hip can reach three to six times body weight, primarily due to the contraction of muscles that cross the hip joint. These muscles, primarily the abductor group (the gluteus medius and minimus) confer stability to the hip and are important in stabilizing the pelvis during gait. Table 1 shows the range of motion that the hip joint is capable of producing. Knee: In contrast to the hip, the knee exhibits only 4 degrees of freedom: internal/external rotation, flexion, and extension. The knee is a hinge joint and stability is conferred upon it by the ligamentous structures that surround it. For example, the collateral and cruciate ligaments confer coronal plane stability with the knee in extension. While there is purely rotational movement about the hip, the knee does allow for translational motion during flexion and extension and is rather a complex series of rotations and translations about an instantaneous center of rotation. While understanding this complex series of motions of the knee is beyond the scope of this text, it is important to note that the knee does undergo additional motions besides flexion and extension and that the functional range of
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62 Table 1 Range of motion of hip joint (Source: Ref. 1) Motion Flexion Extension Abduction Adduction Internal rotation External rotation Average range ( )
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Functional range ( )
o

115 30 50 30 45 45

90 (120 to squat) Not required 20 Not required 0 20

of the articular cartilage (hyaline cartilage). This leads to an efflux of fluid from the cartilage, contributing to the lubrication of the joint (which has a thin film of joint lubricant separating the surfaces) and reduces the coefficient of friction between the articular surfaces. The coefficient of friction (a specific measure of the degree of friction between two surfaces) in joints is a function of synovial fluid, an ultrafiltrate of blood plasma produced by the synovial membrane.

Table 2 Range of motion of knee joint Motion Extension Flexion Internal rotation (at 90o of flexion)b External rotation (at 90o of flexion)b
a

Average range (o) –10 (hyperextension) 130 30 45

Functional range (o) 0 90a Not requiredc Not requiredc

Tissue Biomechanics
Definitions Load refers to the force(s) acting on a body, and can be applied in compression, tension, shear or torsion, or some combination of these. Deformation is the change in shape produced in a body as a result of an applied load. This alteration can be temporary (elastic) or permanent (plastic). Stiffness describes the resistance of a body to deformation. Each of these properties is dependent upon the geometry of a specimen and is therefore considered a structural property. Properties that are independent of geometry are termed material properties and include stress and strain, which are discussed below. Stress is defined as force per unit area and can be normal (perpendicular) to a surface or act in shear (parallel to the surface). It is typically reported in Newtons per square meter (N/m2) (also called pascals). Strain can also be normal or shear and is defined as the change in length/original length of a specimen. As strain is a proportion, it is unitless. Modulus (Young’s modulus of elasticity) is the measure of the ability of a material to resist deformation and is equal to stress/strain, it has no units.

117o required for squatting and lifting; 110o of flexion required to arise from a chair following a total knee arthroplasty. b True rotation of the knee varies with degree of flexion. c During the last 15o of extension, the femur internally rotates on the tibia, allowing full extension. This is called the “screw home” mechanism. (Source: Ref. 1).

motion is different than the total range of motion that the knee is able to undergo. Table 2 shows the actual and functional range of motion of the knee. Joint reaction force: Forces are generated within a joint in response to forces acting on the joint (both intrinsic and extrinsic). Muscle contractions about a joint are the major contributory factor to the joint reaction force. As an example, the gluteus medius and minimus attach to the greater trochanter of the proximal femur and create an abductor moment on the hip. When they contract pulling the femur proximally, the force of contraction creates a joint reactive force against the acetabular wall by the femoral head. Instant center of rotation: This is the point about which a joint rotates. For some joints, the instantaneous axis of rotation (IAR) is static and for others it is dynamic (changes during the arc of motion, such as in the knee and unconstrained total disc replacement). It is helpful in understanding the types of motion that various joints undergo. Rolling/sliding motion: Most joints exhibit simultaneous rolling and sliding motion, such as the knee. Pure rolling occurs when the instant center of rotation is at the rolling surfaces and the contacting points have zero relative velocity. Pure sliding occurs with pure translation or rotation about a stationary axis; there is no angular change in position and no instant center of rotation. Friction/lubrication: The predominant mechanism of lubrication during dynamic joint function is elastohydrodynamic, which means that during joint loading there is cartilage deformation leading to an efflux of fluid into the joint. With joint function and loading, there is deformation

The Stress–Strain Curve
A stress–strain curve plots stress versus strain for a specimen under uniaxial load (Fig. 1). As illustrated in the figure, a specimen will typically exhibit linearly elastic behavior up to a limit, which is referred to as the proportional limit, or yield point. In this region, the material obeys Hooke’s law, which states that stress is proportional to strain or F/A = E(Dl/l0), where F is the force (or load) applied to the specimen, A is its cross-sectional area, and Dl/l0 is the resultant strain. The proportionality constant, E, is referred to as Young’s modulus, and is an important property of the material as it measures its resistance to deformation. This property is independent of specimen geometry. Beyond the yield point, stress is no longer proportional to strain and deformation is no longer fully recoverable because of damage to the internal microstructure of the specimen. Other

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Mechanical Properties of Bone
Bone is a composite material, consisting of minerals, proteins, water, cells, and other macromolecules. Its composition varies with anatomic site, age, diet, and the presence of disease. In general, however, ~90% of the organic matrix of bone is collagen and the main constituent of its mineral phase is hydroxyapatite. Collagen has a low modulus, good tensile strength, and poor compressive strength. Hydroxyapatite is a stiff, brittle material with good compressive strength. This combination yields an anisotropic material that is strongest in compression, weakest in shear, and intermediate in tension. The mineral content is the main determinant of the elastic modulus of cortical bone. Cortical bone is excellent in resisting torque, while trabecular bone is good in resisting compression and shear. Trabecular bone is 25% as dense, 10% as stiff, and 500% as ductile as cortical bone. Trabecular bone density varies significantly with anatomic location and age, and such variations directly impact the mechanical properties of the tissue. For example, trabecular bone properties within the proximal tibia can vary by up to 2 orders of magnitude because of changes in density alone. To further complicate matters, the mechanical properties of trabecular bone also depend on architecture, which, like density, depends on anatomic site and age. Cortical bone is a low porosity solid. Trabecular bone is an open-celled porous foam, composed of a series of thin and thick interconnecting trabeculae. Depending on the type and orientation of these basic structures, the mechanical properties can vary by at least an order of magnitude. Bone is a dynamic material, capable of self-repair and adaptation. Prolonged immobilization induces bone weakness. Exercise increases bone strength. With aging, the mechanical properties of cortical bone progressively deteriorate. This has been demonstrated in cortical bone samples taken from the femoral mid-diaphysis (Fig. 2), which showed a decrease in elastic modulus and ultimate strength of ~2%

Fig. 1 Stress–strain curve

important features of the stress–strain curve are the ultimate strength (the maximum stress value attained by the specimen), the breaking point (the point at which the specimen fails, and the plastic deformation (the change in length after removing the load in the plastic range, before the breaking point). In addition to this information, the stress–strain curve can also be used to calculate strain energy, or toughness, which is the energy required to bring the specimen to failure and is represented by the area under the curve (i.e., the stress–strain curve). Strain energy is a useful measure because injuries transfer energy to a body, which results in deformation and possibly fracture. By determining how much energy can be absorbed by a material before failure, it may be possible to enhance fracture prevention. Strain energy may also be useful in determining possible causes of existing fractures. On the basis of the concepts outlined above, several categories exist that describe material characteristics and behavior:
Brittle Exhibit a linear stress–strain curve to failure and elastic deformation only. An example of a brittle material encountered in orthopedics is polymethylmethacrylate (PMMA). Ductile Undergo a large amount of plastic deformation before reaching failure, such as metals. Elastic Stress is directly proportional to strain for elastic materials and deformation is fully recovered when a load is removed. The properties of elastic materials are insensitive to the rate of loading. Viscoelastic The stress–strain behavior of viscoelastic materials depends on time and rate of loading. Viscoelasticity is a function of internal friction in the material. For such materials, a constant force will produce creep, that is, the deformation will increase with time as long as the force is maintained on the material, until equilibrium is reached. Conversely, a constantly held deformation will cause stress relaxation to occur, that is, the force required to maintain the deformation will diminish with time until equilibrium in reached. Articular cartilage, intervertebral disk, ligament, tendon, and bone exhibit pronounced viscoelastic behavior. Isotropic Have the same mechanical properties in all directions. Anisotropic Mechanical properties vary with the direction of applied load in these materials. Biologic tissues are anisotropic in nature.

Fig. 2 Age-related effects on longitudinal modulus and ultimate tensile strength of human femoral cortical bone (8)

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per decade after 20 years of age. Probably the most significant change in terms of fracture risk, however, is the ~7% reduction in energy absorption that occurs with aging. Taken together, these data indicate that cortical bone becomes less stiff, weaker, and more brittle with aging. To offset agerelated loss in mechanical properties, bone remodels its geometry to increase the inner and outer cortical diameters, thus minimizing bending stresses. The bending rigidity of a cylinder is proportional to r4. Wolff’s law states that bone structure adapts to changing loads. As an example, the trabecular patterns in the femoral head and neck (Fig. 3) are distributed in a pattern to allow the proximal femur to withstand the typical forces experienced by the hip in daily activities. Both the primary and secondary compression groups of trabecular lines are centered on the proximal, medial cortex (calcar) allowing it to withstand the compressive forces that are placed upon it during gait. These stress patterns develop as a person first learns to walk. In certain diseases, Wolff’s Law may no longer hold true as bone loses its ability to remodel to stress. This increases the propensity of abnormal bone to fail under normal loading conditions, leading to a pathologic fracture (Fig. 4). Fractures and mechanism of injury • Stress fractures can occur as a result of fatigue damage. In fatigue fractures, there are three characteristic stages: crack initiation, crack growth, and final fracture. In cortical bone, Haversian canals and lacunae serve as crack initiators since they represent discontinuities in the cortical bone microstructure. The most important factor in fatigue damage is the second stage of crack propagation, as microcracks join together once they have progressed beyond the initiation stage. The final stage of fracture is reached when these cracks coalesce and become large enough to overcome the absorptive properties (ability of bone to absorb energy and resist crack propagation) of the Haversian system. Tension fractures occur by muscle pull with the bone failing in tension. The fracture line is transverse, perpendicular to the load and axis of the bone (Fig. 5). Compression fractures occur by axial loading of bone, with cancellous-type bone failing typically. It results in a crush type of fracture, such as a buckle fracture in a child. Shear fractures occur with a load that is parallel to the bone surface, with the resultant fracture parallel to the direction of loading. Pure shear fractures are rare; however, it is a component in spiral fracture patterns. Fractures that are produced as a result of a bending force produce a characteristic called a butterfly fragment that is indicative of this fracture pattern. The fracture starts on the tension side of the bone and continues transversely (or obliquely) to the compression side of the bone. The bone bifurcates producing a butterfly fragment.

Fig. 3 a Wolff’s law is well demonstrated in the head and neck of the femur. In this area, the bone trabeculae radiate from the articular surface down onto the medial cortex of the femoral neck (the calcar), which is much thicker than the cortex on the lateral side of the femoral neck. b In this slice through the upper end of the femur, the marrow fat has been washed out of the specimen to demonstrate the distribution of the cancellous bone. c The best way to demonstrate clearly the arrangement of the bone trabeculae is by radiography of the specimen

Spiral fractures are a result of tensile and shear forces. In a long bone that undergoes torsion, the greatest stress on the bone is experienced on the periosteal (outer) surface, as opposed to the endosteal surface (Fig. 6).

Fig. 4 a Photograph of a slice through a femoral head showing an area of infarction seen as a triangular opaque yellow area lying immediately beneath the articular surface. Also seen in this photograph is the track of the nail that was used for fixation of the subcapital fracture that preceded the necrosis. b Radiograph of the specimen shown in (a). Note the unaltered trabecular pattern of the infarcted bone. In contrast, the viable bone at the base of the infarct is dense, resulting from the formation of new bone in this area by the process of creeping substitution. The lucent area at the base of the infarction results from fibrous granulation tissue eroding the necrotic bone. The collapse of the necrotic segment is well demonstrated by the fracture through the subchondral plate, which is seen at both edges of the infarct

a

b

Fig. 5 a Transverse patella fracture following central third patellar tendon autograft harvest. b Open reduction and internal fixation of an inferomedial quadrant fracture following central third patellar tendon autograft harvest with dual compression screws

Fig. 6 a Radiograph of a subtrochanteric femur fracture. b Stable limb alignment and length are achieved with open reduction and internal fixation. c The fracture has consolidated in acceptable alignment after 8 months

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Comminuted fractures result from high-energy injuries without a specific force or force pattern creating the fracture. It is a function of the amount of energy transmitted to the bone, resulting in comminution. Furthermore, with high-energy injuries (such as those from a motorcycle), the energy can be dissipated to the surrounding soft tissues resulting in soft-tissue damage (muscle, vascular, and skin damage) (Fig. 7).

attributed to the straightening of the crimped fibrils and to nonuniform recruitment of individual fibers. Tendon, which has one of highest tensile strengths of any soft tissue in the body, consists almost exclusively of fibers oriented along a single direction of force. Ligament, however, has a broader distribution of fiber directions due to more varied loading conditions in vivo.

Mechanical Properties of Tendon and Ligament
Tendons and ligaments are anisotropic and viscoelastic, and can sustain 5–10% tensile strain before failure (vs. 1–4% in bone). A typical stress–strain curve for these tissues (Fig. 8) can be divided into a low modulus (toe) region, followed by a linear region with higher modulus. The toe region has been

Mechanical Properties of Intervertebral Disk
Intervertebral disks are anisotropic and viscoelastic, and also exhibit toe and linear regions in tensile extension, as illustrated in Fig. 8. The anulus fibrosus exhibits high values for Young’s modulus, stiffness, and failure stress, all of which indicate that this tissue is well equipped to sustain the large tensile stresses that it endures in situ. In particular, the outer

Fig. 7 Closed segmental tibia fracture from motor vehicle trauma. a Anteroposterior radiograph. b Lateral radiograph

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Fig. 8 A schematic load–elongation curve for tendon, indicating three distinct regions of response to tensile loading

Fig. 9 Comparison of Young’s modulus (relative values, not to scale) for various orthopedic materials

annulus is ideally suited for minimizing disk bulging. As tensile properties depend on the pathologic state of tissue, however, annulus degeneration can lead to disk herniation. The nucleus pulposus acts predominantly as fluid under static load, generating large hydrostatic pressures that help to maintain disk height, and support and transfer load.

Mechanical Properties of Cartilage
Similar to the other orthopedic soft tissues described above, cartilage is anisotropic and viscoelastic. It exhibits toe and linear regions in tensile extension (Fig. 8). Its ultimate tensile strength is only 5% that of bone, but it is well suited for compressive loading due to its highly viscoelastic properties.

Tissue Replacement
A comparison of Young’s modulus for common artificial materials encountered in orthopedics can be seen in Fig. 9, along with the values of this property associated with biologic tissues. Below is a description of the basic categories into which these replacement materials may fall and a description of their related uses and concerns: Metals: Metals are used as structural elements in joint prostheses. They demonstrate relatively good corrosion resistance and reasonable fatigue life, and their moduli exceed that of bone. Orthopedic implants are typically made of stainless steel (e.g., 316L), cobalt–chromium (Co–Cr), or titanium alloys. The properties of each, such as modulus (see Fig. 9), are varied and are important when choosing the

optimal material for each application. Titanium, for instance, is extremely biocompatible with a high yield strength and a modulus closer to that of bone than stainless steel or Co–Cr. Titanium, however, has poor resistance to wear, raising some concerns regarding its use in implants as the release of corrosion products may incite a macrophage response. Co–Cr alloy generates less metal debris than titanium. Its increased modulus along with that of stainless steel, however, make these metals more likely to induce a condition known as stress shielding, in which normal stress is transferred from the bone to the implant, often with detrimental effects. Polymers: There are two specific applications in orthopedics in which polymers have proved useful and in both cases, the appropriate mechanical properties of the polymer are of major importance. First, polymers are used as articulating surface components in joint prostheses. Thus, they must have a low coefficient of friction and low wear rate when they are in contact with the opposing surface, which is usually made of metal or ceramic. Second, polymers are used for fixation as a structural interface between the implant component and bone tissue. This usually requires that the polymers be able to minimize plastic deformation and resist creep under the stresses found in clinical situations. Examples of polymers with orthopedic applications include polyethylene, PMMA, and silicone. Ultra-high molecular weight polyethylene (UHMWPE) is often used to fabricate weight-bearing implant components, such as acetabular cups and tibial trays, owing to its tough, ductile nature as well as its low friction properties and resistance to wear. Wear damage to a UHMWPE articulating surface is most often caused by foreign body inclusions and the associated wear debris is the main factor affecting the longevity of these joint replacements. PMMA is frequently used as a grouting material for fixation of implants and distribution of load at the bone–implant interface. It functions by mechanically interlocking with bone and while

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it is strongest in compression, it has poor tensile and shear strength and a low modulus. PMMA wear particles can incite a macrophage response that leads to loosening of the implant. Unlike polyethylene and PMMA, silicones are polymers that are most often found in nonweight-bearing joints. Their poor strength and inability to resist wear can lead to frequent synovitis with prolonged use. Ceramics and glasses: Ceramics contain metallic and nonmetallic elements and include inert materials, such as alumina (Al2O3), as well as bioactive (degradable) substances such as bioglass. These are brittle (no elastic deformation), have a high modulus, high compressive strength, low tensile strength, low yield strain, and exhibit favorable wear characteristics but poor crack resistance. Ceramics and glass ceramics have played an increasingly important role in implants and have been used primarily in two different applications. The first of these is their use as articulating surfaces, for which ceramic properties such as resistance to oxidation (i.e., inertness in the body), high modulus, and low friction and wear rate are highly desirable. Al2O3, for instance, has proven quite successful for use in paired femoral head and acetabular components in total hip arthroplasty. The second application takes advantage of the osteophilic surface of certain ceramics and glass ceramics. These materials, termed bioglasses, provide an interface of such biological compatibility with osteoblasts that these cells lay down bone directly next to the material. Several of these compositions have seen wide use as implant materials. The use of bioglass on the metallic stems of hip prostheses provides an alternate approach to fixation instead of using PMMA. Composites: From the previous description of bone properties and a comparison with the corresponding properties of the various metals, polymers, and ceramics, it is clear that there is considerable disparity among these materials. This mismatch fueled the idea that it might be possible to optimize implant properties by combining materials and thus sparked an interest in composite materials. An area where composites may provide an interesting and important application is in bone plates. The rigidity and stiffness of the metallic plates generally used are much greater than that of the adjacent bone. Even after healing is well underway, the plate continues to carry a major portion of the load, thereby stress shielding the underlying bone and delaying, if not preventing, full healing. Eventually a second operation is required to remove the plate. This situation is one in which composites may offer a superior solution. For instance, totally bio-resorbable composite plates have been made from polyglycolic acid (PGA) fibers embedded in a polylactic acid (PLA) matrix. As the degradation rate of such composites can be controlled via the design process, it is conceivable to design a plate that would remain stiff and rigid enough to support the loads of physical activity until the bone has healed sufficiently to do so without assistance. Consequently,

instead of continuing to divert part of the load away from the underlying bone, the plate would gradually degrade and increasing amounts of load would be transferred to the bone, thus providing the proper loading conditions for full healing to proceed. Another orthopedic application of composites is in replacement of tendons and ligaments. In this capacity, biodegradable polymers such as PLA have acted as a scaffold, allowing ingrowth of collagenous tissue in an attempt to reform the damaged connective tissue. Engineered (living) tissue: These constructs typically consist of a cell-seeded scaffold, with or without bioactive elements, and are capable of self-adaptation and repair. Growth factors, introduced during fabrication or delivery of the constructs, hold promise for improving repair quality. In addition, the quality of the engineered tissue might be further enhanced through mechanical stimulation of the constructs during the fabrication process. All of these factors, however, are likely to be tissue and site specific and must be delivered thoughtfully and appropriately if tissue engineers expect to stimulate early cell proliferation and subsequent matrix synthesis. This matrix must also be deposited and rapidly organized if the repair is to be capable of resisting the large in vivo forces of daily activities. Scaffolds must also be identified with enough compliance so the cells can organize the construct but with enough stiffness to resist the expected in vivo loading regimes. These materials should initially attract, anchor, and protect the cells, but then degrade at controlled rates that prevent mechanical disruption of the repair and ensure biocompatibility. Many of these treatments are now being investigated and offer exciting potential for the repair of hard and soft tissue injuries.

Selected Reading
1. Brinker MR, O’;Connor DP. Basic Science, Chap. 1. In Miller, M. (ed) Review of Orthopaedics, 4th ed. Saunders Publishing, Philadelphia, 2004: 1–153. 2. Buckwalter JA, Einhorn TA, Simon SR (eds). Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, 2nd ed. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2000. 3. Moehring HD, Greenspan A. Fractures: Diagnosis and Treatment. McGraw-Hill, New York, 2000. 4. Ratner BD, Hoffman AS, Schoen FJ, Lemons JE (eds). .Biomaterials Science: An Introduction to Materials in Medicine. Academic Press, San Diego, 1996. 5. Li S, Burstein AH. Ultra-high molecular weight polyethylene. The material and its use in total joint implants. J Bone Joint Surg (Am) 1994; 76: 1080–1089. 6. Li P. Bioactive ceramics: state of the art and future trends. Semin Arthroplasty 1998; 9: 165–175. 7. Butler DL, Goldstein SA, Guilak F. Functional tissue engineering: the role of biomechanics. J Biomech Eng 2000; 122(6): 570–575. 8. Burstein AH, Reilly DT, Martens M. Aging of bone tissue: mechanical properties. J Bone Joint Surg 1976; 58A: 82–86.

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