In this study, trabecular architecture is considered as a cellular solid structure, including both intact and damaged bone models. ??Intact?? bone models were constructed based on ideal versions of 25, 60 and 80-year-old specimens with varying trabecular lengths and orientations to 5%, and 10% covariance of variation (COV). The models were also flipped between longer transverse and longer longitudinal trabeculae. With increasing COV of lengths and orientations of trabecular bone, the apparent modulus is linearly decreased, especially in the longer transverse trabeculae lengths. ??Damaged?? bone models were built from the 25 year old model at 5% COV of longer transverse trabeculae, and with removing trabeculae of 5% and 10% of trabecular volume in transverse and longitudinal directions, respectively, as well as in combination to total 10% and 15%. With increasing percent of trabeculae missing, the apparent modulus decreased, especially dramatically when removal was only in the transverse direction. The trabecular bone models were also connected to a cortical shell and it was found that the apparent modulus of an entire slice was increased in comparison to the modulus of trabecular bone alone. We concluded that the architecture of trabecular bone, especially both lengths and percent of trabecular missing in the longitudinal direction, significantly influences mechanical properties.

Background: Osteoarthritis (OA) is a debilitating joint disease marked by cartilage and bone changes. Morphological and mechanical changes to bone, which are thought to increase overall bone stiffness, result in distorted joint mechanics and accelerated cartilage degeneration. Using a parametric finite element (FE) model of the proximal tibia, the primary objective of this study was to determine the relative and combined effects of OA-related osteophyte formation, and morphological and mechanical alterations to subchondral and epiphyseal bone on overall bone stiffness. The secondary objective was to assess how simulated bone changes affect load transmission in the OA joint. Methods: The overall geometry of the model was based on a segmented CT image of a cadaveric proximal tibia used to develop a 2D, symmetric, plane-strain, FE model. Simulated bone changes included osteophyte formation and varied thickness and stiffness (elastic modulus) in subchondral and epiphyseal bone layers. Normal and OA related values for these bone properties were based on the literature. “Effective Stiffness (K)” was defined as the overall stiffness of the proximal tibia, calculated using nodal displacement of the loaded area on the subchondral cortical bone surface and the load magnitude. Findings: Osteophyte formation and thickness or stiffness of the subchondral bone had little effect on overall bone stiffness. Epiphyseal bone stiffness had the most marked effect on overall bone stiffness. Load transmission did not differ between OA and normal bone. Interpretation: Results suggest that epiphyseal (trabecular) bone is a key site of interest in future analyses of OA and normal bone. Results also suggest that observed OA-related alterations in epiphyseal bone may result in OA bone being more flexible than normal bone.

In this study, trabecular architecture is considered as a cellular solid structure, including both intact and damaged bone models. ??Intact?? bone models were constructed based on ideal versions of 25, 60 and 80-year-old specimens with varying trabecular lengths and orientations to 5%, and 10% covariance of variation (COV). The models were also flipped between longer transverse and longer longitudinal trabeculae. With increasing COV of lengths and orientations of trabecular bone, the apparent modulus is linearly decreased, especially in the longer transverse trabeculae lengths. ??Damaged?? bone models were built from the 25 year old model at 5% COV of longer transverse trabeculae, and with removing trabeculae of 5% and 10% of trabecular volume in transverse and longitudinal directions, respectively, as well as in combination to total 10% and 15%. With increasing percent of trabeculae missing, the apparent modulus decreased, especially dramatically when removal was only in the transverse direction. The trabecular bone models were also connected to a cortical shell and it was found that the apparent modulus of an entire slice was increased in comparison to the modulus of trabecular bone alone. We concluded that the architecture of trabecular bone, especially both lengths and percent of trabecular missing in the longitudinal direction, significantly influences mechanical properties.

In the past few decades, an area of skeletal research focusing on shape analyses has gained popularity in the field of physical anthropology, and subsequently forensic anthropology. Known as geometric morphometrics, this type of analysis allows the researcher to place the morphological shape of bones into a statistical framework to answer questions on a variety of topics, including sexual dimorphism. Sex assessment from the long bones has been traditionally conducted using traditional morphometric methods (Iscan and Miller-Shaivitz 1984; Steyn and Iscan 1997), and as a result, relies mainly on size differences and has not considered how joint morphology and shape affect sex. For this project, a geometric morphometric analysis of the proximal tibia in a modern Caucasian American population was conducted using a sample of 100 male and 100 female tibiae from the William M. Bass Donated Skeletal Collection at the University of Tennessee at Knoxville. The proximal tibia's effectiveness as an indicator of sex in a modern American population was evaluated via generalized Procrustes, principal components, and discriminant function analyses. Principal components revealed a lack of separation between males and females in terms of proximal tibia shape. The discriminant function analysis was successful at discriminating males from females, but cross-validation yielded a low total accuracy rate of 58%. The shape of the proximal tibia contributes to sexual dimorphism in a Caucasian American population, but is only slightly useful in a discriminant function. Further research should be conducted on different populations and using different skeletal landmarks.

Die proximale Tibiafraktur stellt eine seltene Fraktur der langen Röhrenknochen im Wachstumsalter dar, welche sich in mehrere Frakturtypen aufteilt. Diese werden zu typischen Altersgipfeln durch typische Unfallmechanismen verursacht. Eine nicht adäquate Therapie dieser Frakturen kann aufgrund des fehlgeleiteten Knochenwachstums zu Beinachsenabweichungen, Beinlängendifferenzen und funktionellen Einschränkungen des Kniegelenks führen. Ziel dieser Studie ist die Therapie und Nachsorge der Patient:innen, die in der Klinik und Poliklinik für Kinderchirurgie des Universitätsklinikums Dresden stattfand, zu bewerten. Dabei wurden die Patient:innen zu einer klinischen Nachuntersuchung und zur Beurteilung des Wohlbefindens eingeladen.:1. EINLEITUNG 1.1 DIE PROXIMALE TIBIAFRAKTUR IM KINDESALTER 1.1.1 Definition und Epidemiologie 1.2 Ätiologie und Klassifikation 1.1.2.1 Ausriss der Eminentia intercondylaris 1.1.2.2 Apophysenausriss der proximalen Tibia 1.1.2.3 Metaphysäre Frakturen der proximalen Tibia 1.1.3 Diagnostik 1.1.3.1 Ausriss der Eminentia intercondylaris 1.1.3.2 Apophysenausriss der proximalen Tibia 1.1.3.3 Metaphysäre Frakturen der proximalen Tibia 1.1.4 Therapie 1.1.4.1 Ausriss der Eminentia intercondylaris 1.1.4.2 Apophysenausriss der proximalen Tibia 1.1.4.3 Metaphysäre Frakturen der proximalen Tibia 1.1.5 Komplikationen und Folgeschäden 1.1.5.1 Ausriss der Eminentia intercondylaris 1.1.5.2 Apophysenausriss der proximalen Tibia 1.1.5.3 Metaphysäre Frakturen der proximalen Tibia 2. FRAGESTELLUNG 3. PATIENT:INNEN UND METHODEN 3.1 PATIENT:INNENGRUPPEN UND VERGLEICHSPOPULATION 3.2 DATENERHEBUNG 3.2.1 Klinische Untersuchung 3.2.1.1 Körpermaße, numerische Schmerzskala, Gangbild 3.2.1.2 Beinlängenmessung und Rotationsfehler 3.2.1.3 Beweglichkeit, Kraftprüfung 3.2.1.4 Interkondylärer und intermalleolärer Abstand 3.2.1.5 Tibiofemoraler Winkel 3.2.2 Fragebögen 3.2.2.1 Pedi-IKDC 3.2.2.2 PODCI 3.3 STATISTISCHE AUSWERTUNG 4. ERGEBNISSE 4.1 EPIDEMIOLOGISCHE DATEN 4.1.1 Alter und Geschlecht 4.1.2 Links-Rechts Verteilung 4.1.3 Frakturklassifikation 4.2 ALTERS-, GESCHLECHTER- UND FRAKTURSEITENVERTEILUNG DER SUBGRUPPEN 4.2.1 Alters- und Geschlechterverteilung der E-Gruppe 4.2.2 Alters- und Geschlechterverteilung der TU-Gruppe 4.2.3 Alters- und Geschlechterverteilung der T-Gruppe 4.3 UNFALLMECHANISMEN 4.3.1 Unfallmechanismen der E-Gruppe 4.3.2 Unfallmechanismen der TU-Gruppe 4.3.3 Unfallmechanismen der T-Gruppe 4.4 MEDIZINISCHE VERSORGUNG 4.5 ERGEBNISSE DER NACHUNTERSUCHUNG 4.5.1 Teilnahme an der Nachuntersuchung 4.6 ERGEBNISSE DER KLINISCHEN UNTERSUCHUNG 4.6.1 Schwellung und Schmerzen 4.6.2 BMI 4.6.3 Längenunterschied und Rotationsfehler der Beine 4.6.4 Beinachsen, interkondylärer- und intermalleolärer Abstand 4.6.5 Beweglichkeit des Kniegelenks und Kraftprüfung 4.7. ERGEBNISSE DER FRAGEBÖGEN 4.7.1 Ergebnisse aus dem Pedi-IKDC 4.7.2 Ergebnisse des PODCI 4.8 GEGENÜBERSTELLUNG DER KLINISCHEN UNTERSUCHUNGSERGEBNISSE UND DEN ERGEBNISSEN DER FRAGEBÖGEN 4.9 FALLBERICHTE 4.9.1 Fallbericht der E-Gruppe 4.9.2 Fallbericht der TU-Gruppe 4.9.3 Fallbericht der T-Gruppe 5. DISKUSSION 5.1 BEWERTUNG DER BASISDATEN 5.2 FRAGESTELLUNG: 1. AUFFÄLLIGKEITEN IN DER KLINISCHEN UNTERSUCHUNG 5.3 FRAGESTELLUNG: 2. AUSWIRKUNGEN AUF DEN FUNKTIONELLEN ZUSTAND DES KNIEGELENKS UND DAS WOHLBEFINDEN 5.4 FRAGESTELLUNG: 3. VERBESSERUNGSFÄHIGE ASPEKTE DES KLINISCHEN MANAGEMENTS VON PROXIMALEN TIBIAFRAKTUREN 5.5 FRAGESTELLUNG: 4. BEWERTUNG DES DIGITALEN VERFAHRENS DER BEINACHSENMESSUNG 5.6 LIMITATIONEN DER STUDIE 6. ZUSAMMENFASSUNG 7. SUMMARY 8. ANHANG 8.1 TABELLEN IM ANHANG 8.2 UNTERSUCHUNGSBOGEN 8.3 PEDI-IKDC FRAGEBOGEN 8.4 PODCI FRAGEBOGEN GRUPPE „2-10 JAHRE“ 8.5 PODCI FRAGEBOGEN GRUPPE „11-18 JAHRE ELTERN“ 8.6 PODCI FRAGEBOGEN GRUPPE „11-18 JAHRE PATIENT:INNEN“ LITERATURVERZEICHNIS

Es erfolgt eine Knochenstrukturanalyse der proximalen Tibia unter Berücksichtigung verschiedenster radiologischer, biomechanischer und histomorphometrischer Aspekte. Die regionen-, alters- und geschlechtsspezifischen Aspekte dieser Problemregion werden herausgearbeitet. Der eindeutige Nachweis einer regionen-abhängigen Verteilung der Knochendichte und der biomechanischen Eigenschaften in der proximalen Tibia ist eines der Hauptergebnisse der vorliegenden Studie. In der proximalen Tibia besteht eine signifikante Abnahme der Knochendichte von proximal nach distal. Im zentralen Bereich der proximalen Tibia besteht in allen Sektionen im Vergleich zu den anterior/posterior und medial/lateral liegenden Gebieten die niedrigste Knochendichte. In der vorliegenden Studie wurde die proximale Tibia in 3 Etagen (von proximal nach distal) unterteilt. Beim Vergleich der auf diesen Etagen aufgebrachten ROIs (region of interest,jeweils 5 in den beiden proximalen Etagen und 4 im distalen Abschnitt) zeigte sich in den beiden proximalen Etagen lateral (Ebene I anterolateral/ Ebene II posterolateral) die höchste Knochendichte. Im Gegensatz dazu zeigte sich in der distalen Etage anteromedial die höchste Knochendichte. Weiterhin wurden die 3 gängigen Stabilisierungsverfahren für diese Region einer umfangreichen biomechanischen Testung unterzogen. Es zeigte sich, dass der Ilizarov Fixateur bei den verschiedensten Lastfällen meist das instabilste Implantat war. Trotz der biomechanischen Defizite konnten die in der klinischen Studie mit Composite Fixateur versorgten Frakturen trotz erheblichem Weichteilschaden und instabiler Fraktursituation zur Ausheilung gebracht werden. Das LIS-System erwies sich gegenüber der konventionellen Abstützplatte hinsichtlich der biomechanischen Steifigkeit sowohl in der statischen als auch in der zyklischen Testung als gleichwertiges oder sogar biomechanisch günstigeres Implantat. Diese positiven klinischen wie biomechanischen Erfahrungen führen auch zur Förderung der Entwicklung anderer winkelstabiler Fixateur interne-Systeme in den verschiedensten Problemregionen (Pilon tibiale, proximaler und distaler Humerus, distaler Radius). Als wesentliche neue Therapieansätze für das operative Vorgehen in der Problemregion der proximalen Tibia lassen sich die folgenden Gesichtspunkte herausarbeiten: 1) Knochendichteadaptierte Implantat- und Schraubenpositionierung bei der konventionellen Osteosynthese, 2) Knochendichteadaptierte Pin- und Olivendrahtpositionierung bei externen Fixationsverfahren (Ilizarovringfixateur, Fixateur externe) im Bereich der proximalen Tibia, 3) Implantatverbesserungen (LISS-Schraubenkonfiguration und -positionierung, Plattendesign, Umstellungsplatte, Verriegelungsbolzen bei Marknägeln wie UTN, PTN), 4) Prothesenverbesserung (knochendichteadaptiertes Zapfendesign mit 3 Zapfen für die tibiale Komponente). / In this study an analysis of the bone structure of the proximal tibia was performed with special attention paid to the different radiological, biomechanical and histomorphometrical aspects. Region-, age- and gender-specific attributes of the localised bone were also examined. Evidence of a region related variation of bone density and biomechanical behaviour is one of the main results of this study. In the proximal tibia, a significant reduction in the bone density exists from proximal to distal. In comparison to the anterior/posterior or medial/lateral areas, the lowest bone mineral densities were found in the central region. In this study the proximal tibia was divided into 3 different levels (from proximal to distal). When comparing the different regions of interest (ROIs) 5 each in the two proximal levels and 4 in the most distal level), the lateral regions (level 1 anterolateral/ level 2 posterolateral) presented the highest bone mineral density. In contrast, the highest bone density in the distal- level was detected in the anteromedial region. Furthermore, complex biomechanical testing of- 3 common fixation techniques for fracture situations of the proximal tibia was performed. It was shown that the Ilizarov fixator was the most unstable implant in several load tests. Despite this biomechanical deficit fractures treated by composite- fixators in different clinical trails healed uneventfully, even with severe soft tissue damage or an unstable fracture situation. In comparison to the conventional buttress plate, the LIS-System was an equal or superior implant, both in static and cyclic stiffness testing. These clinical and biomechanical experiences lead to the development of other angle stable internal fixator systems for different problematic regions (tibial plafond, proximal and distal humerus, distal radius). The following new therapeutic aspects were developed for the surgical treatment of the proximal tibia: 1) Bone mineral density adapted implant-and screw placement in conventional plating. 2) Bone density adapted pin- and olive wire placement during external fixation (ilizarov ring fixator, external fixator) techniques of the proximal tibia. 3) Improvement of implant design (LISS screw configuration and- placement, plate design, locking bolt configuration in nails). 4) Improvement of prosthetic design (bone density adapted design of the tibial components)

This thesis deals with stress analysis strain proximal end of tibia with total joint replacements. The analysis is done on the basis of deformation characteristics of voltage, through the finite element method (FEM). We have developed two-dimensional models of the proximal end of tibia with tibial components total endoprosthesis (TEP), without loss and bone loss. Geometry model is created based on data obtained from computerized tomography, which were further processed in the program, Rhinoceros 3.0 and SolidWorks 2009th Computational solution was carried out by finite element method in Ansys Workbench 12.0. The model without loss of bone tissue was tested the hypothesis that the deformation is very small and there is no violation of the shank prosthesis. Due to loss of bone tissue is lost support to the tibial pulse in the proximal tibia and by a progressive increase in stress, which can lead to a breach of the shank total joint replacement. The analysis results show that, if the loss of bone tissue, so that the tibial part of the TEP will lose support, there is a crack stem total hip replacement due to stress.

Αναδρομική μελέτη των 13 ασθενών με σηπτική ψευδάρθρωση κάτω πέρατος μηριαίου που αντιμετωπίστηκαν με ευρύ χειρουργικό καθαρισμό και με τη μέθοδο Ilizarov. Κατά την έναρξη της τελικής αντιμετώπισης όλοι οι ασθενείς είχαν σημαντικό περιορισμό της κίνησης της άρθρωσης του γόνατος. Ο μέσος όρος προηγούμενων χειρουργικών επεμβάσεων ήταν τρεις. Ο μέσος όρος οστικού ελλείμματος ήταν 8.3 εκ. Ο μέσος χρόνος εξωτερικής οστεοσύνθεσης ήταν 309.8 ημέρες. Σύμφωνα με τα κριτήρια Paley σε οκτώ ασθενείς είχαμε άριστο οστικό αποτέλεσμα, ενώ το λειτουργικό αποτέλεσμα ήταν σε τρεις περιπτώσεις άριστο, σε τέσσερις καλό. Πώρωση του κατάγματος, εκρίζωση της λοίμωξης και αποκατάσταση της στηρικτικής ικανότητας του σκέλους επιτεύχθηκε σε όλους τους ασθενείς. Η αύξηση του χρόνου εξωτερικής οστεοσύνθεσης παρατηρήθηκε: 1) η οριστική αντιμετώπιση εφαρμόστηκε 6 μήνες μετά από τον αρχικό τραυματισμό. 2) ο ασθενής υποβλήθηκε σε 4 τουλάχιστον προηγούμενες χειρουργικές επεμβάσεις 3) η αρχική αντιμετώπιση συμπεριλάμβανε ανοικτή ανάταξη και εσωτερική οστεοσύνθεση. Με την μέθοδο Ilizarov επιτυγχάνεται πλήρη εκρίζωση της οστικής λοίμωξης, υψηλό ποσοστό πώρωσης και αποκατάσταση της στηρικτικής ικανότητας του σκέλους. Ωστόσο συχνά η δυσκαμψία του γόνατος και η χωλότητα αποτελούν χρόνιο πρόβλημα για αρκετούς ασθενείς. / We retrospectively reviewed 13 patients with infected nonunion of the distal femur, which had been treated by radical surgical debridement and Ilizarov method. All had severely restricted movement of the knee and a mean of 3.1 previous operations. The mean bone defect was 8.3 cm and no patient was able to bear weight. The mean external fixation time was 309.8 days. According to the Paley’s grading system, eight patients had an excellent bone result and seven excellent and good functional results. Bone union, the ability to bear weight fully, and eradication of infection were achieved in all the patients. The external fixation time was increased when the definitive treatment started six months or more after the initial trauma, the patient had been subjected to more than four previous operations and the initial operation had been ORIF. The treatment of infected defect pseudarthrosis of the distal femur using the Ilizarov device is a salvage procedure, as it offers complete eradication of infection, high union rate and ability for full weight bearing. Nevertheless problems such as, impaired knee joint motion and limping bother the patients permanently.