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BACKGROUND: Narrative letters of recommendation are an important component of the residency application process. However, because narrative letters of recommendation are almost always positive, it is unclear whether those reviewing the letters understand the writer’s intended strength of support for a given applicant. QUESTIONS/PURPOSES: (1) Is the perception of letter readers for narrative letters of recommendation consistent with the intention of the letter’s author? (2) Is there inter-reviewer consistency in selection committee members’ perceptions of the narrative letters of recommendation? METHODS: Letter writers who wrote two or more narrative letters of recommendation for applicants to one university-based orthopaedic residency program for the 2014 to 2015 application cycle were sent a survey linked to a specific letter of recommendation they authored to assess the intended meaning regarding the strength of an applicant. A total of 247 unstructured letters of recommendation and accompanying surveys were sent to their authors, and 157 surveys were returned and form the basis of this study (response percentage 64%). The seven core members of the admissions committee (of 22 total reviewers) at a university-based residency program were sent a similar survey regarding their perception of the letter. To answer our research question about whether letter readers’ perceptions about a candidate were consistent with the letter writer’s intention, we used kappa values to determine agreement for survey questions involving discrete variables and Spearman correlation coefficients (SCCs) to determine agreement for survey questions involving continuous variables. To answer our research question regarding inter-reviewer consistency among the seven faculty members, we compared the letter readers’ responses to each survey question using intraclass correlation coefficients (ICCs). RESULTS: There was a negligible to moderate correlation between the intended and perceived strength of the letters (SCC 0.26 to 0.57), with only one of seven letter readers scoring in the moderate correlation category. When stratifying the applicants into thirds, there was only slight agreement (kappa 0.07 to 0.19) between the writers and reviewers. There were similarly low kappa values for agreement about how the writers and readers felt regarding the candidate matching into their program (kappa 0.14 to 0.30). The ICC for each question among the seven faculty reviewers ranged from poor to moderate (ICC 0.42 to 0.52). CONCLUSION: Our results demonstrate that the reader’s perception of narrative letters of recommendation did not correlate well with the letter writer’s intended meaning and was not consistent between letter readers at a single university-based urban orthopaedic surgery residency program. CLINICAL RELEVANCE: Given the low correlation between the intended strength of the letter writers and the perceived strength of those letters, we believe that other options such as a slider bar or agreed-upon wording as is used in many dean’s letters may be helpful.

The biomechanical mechanisms leading to vertebral fractures are not well understood. Clinical and laboratory evidence suggests that the vertebral endplate plays a key role in failure of the vertebra as a whole, but how this role differs for different types of vertebral loading is not known. Mechanical testing of human thoracic spine segments, in conjunction with time-lapsed micro-computed tomography, enabled quantitative assessment of deformations occurring throughout the entire vertebral body under axial compression combined with anterior flexion ("combined loading") and under axial compression only ("compression loading"). The resulting deformation maps indicated that endplate deflection was a principal feature of vertebral failure for both loading modes. Specifically, the onset of endplate deflection was temporally coincident with a pronounced drop in the vertebra's ability to support loads. The location of endplate deflection, and also vertebral strength, were associated with the porosity of the endplate and the microstructure of the underlying trabecular bone. However, the location of endplate deflection and the involvement of the cortex differed between the two types of loading. Under the combined loading, deflection initiated, and remained the largest, at the anterior central endplate or the anterior ring apophysis, depending in part on health of the adjacent intervertebral disc. This deflection was accompanied by outward bulging of the anterior cortex. In contrast, the location of endplate deflection was more varied in compression loading. For both loading types, the earliest progression to a mild fracture according to a quantitative morphometric criterion occurred only after much of the failure process had occurred. The outcomes of this work indicate that for two physiological loading modes, the vertebral endplate and underlying trabecular bone are critically involved in vertebral fracture. These outcomes provide a strong biomechanical rationale for clinical methods, such as algorithm-based qualitative (ABQ) assessment, that diagnose vertebral fracture on the basis of endplate depression. © 2015 American Society for Bone and Mineral Research.

Epidemiological and biomechanical evidence indicates that the risk of vertebral fracture differs between men and women, and that vertebral fracture frequently involves failure of the endplate region. The goal of this study was to compare the bone microstructure of the endplate region-defined as the (bony) vertebral endplate and underlying subchondral trabecular bone-between sexes and to determine whether any such sex differences are associated with vertebral strength. The bone density (volume fraction, apparent density and tissue mineral density) of the superior-most 2 mm of the vertebra, and the bone density and trabecular architecture of the next 5 mm were quantified using micro-computed tomography in human T8 (12 female, 16 male) and L1 (13 female, 12 male) vertebrae. Average density of the vertebra (integral bone mineral density (BMD)) was determined by quantitative computed tomography and compressive strength by mechanical testing. Few differences were found between male and female vertebrae in the density of the endplate region; none were found in trabecular architecture. However, whereas endplate volume fraction was positively correlated with integral BMD in male vertebrae (r = 0.654, p .001), no correlation was found in the female vertebrae (r = 0.157, p = .455). Accounting for the density of the endplate region improved predictions of vertebral strength (p .034) and eliminated sex-specificity in the strength prediction that was based on integral BMD alone. These results suggest that the density of the endplate region influences vertebral fracture and that non-invasive assessment of this region's density can contribute to predictions of vertebral strength in men and women.

The mechanical properties of bone are fundamental to the ability of our skeletons to support movement and to provide protection to our vital organs. As such, deterioration in mechanical behavior with aging and/or diseases such as osteoporosis and diabetes can have profound consequences for individuals’ quality of life. This article reviews current knowledge of the basic mechanical behavior of bone at length scales ranging from hundreds of nanometers to tens of centimeters. We present the basic tenets of bone mechanics and connect them to some of the arcs of research that have brought the field to recent advances. We also discuss cortical bone, trabecular bone, and whole bones, as well as multiple aspects of material behavior, including elasticity, yield, fracture, fatigue, and damage. We describe the roles of bone quantity (e.g., density, porosity) and bone quality (e.g., cross-linking, protein composition), along with several avenues of future research.

Radiographic Union Score for Tibia (RUST) and modified RUST (mRUST) are radiographic tools for quantitatively evaluating fracture healing using a cortical scoring system. This tool has high intra-class correlation coefficients (ICCs); however, little evidence has evaluated the scores against the physical properties of bone healing. Closed, stabilized fractures were made in the femora of C3H/HeJ male mice (8-12 week-old) of two dietary groups: a control and a phosphate restricted diet group. Micro-computed tomography (μCT) and torsion testing were carried out at post-operative days (POD) 14, 21, 35, and 42 (n=10-16) per group time-point. Anteroposterior and lateral radiographic views were constructed from the μCT scans and scored by five raters. The raters also indicated if the fracture were healed. ICCs were 0.71 (mRUST) and 0.63 (RUST). Both RUST scores were positively correlated with callus bone mineral density (BMD) (r = 0.85 and 0.80, p 0.318). Clinical relevance of this study is both RUST scores showed high correlation to physical properties of healing and generally distinguished healed vs. non-healed fractures. This article is protected by copyright. All rights reserved.

Full-field measurement of deformation in biological structures such as bones is a promising experimental approach for study of the spatial heterogeneity in mechanical behavior. With the advent of high-resolution, 3-D imaging, digital volume correlation (DVC) allows for the measurement of spatially heterogeneous, 3-D deformation fields throughout entire volumes. For bones such as the vertebra, use of DVC to detect the onset and progression of failure is of direct relevance to the study of osteoporotic fractures. Application of DVC to whole bones, as opposed to machined specimens of bone tissue, involves additional challenges such as the irregular geometry, large data sets, and decreased signal-to-noise ratio. These challenges are addressed in this paper, and the DVC method that results is used to examine yield and post-yield deformations in vertebral compression experiments.

Knowledge of the nature of the elastic symmetry of trabecular bone is fundamental to the study of bone adaptation and failure. Previous studies have classified human vertebral trabecular bone as orthotropic or transversely isotropic but have typically obtained samples from only selected regions of the centrum. In this study, the elastic symmetry of human vertebral trabecular bone was characterized using microfinite element (μFE) analyses performed on 1019 cubic regions of side length equal to 5 mm, obtained via thorough sampling of the centrums of 18 human L1 vertebrae (age = 81.17 ± 7.7 yr; eight males and ten females). An optimization procedure was used to find the closest orthotropic representation of the resulting stiffness tensor for each cube. The orthotropic elastic constants and orientation of the principal elastic axes were then recorded for each cube and were compared to the constants predicted from Cowin's fabric-based constitutive model (Cowin, 1985, “The Relationship Between the Elasticity Tensor and the Fabric Tensor,” Mech. Mater., 4(2), pp. 137–147.) and the orientation of the principal axes of the fabric tensor, respectively. Deviations from orthotropy were quantified by the “orthotropic error” (van Rietbergen et al., 1996, “Direct Mechanics Assessment of Elastic Symmetries and Properties of Trabecular Bone Architecture,” J. Biomech., 29(12), pp. 1653–1657), and deviations from transverse isotropy were determined by statistical comparison of the secondary and tertiary elastic moduli. The orthotropic error was greater than 50% for nearly half of the cubes, and the secondary and tertiary moduli differed from one another (p

This study's goal was to determine associations among the intravertebral heterogeneity in bone density, bone strength, and intervertebral disc (IVD) health. Results indicated that predictions of vertebral strength can benefit from considering the magnitude of the density heterogeneity and the congruence between the spatial distribution of density and IVD health.This study aims to determine associations among the intravertebral heterogeneity in bone density, bone strength, and IVD healthRegional measurements of bone density were performed throughout 30 L1 vertebral bodies using micro-computed tomography (μCT) and quantitative computed tomography (QCT). The magnitude of the intravertebral heterogeneity in density was defined as the interquartile range and quartile coefficient of variation in regional densities. The spatial distribution of density was quantified using ratios of regional densities representing different anatomical zones (e.g., anterior to posterior regional densities). Cluster analysis was used to identify groups of vertebrae with similar spatial distributions of density. Vertebral strength was measured in compression. IVD health was assessed using two scoring systems.QCT- and μCT-based measures of the magnitude of the intravertebral heterogeneity in density were strongly correlated with each other (p 0.005). Accounting for the interquartile range in regional densities improved predictions of vertebral strength as compared to predictions based only on mean density (R (2) = 0.59 vs. 0.43; F-test p-value = 0.018). Specifically, after adjustment for mean density, vertebral bodies with greater heterogeneity in density exhibited higher strength. No single spatial distribution of density was associated with high vertebral strength. Analyses of IVD scores suggested that the health of the adjacent IVDs may modulate the effect of a particular spatial distribution of density on vertebral strength.Noninvasive measurements of the intravertebral distribution of bone density, in conjunction with assessments of IVD health, can aid in predictions of bone strength and in elucidating biomechanical mechanisms of vertebral fracture.

Osteoporosis is a disease characterized by a loss of bone mass and deterioration in trabecular architecture, leading to decreased bone strength and increased susceptibility to fracture [1]. Vertebral fractures account for more than half of the approximately 1.5 million osteoporotic fractures that occur each year in the United States [2], heightening the need for accurate, noninvasive estimates of vertebral strength and stiffness. Quantitative computed tomography-based finite element models are increasingly used for noninvasive determination of mechanical properties of vertebrae [3,4], as they provide better predictions of vertebral strength compared to methods currently used in clinical diagnosis [5]. However, the material properties in the QCT-based FE models are typically estimated solely from local variations in bone mineral density [6,7] despite evidence that the biomechanical behavior of the vertebra depends also on the architecture of the vertebral trabecular bone [8,9], that the architecture is spatially inhomogeneous [10], and that the architecture is altered with age [11]. Advances in QCT imaging allow measurement of some architectural parameters [12,13], such as trabecular anisotropy [14], at clinically permissible doses of radiation. However, whether the effect of incorporating architectural information on the accuracy of the model predictions is large enough to warrant the additional model complexity and radiation exposure has not been established. Anisotropy of the trabecular architecture is believed to result from adaption of bone to its mechanical environment (Wolff's law). Trabecular anisotropy, represented by the principal orientation of the trabecular network and by the degree of anisotropy, is influential in the mechanical behavior of vertebra [8]. With an increase in DA due to aging and osteoporosis [11,15], the number of horizontal trabeculae reduces, rendering the vertebra less capable of withstanding unusual or off-axis loads and also more prone to buckling under axial compressive loads [16]. Prior QCT-based, FE models of the vertebra, which were based solely on BMD, have assumed a constant DA and have had the principal direction always aligned with the superior-inferior (SI) direction [4,6,7] and, thus, may fail to capture differences in the biomechanical response of vertebrae with different trabecular architectures. Variations in anisotropy within and among vertebrae can be accounted for using morphology-based constitutive models [17–19]. Recent studies that have incorporated one of these types of constitutive models as well as explicit modeling of the cortical shell in high-resolution peripheral QCT (HR-pQCT)-based FE models of vertebrae have shown combined effects of these additions on predictions of vertebral stiffness and locations of damage accumulation [20,21]. Accurate, explicit modeling of the shell is not possible at present using QCT in the axial skeleton; however, a realistic representation of the specimen-specific trabecular anisotropy alone would potentially improve the accuracy of QCT-based FE models of the vertebra. The overall goal of this study was to evaluate the importance of incorporating specimen-specific trabecular anisotropy for QCT-based FE predictions of vertebral stiffness. The major aims of this study were: (1) to compare the QCT-based FE results obtained with fixed, anisotropic material properties (“generic-anisotropic”) for trabecular bone to those obtained with specimen-specific, anisotropic material properties and (2) to study the influence of DA on the FE predictions of vertebral stiffness. The FE models were evaluated under loading conditions of axial compression, pure anterior bending, and combined loading of axial compression and anterior bending (Fig. ​(Fig.11). Fig. 1 List of the FE analyses conducted to evaluate the effect of incorporating specimen-specific, trabecular anisotropy on QCT-based FE predictions of vertebral stiffness and deformation patterns: For each combination of type of model, type of material property, ...

Vascular formation is intimately associated with bone formation during distraction osteogenesis (DO). While prior studies on this association have focused on vascular formation locally within the regenerate, we hypothesized that this vascular formation, as well as the resulting osteogenesis, relies heavily on the response of the vascular network in surrounding muscular compartments. To test this hypothesis, the spatiotemporal sequence of vascular formation was assessed in both muscular and osseous compartments in a murine model of DO and was compared to the progression of osteogenesis. Micro-computed tomography (μCT) scans were performed sequentially, before and after demineralization, on specimens containing contrast-enhanced vascular casts. Image registration and subtraction procedures were developed to examine the co-related, spatiotemporal patterns of vascular and osseous tissue formation. Immunohistochemistry was used to assess the contributory roles of arteriogenesis (formation of large vessels) and angiogenesis (formation of small vessels) to overall vessel formation. Mean vessel thickness showed an increasing trend during the period of active distraction (p=0.068), whereas vessel volume showed maximal increases during the consolidation period (p=0.009). The volume of mineralized tissue in the regenerate increased over time (p

Vertebral fractures are the hallmark of osteoporosis, yet the failure mechanisms involved in these fractures are not well understood. Failure patterns within whole vertebrae are typically estimated from finite element analyses or from images acquired after fracture has occurred. Experimental measurement of deformations sustained by vertebrae during injurious loading would enable direct visualization of vertebral failure mechanisms as well as the possibility of validating the results of numerical simulations of vertebral fracture. Time-lapsed micro-computed tomography (μCT) has been used previously to visualize failure processes in excised specimens of trabecular bone [1,2], and methods of digital volume correlation (DVC) can be applied to these types of image series to obtain quantitative information on the deformations that the bone undergoes [3]. However, application of DVC to whole bones has not been reported and involves additional challenges such as the irregular geometry of the volume and the large size of the sets of image data. The overall goal of this study was to develop a DVC-based method for quantifying deformations throughout entire vertebrae as these vertebrae are loaded to failure.Copyright © 2010 by ASME