Compliance calibration for fracture testing of equine cortical bone

An experimental compliance calibration method for measuring crack length in fracture toughness tests of cortical bone was developed. Calibration tests were conducted on twenty compact type fracture specimens machined from the mid-diaphysis of five pairs of equine third metacarpal bones. Specimens were oriented for crack propagation in a direction transverse to the longitudinal axis of the bone. Specimen compliance was determined from the load vs. crack opening displacement record over a range of crack lengths from 0.48 to 0.75 times the specimen width. The results demonstrate that the compliance calibration method developed for isotropic materials can be used to determine crack length in bone, which is transversely isotropic. However, specimens from lateral and dorsal regions exhibited significantly different compliance calibrations even after differences in elastic modulus were taken into account in the normalized compliance.     

Anisotropy of age-related toughness loss in human cortical bone: a finite element study

A mechanistic understanding of the role of bone quality on fracture processes is essential for determining the underlying causes of age-related changes in the mechanical response of the human bone. In this study, a previously developed cohesive finite element model was used to investigate the effects of age-related changes and the orientation of crack growth on the toughening behavior of human cortical bone. The change in the anisotropy of toughening mechanisms with age was also studied. Finite element method (FEM) simulations showed that the initiation toughness decreased by 3% and 8%/decade for transverse and longitudinal crack growth, respectively. In contrast, fracture resistance curve slope for transverse and longitudinal crack growth decreased by 2% and 3%/decade, respectively. Initiation fracture toughness values were higher for the transverse than for the longitudinal for a given age. On the other hand, propagation fracture toughness values were higher for longitudinal than for transverse crack growth for a given age. With respect to age, the toughness ratio for crack initiation decreased by 6%/decade, but that for propagation showed almost no change (less than 1%). In light of these findings, an analytical model evaluating the crack arresting feature of cement lines, is proposed to explain the factors that determine crack penetration into osteons or its deflection by cement lines.     

The relative contributions of non-enzymatic glycation and cortical porosity on the fracture toughness of aging bone

The risk of fracture increases with age due to the decline of bone mass and bone quality. One of the age-related changes in bone quality occurs through the formation and accumulation of advanced glycation end-products (AGEs) due to non-enzymatic glycation (NEG). However as a number of other changes including increased porosity occur with age and affect bone fragility, the relative contribution of AGEs on the fracture resistance of aging bone is unknown. Using a high-resolution nonlinear finite element model that incorporate cohesive elements and micro-computed tomography-based 3d meshes, we investigated the contribution of AGEs and cortical porosity on the fracture toughness of human bone. The results show that NEG caused a 52% reduction in propagation fracture toughness (R-curve slope). The combined effects of porosity and AGEs resulted in an 88% reduction in propagation toughness. These findings are consistent with previous experimental results. The model captured the age-related changes in the R-curve toughening by incorporating bone quantity and bone quality changes, and these simulations demonstrate the ability of the cohesive models to account for the irreversible dynamic crack growth processes affected by the changes in post-yield material behavior. By decoupling the matrix-level effects due to NEG and intracortical porosity, we are able to directly determine the effects of NEG on fracture toughness. The outcome of this study suggests that it may be important to include the age-related changes in the material level properties by using finite element analysis towards the prediction of fracture risk.     

Assessment of cortical bone fracture resistance curves by fusing artificial neural networks and linear regression

Bone injures (BI) represents one of the major health problems, together with cancer and cardiovascular diseases. Assessment of the risks associated with BI is nontrivial since fragility of human cortical bone is varying with age. Due to restrictions for performing experiments on humans, only a limited number of fracture resistance curves (R-curves) for particular ages have been reported in the literature. This study proposes a novel decision support system for the assessment of bone fracture resistance by fusing various artificial intelligence algorithms. The aim was to estimate the R-curve slope, toughness threshold and stress intensity factor using the two input parameters commonly available during a routine clinical examination: patients age and crack length. Using the data from the literature, the evolutionary assembled Artificial Neural Network was developed and used for the derivation of Linear regression (LR) models of R-curves for arbitrary age. Finally, by using the patient (age)-specific LR models and diagnosed crack size one could estimate the risk of bone fracture under given physiological conditions. Compared to the literature, we demonstrated improved performances for estimating nonlinear changes of R-curve slope (R² = 0.82 vs. R² = 0.76) and Toughness threshold with ageing (R² = 0.73 vs. R² = 0.66).     

Measurement of the microstructural fracture toughness of cortical bone using indentation fracture

The purpose of this work is to investigate the use of indentation fracture as a method of measuring toughness at the microscale in cortical bone. Indentation fracture employs sharp indenters to initiate cracks, whose length can be used to calculate the toughness of the material. Only a cube corner indenter tip is found to initiate cracks at a suitable size scale for microstructural measurement. Cracks from 7 to 56 microm in length are produced using loads from 0.05 to 3N. Preliminary data predicts rising toughness with increasing crack length (rising R-curve behaviour) at the microscale. This technique provides a new insight into fracture in cortical bone since it allows the investigator to observe mechanisms and measure toughness at a size scale at which in vivo damage is known to exist.     

Rising crack-growth-resistance behavior in cortical bone: implications for toughness measurements

Fracture mechanics studies have characterized bone's resistance to fracture in terms of critical stress intensity factor and critical strain energy release rate measured at the onset of a fracture crack. This approach, although useful, provide a limited insight into fracture behavior of bone because, unlike classical brittle materials, bone is a microcracking solid that derives its resistance to fracture during the process of crack propagation from microfracture mechanisms occurring behind the advancing crack front. To address this shortfall, a crack propagation-based approach to measure bone toughness is described here and compared with crack initiation approach. Post hoc analyses of data from previously tested bovine and antler cortical bone compact specimens demonstrates that, in contrast to crack initiation approach, the crack propagation approach successfully identifies the superior toughness properties of red deer's antler cortical bone. Propagation-based slope of crack growth resistance curve is, therefore, a more useful parameter to evaluate cortical bone fracture toughness.     

Cohesive finite element modeling of age-related toughness loss in human cortical bone

Although the age-related loss of bone quality has been implicated in bone fragility, a mechanistic understanding of the relationship is necessary for developing diagnostic and treatment modalities in the elderly population at risk of fracture. In this study, a finite element based cohesive zone model is developed and applied to human cortical bone in order to capture the experimentally shown rising crack growth behavior and age-related loss of bone toughness. The cohesive model developed here is based on a traction–crack opening displacement relationship representing the fracture processes in the vicinity of a propagating crack. The traction–displacement curve, defining the cohesive model, is composed of ascending and descending branches that incorporate material softening and nonlinearity. The results obtained indicate that, in contrast to initiation toughness, the finite element simulations of crack growth in compact tension (CT) specimens successfully capture the rising R-curve (propagation toughness) behavior and the age-related loss of bone toughness. In close correspondence with the experimentally observed decrease of 14–15% per decade, the finite element simulation results show a decrease of 13% in the R-curve slope per decade. The success of the simulations is a result of the ability of cohesive models to capture and predict the parameters related to bone fracture by representing the physical processes occurring in the vicinity of a propagating crack. These results illustrate that fracture mechanisms in the process zone control bone toughness and any modification to these would cause age-related toughness loss.     

Contribution, development and morphology of microcracking in cortical bone during crack propagation

A fracture mechanics study of cortical bone is presented to investigate the contribution, development morphology of microcracking in cortical bone during crack propagation. Post-hoc analyses of microcrack orientation, crack propagation velocity and fracture surface roughness were conducted on previously tested human and bovine bone compact tension specimens. It was found that, consistent with its higher toughness, bovine bone formed significantly more longitudinal, transverse and inclined microcracks than human bone. However, in human bone more of the microcracks that formed were longitudinal than transverse or inclined, a feature that would optimise bone's toughness. Crack propagation velocity in human and bovine bone displayed the same characteristic pattern with crack extension, where an increase in velocity is followed by a consequent decrease and vice versa. On the basis of this pattern, a model or crack propagation has been proposed. It provides a detailed account of mocrocrack formation and contribution towards the propagation of a fracture crack. Analyses of fracture surfaces indicated that, consistent with its higher toughness, bovine bone displays a rougher surface than human bone but they both have the same basic fractured element, i.e. a mineralised collagen fibril.     

Experimental validation of a microcracking-based toughening mechanism for cortical bone

It has been proposed that cortical bone derives its toughness by forming microcracks during the process of crack propagation (J. Biomech. 30 (1997) 763; J. Biomech. 33 (2000) 1169). The purpose of this study was to experimentally validate the previously proposed microcrack-based toughening mechanism in cortical bone. Crack initiation and propagation tests were conducted on cortical bone compact tension specimens obtained from the antlers of red deer. For these tests, the main fracture crack was either propagated to a predetermined crack length or was stopped immediately after initiating from the notch. The microcracks produced in both groups of specimens were counted in the same surface area of interest around and below the notch, and crack growth resistance and crack propagation velocity were analyzed. There were more microcracks in the surface area of interest in the propagation than in initiation specimens showing that the formation of microcracks continued after the initiation of a fracture crack. Crack growth resistance increased with crack extension, and crack propagation velocity vs. crack extension curves demonstrated the characteristic jump increase and decrease pattern associated with the formation of microcracks. The scanning electron micrographs of crack initiation and propagation displayed the formation of a frontal process zone and a wake, respectively. These results support the microcrack-based toughening mechanism in cortical bone. Bone toughness is, therefore, determined by its ability to form microcracks during fracture.     

Fracture toughness and fatigue crack propagation rate of short fiber reinforced epoxy composites for analogue cortical bone

Third-generation mechanical analogue bone models and synthetic analogue cortical bone materials manufactured by Pacific Research Laboratories, Inc. (PRL) are popular tools for use in mechanical testing of various orthopedic implants and biomaterials. A major issue with these models is that the current third-generation epoxy-short fiberglass based composite used as the cortical bone substitute is prone to crack formation and failure in fatigue or repeated quasistatic loading of the model. The purpose of the present study was to compare the tensile and fracture mechanics properties of the current baseline (established PRL "third-generation" E-glass-fiber-epoxy) composite analogue for cortical bone to a new composite material formulation proposed for use as an enhanced fourth-generation cortical bone analogue material. Standard tensile, plane strain fracture toughness, and fatigue crack propagation rate tests were performed on both the third- and fourth-generation composite material formulations using standard ASTM test techniques. Injection molding techniques were used to create random fiber orientation in all test specimens. Standard dog-bone style tensile specimens were tested to obtain ultimate tensile strength and stiffness. Compact tension fracture toughness specimens were utilized to determine plane strain fracture toughness values. Reduced thickness compact tension specimens were also used to determine fatigue crack propagation rate behavior for the two material groups. Literature values for the same parameters for human cortical bone were compared to results from the third- and fourth-generation cortical analogue bone materials. Tensile properties of the fourth-generation material were closer to that of average human cortical bone than the third-generation material. Fracture toughness was significantly increased by 48% in the fourth-generation composite as compared to the third-generation analogue bone. The threshold stress intensity to propagate the crack was much higher for the fourth-generation material than for the third-generation composite. Even at the higher stress intensity threshold, the fatigue crack propagation rate was significantly decreased in the fourth-generation composite compared to the third-generation composite. These results indicate that the bone analogue models made from the fourth-generation analogue cortical bone material may exhibit better performance in fracture and longer fatigue lives than similar models made of third-generation analogue cortical bone material. Further fatigue testing of the new composite material in clinically relevant use of bone models is still required for verification of these results. Biomechanical test models using the superior fourth-generation cortical analogue material are currently in development.     

Effects of intracortical porosity on fracture toughness in aging human bone: a microCT-based cohesive finite element study

The extent to which increased intracortical porosity affects the fracture properties of aging and osteoporotic bone is unknown. Here, we report the development and application of a microcomputed tomography based finite element approach that allows determining the effects of intracortical porosity on bone fracture by blocking all other age-related changes in bone. Previously tested compact tension specimens from human tibiae were scanned using microcomputed tomography and converted to finite element meshes containing three-dimensional cohesive finite elements in the direction of the crack growth. Simulations were run incorporating age-related increase in intracortical porosity but keeping cohesive parameters representing other age-related effects constant. Additional simulations were performed with reduced cohesive parameters. The results showed a 6% decrease in initiation toughness and a 62% decrease in propagation toughness with a 4% increase in porosity. The reduction in toughnesses became even more pronounced when other age-related effects in addition to porosity were introduced. The initiation and propagation toughness decreased by 51% and 83%, respectively, with the combined effect of 4% increase in porosity and decrease in the cohesive properties reflecting other age-related changes in bone. These results show that intracortical porosity is a significant contributor to the fracture toughness of the cortical bone and that the combination of computational modeling with advanced imaging improves the prediction of the fracture properties of the aged and the osteoporotic cortical bone.     

Osteon interfacial strength and histomorphometry of equine cortical bone

The interfacial strength of secondary osteons from the diaphysis of the Thoroughbred equine third metacarpal was evaluated using the fiber pushout test. The pushout was performed on 300-500 microm sections of 4x4x15 mm bone blocks machined from four anatomic regions of the cortex. Pushout strength was evaluated from proximal to distal location within the diaphysis on four osteon types classified under polarized light on adjacent histologic sections from each block. The shear strength of the interfaces were estimated from shear lag theory. Differences were found in the interfacial strength of osteons based on appearance under polarized light with bright field having the highest interfacial strength (40.3 MPa). The lowest strength was found in the dark field osteons (22.8 MPa). The dorsal region had the highest shear strength and toughness compared to all other regions. The cement line and interlamellar interfaces are similar in strength, but exhibit regional dependence--specifically, the palmar region strength is less (17.5 MPa) than the osteon interlamellar interfaces (30.4 MPa) and osteon type dependent (alternating significantly weaker than other types). Histomorphometry revealed significant regional differences (p<0.0001) in osteon area fraction among the four osteon types as well as differences in the osteon diameter (p=0.01), with dorsal regions having larger osteons (170 microm) than the palmar region (151 microm). Fatigue life and fracture toughness of Haversian bone are reported in the literature to be regionally dependent and are known to be associated with osteon pullout--an osteon interfacial phenomenon. Therefore, the results presented in this study are important to further the understanding of the mechanisms of fragility and damage accumulation in cortical bone.     

Age-related properties at the microscale affect crack propagation in cortical bone

The increased risk for fracture with age is associated not only with reduced bone mass but also with impaired bone quality. At the microscale, bone quality is related to porosity, microstructural organization, accumulated microdamage and intrinsic material properties. However, the link between these characteristics and fracture behavior is still missing. Bone tissue has a complex structure and as age-related compositional and structural changes occur at all hierarchical length scales it is difficult to experimentally identify and discriminate the effect of each mechanism. The aim of this study was therefore to use computational models to analyze how microscale characteristics in terms of porosity, intrinsic toughness properties and microstructural organization affect the mechanical behavior of cortical bone. Tensile tests were simulated using realistic microstructural geometries based on microscopy images of human cortical bone. Crack propagation was modelled using the extended finite element method where cement lines surrounding osteons were modelled with an interface damage law to capture crack deflections along osteon boundaries. Both increased porosity and impaired material integrity resulted in straighter crack paths with cracks penetrating osteons, similar to what is seen experimentally for old cortical bone. However, only the latter predicted a more brittle failure behavior. Furthermore, the local porosity influenced the crack path more than the macroscopic porosity. In conclusion, age-related changes in cortical bone affect the crack path and the mechanical response. However, increased porosity alone was not driving damage in old bone, but instead impaired tissue integrity was required to capture brittle failure in aging bone.     

Material heterogeneity,microstructure, and microcracks demonstrate differential influence on crack initiation and propagation in cortical bone

The recent studies have shown that long-term bisphosphonate use may result in a number of mechanical alterations in the bone tissue including a reduction in compositional heterogeneity and an increase in microcrack density. There are limited number of experimental and computational studies in the literature that evaluated how these modifications affect crack initiation and propagation in cortical bone. Therefore, in this study, the entire crack growth process including initiation and propagation was simulated at the microscale by using the cohesive extended finite element method. Models with homogeneous and heterogeneous material properties (represented at the microscale capturing the variability in material property values and their distribution) as well as different microcrack density and microstructure were compared. The results showed that initiation fracture resistance was higher in models with homogeneous material properties compared to heterogeneous ones, whereas an opposite trend was observed in propagation fracture resistance. The increase in material heterogeneity level up to 10 different material property sets increased the propagation fracture resistance beyond which a decrease was observed while still remaining higher than the homogeneous material distribution. The simulation results also showed that the total osteonal area influenced crack propagation and the local osteonal area near the initial crack affected the crack initiation behavior. In addition, the initiation fracture resistance was higher in models representing bisphosphonate treated bone (low material heterogeneity, high microcrack density) compared to untreated bone models (high material heterogeneity, low microcrack density), whereas an opposite trend was observed at later stages of crack growth. In summary, the results demonstrated that tissue material heterogeneity, microstructure, and microcrack density influenced crack initiation and propagation differently. The findings also elucidate how possible modifications in material heterogeneity and microcrack density due to bisphosphonate treatment may influence the initiation and propagation fracture resistance of cortical bone.     

Advances in the fracture mechanics of cortical bone

As cortical bone is a semi-brittle solid, its fracture is dependent not only on the magnitude of the applied stress, but also on the nature of any intrinsic or introduced cracks. Consequently a variety of fracture mechanics techniques have been utilised to evaluate the fracture toughness of cortical bone, including the single edge notched, centre notched cylindrical and compact tension methods, and values have been established for the critical stress intensity factor (Kc) and the critical strain energy release rate (Gc). The Kc and Gc values obtained depend on the orientation of the cortical bone, as well as on bone density, the velocity of crack propagation and specimen geometry. The significance of these fracture mechanics parameters for cortical bone is critically reviewed.     

Collagen fiber organization is related to mechanical properties and remodeling in equine bone. A comparsion of two methods

We studied birefringence as an indicator of collagen fiber orientation in the diaphysis of the equine third metacarpal bone. We had previously shown that tissue from the lateral cortex of this bone is stronger monotonically, but less fatigue resistant, than tissue from the medial and dorsal regions. To learn whether collagen fiber orientation might play a role in this regional specialization, we tested three hypotheses using the same specimens: (1) collagen fiber orientation is regionally dependent; (2) remodeling changes collagen fiber orientation; (3) longitudinal collagen fibers correlate positively with modulus and monotonic bending strength and negatively with flexural fatigue life. Beams (N=36) cut parallel to the long axes of six pairs of bones had been tested to determine elastic modulus (N=36), and fatigue life (N=24) or monotonic strength (N=12) in four-point bending. Subsequently, histologic cross-sections were prepared, and porosity, active remodeling and past remodeling were quantified. Birefringence was measured as an indicator of transverse collagen orientation using plane-polarized light (PPL), and again using circularly polarized light (CPL). The CPL measurement was less variable than the PPL measurement. Both birefringence measures indicated that collagen was more longitudinally oriented in the lateral cortex than in the other two cortices. Longitudinally disposed collagen correlated with greater modulus and monotonic strength, but did not correlate with fatigue life. Remodeling was associated with more transverse collagen. Neither measure of birefringence was significantly correlated with porosity. It was concluded that, in the equine cannon bone, longitudinal collagen fiber orientation is regionally variable, contributes to increased modulus and strength but not fatigue life, and is reduced by osteonal remodeling.     

Crack propagation in cortical bone is affected by the characteristics of the cement line: a parameter study using an XFEM interface damage model

Bulk properties of cortical bone have been well characterized experimentally, and potent toughening mechanisms, e.g., crack deflections, have been identified at the microscale. However, it is currently difficult to experimentally measure local damage properties and isolate their effect on the tissue fracture resistance. Instead, computer models can be used to analyze the impact of local characteristics and structures, but material parameters required in computer models are not well established. The aim of this study was therefore to identify the material parameters that are important for crack propagation in cortical bone and to elucidate what parameters need to be better defined experimentally. A comprehensive material parameter study was performed using an XFEM interface damage model in 2D to simulate crack propagation around an osteon at the microscale. The importance of 14 factors (material parameters) on four different outcome criteria (maximum force, fracture energy, crack length and crack trajectory) was evaluated using ANOVA for three different osteon orientations. The results identified factors related to the cement line to influence the crack propagation, where the interface strength was important for the ability to deflect cracks. Crack deflection was also favored by low interface stiffness. However, the cement line properties are not well determined experimentally and need to be better characterized. The matrix and osteon stiffness had no or low impact on the crack pattern. Furthermore, the results illustrated how reduced matrix toughness promoted crack penetration of the cement line. This effect is highly relevant for the understanding of the influence of aging on crack propagation and fracture resistance in cortical bone.

     

Cortical bone failure mechanisms during screw pullout

An experimental and computational study of screw pullout from cortical bone has been conducted. A novel modification of standard pullout tests providing real time image capture of damage mechanisms during screw pullout was developed. Pullout forces, measured using the novel test rig, have been validated against standard pullout tests. Pullout tests were conducted, considering osteon alignment, to investigate the effect of osteons aligned parallel to the axis of the orthopaedic screw (longitudinal pullout) as well as the effect of osteons aligned perpendicular to the axis of the screw (transverse pullout). Distinctive alternate failure mechanisms, for longitudinally and transversely orientated cortical bone during screw pullout, were uncovered. Vertical crack propagation, parallel to the axis of the screw, was observed for a longitudinal pullout. Horizontal crack propagation, perpendicular to the axis of the screw, was observed for a transverse pullout. Finite element simulation of screw pullout, incorporating material damage and crack propagation, was also performed. Simulations revealed that a homogenous material model for cortical bone predicts vertical crack propagation patterns for both longitudinal and transverse screw pullout. A bi-layered composite model representing cortical bone microstructure was developed. A unique set of material and damage properties was used for both transverse and longitudinal pullout simulations, with only layer orientations being changed. Simulations predicted: (i) higher pullout forces for transverse pullout; (ii) horizontal crack paths perpendicular to screw axis for transverse pullout, whereas vertical crack paths were computed for longitudinal pullout. Computed results agreed closely with experimental observations in terms of pullout force and crack propagation.     

Atypical subtrochanteric femoral shaft fractures: role for mechanics and bone quality

Bisphosphonates are highly effective agents for reducing osteoporotic fractures in women and men, decreasing fracture incidence at the hip and spine up to 50%. In a small subset of patients, however, these agents have recently been associated with ''atypical femoral fractures'' (AFFs) in the subtrochanteric region or the diaphysis. These fractures have several atypical characteristics, including occurrence with minimal trauma; younger age than typical osteoporotic fractures; occurrence at cortical, rather than cancellous sites; early radiographic appearance similar to that of a stress fracture; transverse fracture pattern rather than the familiar spiral or transverse-oblique morphologies; initiation on the lateral cortex; and high risk of fracture on the contralateral side, at the same location as the initial fracture. Fracture is a mechanical phenomenon that occurs when the loads applied to a structure such as a long bone exceed its load-bearing capacity, either due to a single catastrophic overload (traumatic failure) or as a result of accumulated damage and crack propagation at sub-failure loads (fatigue failure). The association of AFFs with no or minimal trauma suggests a fatigue-based mechanism that depends on cortical cross-sectional geometry and tissue material properties. In the case of AFFs, bisphosphonate treatment may alter cortical tissue properties, as these agents are known to alter bone remodeling. This review discusses the use of bisphosphonates, their effects on bone remodeling, mechanics and tissue composition, their significance as an effective therapy for osteoporosis, and why these agents may increase fracture risk in a small population of patients.     

Insulin-Like Growth Factor 1, Glycation and Bone Fragility: Implications for Fracture Resistance of Bone

Despite our extensive knowledge of insulin-like growth factor 1 (IGF1) action on the growing skeleton, its role in skeletal homeostasis during aging and age-related development of certain diseases is still unclear. Advanced glycation end products (AGEs) derived from glucose are implicated in osteoporosis and a number of diabetic complications. We hypothesized that because in humans and rodents IGF1 stimulates uptake of glucose (a glycation substrate) from the bloodstream in a dose-dependent manner, the decline of IGF1 could be associated with the accumulation of glycation products and the decreasing resistance of bone to fracture. To test the aforementioned hypotheses, we used human tibial posterior cortex bone samples to perform biochemical (measurement of IGF1, fluorescent AGEs and pentosidine (PEN) contents) and mechanical tests (crack initiation and propagation using compact tension specimens). Our results for the first time show a significant, age-independent association between the levels of IGF1 and AGEs. Furthermore, AGEs (fAGEs, PEN) predict propensity of bone to fracture (initiation and propagation) independently of age in human cortical bone. Based on these results we propose a model of IGF1-based regulation of bone fracture. Because IGF1 level increases postnatally up to the juvenile developmental phase and decreases thereafter with aging, we propose that IGF1 may play a protective role in young skeleton and its age-related decline leads to bone fragility and an increased fracture risk. Our results may also have important implications for current understanding of osteoporosis- and diabetes-related bone fragility as well as in the development of new diagnostic tools to screen for fragile bones.