Simulating distal radius fracture strength using biomechanical tests: a modeling study examining the influence of boundary conditions

Distal radius fracture strength has been quantified using in vitro biomechanical testing. These tests are frequently performed using one of two methods: (1) load is applied directly to the embedded isolated radius or (2) load is applied through the hand with the wrist joint intact. Fracture loads established using the isolated radius method are consistently 1.5 to 3 times greater than those for the intact wrist method. To address this discrepancy, a validated finite element modeling procedure was used to predict distal radius fracture strength for 22 female forearms under boundary conditions simulating the isolated radius and intact wrist method. Predicted fracture strength was highly correlated between methods (r = 0.94; p < 0.001); however, intact wrist simulations were characterized by significantly reduced cortical shell load carriage and increased stress and strain concentrations. These changes resulted in fracture strength values less than half those predicted for the isolated radius simulations (2274 ± 824 N for isolated radius, 1124 ± 375 N for intact wrist; p < 0.001). The isolated radius method underestimated the mechanical importance of the trabecular compartment compared to the more physiologically relevant intact wrist scenario. These differences should be borne in mind when interpreting the physiologic importance of mechanical testing and simulation results.     

Relationships between femoral fracture loads for two load configurations

Studies of proximal femoral strength usually involve one of two types of loading conditions, loading similar to joint loading during single-limb stance or loading simulating impact from a fall. When interpreting the results of studies involving only one of these load configurations, the question arises as to their applicability to the other configuration. In addition, it is desirable to know whether, for an individual bone, fracture load for one load configuration is indicative of fracture load for the other configuration. In this study, the relationship between proximal femoral fracture loads for single-limb stance loading and loading simulating impact from a type of fall was determined from mechanical testing of 17 matched pairs of human proximal femora. Fracture loads for these two configurations were found to be linearly related (r = 0.901, p < 0.001). However, the correlation between fracture loads is not notably stronger than correlations currently available between fracture load and measures of bone density and geometry. In addition, the regression results indicate that 81% of the variance in fracture load for one loading condition is accounted for by fracture load for the other loading condition. Thus, 19% of the variance remains unexplained, indicating that the results of studies involving only one load configuration are not necessarily indicative of those that would be found for another configuration.     

Effect of boundary conditions,impact loading and hydraulic stiffening on femoral fracture strength

Patient specific quantitative CT (QCT) imaging data together with the finite element (FE) method may provide an accurate prediction of a patient's femoral strength and fracture risk. Although numerous FE models investigating femoral fracture strength have been published, there is little consent on the effect of boundary conditions, dynamic loading and hydraulic strengthening due to intra-medullary pressure on the predicted fracture strength. We developed a QCT-derived FE model of a proximal femur that included node-specific modulus assigned based on the local bone density. The effect of three commonly used boundary conditions published in literature were investigated by comparing the resulting strain field due to an applied fracture load. The models were also augmented with viscoelastic material properties and subject to a realistic impact load profile to determine the effect of dynamic loads on the strain field. Finally, the effect of hydraulic strengthening was investigated by including node specific permeability and performing a coupled pore diffusion and stress analysis of the FE model. Results showed that all boundary conditions yield the same strain field patterns, but peak strains were 22% lower and fracture load was 18% higher when loaded at the greater trochanter than when loaded at the femoral head. Comparison of the dynamic models showed that material viscoelasticity was important, but inertial effects (vibration and shock) were not. Finally, pore pressure changes did not cause significant hydraulic strengthening of bone under fall impact loading.     

Changes in the selection differential exerted on a marine snail during the ontogeny of a predatory shore crab

Empirical estimates of selection gradients caused by predators are common, yet no one has quantified how these estimates vary with predator ontogeny. We used logistic regression to investigate how selection on gastropod shell thickness changed with predator size. Only small and medium purple shore crabs (Hemigrapsus nudus) exerted a linear selection gradient for increased shell‐thickness within a single population of the intertidal snail (Littorina subrotundata). The shape of the fitness function for shell thickness was confirmed to be linear for small and medium crabs but was humped for large male crabs, suggesting no directional selection. A second experiment using two prey species to amplify shell thickness differences established that the selection differential on adult snails decreased linearly as crab size increased. We observed differences in size distribution and sex ratios among three natural shore crab populations that may cause spatial and temporal variation in predator‐mediated selection on local snail populations.     

Associations between shell morphology and land crab predation in the land snail Cerion

1. The land crab Gecarcinus lateralis is a significant predator of the abundant Bahamian land snails of the genus Cerion . The crabs typically 'scissor' the cylindrical shells in half or break the lip and peel back the shell to reach the animal which withdraws two or three whorls into the shell. Scars on shells of live adults at 73 sites in the Bahamas and Florida Keys show that about 8% (range: 0–44%) of the snails have survived attacks of this type.
2. An artificial crab claw was used to investigate the compressive force required to break Cerion shells of different morphotypes. Defining shell strength as the ability to withstand compressive forces, 10 morphotypes were found that exhibited mean relative strengths of between 30 and 300 newtons. Feeding trials with one adult crab showed that snails whose shells could withstand compressive forces of > 95 N were safe from this individual predator.
3. Multiple linear regression analyses showed that both shell size (length and width) and shell wall thickness were the ultimate determinants of shell strength. Ribs strengthen the shell by contributing to wall thickness and also by increasing overall shell width. The thickened adult shell lip and collabral ribs provide effective protection from attack by peeling.     

Shell colour diversification induced by ecological release: A shift in natural selection after a migration event

Ecological release is often attributed to the rapid adaptive diversification of phenotypic traits. However, it is not well understood how natural selection changes its strength and direction through the process of ecological release. Herein, we demonstrated how shell colour of the Japanese land snail Euhadra peliomphala simodae has diversified via a shift in natural selection due to ecological release after migration from the mainland to an island. This snail''s shell colour diversified on the island due to disruptive selection after migration from the mainland. We used trail camera traps to identify the cause of natural selection on both the mainland and the island. We then conducted a mark–recapture experiment while collecting microhabitat use data. In total, we captured and marked around 1,700 snails on the mainland, some of which were preyed upon by an unknown predator. The trail camera traps showed that the predator is the large Japanese field mouse Apodemus speciosus, and the predatory frequency was higher on the mainland than on the island. However, this predation did not correlate with shell colour. Microhabitat use on the island was more extensive than on the mainland, with snails on the island using both ground and arboreal microhabitats. A Bayesian estimation showed that the stabilizing selection on shell colour came from factors other than predation. Our results suggest that the course of natural selection was modified due to ecological release after migration from the mainland, explaining one cause of the phenotypic diversification.     

Fracture prediction for the proximal femur using finite element models: Part II--Nonlinear analysis.

In Part I we reported the results of linear finite element models of the proximal femur generated using geometric and constitutive data collected with quantitative computed tomography. These models demonstrated excellent agreement with in vitro studies when used to predict ultimate failure loads. In Part II, we report our extension of those finite element models to include nonlinear behavior of the trabecular and cortical bone. A highly nonlinear material law, originally designed for representing concrete, was used for trabecular bone, while a bilinear material law was used for cortical bone. We found excellent agreement between the model predictions and in vitro fracture data for both the onset of bone yielding and bone fracture. For bone yielding, the model predictions were within 2 percent for a load which simulated one-legged stance and 1 percent for a load which simulated a fall. For bone fracture, the model predictions were within 1 percent and 17 percent, respectively. The models also demonstrated different fracture mechanisms for the two different loading configurations. For one-legged stance, failure within the primary compressive trabeculae at the subcapital region occurred first, leading to load transfer and, ultimately, failure of the surrounding cortical shell. However, for a fall, failure of the cortical and trabecular bone occurred simultaneously within the intertrochanteric region. These results support our previous findings that the strength of the subcapital region is primarily due to trabecular bone whereas the strength of the intertrochanteric region is primarily due to cortical bone.     

Off-axis loads cause failure of the distal radius at lower magnitudes than axial loads: a finite element analysis

Distal radius (Colles') fractures are a common fall-related injury in older adults and frequently result in long-term pain and reduced ability to perform activities of daily living. Because the occurrence of a fracture during a fall depends on both the strength of the bone and upon the kinematics and kinetics of the impact itself, we sought to understand how changes in bone mineral density (BMD) and loading direction affect the fracture strength and fracture initiation location in the distal radius. A three-dimensional finite element model of the radius, scaphoid, and lunate was used to examine changes of +/-2% and +/-4% BMD, and both axial and physiologically relevant off-axis loads on the radius. Changes in BMD resulted in similar percent changes in fracture strength. However, modifying the applied load to include dorsal and lateral components (assuming a dorsal view of the wrist, rather than an anatomic view) resulted in a 47% decrease in fracture strength (axial failure load: 2752N, off-axis: 1448N). Loading direction also influenced the fracture initiation site. Axially loaded radii failed on the medial surface immediately proximal to the styloid process. In contrast, off-axis loads, containing dorsal and lateral components, caused failure on the dorsal-lateral surface. Because the radius appears to be very sensitive to loading direction, the results suggest that much of the variability in fracture strength seen in cadaver studies may be attributed to varying boundary conditions. The results further suggest that interventions focused on reducing the incidence of Colles' fractures when falls onto the upper extremities are unavoidable may benefit from increasing the extent to which the radius is loaded along its axis.     

Plastic Responses of a Sessile Prey to Multiple Predators: A Field and Experimental Study

Background

Theory predicts that prey facing a combination of predators with different feeding modes have two options: to express a response against the feeding mode of the most dangerous predator, or to express an intermediate response. Intermediate phenotypes protect equally well against several feeding modes, rather than providing specific protection against a single predator. Anti-predator traits that protect against a common feeding mode displayed by all predators should be expressed regardless of predator combination, as there is no need for trade-offs.

Principal Findings

We studied phenotypic anti-predator responses of zebra mussels to predation threat from a handling-time-limited (crayfish) and a gape-size-limited (roach) predator. Both predators dislodge mussels from the substrate but diverge in their further feeding modes. Mussels increased expression of a non-specific defense trait (attachment strength) against all combinations of predators relative to a control. In response to roach alone, mussels showed a tendency to develop a weaker and more elongated shell. In response to crayfish, mussels developed a harder and rounder shell. When exposed to either a combination of predators or no predator, mussels developed an intermediate phenotype. Mussel growth rate was positively correlated with an elongated weaker shell and negatively correlated with a round strong shell, indicating a trade-off between anti-predator responses. Field observations of prey phenotypes revealed the presence of both anti-predator phenotypes and the trade-off with growth, but intra-specific population density and bottom substrate had a greater influence than predator density.

Conclusions

Our results show that two different predators can exert both functionally equivalent and inverse selection pressures on a single prey. Our field study suggests that abiotic factors and prey population density should be considered when attempting to explain phenotypic diversity in the wild.     

Use of the rat forelimb compression model to create discrete levels of bone damage in vivo

Skeletal responses to damage are significant for understanding the etiology of stress fractures and possibly osteoporotic fractures. We refined the rat forelimb-loading model to produce a range of sub-fracture damage levels during in vivo cyclic loading. A total of 98 right forelimbs of anesthetized, male, 5-month old Fischer rats were loaded cyclically (2 Hz) in axial compression. Rats were killed immediately after loading. In the first experiment, forelimbs were loaded to fracture, which occurred after an increase in peak displacement of 2.0+/-0.2 mm, independent of peak force or cycle number. In the next experiment, we loaded forelimbs at a constant peak force until the peak displacement increased by 0.6-1.8 mm (30-90% of fracture displacement). Mechanical properties of the loaded (right) and contralateral control (left) ulnae were determined ex vivo using three-point bending, and cracks were analyzed using micro-computed tomography. Results demonstrated a dose-response between increased forelimb displacement and increased ulnar damage, with four discrete damage levels. "Low" damage was produced by cyclic loading to 30% of fracture displacement, with no visible cracks and a 10% strength loss. "Mild" damage was produced by loading to 45% of fracture displacement, with variable linear cracks and 20% strength loss. "Moderate" damage was produced by loading to 60-75% of fracture displacement, with consistent linear cracks and 40% strength loss. "High" damage was produced by loading to 85-90% of fracture displacement, with branching cracks and 60% strength loss. This loading model will be useful for examining biological responses to a range of sub-fracture damage levels in future experiments.     

Contrasting patterns of herbivore and predator pressure on invasive and native plants

Invasive non-native plant species often harbor fewer herbivorous insects than related native plant species. However, little is known about how herbivorous insects on non-native plants are exposed to carnivorous insects, and even less is known on plants that have recently expanded their ranges within continents due to climate warming. In this study we examine the herbivore load (herbivore biomass per plant biomass), predator load (predator biomass per plant biomass) and predator pressure (predator biomass per herbivore biomass) on an inter-continental non-native and an intra-continental range-expanding plant species and two congeneric native species. All four plant species co-occur in riparian habitat in north-western Europe. Insects were collected in early, mid and late summer from three populations of all four species. Before counting and weighing the insects were classified to trophic guild as carnivores (predators), herbivores, and transients. Herbivores were further subdivided into leaf-miners, sap-feeders, chewers and gallers. Total herbivore loads were smaller on inter-continental non-native and intra-continental range-expanding plants than on the congeneric natives. However, the differences depended on time within growing season, as well as on the feeding guild of the herbivore. Although the predator load on non-native plants was not larger than on natives, both non-native plant species had greater predator pressure on the herbivores than the natives. We conclude that both these non-native plant species have better bottom-up as well as top-down control of herbivores, but that effects depend on time within growing season and (for the herbivore load) on herbivore feeding guild. Therefore, when evaluating insects on non-native plants, variation within season and differences among feeding guilds need to be taken into account.     

Finite element modeling of shell shape in the freshwater turtle Pseudemys concinna reveals a trade‐off between mechanical strength and hydrodynamic efficiency

Aquatic species can experience different selective pressures on morphology in different flow regimes. Species inhabiting lotic regimes often adapt to these conditions by evolving low‐drag (i.e., streamlined) morphologies that reduce the likelihood of dislodgment or displacement. However, hydrodynamic factors are not the only selective pressures influencing organismal morphology and shapes well suited to flow conditions may compromise performance in other roles. We investigated the possibility of morphological trade‐offs in the turtle Pseudemys concinna. Individuals living in lotic environments have flatter, more streamlined shells than those living in lentic environments; however, this flatter shape may also make the shells less capable of resisting predator‐induced loads. We tested the idea that “lotic” shell shapes are weaker than “lentic” shell shapes, concomitantly examining effects of sex. Geometric morphometric data were used to transform an existing finite element shell model into a series of models corresponding to the shapes of individual turtles. Models were assigned identical material properties and loaded under identical conditions, and the stresses produced by a series of eight loads were extracted to describe the strength of the shells. “Lotic” shell shapes produced significantly higher stresses than “lentic” shell shapes, indicating that the former is weaker than the latter. Females had significantly stronger shell shapes than males, although these differences were less consistent than differences between flow regimes. We conclude that, despite the potential for many‐to‐one mapping of shell shape onto strength, P. concinna experiences a trade‐off in shell shape between hydrodynamic and mechanical performance. This trade‐off may be evident in many other turtle species or any other aquatic species that also depend on a shell for defense. However, evolution of body size may provide an avenue of escape from this trade‐off in some cases, as changes in size can drastically affect mechanical performance while having little effect on hydrodynamic performance. J. Morphol. 2011. © 2011 Wiley‐Liss, Inc.     

Effect of loading rate on endplate and vertebral body strength in human lumbar vertebrae

Previous studies have implied that increases in loading rate resulted in changes in vertebral mechanical properties and these changes were causative factors in the different fracture types seen with high-speed events. Thus many researchers have explored the vertebral body response under various loading rate conditions. No other study has investigated the role of the endplate in high-speed vertebral injuries. The current study determined changes in the endplate and vertebral body strength with increases in displacement rate. The endplate and vertebral body failure loads in individual lumbar vertebrae were documented for two displacement rates: 10 and 2500 mm/s. Using cross-sectional areas from the endplate and vertebral body, failure stresses for both components were calculated and compared. Both the endplate and vertebral body failure loads increased significantly with increased loading rate (p<0.005). Although the vertebral body failure stress increased significantly with loading rate as well (p<0.01), the endplate stresses did not (p>0.35). In addition, the endplate and vertebral strengths were not significantly different under high-speed loading (p>0.60), which inhibits possible predictions as to which bony component would fail initially during a high-speed injury event. It is possible that load distribution may contribute more to the fracture patterns seen at high speeds over vertebral component strength.     

Phenotypic homogeneity of two intertidal snails across a wave exposure gradient in South Australia

Dislodgement by the large drag forces imparted by breaking waves is an important cause of mortality for intertidal snails. The risk of drag-induced dislodgement can be reduced with: (1) a smaller shell of lower maximum projected surface area (MPSA); (2) a streamlined shell shape characterized by a squatter shell; and/or (3) greater adhesive strength attained through a larger foot area or increased foot tenacity. Snails on exposed coasts tend to express traits that increase dislodgement resistance. Such habitat-specific differences could result from direct selection against poorly adapted phenotypes on exposed shores but may reflect gastropod adaptation to high wave action achieved through phenotypic plasticity or genetic polymorphism. With this in mind, we examined the size, shape and adhesive strength of populations of two gastropod species, Austrocochlea constricta (Lamarck) and Nerita atramentosa (Reeve), from two adjacent shores representing extremes in wave exposure. Over a 5 day period, maximum wave forces were more than 10 times greater on the exposed than sheltered shore. Size-frequency distributions indicate that a predator consuming snails within the 1.3-1.8 cm length range regulates sheltered shore populations of both snail species. Although morphological scaling considerations suggest that drag forces should not place physical limits on the size of these gastropods, exposed shore populations of both snails were small relative to the maximum size documented for these species. Therefore, selective forces at the exposed site might favour smaller individuals with increased access to microhabitat refuges. Unexpectedly, however, neither snail species exhibited between-shore differences in shape, foot area or foot tenacity, which are likely to have adaptive explanations. Hence, it is possible that these snails are incapable of adaptive developmental responses to high wave action. Instead, the homogeneous and wave-exposed nature of Australia's southern coastline may have favoured the evolution of generalist strategies in these species.     

Expiratory muscle fatigue in normal subjects

We examined expiratory muscle fatigue during expiratory resistive loading in 11 normal subjects. Subjects breathed against expiratory resistances at their own breathing frequency and tidal volume until exhaustion or for 60 min. Respiratory muscle strength was assessed from both the maximum static expiratory and inspiratory mouth pressures (PEmax and PImax). At the lowest resistance, PEmax and PImax measured after completion of the expiratory loaded breathing were not different from control values. With higher resistance, both PEmax and PImax were decreased (P less than 0.05), and the decrease lasted for greater than or equal to 60 min. The electromyogram high-to-low frequency power ratio for the rectus abdominis muscle decreased progressively during loading (P less than 0.01), but the integrated EMG activity did not change during recovery. Transdiaphragmatic pressure during loading was increased 3.6-fold compared with control (P less than 0.05). These findings suggest that expiratory resistive loaded breathing induces muscle fatigue in both expiratory and inspiratory muscles. Fatigue of the expiratory muscles can be attributed directly to the high work load and that of the inspiratory muscles may be related to increased work due to shortened inspiratory time.     

Tuning in to multiple predators: conflicting demands for shell morphology in a freshwater snail

1. We examined the response to chemical cues from fish and crayfish, two predators with contrasting feeding modes, and their single and combined effect on shell morphology in the freshwater snail Radix balthica. 2. Snails were subjected to four treatments: tench (Tinca tinca), signal crayfish (Pacifastacus leniusculus), a combination of tench and signal crayfish and no predators (control). Shell shape, crushing resistance and shell thickness were quantified. We also analysed whether shape or shell thickness contributes most to crushing resistance. 3. Chemical cues from the fish induced a rounder shell shape in R. balthica, a thicker shell and a higher crushing resistance, whereas crayfish chemical cues had no effect on shell morphology, shell thickness or crushing resistance. Shell shape contributed more to crushing resistance than shell thickness. 4. The combined predator treatment showed an intermediate response between the fish and crayfish treatments. Shell roundness was reduced compared with the fish treatment, but the reduced crushing resistance that comes with a less rounded shell was compensated by an increased investment in extra shell material, exceeding that of the fish treatment. 5. Our study extends previous studies of multipredator effects on phenotypically plastic freshwater snails by showing that the snails are able to fine‐tune different elements of morphology to counter predator‐specific foraging modes.     

Shell strength and primate seed predation of nontoxic species in eastern and southern Africa

The large African primates that eat fruit destroy the seeds of a number of fruiting species. This paper addresses several questions about seed-eating: What is the nature of the dietary niche provided by the nonpoisonous seeds of eastern and southern Africa? How well are these seeds mechanically protected? What other means of reducing seed predation are employed by the plants? and is the niche ecologically stable? Measurements of seed shell strength on 37 species from 17 families reveal a range of values, from <100-kg (numerous species) to over 2000-kg (palm nuts) breaking load. Primates crack open with their teeth seed shells from species exhibiting test strengths less than 600 kg. Variation in shell strength appears to increase dramatically for average species strengths above 100 kg. Plant species are not characterized by specific shell strengths but instead, display envelopes of shell strength overlapping broadly with other species. Taking this into account, adult male baboons (Papio spp.) appear to be dentally capable of preying upon most of the seed species of eastern and southern Africa. The possibility for predation of nonpoisonous seeds exists primarily because the plants periodically produce large crops in synchrony and the hard-shelled seeds are effectively dispersed, sometimes explosively but more often by means of edible fruits. The concomitant primate seed predation is a facultative specialization, of little apparent threat to the community of plants that support it.     

Are angle-fixed implants with elastic properties advantageous for the internal fixation of proximal humerus fractures?]

There is a recent interest for the use of angle-fixed plates in the management of proximal humerus fractures. Rigid implants might be associated with an increased risk of cutting-out. In order to analyse the potential beneficial effects of the implant elasticity on fracture fixation, the biomechanical properties of a rigid and an elastic angle-fixed plating system were assessed in an experimental study. An unstable fracture of the surgical neck was created in 8 pairs of human humeri. Specimens were subjected to axial loading and torque. Stiffness, subsidence and load to failure were assessed. The implant with elastic properties was characterized by a lower torsional stiffness and a higher subsidence during axial loading and torque. This implant failed at lower loads than the rigid implant did. Elastic implant properties of angle-fixed plates have shown not to be advantageous for the management of fractures of the proximal humerus.     

Incorporating uncertainty in mechanical properties for finite element-based evaluation of bone mechanics

Finite element (FE) models of bone, developed from computed tomography (CT) scan data, are used to evaluate stresses and strains, load transfer and fixation of implants, and potential for fracture. The experimentally derived relationships used to transform CT scan data in Hounsfield unit to modulus and strength contain substantial scatter. The scatter in these relationships has potential to impact the results and conclusions of bone studies. The objectives of this study were to develop a computationally efficient probabilistic FE-based platform capable of incorporating uncertainty in bone property relationships, and to apply the model to a representative analysis; variability in stresses and fracture risk was predicted in five proximal femurs under stance loading conditions. Based on published variability in strength and modulus relationships derived in the proximal femur, the probabilistic analysis predicted the distributions of stress and risk. For the five femurs analyzed, the 1 and 99 percentile bounds varied by an average of 17.3 MPa for stress and by 0.28 for risk. In each femur, the predicted variability in risk was greater than 50% of the mean risk calculated, with obvious implications for clinical assessment. Results using the advanced mean value (AMV) method required only seven analysis trials (1h) and differed by less than 2% when compared to a 1000-trial Monte-Carlo simulation (400 h). The probabilistic modeling platform developed has broad applicability to bone studies and can be similarly implemented to investigate other loading conditions, structures, sources of uncertainty, or output measures of interest.     

Specimen-specific modeling of hip fracture pattern and repair

Hip fracture remains a major health problem for the elderly. Clinical studies have assessed fracture risk based on bone quality in the aging population and cadaveric testing has quantified bone strength and fracture loads. Prior modeling has primarily focused on quantifying the strain distribution in bone as an indicator of fracture risk. Recent advances in the extended finite element method (XFEM) enable prediction of the initiation and propagation of cracks without requiring a priori knowledge of the crack path. Accordingly, the objectives of this study were to predict femoral fracture in specimen-specific models using the XFEM approach, to perform one-to-one comparisons of predicted and in vitro fracture patterns, and to develop a framework to assess the mechanics and load transfer in the fractured femur when it is repaired with an osteosynthesis implant. Five specimen-specific femur models were developed from in vitro experiments under a simulated stance loading condition. Predicted fracture patterns closely matched the in vitro patterns; however, predictions of fracture load differed by approximately 50% due to sensitivity to local material properties. Specimen-specific intertrochanteric fractures were induced by subjecting the femur models to a sideways fall and repaired with a contemporary implant. Under a post-surgical stance loading, model-predicted load sharing between the implant and bone across the fracture surface varied from 59%:41% to 89%:11%, underscoring the importance of considering anatomic and fracture variability in the evaluation of implants. XFEM modeling shows potential as a macro-level analysis enabling fracture investigations of clinical cohorts, including at-risk groups, and the design of robust implants.