Analysis of bone–prosthesis interface micromotion for cementless tibial prosthesis fixation and the influence of loading conditions

A lack of initial stability of the fixation is associated with aseptic loosening of the tibial components of cementless knee prostheses. With sufficient stability after surgery, minimal relative motion between the prosthesis and bone interfaces allows osseointegation to occur thereby providing a strong prosthesis-to-bone biological attachment. Finite element modelling was used to investigate the bone–prosthesis interface micromotion and the relative risk of aseptic loosening. It was anticipated that by prescribing different joint loads representing gait and other activities, and the consideration of varying tibial–femoral contact points during knee flexion, it would influence the computational prediction of the interface micromotion. In this study, three-dimensional finite element models were set up with applied loads representing walking and stair climbing, and the relative micromotions were predicted. These results were correlated to in-vitro measurements and to the results of prior retrieval studies. Two load conditions, (i) a generic vertical joint load of 3×body weight with 70%/30% M/L load share and antero-posterior/medial-lateral shear forces, acted at the centres of the medial and lateral compartments of the tibial tray, and (ii) a peak vertical joint load at 25% of the stair climbing cycle with corresponding antero-posterior shear force applied at the tibial–femoral contact points of the specific knee flexion angle, were found to generate interface micromotion responses which corresponded to in-vivo observations. The study also found that different loads altered the interface micromotion predicted, so caution is needed when comparing the fixation performance of various reported cementless tibial prosthetic designs if each design was evaluated with a different loading condition.     

Early cement damage around a femoral stem is concentrated at the cement/bone interface

This study aimed to improve understanding of the mechanical aspects of cemented implant loosening. After aggressive fatigue loading of stem/cement/femur constructs, micro-cracks and stem/bone micro-motions were quantified to answer three research questions: Are cracks preferentially associated with the stem/cement interface, the cement/bone interface or voids? Is cement damage dependent on axial position? Does cement damage correlate with micro-motion between the stem and the bone? Eight Charnley Cobra stems were implanted in cadaveric femora. Six stem/cement/femur constructs were subjected to "stair-climbing" loads for 300 kcycles at 2Hz. Loads were normalized by construct stiffness to avoid fracture. Two additional constructs were not loaded. Transverse sections were cut at 10mm intervals, stained with a fluorescent dye penetrant and examined using epi-fluorescence stereomicroscopy. Crack lengths and cement areas were recorded for 9 sections per specimen. Crack length-density was calculated by dividing summed crack length by cement mantle area. To isolate the effect of loading, length-density data were offset by the baseline length-density measured in the non-loaded specimens. Significantly more cracks were associated with the interdigitated area (35.1%+/-11.6%) and the cement/bone interface (31.0%+/-6.2%) than with the stem/cement interface (11.0%+/-5.2%) or voids (6.1%+/-4.8%) (p<0.05). Load-induced micro-crack length-density was significantly dependent on axial position, increasing proximally (p<0.001). Micro-motions were small, all stems rotated internally. Cement damage did not correlate with micro-motion.     

Cortical bone viscoelasticity and fixation strength of press-fit femoral stems: an in-vitro model

Cementless total hip femoral components rely on press-fit for initial stability and bone healing and remodeling for secondary fixation. However, the determinants of satisfactory press-fit are not well understood. In previous studies, human cortical bone loaded circumferentially to simulate press-fit exhibited viscoelastic, or time dependent, behavior. The effect of bone viscoelastic behavior on the initial stability of press-fit stems is not known. Therefore, in the current study, push-out loads of cylindrical stems press-fit into reamed cadaver diaphyseal femoral specimens were measured immediately after assembly and 24 h with stem-bone diametral interference and stem surface treatment as independent variables. It was hypothesized that stem-bone interference would result in a viscoelastic response of bone that would decrease push-out load thereby impairing initial press-fit stability. Results showed that push-out load significantly decreased over a 24 h period due to bone viscoelasticity. It was also found that high and low push-out loads occurred at relatively small amounts of stem-bone interference, but a relationship between stem-bone interference and push-out load could not be determined due to variability among specimens. On the basis of this model, it was concluded that press-fit fixation can occur at relatively low levels of diametral interference and that stem-bone interference elicits viscoelastic response that reduces stem stability over time. From a clinical perspective, these results suggest that there could be large variations in initial press-fit fixation among patients.     

The Odocoileus virginianus Femur: Mechanical Behavior and Morphology

Biomechanical research relies heavily on laboratory evaluation and testing with osseous animal structures. While many femora models are currently in use, including those of the European red deer (Cervus elaphus), the Odocoileus virginianus femur remains undocumented, despite its regional abundance in North America. The objective of this study was to compare biomechanical and morphological properties of the Odocoileus virginianus femur with those of the human and commonly used animal models. Sixteen pairs of fresh-frozen cervine femora (10 male, 6 female, aged 2.1 ± 0.9 years) were used for this study. Axial and torsional stiffnesses (whole bone) were calculated following compression and torsion to failure tests (at rates of 0.1 mm/sec and 0.2°/sec). Lengths, angles, femoral head diameter and position, periosteal and endosteal diaphyseal dimensions, and condylar dimensions were measured. The results show that the cervine femur is closer in length, axial and torsional stiffness, torsional strength, and overall morphology to the human femur than many other commonly used animal femora models; additional morphological measurements are comparable to many other species’ femora. The distal bicondylar width of 59.3mm suggests that cervine femora may be excellent models for use in total knee replacement simulations. Furthermore, the cervine femoral head is more ovoid than other commonly-used models for hip research, making it a more suitable model for studies of hip implants. Thus, with further, more application-specific investigations, the cervine femur could be a suitable model for biomechanical research, including the study of ballistic injuries and orthopaedic device development.     

Stair climbing is more critical than walking in pre-clinical assessment of primary stability in cementless THA in vitro

Pre-clinical testing of hip endoprostheses is a mandatory requirement before clinical release. Inadequate loading conditions may lead to lower elastic and plastic interface movements than those occurring post-operatively in vivo. This study investigated the influence of patient activity on the primary stability of cementless prostheses with a special emphasis on active simulation of muscle forces. A loading setup, based on validated musculo-skeletal analyses, was used to generate the hip contact force during walking and stair climbing by transmitting muscle forces through the femur. In addition, a loading configuration which only generated the hip contact force occurring during stair climbing at the prosthesis head was simulated. CLS prostheses were implanted in 18 composite femora and subjected to cyclical loading. The relative micro-movements at the bone-prosthesis interface were determined and appeared to be extremely sensitive to the specific patient activity. Compared to walking, stair climbing generated higher micro-movements, with pronounced axial and rotational components. Stair climbing with the femur loaded by the resultant hip contact force only exhibited a characteristic valgus tilt of the stem with significantly lower interface micro-movements than under active simulation of muscle forces. The analyses suggest that stair climbing induced the highest mechanical instability at the bone-prosthesis interface, a level which may compromise the necessary osseointegration process. Active simulation of muscle forces considerably affects the primary stability of cementless hip endoprostheses. Pre-clinical in vitro tests should therefore simulate stair climbing and include muscle activity in the assessment of initial implant stability, otherwise micro-movements may be underestimated and the primary stability overestimated.     

Compressive properties of trabecular bone in the distal femur

Early loosening and implant migration are two problems that lead to failures in cementless (press-fit) femoral knee components of total knee replacements. To begin to address these early failures, this study determined the anterior-posterior mechanical properties from four locations in the human distal femur. Thirty-three cylindrical specimens were removed perpendicular to the press-fit surface after the surgical cuts on 10 human cadaveric femurs (age 71.5+/-14.2 years) had been made. Compression testing was performed that utilized methods to reduce the effects of end-artifacts. The bone mineral apparent density (BMAD), apparent modulus of elasticity, yield and ultimate stress, and yield and ultimate strain were measured for 28 cylindrical specimens. The apparent modulus, yield and ultimate stress, and yield and ultimate strain each significantly differed (p<0.05) in the superior and inferior locations. Linear and power law relationships between superior and inferior mechanical properties and BMAD were determined. The inferior apparent modulus and stresses were higher than those in the superior locations. These results show that the press-fit fixation characteristics of the femoral knee component differ on the anterior shield and posterior condyles. This information will be useful in the assignment of mechanical properties in finite element models for further investigations of femoral knee components. The property-density relations also have applications for implant design and preoperative assessment of bone strength using clinically available tools.     

Cortical bone viscoelasticity and fixation strength of press-fit femoral stems: finite element model

Many cementless implant designs rely upon a diaphyseal press-fit in conjunction with a porous coated implant surface to achieve primary or short term fixation, thereby constraining interface micromotion to such a level that bone ingrowth and consequent secondary or long-term fixation, i.e., osseointegration, can occur. Bone viscoelasticity, however, has been found to affect stem primary stability by reducing push-out load. In this investigation, an axisymmetric finite element model of a cylindrical stem and diaphyseal cortical bone section was created in order to parametrically evaluate the effect of bone viscoelasticity on stem push-out while controlling coefficient of friction (mu = 0.15, 0.40, and 1.00) and stem-bone diametral interference (delta = 0.01, 0.05, 0.10, and 0.50 mm). Based on results from a previous study, it was hypothesized that stem-bone interference (i.e., press-fit) would elicit a bone viscoelastic response which would reduce the initial fixation of the stem as measured by push-out load. Results indicate that for all examined combinations of mu and delta, bone viscoelastic behavior reduced the push-out load by a range of 2.6-82.6% due to stress relaxation of the bone. It was found that the push-out load increased with mu for each value of delta, but minimal increases in the push-out load (2.9-4.9%) were observed as delta was increased beyond 0.10 mm. Within the range of variables reported for this study, it was concluded that bone viscoelastic behavior, namely stress relaxation, has an asymptotic affect on stem contact pressure, which reduces stem push-out load. It was also found that higher levels of coefficient of friction are beneficial to primary fixation, and that an interference "threshold" exists beyond which no additional gains in push-out load are achieved.     

Improvement of femoral bone-cement adhesion in cemented revision hip arthroplasty by application of an amphiphilic bonder in a dynamic femur expulsion testing in vitro ]

Cemented femoral stems have shown decreased longevity compared to cementless implants in hip revision arthroplasty. The aim of this study was to evaluate the effect of an amphiphilic bonder on bone cement stability in a biomechanical femur expulsion test. A simplified hip simulator test setup with idealised femur stem specimens was carried out. The stems were implanted into bovine femurs (group 1: no bonder, n=10; group 2: bonder including glutaraldehyde, n=10; group 3: bonder without glutaraldehyde, n=10). A dynamic loading (maximum load: 800 N; minimum load: 100 N; frequency: 3 Hz; 105 cycles) was performed. Subsequently, the stem specimens were expulsed axially out of their implant beds and maximum load at failure was recorded. The static controls showed a mean maximum load to failure of 4123 N in group 1, 8357.5 N in group 2 and 5830.8 N in group 3. After dynamic loading, the specimens of group 2 reached the highest load to failure (8191.5 N), followed by group 3 (5649.5 N) and group 1 (3462 N), respectively. In group 2, we observed nine periprosthetic fractures at a load of 8400 N without signs of interface loosening. Application of an amphiphilic bonder led to a significant improvement of bonding stability, especially when glutaraldehyde was added to the bonder. This technique might offer an increased longevity of cemented femur revision stems in total hip replacement.     

The bending rod prosthesis: an experimental approach to metaphyseal hip arthroplasty]

The aim of our study was to develop a femoral component for total hip arthroplasty that would exclusively anchor in the metaphysis of the femoral neck. To forego trochanteric fixation, the load needs to be transferred to the metaphysis at as many points as possible. A computer simulation model suggested that an implant with a central cylinder and 16 rods aligned along a thread would be the preferable solution. To evaluate primary implantation stability, 14 fresh frozen cadaver femora were used. A special instrument set was developed to allow for centered implantation of the prosthesis without the need to dissect the greater trochanter. For our tests, we used two prototype implants: one made from titanium and the other from a CoCrMo alloy. For the measurement of micromotions at the medial proximal femur, sinusoid dynamic loading with a force between 300 N and 1700 N and a frequency of 1 Hz was employed. In a neutral position of 16 degrees adduction and 9 degrees antetorsion, the average micromotions measured were 119 microm. Despite these convincing in vitro results with regards to primary stability, circular cut-out of the implant, followed by aseptic osteonecrosis, loosening might still occur in a clinical situation. Animal experiments are therefore required to further evaluate this new implant design.     

Predicting the subject-specific primary stability of cementless implants during pre-operative planning: preliminary validation of subject-specific finite-element models

Pre-operative planning help the surgeon in taking the proper clinical decision. The ultimate goal of this work is to develop numerical models that allow the surgeon to estimate the primary stability during the pre-operative planning session. The present study was aimed to validate finite-element (FE) models accounting for patient and prosthetic size and position as planned by the surgeon. For this purpose, the FE model of a cadaveric femur was generated starting from the CT scan and the anatomical position of a cementless stem derived by a skilled surgeon using a pre-operative CT-based planning simulation software. In-vitro experimental measurements were used as benchmark problem to validate the bone-implant relative micromotions predicted by the patient-specific FE model. A maximum torque in internal rotation of 11.4 Nm was applied to the proximal part of the hip stem. The error on the maximum predicted micromotion was 12% of the peak micromotion measured experimentally. The average error over the entire range of applied torques was only 7% of peak measurement. Hence, the present study confirms that it is possible to accurately predict the level of primary stability achieved for cementless stems using numerical models that account for patient specificity and surgical variability.     

Influence of interface condition and implant design on bone remodelling and failure risk for the resurfaced femoral head

Resurfacing of the femur has experienced a revival, particularly in younger and more active patients. The implant is generally cemented onto the reamed trabecular bone and theoretical remodelling for this configuration, as well as uncemented variations, has been studied with relation to component positioning for the most common designs. The purpose of this study was to investigate the influence of different interface conditions, for alternative interior implant geometries, on bone strains in comparison to the native femur, and its consequent remodelling. A cylindrical interior geometry, two conical geometries and a spherical cortex-preserving design were compared with a standard implant (ASR, DePuy International, Ltd., UK), which has a 3° cone. Cemented as well as uncemented line to line and press-fit conditions were modelled for each geometry. A patient-specific finite element model of the proximal femur was used with simulated walking loads. Strain energy density was compared between the reference and resurfaced femur, and input into a remodelling algorithm to predict density changes post-operatively. The common cemented designs (cylindrical, slightly conical) had strain shielding in the superior femoral head (>35% reduction) as well as strain concentrations (strain>5%) in the neck regions near the implant rim. The cortex-preserving (spherical) and strongly conical designs showed less strain shielding. In contrast to the cemented implants, line to line implants showed a density decrease at the centre of the femoral head, while all press-fit versions showed a density increase (>100%) relative to the native femur, which suggests that uncemented press-fit implants could limit bone resorption.     

The effect of cross-sectional stem shape on the torsional stability of cemented implant components

Stability of a cemented implant, once the stem-cement interface has debonded, is reliant upon stem geometry and surface finish. There are relatively few studies addressing the effect of cross-sectional stem shape on cemented implant fixation. The purpose of this investigation was to compare the torsional stability of five different stem cross-sectional shapes-circular, oval, triangular, rectangular with rounded edges, and rectangular with sharp edges-under monotonically increasing and cyclic loading conditions. Seven samples of each stem geometry were tested. Stems were potted in bone cement and loaded to 5 deg of rotation. For monotonic loading, torque was applied at a constant rate of 2.5 deg/min. For cyclic loading, a sine wave torque pattern was applied, with a maximum magnitude that began at 4.5 Nm for 1500 cycles and then increased by 2.25 Nm every 1500 cycles until 5 deg of rotation. The rectangular stem with the sharp edges always provided the greatest resistance to torque, followed by the rectangular with rounded edges, triangular, oval, and circular. These results, including the effects of sharp corners, may differ for modes of loading other than torsion. These experimental results support the findings of earlier finite element models, indicating stem shape has a significant effect on resistance to torsional loading.     

Cementless stem fixation and primary stability under physiological-like loads in vitro.

Primary stability and in consequence osteointegration are commonly related to the stem anchorage but also to the complex musculoskeletal loading of the hip region. This study investigated the influence of metaphyseal and meta-diaphyseal anchorage on the primary stability of cementless stems under physiological-like loading in vitro. Metaphyseal and meta-diaphyseal anchoring stems (n=6 each) were implanted into composite femora. Musculoskeletal loads, validated by in vivo data (peak joint force 2348 N), were applied using a mechanical set-up. Interface movements were recorded by seven displacement transducers and primary stability was compared. Both stems exhibited similar movement patterns and principally moved distally with a retroversional twist. Although elastic movements were comparable, the metaphyseal stem exhibited higher plastic deformations than the meta-diaphyseal stem, particularly for the metaphyseal, medio-lateral and antero-posterior components. Under physiological-like loading, the metaphyseal stem allowed higher interface movements and tended to initially migrate faster than the meta-diaphyseal stem and then stabilized. Elastic movements were comparable and seemed to be less influenced by the anchoring concept than by the mechanical properties of the bone. The analyses emphasize the importance of metaphyseal bone in proximal anchorage and the necessity of an accurate canal preparation to prevent excessive initial migration.     

Virtual trial to evaluate the robustness of cementless femoral stems to patient and surgical variation

Primary stability is essential for the success of cementless femoral stems. In this study, patient specific finite element (FE) models were used to assess changes in primary stability due to variability in patient anatomy, bone properties and stem alignment for two commonly used cementless femoral stems, Corail® and Summit® (DePuy Synthes, Warsaw, USA). Computed-tomography images of the femur were obtained for 8 males and 8 females. An automated algorithm was used to determine the stem position and size which minimized the endo-cortical space, and then span the plausible surgical envelope of implant positions constrained by the endo-cortical boundary. A total of 1952 models were generated and ran, each with a unique alignment scenario. Peak hip contact and muscle forces for stair climbing were scaled to the donor’s body weight and applied to the model. The primary stability was assessed by comparing the implant micromotion and peri-prosthetic strains to thresholds (150 μm and 7000 µε, respectively) above which fibrous tissue differentiation and bone damage are expected to prevail. Despite the wide range of implant positions included, FE prediction were mostly below the thresholds (medians: Corail®: 20–74 µm and 1150–2884 µε, Summit®: 25–111 µm and 860–3010 µε), but sensitivity of micromotion and interfacial strains varied across femora, with the majority being sensitive (p < 0.0029) to average bone mineral density, cranio-caudal angle, post-implantation anteversion angle and lateral offset of the femur. The results confirm the relationship between implant position and primary stability was highly dependent on the patient and the stem design used.     

Activity intensity,assistive devices and joint replacement influence predicted remodelling in the proximal femur

Bone morphology and density changes are commonly observed following joint replacement, may contribute to the risks of implant loosening and periprosthetic fracture and reduce the available bone stock for revision surgery. This study was presented in the ‘Bone and Cartilage Mechanobiology across the scales’ WCCM symposium to review the development of remodelling prediction methods and to demonstrate simulation of adaptive bone remodelling around hip replacement femoral components, incorporating intrinsic (prosthesis) and extrinsic (activity and loading) factors. An iterative bone remodelling process was applied to finite element models of a femur implanted with a cementless total hip replacement (THR) and a hip resurfacing implant. Previously developed for a cemented THR implant, this modified process enabled the influence of pre- to post-operative changes in patient activity and joint loading to be evaluated. A control algorithm used identical pre- and post-operative conditions, and the predicted extents and temporal trends of remodelling were measured by generating virtual X-rays and DXA scans. The modified process improved qualitative and quantitative remodelling predictions for both the cementless THR and resurfacing implants, but demonstrated the sensitivity to DXA scan region definition and appropriate implant–bone position and sizing. Predicted remodelling in the intact femur in response to changed activity and loading demonstrated that in this simplified model, although the influence of the extrinsic effects were important, the mechanics of implantation were dominant. This study supports the application of predictive bone remodelling as one element in the range of physical and computational studies, which should be conducted in the preclinical evaluation of new prostheses.     

Cancellous and cortical morselized allograft in revision total hip replacement: A biomechanical study of implant stability

To restore femoral intramedullary bone stock loss in revision surgery of failed total hip arthroplasties, impacted morselized cancellous allograft is recommended. This study investigated the mechanical properties of both impacted cortical (group A) and cancellous (group B) morselized bone graft for reconstruction of femoral bones. Ten matched pairs of fresh frozen human femora were prepared by over-reaming to create a smooth-walled cortical shell. Each pair had one cortical and one cancellous impacted morselized allograft and cement. Stem subsidence was evaluated by a cyclic axial load, which was applied by a servohydraulic test. The stem subsidence was measured for initial subsidence (subsidence at the first 1000 cycles), the total axial subsidence (subsidence at the end of cycles under load) and the final axial subsidence (subsidence after the unloading phase). Torque test was measured by torsional loads through the prosthetic femoral heads. Total axial subsidence was significantly higher in group B (mean: 1.32+/-0.32 mm) compared to group A (mean: 0.94+/-0.26 mm) (P<0.01).There was no significant difference between the two groups in terms of initial subsidence (P=0.09) and final axial subsidence.The mean maximum torque before failure was 39.5+/-22.2 N-m for the cortical morselized allograft and 32.5+/-18.1N-m for cancellous.We concluded that impacted morselized cortical bone graft used for reconstruction of contained femoral bone loss in revision hip arthroplasty, may reduce the stem subsidence. Further animal experimentation for mechanical and histological evaluation of in vivo application is warranted.     

Experimental and finite element comparison of various fixation designs in combined loads

The short- and long-term successes of tibial cementless implants depend on the initial fixation stability often provided by posts and screws. In this work, a metallic plate was fixed to a polyurethane block with either two bone screws, two smooth-surfaced posts, or two novel smooth-surfaced posts with adjustable inclinations. For this last case, inclinations of 0, 1.5, and 3 deg were considered following insertion. A load of 1031 N was eccentrically applied on the plate at an angle of approximately 14 deg, which resulted in a 1000 N axial compressive force and a 250 N shear force. The response was measured under static and repetitive loading up to 4000 cycles at 1 Hz. The measured results demonstrate subsidence under load, lift-off on the unloaded side, and horizontal translation of the plate specially at the loaded side. Fatigue loading increased the displacements, primarily during the first 100 cycles. Comparison of various fixation systems indicated that the plate with screw fixation was the stiffest with the least subsidence and liftoff. The increase in post inclination from 0 to 3 deg stiffened the plate by diminishing the liftoff. All fixation systems demonstrated deterioration under repetitive loads. In general, the finite element predictions of the experimental fixation systems were in agreement with measurements. The finite element analyses showed that porous coated posts (modeled with nonlinear interface friction with and without coupling) generated slightly less resistance to liftoff than smooth-surfaced posts. In the presence of porous coated posts, Coulomb friction greatly overestimated the rigidity by reducing the liftoff and subsidence to levels even smaller than those predicted for the design with screw fixation. The sequence of combined load application also influenced the predicted response. Finally, the finite element model incorporating measured interface friction and pull-out responses can be used for the analysis of cementless total joint replacement systems during the post-operation period.     

Prediction of strength and strain of the proximal femur by a CT-based finite element method

Hip fractures are the most serious complication of osteoporosis and have been recognized as a major public health problem. In elderly persons, hip fractures occur as a result of increased fragility of the proximal femur due to osteoporosis. It is essential to precisely quantify the strength of the proximal femur in order to estimate the fracture risk and plan preventive interventions. CT-based finite element analysis could possibly achieve precise assessment of the strength of the proximal femur. The purpose of this study was to create a simulation model that could accurately predict the strength and surface strains of the proximal femur using a CT-based finite element method and to verify the accuracy of our model by load testing using fresh frozen cadaver specimens. Eleven right femora were collected. The axial CT scans of the proximal femora were obtained with a calibration phantom, from which the 3D finite element models were constructed. Materially nonlinear finite element analyses were performed. The yield and fracture loads were calculated, while the sites where elements failed and the distributions of the principal strains were determined. The strain gauges were attached to the proximal femoral surfaces. A quasi-static compression test of each femur was conducted. The yield loads, fracture loads and principal strains of the prediction significantly correlated with those measured (r=0.941, 0.979, 0.963). Finite element analysis showed that the solid elements and shell elements in undergoing compressive failure were at the same subcapital region as the experimental fracture site.     

Femoral stiffness and strength critically depend on loading angle: a parametric study in a mouse-inbred strain

Biomechanical tests of human femora have shown that small variations of the loading direction result in significant changes in measured bone mechanical properties. However, the heterogeneity in geometrical and bone tissue properties does not make human bones well suited to reproducibly assess the effects of loading direction on stiffness and strength. To precisely quantify the influence of loading direction on stiffness and strength of femora loaded at the femoral head, we tested femora from C57BL/6 inbred mice. We developed an image-based alignment protocol and investigated the loading direction influence on proximal femur stiffness and strength. An aluminum femoral phantom and C57BL/6 femora were tested under compression with different loading directions. Both tests, with the aluminum phantom and the murine bones, showed and quantified the linear dependence of stiffness on loading direction: a 5 degrees change in loading direction resulted in almost 30% change in stiffness. Murine bone testing also revealed and quantified the variation in strength due to loading direction: 5 degrees change in loading direction resulted in 8.5% change in strength. In conclusion, this study quantified, for the first time, the influence of misalignment on bone stiffness and strength for femoral head loading. We showed the extreme sensitivity of this site regarding loading direction.