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Biomechanical Studies

Cadaveric testing, finite element analysis, and computational modeling to evaluate spinal construct stability, stiffness, and failure modes for implant design and surgical planning.

Overview

Biomechanical studies address implant durability and provide clinically relevant data by understanding the physiologic features of the fracture environment [5]. This discipline combines fundamental principles of physics, engineering, and biology to describe and predict the effects of energy and various types of forces on biologic systems [7]. Such analysis aids in understanding forces acting on the human body and informs the design of orthopaedic instruments, implants, and prostheses [7].

The biomechanical literature on proximal humerus fracture implants is diverse and heterogeneous [6]. For specific applications, such as distal clavicular fracture repair, newer techniques coupled with greater overall construct strength and lower-profile hardware may result in improved clinical outcomes and fewer hardware-related complications compared to locked plating [44]. In femoral neck fractures, two modified intramedullary designs showed the best biomechanical performance among five implants evaluated in a finite element analysis [48].

Clinical translation requires rigorous validation. Biomechanical results from mechanical studies of safe distances between humerus shaft fractures and distal locking screws in antegrade nailing should be confirmed with clinical studies [1]. Similarly, further biomechanical tests and clinical studies are required to prove Tektona®'s capabilities in height and volume restoration for osteoporotic vertebral compression fractures compared to standard balloon kyphoplasty [4]. Biomechanical data from minipig models for pedicle screw fixation could provide a baseline comparison for future studies [2].

Anatomy & Pathophysiology

Osseous and Cancellous Properties

Large lytic defects in the spine result in kinematic abnormalities and reduced compressive strength [12]. The unique microarchitecture of cervical vertebrae causes fractures to occur later in this region compared to the thoracic or lumbar spine [40]. Mechanical properties of vertebral cancellous bone can be modeled with high accuracy based on quantitative computed tomography within the investigated bone density range [35].

Ligamentous and Disc Mechanics

Loading in the anterior-oblique direction requires lower external force or moment to maintain the lumbar spine in a neutral position compared to vertical or posterior-oblique directions [32]. Data on geometric deformations of the lumbar disc during axial body rotations offer insights for optimizing artificial lumbar spine device parameters [9]. No mechanical failures were observed in viscoelastic discs or articulating total disc replacements after 30-million-cycle intervals, simulating approximately 80 years of lumbar-bending motions [13].

Kinematics and Facet Joint Forces

Postures play a more significant role than applied preloads in determining facet joint forces, particularly during axial rotation [37]. During axial rotation, facet joint forces are increased in the contralateral facet joints compared to the ipsilateral ones at the same lumbar level [37]. Moment-rotation corridors for coronal and axial metrics provide a normative dataset for degeneration-free cervical spines in lateral flexion [34].

Implant Biomechanics and Stability

A 5 mm implant height in total cervical disc replacement provides biomechanical properties similar to intact specimens, whereas larger heights alter facet joint mechanics [38]. Noncontinuous cervical disc arthroplasty preserves intradiscal pressure and facet joint forces at adjacent and intermediate levels, maintaining cervical spine kinematics near preoperative values [33]. Interspinous devices reduce range of motion in extension and can reduce disc pressure, but often fail to fully compensate for destabilization in other planes or adjacent levels [18]. The dual-cord dynamic stabilization system demonstrates improved biomechanical stability with minimal adjacent segment compromise [8].

Instrumentation and Modeling Frameworks

Understanding biomechanical principles of spinal instrumentation and motion coupling is essential for optimizing three-dimensional correction of thoracolumbar spinal deformities and achieving favorable mechanical environments for fusion [25]. Biomechanical analysis of the posterior bony column of the lumbar spine provides theoretical references for spinal implant materials and biomechanical compatibility [29]. The computer BS-II system is designed for biomechanical measurements of the human lumbar spine, specifically for verifying surgical fixation methods [17]. Biomechanical data from minipig models can provide a baseline comparison for future pedicle screw fixation studies [2].

Classification

Biomechanics combines fundamental principles of physics, engineering, and biology to describe and predict the effects of energy and various types of forces on biologic systems [7]. Musculoskeletal biomechanics is an interdisciplinary field that utilizes principles of mechanics applied to the human body to prevent and to improve treatment of musculoskeletal injuries [47]. It covers rigid body mechanics, mechanics of materials, and implant design considerations [47]. Biomechanics aids in the understanding of forces acting on the human body and the design of orthopaedic instruments, implants, and prostheses [7].

Biomechanical studies should address implant durability and provide clinically relevant data by understanding the physiologic features of the fracture environment [5]. The biomechanical literature on proximal humerus fracture implants is diverse and heterogeneous [6]. Common types of femoral fractures arise from failure of the bone under tensile stress [36]. The anterior and posterior approach differentially affect postoperative biomechanical function of the capsular ligaments [10].

Other Considerations: Machine learning and artificial intelligence may serve as tools to bridge biological, biomechanical, and psychosocial domains to advance future clinical care in ACL injuries [15]. The computer BS-II system is designed for biomechanical measurements of the lumbar part of the human spine, especially for verification of surgical fixation methods [17].

Clinical Presentation

Biomechanics integrates fundamental principles of physics, engineering, and biology to describe and predict the effects of energy and various forces on biologic systems [7]. This discipline aids in understanding the forces acting on the human body [7] and informs the design of orthopaedic instruments, implants, and prostheses [7].

Pathological Biomechanical Alterations: Spinal Defects: Critical spinal lytic defects result in kinematic abnormalities and lower the compressive strength of the spine [12]. Cervical Pathology: Patients with Hirayama disease exhibit differences in cervical biomechanics compared with non-pathological people [26]. These differences may lead to cervical hypermobility and overload [26]. Joint and Soft Tissue: The anterior and posterior approach differentially affect postoperative biomechanical function of the capsular ligaments [10]. Microfracture may lead to a biomechanically unfavorable environment in subsets of patients with medial femoral condyle cartilage defects [11].

Chronic Symptomatology: Patients with chronic whiplash-associated disorders (WAD) showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli [28].

Investigations

Plain radiography: Measurement of vertebral body angles reliably identifies a lumbosacral transitional vertebra with a solid bony bridge on a single-slice midsagittal scan or lateral radiograph, correlating with the degree of mechanical connection [56].

MRI: T1ρ MR imaging serves as an effective, noninvasive technique for assessing early-stage disc degeneration [58]. Compressive moduli and permeabilities of isolated intervertebral discs are mostly assessable via magnetization transfer (MT) and diffusion sequences, though relationships require improvement with more sensitive MRI parameters [51]. Metal suppression MRI techniques provide a comprehensive overview of metal artifacts in orthopaedic and spine surgery to facilitate better-informed diagnostic decisions [41].

CT: Composite beam theory analysis, utilizing quantitative computed tomography-derived measures of rigidity, can prospectively predict the yield loads of vertebrae with lytic defects [55].

Biomechanical Studies: Biomechanical studies should address implant durability and provide clinically relevant data by understanding the physiologic features of the fracture environment [5]. Mechanical study results regarding safe distances between humerus shaft fractures and distal locking screws in antegrade nailing require confirmation with clinical studies [1]. Biomechanical data on minipig models for pedicle screw fixation can provide a baseline comparison for future studies [2]. Further biomechanical tests and clinical studies are required to prove Tektona®'s capabilities in height and volume restoration for osteoporotic vertebral compression fractures [4]. The dual-cord dynamic stabilization system demonstrates improved biomechanical stability with minimal adjacent segment compromise [8]. Data on geometric deformations of the lumbar disc during axial body rotations can provide new insights into lumbar spine biomechanics and optimize parameters of artificial lumbar spine devices [9]. Microfracture may lead to a biomechanically unfavorable environment in subsets of patients with medial femoral condyle cartilage defects [11]. Critical spinal lytic defects result in kinematic abnormalities and lower the compressive strength of the spine [12]. A new loaded rolling wheel system is a reliable technique for measuring spinal stiffness over an entire spinal region in asymptomatic human participants [16]. None of the three evaluated coracoclavicular ligament reconstruction techniques provided equivalent rotational stability in all planes compared with the native state [20]. Both all-epiphyseal (AE) and complete transphyseal (CT) pediatric anterior cruciate ligament reconstructions reduced anterior translations and posteromedial contact stresses in response to an anterior load [49]. The AE technique more effectively reduced axial rotation and posterolateral contact stresses during a simulated pivot shift exam compared to the CT technique [49]. Anatomic anterolateral ligament (ALL) reconstruction did not reduce anterolateral rotational laxity [50]. Subchondral bone is capable of contributing to dynamic force attenuation as much as or more than articular cartilage due to its greater thickness in vivo [59].

Other Considerations:

Treatment

Non-Operative

Surgical management is indicated for progressive, painful, unilateral coxa vara deformity or leg-length discrepancy in childhood [52]. Moderate nonprogressive coxa vara deformity in childhood often does not require surgery [52]. Manual traction is as effective as fracture table traction for temporary intra-operative reduction techniques for tibial fracture fixation, based on data from a randomised clinical trial [43].

Operative

Indications: Biomechanical data from minipig models for pedicle screw fixation provides a baseline comparison for future studies [2]. Further biomechanical tests and clinical studies are required to prove the capabilities of Tektona® for height and volume restoration in osteoporotic vertebral compression fractures [4]. Biopsy (BPS) provided the greatest stability in multilevel lateral lumbar interbody fusion, followed by UPS and LP, though less invasive adjunctive fixation methods may provide sufficient biomechanical stability [46].

Surgical Approach / Technique: Anterior and posterior approaches differentially affect the postoperative biomechanical function of capsular ligaments after arthroplasty [10]. None of the described techniques for coracoclavicular ligament reconstruction provided equivalent rotational stability in all planes compared with the native state [20]. Increased motion between lumbar vertebrae after excision of the capsule and cartilage of the facets may increase tensile strain in a graft, potentially predisposing to non-union in lumbar arthrodesis without instrumentation [53].

Implant Selection: The biomechanical literature for proximal humerus fracture implants is diverse and heterogeneous [6]. Anchors with specific indications for hip arthroscopy showed very little displacement and had consistent failure loads under cyclic conditions in the acetabular rim [19]. Knotless fixation with suture tape had improved biomechanical performance as compared with knots or knotless fixation with No. 2 suture [39]. Reinforcing the head and neck junction of locking screws significantly improves their biomechanical performance in opening-wedge high tibial osteotomy applications [42]. PHILOS plating with 4 cement-augmented screws demonstrated comparable stability versus plating with 4 nonaugmented head screws plus 2 additional calcar screws, suggesting the former is a valid alternative particularly in low bone quality [57]. The ability to achieve initial calcar-collar contact and loading with cemented femoral components was demonstrated, though long-term effectiveness remains unknown [14].

Adjuncts: A dual-cord dynamic stabilization system demonstrates improved biomechanical stability with minimal adjacent segment compromise [8].

Other Considerations: Biomechanical results for safe distances between humerus shaft fractures and distal locking screws in antegrade nailing require confirmation with clinical studies [1]. Biomechanical studies should address implant durability and provide clinically relevant data by understanding the physiologic features of the fracture environment [5].

Complications

Other Considerations: Biomechanical results from mechanical studies of safe distances between humerus shaft fractures and distal locking screws in antegrade nailing require confirmation with clinical studies [1]. Further biomechanical tests and clinical studies are required to prove the capabilities of Tektona® for height and volume restoration in osteoporotic vertebral compression fractures [4]. Long-term effectiveness of achieving initial calcar-collar contact and loading with cemented femoral components remains unknown [14]. Long-term use of cyclosporin-A can weaken biomechanical properties, thereby increasing the fracture rate of the lumbar vertebra and the proximal femur [21].

Recovery

The biomechanical literature for proximal humerus fracture implants is diverse and heterogeneous [6]. Biomechanical results for the safe distance between humerus shaft fracture and distal locking screws in antegrade nailing should be confirmed with clinical studies [1]. Biomechanical studies should address implant durability and provide clinically relevant data by understanding the physiologic features of the fracture environment [5]. Biomechanical data from minipig models for pedicle screw fixation could provide a baseline comparison for future studies [2]. Further biomechanical tests and clinical studies are required to prove Tektona®'s capabilities in height and volume restoration for osteoporotic vertebral compression fractures [4].

Light activity (weeks): No specific week ranges for light activity are provided in the current evidence base.

Full activity (months): No specific month ranges for full activity are provided in the current evidence base.

Complete recovery / outcome plateau (months): Patients with a preoperative symptom duration of medial knee overload or arthritis of two years or greater do not experience inferior patient-reported outcomes or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up after high tibial osteotomy [22].

Rehabilitation protocol: Significant derotation within a short time period during Harrington rod correction of idiopathic scoliosis is unlikely unless the torsional stiffnesses of the motion segments are significantly decreased [64]. A dual-cord dynamic stabilization system demonstrates improved biomechanical stability with minimal adjacent segment compromise [8]. Time-zero failure properties of ulnar collateral ligament repair with internal bracing are on par with those of traditional reconstruction, even after 500 cycles of valgus loading [66].

Functional milestones: Forty-seven (96 per cent) of forty-nine shoulders had a good clinical result after distal release of deltoid muscle contracture [65]. Microfracture may lead to a biomechanically unfavorable environment in specific patient subsets with medial femoral condyle cartilage defects [11].

Other Considerations: No mechanical failures were observed in viscoelastic disc or articulating total disc replacements after 30-million-cycle intervals, which simulate approximately 80 years of lumbar-bending motions [13]. The ability to achieve initial calcar-collar contact and loading with cemented femoral components was demonstrated, though long-term effectiveness remains unknown [14]. Long-term use of cyclosporin-a can weaken the biomechanical properties of skeletal tissue, thus increasing the fracture rate of the lumbar vertebra and the proximal femur [21].

Key Evidence

  • [L5] These biomechanical results, although very promising, should be confirmed with clinical studies. (10.1186/s12891-025-08711-y)
  • [L5] This biomechanical data could provide a baseline comparison for future studies. (10.1186/s13018-019-1292-9)
  • [L5] Further biomechanical tests and clinical studies have to proof Tektona®'s capabilities. (10.1186/s12891-020-03899-7)
  • [L5] Biomechanical studies should address implant durability and provide clinically relevant data by understanding the physiologic features of the fracture environment. (10.5435/jaaos-20-02-086)
  • [L4] The biomechanical literature was found to be both diverse and heterogeneous. (10.1186/s12891-015-0627-x)
  • [Paper] The dual-cord dynamic stabilization system demonstrates improved biomechanical stability with minimal adjacent segment compromise. (10.1186/s13018-025-06130-2)
  • [L4] These data can provide new insights into the biomechanics of the lumbar spine and optimize the parameters of artificial lumbar spine devices. (10.1186/s12891-022-05160-9)
  • [L5] The anterior and posterior approach differentially affect postoperative biomechanical function of the capsular ligaments. (10.1302/0301-620x.101b4.bjj-2018-1321.r1)
  • [L5] This may lead to a biomechanically unfavorable environment after microfracture in these patient subsets. (10.1177/0363546515613517)
  • [L5] Critical spinal lytic defects result in kinematic abnormalities and lower the compressive strength of the spine. (10.2106/jbjs.19.00419)
  • [L5] No mechanical failures were observed, even after each 30-million-cycle interval, which simulates approximately 80 years of lumbar-bending motions. (10.2106/jbjs.25.00594)
  • [L5] The ability to achieve initial calcar-collar contact and loading was demonstrated, though long-term effectiveness remains unknown. (10.2106/00004623-198466020-00016)
  • [L5] The article highlights five landmark studies utilizing innovative technologies that advanced the science and clinical care of ACL injuries, and suggests that machine learning and artificial intelligence may serve as tools to bridge biological, biomechanical, and psychosocial domains to advance future clinical care. (10.1177/03635465221136834)
  • [L4] This study introduced a new technique for measuring spinal stiffness over an entire spinal region in asymptomatic human participants. (10.1186/s12891-019-2543-y)
  • [L5] The designed computer BS-II system is designed for biomechanical measurements of the lumbar part of the human spine, especially for verification of surgical fixation methods. (10.1186/s13018-019-1463-8)
  • [L4] The paper reviews biomechanical studies to clarify the effects of interspinous devices on treated and adjacent spinal segments, noting that while devices reduce range of motion in extension and can reduce disc pressure, they often fail to fully compensate for destabilization in other planes or adjacent levels. (10.1155/2014/839325)
  • [L5] Anchors with specific indications for hip arthroscopy showed very little displacement and had consistent failure loads under cyclic conditions in the acetabular rim. (10.1016/j.arthro.2009.10.013)
  • [L5] None of the described techniques provided equivalent rotational stability in all planes compared with the native state. (10.1016/j.arthro.2020.01.033)
  • [L5] Long-term use of CsA can weaken the biomechanical properties and thus increase the fracture rate of the lumbar vertebra and the proximal femur. (10.1186/1471-2474-12-240)
  • [L4] Patients with a preoperative duration of symptomatic medial knee overload/arthritis of two years or greater do not experience inferior PRO or clinical outcomes than patients with a symptom duration of less than 2 years at mid-term follow-up. (10.1016/j.jisako.2022.03.003)
  • [L5] Understanding the biomechanical principles of spinal instrumentation and motion coupling is essential for optimizing three-dimensional correction of thoracolumbar spinal deformities and achieving favorable mechanical environments for fusion. (10.5435/jaaos-d-24-01156)
  • [L5] Compared with non-pathological people, Hirayama disease patients have differences in cervical biomechanics, which may lead to cervical hypermobility and overload. (10.1186/s13018-022-02984-y)
  • [L4] The patients with chronic WAD showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli. (10.1186/1471-2474-11-29)
  • [L5] These data can be useful in future spinal biomechanics research leading to better biomechanical compatibility and provide theoretical references for spinal implant materials. (10.1186/s13018-017-0631-y)
  • [L5] Loading in the anterior-oblique direction required lower external force or moment to keep the lumbar spine in the neutral position compared to vertical or posterior-oblique directions. (10.1155/2018/4517471)
  • [L5] Noncontinuous CDA could preserve IDP and facet joint forces at the adjacent and intermediate levels to maintain the kinematics of cervical spine near preoperative values. (10.1186/s13018-020-1549-3)
  • [L5] The presentation of moment-rotation corridors for both metrics forms a normative dataset for the degeneration-free cervical spines. (10.2106/jbjs.f.00200)
  • [L5] The mechanical bone properties of vertebral cancellous bone could be modelled with high accuracy in the investigated bone density range. (10.1186/s12891-021-04571-4)
  • [L5] The study demonstrates that common types of femoral fractures arise from failure of the bone under tensile stress, similar to linear skull fractures. (10.2106/00004623-195133020-00025)
  • [L5] Compared with the applied preloads, the postures played a more important role, especially in axial rotation; the facet joint forces were increased in the contralateral facet joints as compared to the ipsilateral ones at the same level of the lumbar spine. (10.1186/1471-2474-11-151)
  • [L5] The study suggests that a 5 mm implant height provides biomechanical properties similar to intact specimens, whereas larger heights alter facet joint mechanics. (10.1186/s13018-020-02157-9)
  • [L5] Knotless fixation with suture tape had improved biomechanical performance as compared with knots or knotless fixation with No. 2 suture. (10.1177/2325967118774000)
  • [L5] Due to the unique microarchitecture of the cervical vertebrae, fractures occur much later in this region than they do in the thoracic or lumbar spine. (10.1186/s13018-022-03105-5)
  • [L5] This review provides a comprehensive overview of different metal artifacts in orthopaedic MRI and factors affecting their magnitude, discussing commonly applied techniques and recent technological advances to facilitate better-informed diagnostic decisions. (10.5435/jaaos-d-24-01057)
  • [L5] Reinforcing the head and neck junction of locking screws significantly improves their biomechanical performance. (10.1186/s13018-025-06015-4)
  • [L4] The data from the only randomised clinical trial suggests manual traction is as effective as fracture table traction. (10.1016/j.injury.2010.07.250)
  • [L5] Coupled with greater overall construct strength and lower-profile hardware, these newer techniques may result in improved clinical outcome and fewer hardware-related complications. (10.1016/j.jse.2018.11.041)
  • [L5] BPS provided the greatest stability, followed by UPS and LP, though less invasive adjunctive fixation methods may provide sufficient biomechanical stability. (10.1186/s12891-021-04151-6)
  • [L5] The two modified intramedullary designs showed the best biomechanical performance among the five implants included in this study. (10.3389/fbioe.2023.1116976)
  • [L5] While both AE and CT reconstructions reduced anterior translations and posteromedial contact stresses in response to an anterior load, the AE technique more effectively reduced axial rotation and posterolateral contact stresses during a simulated pivot shift exam. (10.1177/2325967114s00112)
  • [L5] Anatomic ALL reconstruction did not reduce anterolateral rotational laxity. (10.1177/2325967116s00027)
  • [L5] The compressive moduli and permeabilities of isolated IVDs can be assessed mostly by MT and diffusion sequences, though relationships need improvement with more sensitive MRI parameters. (10.1186/1471-2474-13-195)
  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [L5] This increased motion may increase tensile strain in a graft, potentially predisposing to non-union in lumbar arthrodesis without instrumentation. (10.2106/00004623-199412000-00012)
  • [L5] Composite beam theory analysis with quantitative computed tomography-derived measures of rigidity can be used to prospectively predict the yield loads of vertebrae with lytic defects. (10.2106/00004623-200009000-00004)
  • [L3] Measurement of VMVAs is a reliable method of identifying a LSTV on a single-slice midsagittal MR scan or lateral radiograph, and correlates with the degree of mechanical connection of the LSTV. (10.1302/0301-620x.95b11.32331)
  • [L5] From a biomechanical perspective, PHILOS plating with 4 cement-augmented screws demonstrated comparable stability versus plating with 4 nonaugmented head screws plus 2 additional calcar screws, suggesting that the former fixation technique represents a valid alternative to the latter, particularly in case of low bone quality. (10.1016/j.jse.2025.07.006)
  • [L5] T1ρ MR imaging is an effective and noninvasive technique for assessment of early stage disc degeneration. (10.1186/1471-2474-15-340)
  • [L5] Subchondral bone is capable of contributing to dynamic force attenuation as much as or more than articular cartilage due to its greater thickness in vivo. (10.2106/00004623-197052030-00004)
  • [L5] Significant derotation within a short time period is unlikely unless the torsional stiffnesses of the motion segments are significantly decreased. (10.2106/00004623-197355050-00007)
  • [L3] Forty-seven (96 per cent) of the forty-nine shoulders had a good clinical result after distal release of the contracture. (10.2106/00004623-199802000-00010)
  • [L5] Time-zero failure properties of this repair technique are on par with those of traditional reconstruction, even after 500 cycles of valgus loading. (10.1177/2325967118755991)

See Also

References

[1] Mechanical study of the safe distance between humerus shaft fracture and distal locking screws in antegrade nailing. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08711-y

[2] The minipig as a potential model for pedicle screw fixation: morphometry and mechanics. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1292-9

[4] Height and volume restoration in osteoporotic vertebral compression fractures: a biomechanical comparison of standard balloon kyphoplasty versus Tektona® in a cadaveric fracture model. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-020-03899-7

[5] Biomechanical Testing of Fracture Fixation Constructs: Variability, Validity, and Clinical Applicability. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-02-086

[6] A scoping review of biomechanical testing for proximal humerus fracture implants. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0627-x

[7] Chapter 57 Biomechanics. 2019.

[8] Evaluating the performance of a novel double-threaded dynamic stabilization system: a finite element study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06130-2

[9] Investigation of geometric deformations of the lumbar disc during axial body rotations. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05160-9

[10] Hip capsule biomechanics after arthroplasty. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.101b4.bjj-2018-1321.r1

[11] Medial Femoral Condyle Cartilage Defect Biomechanics. The American Journal of Sports Medicine. 2015. DOI: 10.1177/0363546515613517

[12] Large Lytic Defects Produce Kinematic Instability and Loss of Compressive Strength in Human Spines. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.19.00419

[13] Comparative in Vitro Analysis of Wear Particles Generated by a Viscoelastic Disc Versus 2 Articulating Total Disc Replacements. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.25.00594

[14] The influence of prosthetic stem stiffness and of a calcar collar on stresses in the proximal end of the femur with a cemented femoral component.. The Journal of Bone & Joint Surgery. 1984. DOI: 10.2106/00004623-198466020-00016

[15] Fifty Years of ACL Biomechanics: What’s Next?. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221136834

[16] Reliability of a new loaded rolling wheel system for measuring spinal stiffness in asymptomatic participants. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2543-y

[17] The prototype BS-II for computer measurement of biomechanical characteristics of the human cadaverous lumbar spine. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1463-8

[18] Biomechanics of Interspinous Devices. BioMed Research International. 2014. DOI: 10.1155/2014/839325

[19] Cyclic Load Testing and Ultimate Failure Strength of Suture Anchors in the Acetabular Rim. Arthroscopy. 2010. DOI: 10.1016/j.arthro.2009.10.013

[20] Vertical and Rotational Stiffness of Coracoclavicular Ligament Reconstruction: A Biomechanical Study of 3 Different Techniques. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.01.033

[21] Effects of cyclosporin-a on rat skeletal biomechanical properties. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-240

[22] Preoperative symptom duration does not affect clinical outcomes after high tibial osteotomy at a minimum of 2-year follow-up. Journal of ISAKOS. 2022. DOI: 10.1016/j.jisako.2022.03.003

[25] Biomechanical Principles of Spinal Deformity Correction in the Thoracolumbar Spine. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01156

[26] How to reconstruct the lordosis of cervical spine in patients with Hirayama disease? A finite element analysis of biomechanical changes focusing on adjacent segments after anterior cervical discectomy and fusion. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-02984-y

[28] Minimizing the source of nociception and its concurrent effect on sensory hypersensitivity: An exploratory study in chronic whiplash patients. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-29

[29] Biomechanical analysis of the posterior bony column of the lumbar spine. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0631-y

[32] The Effect of Muscle Direction on the Predictions of Finite Element Model of Human Lumbar Spine. BioMed Research International. 2018. DOI: 10.1155/2018/4517471

[33] Biomechanical comparison of noncontiguous cervical disc arthroplasty and noncontiguous cervical discectomy and fusion in the treatment of noncontinuous cervical degenerative disc disease: a finite element analysis. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-1549-3

[34] Level-Dependent Coronal and Axial Moment-Rotation Corridors of Degeneration-Free Cervical Spines in Lateral Flexion. The Journal of Bone & Joint Surgery. 2007. DOI: 10.2106/jbjs.f.00200

[35] Material properties of human vertebral trabecular bone under compression can be predicted based on quantitative computed tomography. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04571-4

[36] THE ROLE OF TENSILE STRESS IN THE MECHANISM OF FEMORAL FRACTURES. The Journal of Bone & Joint Surgery. 1951. DOI: 10.2106/00004623-195133020-00025

[37] Biomechanical analysis of the lumbar spine on facet joint force and intradiscal pressure - a finite element study. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-151

[38] The impact of different artificial disc heights during total cervical disc replacement: an in vitro biomechanical study. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-020-02157-9

[39] Knotless Fixation Is Stronger and Less Variable Than Knotted Constructs in Securing a Suture Loop. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118774000

[40] Breaking strength and bone microarchitecture in osteoporosis: a biomechanical approximation based on load tests in 104 human vertebrae from the cervical, thoracic, and lumbar spines of 13 body donors. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03105-5

[41] Metal Suppression Magnetic Resonance Imaging Techniques in Orthopaedic and Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01057

[42] Reinforced locking screws with enhanced head and neck junction: improving biomechanical stability in opening-wedge high tibial osteotomy applications. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06015-4

[43] Temporary intra-operative reduction techniques for tibial fracture fixation: A review of the literature. Injury. 2010. DOI: 10.1016/j.injury.2010.07.250

[44] A biomechanical comparison of new techniques for distal clavicular fracture repair versus locked plating. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.11.041

[46] Cadaveric biomechanical analysis of multilevel lateral lumbar interbody fusion with and without supplemental instrumentation. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04151-6

[47] Chapter 8 Musculoskeletal Biomechanics. 2020.

[48] Biomechanical evaluation of two modified intramedullary fixation system for treating unstable femoral neck fractures: A finite element analysis. Frontiers in Bioengineering and Biotechnology. 2023. DOI: 10.3389/fbioe.2023.1116976

[49] Kinematics and Contact Stress Analysis of Pediatric Anterior Cruciate Ligament Reconstructions: Do the All-Epiphyseal and Complete Transphyseal Reconstructions Restore Anterior and Rotational Stability?. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00112

[50] Biomechanical Analysis of Simulated Clinical Testing and Reconstruction of the Anterolateral Ligament of the Knee. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116s00027

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