Trabecular bone structure and strength - remodelling and repair.

The strength of the spinal trabecular bone declines by a factor of 4-5 from the age of 20 to 80 years. At the same time, the volumetric (apparent) density declines by a factor of only 2. This discrepancy can be explained by the known power relationship between density and strength; this power relationship is based on the fact that trabecular bone is a porous material. To date, it has not been possible to determine or quantify the influence other factors may have in determining the strength of a loadbearing trabecular network. However, it is known that with age: 1) There is a loss of connectivity through osteoclastic perforations of horizontal struts. 2) There is an increase in anisotropy - again due to loss of horizontal struts, and perhaps also due to micro-modelling drift or to thickening of some vertical trabeculae. 3) The changes in the network can lead to the slenderness ratio between vertical and horizontal struts reaching a certain magnitude and thereby inducing buckling under compression. 4) Microdamage and microfractures will occur - mainly in these very loaded vertical struts. The microfractures will be repaired by microcallus formation, and these calluses will later be removed by the remodelling process. 5) Bone material quality will slightly change, leading to a decrease in collagen content and a relative increase in the degree of mineralisation. But, it is not known how these factors will influence the power relationship between density and strength. Nor is it known how different treatment regimens will affect the 'natural' power relationship: will the same curve be followed, but in the opposite direction? Or will the curve be less or more steep? Will the gain in bone strength be larger if treatment is started early - on the steep part of the curve? Furthermore, as trabecular bone can never be isolated in vivo, other factors need to be investigated: The interplay between the cortical shell and the trabecular network; transmission of load; the interplay between soft tissues (cartilage, connective tissue, muscle) and bone; the shock absorbing capacity of the discs; and the hydraulic effect of the bone marrow. In order to answer these questions, more in vitro and in vivo studies on human bone in relation to aging, to immobilisation, to exercise and in relation to different treatment regimens are needed.