This work was supported by RISystem AG, Davos, Switzerland.

All procedures were performed according to the National Institutes of Health guidelines for the use of experimental animals and followed institutional guidelines (Landesamt f&#252;r Verbraucherschutz, Zentralstelle Amtstier&#228;rztlicher Dienst, Saarbr&#252;cken, Germany).
1. Preparation of Surgical Instruments and Implants
<ol>
	<li>Select a scalpel blade (size 15), a small swab, fine forceps, a 27 G needle, a non-resorbable 5-0 suture, scissors and a needle holder from the microsurgical instrument box.</li>
	<li>Unpack the intramedullary screw, the guide wire (0.3/0.2 mm diameter, 10 cm length), the centering drill bit (0.5 mm diameter) and the hand drill (Figure 1; see Table of Materials). 
	NOTE: The intramedullary screw (0.5 mm diameter, 17.2 mm length) is made of medical-grade stainless steel for retrograde implantation into the femur. The screw has a proximal thread (0.5 mm diameter, 4 mm length) with a nose (0.2 mm diameter, 0.4 mm length) at the tip and distal cone-shaped head (0.8 mm diameter, 0.9 mm length) to achieve fracture compression as well as axial and rotational stability.</li>
	<li>Expose the implants and all surgical instruments to a disinfecting solution (96 % alcohol) for 5 min or sterilize them (steam sterilization, 130 &#176;C, 25 min). After disinfection or sterilization, place the instruments on an operation cloth. Position the operation cloth directly adjacent to the small animal operation table.</li>
</ol>
2. Animals, Anesthesia, and Analgesia
<ol>
	<li>Choose the strain, age, and sex of the mice according to the study question which is addressed. 
	NOTE: For this study 12- to 14-week-old male CD-1 mice were used. The appropriate body weight to use the intramedullary screw is between 25-35 g.</li>
	<li>Anesthetize the mice with an intraperitoneal injection of 15 mg/kg xylazine and 75 mg/kg ketamine. Confirm the anesthetization by toe pinch. Apply eye lubricant to protect the animals&#39; eyes from drying during anesthesia. After induction of anesthesia, place the mouse under a heat radiator to keep the body temperature constant.&#160;During the procedure, animals were monitored with repeated toe pinch to ensure an appropriate plane of anesthesia.</li>
	<li>Apply tramadol-hydrochloride in the drinking water (1.0 mg/mL) for analgesia from day 1 before the surgery until day 3 after the surgery. 
	NOTE: Analgesia and infection prevention should be in agreement with the respective guidelines of the country and institution where the experiments are to be performed.</li>
</ol>
3. Surgical Procedure and Intramedullary Screw Implantation
<ol>
	<li>Before surgery, shave the entire right hind leg and apply a depilatory cream. After 5 min, remove the cream and clean the leg with water. Then, apply a disinfecting solution with 96 % alcohol.&#160;Betadine or chlorhexidine can be added to the alcohol to ensure complete asepsis.</li>
	<li>Under aseptic conditions, place the mouse in the supine position on the small animal operation table. Bend the right knee to allow for an anterior approach to the condyles of the knee. Perform a 5-mm medial parapatellar incision at the right knee using the scalpel blade.</li>
	<li>Mobilize the patellar ligament carefully with the scalpel blade and the swab. Then, shift the patella laterally with the fine forceps to expose the intercondylar notch of the femur.</li>
	<li>Open the intercondylar notch exactly in the middle of the femur between both condyles. Make sure not to exceed 1.0 mm in depth for the drill hole.
	<ol>
		<li>Start manual drilling at a slow speed and a 45 &#176; offset ventrally to the femur axis using the 0.5 mm centering drill bit and the hand drill (Figure 1C and D, Figure 2). During drilling, continuously decrease the angle to 0 &#176; offset (parallel with the bone axis of the femur). Stop drilling when a depth of 1.0 mm is reached.</li>
	</ol>
	</li>
	<li>After opening the bone at the intercondylar notch, insert the 27 G needle into the intramedullary cavity over the whole length of the femur. Ream the intramedullary cavity of the femur manually through rotary motions of the 27 G needle. Push the needle forward to perforate the cortical bone at the greater trochanter proximally.</li>
	<li>Remove the 27 G needle and apply the guide wire through the distal part of the femur.
	<ol>
		<li>Make a skin incision with a scalpel blade (size 15) proximally over the guide wire and push the guide wire forward until both ends of the guide wire are outside. Make sure to keep the guide wire in place.</li>
	</ol>
	</li>
	<li>Create a defined closed fracture by using the guillotine.
	<ol>
		<li>Place the mouse in lateral position with the right leg under the guillotine. Make sure that the diaphyseal part of the femur is placed in the middle of the guillotine.</li>
		<li>Drop the weight (200 g) from the defined distance of 25.5 cm.</li>
	</ol>
	</li>
	<li>Control the fracture configuration and fracture position as well as the position of the guide wire (Figure 3) using the x-ray device (see Table of Materials).</li>
	<li>Connect the intramedullary screw with the nose at the distal end to the 0.2 mm guide wire and insert it into the femur under continuous pressure, and clockwise rotation.
	<ol>
		<li>Shear of the drive shaft when the sufficient torque is achieved.</li>
		<li>Remove the guide wire proximally.</li>
	</ol>
	</li>
	<li>Reposition the patella and fix the patella tendon to the muscles with one single suture using a 5-0 synthetic, monofilament, nonabsorbable polypropylene suture. Use single sutures of the same material and size to close the wound. Control the reduction of the fragments and the screw position radiologically using the x-ray device (see Table of Materials).</li>
	<li>Keep the animals under the heat radiator until they recover from anesthesia. Do not leave the animals unattended until they have regained sufficient consciousness to maintain ventral recumbency. Return the animals to single cages in the animal facility. Do not return the animals to the company of other animals during the first 24 h, even if they have fully recovered from anesthesia.</li>
	<li>Monitor the animals carefully every day. Maintain postoperative analgesia using tramadol-hydrochloride in the drinking water with a dosage of 1.0 mg/mL during the first three days. Continue analgesia if, on day 4 after surgery, the animals still show evidence of pain, as indicated by vocalization, restlessness, lack of mobility, failure to groom, abnormal posture, and lack of normal interest in surroundings. Terminate analgesia when the animals are pain-free.</li>
	<li>At the end of the experiment euthanize&#160;the animal by an overdose of barbiturate.</li>
</ol>

<ol>
	<li>Jacenko, O., Olsen, B. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transgenic+mouse+models+in+studies+of+skeletal+disorders.">Transgenic mouse models in studies of skeletal disorders.</a> J Rheumatol Suppl. 43, 39-41 (1995).</li><li>Histing, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Small+animal+bone+healing+models:+standards,+tips,+and+pitfalls+results+of+a+consensus+meeting.">Small animal bone healing models: standards, tips, and pitfalls results of a consensus meeting.</a> Bone. 49 (4), 591-599 (2011).</li><li>Bonnarens, F., Einhorn, T. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Production+of+a+standard+closed+fracture+in+laboratory+animal+bone.">Production of a standard closed fracture in laboratory animal bone.</a> J Orthop Res. 2 (1), 97-101 (1984).</li><li>Holstein, J. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+a+stable+closed+femoral+fracture+model+in+mice.">Development of a stable closed femoral fracture model in mice.</a> J Surg Res. 153 (1), 71-75 (2009).</li><li>Histing, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ex+vivo+analysis+of+rotational+stiffness+of+different+osteosynthesis+techniques+in+mouse+femur+fracture.">Ex vivo analysis of rotational stiffness of different osteosynthesis techniques in mouse femur fracture.</a> J Orthop Res. 27 (9), 1152-1156 (2009).</li><li>Claes, L., Augat, P., Suger, G., Wilke, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Influence+of+size+and+stability+of+the+osteotomy+gap+on+the+success+of+fracture+healing.">Influence of size and stability of the osteotomy gap on the success of fracture healing.</a> J Orthop Res. 15 (4), 577-584 (1997).</li><li>Histing, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Characterization+of+the+healing+process+in+non-stabilized+and+stabilized+femur+fractures+in+mice.">Characterization of the healing process in non-stabilized and stabilized femur fractures in mice.</a> Arch Orthop Trauma Surg. 136 (2), 203-211 (2016).</li><li>Thompson, Z., Miclau, T., Hu, D., Helms, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+model+for+intramembranous+ossification+during+fracture+healing.">A model for intramembranous ossification during fracture healing.</a> J Orthop Res. 20 (5), 1091-1098 (2002).</li><li>Cheung, K. M., Kaluarachi, K., Andrew, G., Lu, W., Chan, D., Cheah, K. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+externally+fixed+femoral+fracture+model+for+mice.">An externally fixed femoral fracture model for mice.</a> J Orthop Res. 21 (4), 685-690 (2003).</li><li>Garcia, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+technique+for+internal+fixation+of+femoral+fractures+in+mice:+impact+of+stability+on+fracture+healing.">A new technique for internal fixation of femoral fractures in mice: impact of stability on fracture healing.</a> J Biomech. 41 (8), 1689-1696 (2008).</li><li>Histing, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+internal+locking+plate+to+study+intramembranous+bone+healing+in+a+mouse+femur+fracture+model.">An internal locking plate to study intramembranous bone healing in a mouse femur fracture model.</a> J Orthop Res. 28 (3), 397-402 (2010).</li><li>Garcia, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+LockingMouseNail-a+new+implant+for+standardized+stable+osteosynthesis+in+mice.">The LockingMouseNail-a new implant for standardized stable osteosynthesis in mice.</a> J Surg Res. 169 (2), 220-226 (2011).</li><li>Histing, T., Klein, M., Stieger, A., Stenger, D., Steck, R., Matthys, R., Holstein, J. H., Garcia, P., Pohlemann, T., Menger, M. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+model+to+analyze+metaphyseal+bone+healing+in+mice.">A new model to analyze metaphyseal bone healing in mice.</a> J Surg Res. 178 (2), 715-721 (2012).</li><li>Histing, T., Menger, M. D., Pohlemann, T., Matthys, R., Fritz, T., Garcia, P., Klein, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+Intramedullary+Locking+Nail+for+Standardized+Fixation+of+Femur+Osteotomies+to+Analyze+Normal+and+Defective+Bone+Healing+in+Mice.">An Intramedullary Locking Nail for Standardized Fixation of Femur Osteotomies to Analyze Normal and Defective Bone Healing in Mice.</a> J Vis Exp. (117), (2016).</li><li>Hiltunen, A., Vuorio, E., Aro, H. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+standardized+experimental+fracture+in+the+mouse+tibia.">A standardized experimental fracture in the mouse tibia.</a> J Orthop Res. 11 (2), 305-312 (1993).</li><li>Manigrasso, M. B., O'Connor, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Characterization+of+a+closed+femur+fracture+model+in+mice.">Characterization of a closed femur fracture model in mice.</a> J Orthop Trauma. 18 (10), 687-695 (2004).</li><li>Holstein, J. H., Menger, M. 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The authors declare that they have no competing financial interests.

Critical steps of the surgical procedure are to find the correct entry point for screw implantation in the middle of the femur condyles at the intercondylar notch as well as the optimal orientation of the needle parallel to the bone axis for reaming of the intramedullary cavity. To avoid an incorrect entry position, the surgeon should prepare the notch until an optimal view is achieved. To control the orientation during reaming, the femur of the mice should be held with the fingers in a stable position. A further critical step is the insertion of the screw into the femur over the guide wire because the guide wire can slip out of the proximal bone fragment resulting in a fracture dislocation. In this case, the surgeon can try to thread the bone fragments again, but this maneuver is mostly unsuccessful, and the animals have then to be excluded from the study.
In addition, the surgical procedure may develop some complications. For example, the patellar ligament, which is shifted laterally to get an optimal view to the condyles, may rupture. This requires suturing of the ligament after screw insertion. During opening the bone at the condyles and reaming the intramedullary cavity, the condyles may burst. In this case, there is no possibility of troubleshooting, because the screw cannot adequately be fixed at the distal end and the compression of the fracture is not achieved. Another complication is the dislocation of the inserted guide wire or an incorrect position out of the bone. This complication can be reduced by handling with caution and by radiographic analysis after insertion to confirm the correct placement during surgery. Furthermore, the surgeon should pay attention that the screw is completely inserted because a protrusion of the screw can restrict the mobility of the mouse or reduce the fracture compression. Therefore, an x-ray device is mandatory for the surgical procedure. Only animals after radiographic confirmation at the end of surgery should be included in the study protocol.
Removal of the intramedullary screw at the end of the experiment can be performed without any difficulties, because the head of the screw can be connected to a special removal instrument or, alternatively, the screw can be removed also with the needle holder.
One limitation of the technique is that the intramedullary screw is provided by the company only in one size with a defined length of 17.2 mm and therefore the size of the femur must be considered. A further limitation on the use of the intramedullary screw is that in vivo micro computed tomography- (CT) or magnetic resonance imaging (MRI) analyses of the healing process are almost impossible due to the implant material, which affects the image quality. Therefore, these analyses can only be performed after euthanasia and removal of the implant at the end of the study period. Finally, the screw cannot be used to analyze bone defect healing, because the axial stability is achieved through the compression of the bone fragments by the proximal thread and the distal head.
Bone healing studies use either open8,9,10,11,12,13,14 or closed4,15,16,17 bone healing models. Open bone healing models allow a more rigid fixation of the fragments compared to closed bone healing models, resulting in a higher amount of intramembranous healing without a pronounced callus formation. Because open models are associated with little callus formation, these models may not be preferred in experiments that require larger amounts of callus tissue for biochemical and molecular analyses. A further disadvantage of the open models is the need for an invasive lateral approach with a major soft tissue trauma. In contrast, the use of a closed model requires only a small less invasive incision. Until now only a few closed models exist in mice2.
In closed bone healing models, mostly a simple intramedullary pin is used. However, this technique has distinct disadvantages. Most notably, the lack of axial and rotational stability. This can result in a heterogeneous healing response5. Although this disadvantage is known to influence experimental results18, recent studies, which intend to analyze the mechanisms of bone healing, still use murine models in which the fracture is stabilized only with a pin or is even left unstabilized7. We feel that stable osteosynthesis techniques, comparable to those used in clinical practice, should also be used in mice. To achieve axial and rotational stability, the intramedullary screw was developed which induces fracture compression by a distal head and a proximal thread. Of interest, the application of the intramedullary screw does not produce a rigid fixation, and, thus, the torsional stiffness of fractured femora stabilized with the intramedullary screw is significantly lower when compared to that of fractured femora stabilized by an external fixator or a locking plate5. However, a less rigid fixation is required to study endochondral bone healing, because only a less rigid fixation allows the micromovements of the bone fragments, which provoke the endochondral healing process. Nonetheless, as shown in a previous ex vivo study, the intramedullary screw produces a distinct axial and rotational stability. Biomechanical analyses revealed that the intramedullary screw achieves a torsional stiffness of 0.34 &#177; 0.18 Nmm/&#176;, which is significantly higher when compared to that achieved with a conventional pin (0.00 &#177; 0.00 Nmm/&#176;)5. Thus, the intramedullary screw introduced here is the only implant that can be used in a minimally invasive technique and that provide standardized biomechanical conditions for the study endochondral fracture healing in mice.

Bone healing studies in mice are in great demand because of a broad spectrum of antibodies and genetically-modified animals. These facts allow to study the molecular mechanisms of bone healing1. In the past few years, different bone healing models for mice have been developed2. These models can be divided into open models, in which the bone is osteotomized using an open lateral surgical approach and in closed models, in which the bone is fractured based on the fracture model introduced by Bonnares and Einhorn3. Using this technique, a standardized transverse fracture can be produced by a 3-point bending device and intramedullary implants can be inserted through a small medial parapatellar incision in a minimally invasive technique avoiding a major soft tissue trauma.
The intramedullary screw can be applied for closed fracture stabilization in mice. The screw offers rotational and axial stability. This is achieved by fracture compression through a proximal thread and a distal head4. Further advantages of the screw are the simple surgical technique, the low grade of invasivity, the low implant weight and, most notably, a higher stability providing standardized and controlled biomechanical conditions compared to other intramedullary implants5. In fact, in the most closed fracture models, the fragments are stabilized only by simple pins, which is associated with a complete lack of rotational and axial stability and a high risk of pin and also fracture dislocation. This can markedly influence the healing process, which may result in delayed healing or non-union formation.
It is well known that the stability of the fracture fixation has a tremendous impact on the healing process6,7. A high rigid fixation results in intramembranous healing, while a less rigid fixation, which may allow micromovements in the fracture gap, results in endochondral healing. Stabilization of the fracture with the intramedullary screw shows predominantly an endochondral healing with a large amount of callus tissue, particularly after 2 weeks of fracture healing. The possibility to harvest a large amount of callus tissue enables the analysis of multiple parameters by different techniques.
Here, we report on the design and application of the intramedullary screw in mice, as well as on its advantages and disadvantages in experimental studies on normal endochondral bone healing.

<table>
	<tbody>
		<tr>
			<td>Mouse Screw</td>
			<td>RISystem AG</td>
			<td>221,100</td>
			<td></td>
		</tr>
		<tr>
			<td>Guide wire</td>
			<td>RISystem AG</td>
			<td>521,100</td>
			<td></td>
		</tr>
		<tr>
			<td>Centering bit</td>
			<td>RISystem AG</td>
			<td>590,205</td>
			<td></td>
		</tr>
		<tr>
			<td>Hand drill</td>
			<td>RISystem AG</td>
			<td>390,130</td>
			<td></td>
		</tr>
		<tr>
			<td>Cotton-Swab (150 mm, small head)</td>
			<td>Fink Walter GmbH</td>
			<td>8822428</td>
			<td></td>
		</tr>
		<tr>
			<td>Suture (5-0 Prolene)</td>
			<td>Ethicon</td>
			<td>8614H</td>
			<td></td>
		</tr>
		<tr>
			<td>Forceps</td>
			<td>Braun Aesculap AG &#38;CoKG</td>
			<td>BD520R</td>
			<td></td>
		</tr>
		<tr>
			<td>Scissors</td>
			<td>Braun Aesculap AG &#38;CoKG</td>
			<td>BC100R</td>
			<td></td>
		</tr>
		<tr>
			<td>Needle holder</td>
			<td>Braun Aesculap AG &#38;CoKG</td>
			<td>BM024R</td>
			<td></td>
		</tr>
		<tr>
			<td>27 G needle</td>
			<td>Braun Melsungen AG</td>
			<td>9186182</td>
			<td></td>
		</tr>
		<tr>
			<td>Scalpel blade size 15</td>
			<td>Braun Aesculap AG &#38;CoKG</td>
			<td>16600525</td>
			<td></td>
		</tr>
		<tr>
			<td>Heat radiator</td>
			<td>Sanitas</td>
			<td>605.25</td>
			<td></td>
		</tr>
		<tr>
			<td>Depilatory cream</td>
			<td>Asid bonz GmbH</td>
			<td>NDXZ10</td>
			<td></td>
		</tr>
		<tr>
			<td>Eye lubricant</td>
			<td>Bayer Vital GmbH</td>
			<td>2182442</td>
			<td></td>
		</tr>
		<tr>
			<td>Xylazine</td>
			<td>Bayer Vital GmbH</td>
			<td>1320422</td>
			<td></td>
		</tr>
		<tr>
			<td>Ketamine</td>
			<td>Serumwerke Bernburg</td>
			<td>7005294</td>
			<td></td>
		</tr>
		<tr>
			<td>Tramadol</td>
			<td>Gr&#252;nenthal GmbH</td>
			<td>2256241</td>
			<td></td>
		</tr>
		<tr>
			<td>Disinfection solution (SoftaseptN)</td>
			<td>Braun Melsungen AG</td>
			<td>8505018</td>
			<td></td>
		</tr>
		<tr>
			<td>CD-1 mice</td>
			<td>Charles River</td>
			<td>22</td>
			<td></td>
		</tr>
		<tr>
			<td>X-ray Device</td>
			<td>Faxitron MX-20, Faxitron X-ray Corporation</td>
			<td>2321A0988</td>
			<td></td>
		</tr>
		<tr>
			<td>Fracture device small</td>
			<td>RISystem AG</td>
			<td>891,100</td>
			<td></td>
		</tr>
	</tbody>
</table>

a minimally invasive model to analyze endochondral fracture healing in mice under standardized biomechanical conditions

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an increased use of mouse models in orthopedic research was noted, most probably because mouse models offer a large number of genetically-modified strains and special antibodies for the analysis of molecular mechanisms of fracture healing. To control the biomechanical conditions, well-characterized osteosynthesis techniques are mandatory, also in mice. Here, we report on the design and use of a closed bone healing model to stabilize femur fractures in mice. The intramedullary screw, made of medical-grade stainless steel, provides through fracture compression an axial and rotational stability compared to the mostly used simple intramedullary pins, which show a complete lack of axial and rotational stability. The stability achieved by the intramedullary screw allows the analysis of endochondral healing. A large amount of callus tissue, received after stabilization with the screw, offers ideal conditions to harvest tissue for biochemical and molecular analyses. A further advantage of the use of the screw is the fact that the screw can be inserted into the femur with a minimally invasive technique without inducing damage to the soft tissue. In conclusion, the screw is a unique implant that can ideally be used in closed fracture healing models offering standardized biomechanical conditions.

The operating time from skin incision to wound closure was 20 min. The surgery can be performed without a stereo-microscope. Postoperatively, the animals were monitored daily. Post-operative analgesia was terminated after 2 days because none of the animals showed evidence of pain after this time period. The animals showed also normal weight-bearing within 2 days after surgery. Wound infections were not observed during the entire observation period.
Radiological analyses after 2 weeks showed an obvious formation of callus tissue bridging the fracture gap (Figure 4A). After 5 weeks, the fracture was healed, and the periosteal callus was almost completely remodeled (Figure 4B).
Histological analyses of the callus and the fracture zone after 2 weeks showed typical tissue distribution of endochondral healing with cartilage tissue built during the chondrogenic process and woven bone (Figure 5A). After 5 weeks, the cartilage tissue disappeared, and the woven bone was converted to the lamellar bone in order to reconstitute the normal anatomical and load-carrying properties of the bone (Figure 5B).
Biomechanical analyses after 2 weeks indicated a bending stiffness of 37 % compared to the contralateral unfractured bone. After 5 weeks, the bending stiffness was almost 100 % indicating complete healing (Figure 6).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57255/57255fig1.jpg" /> 
Figure 1: Implants. A. The intramedullary screw (0.5 mm diameter, 17.2 mm length) with the thread (0.5 mm diameter, 4 mm length) and the nose (0.2 mm diameter, 0.4 mm length) proximal and a cone-shaped head (0.8 mm diameter, 0.9 mm length) distal. B. The guide wire (0.3/0.2 mm diameter, 10 cm length). C. The centering drill bit (0.5 mm diameter). D. The hand drill. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57255/57255fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/57255/57255fig2.jpg" /> 
Figure 2: Schematic drawing of the femur condyles indicating the entry point for the intramedullary screw. Femur condyles with the intercondylar notch in anterior-posterior view (left) and sagittal view (right). The cross (left) indicates the entry point for the intramedullary screw, the arrow (right) indicates the 45 &#176; offset to the femur axis to start drilling. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57255/57255fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/57255/57255fig3.jpg" /> 
Figure 3: Radiograph of the femur with a transverse fracture and the inserted guide wire. Radiograph shows the transverse fracture configuration in the diaphyseal part of the femur (arrow) and the guide wire within the intramedullary cavity bridging the fracture. Scale bars represent 5 mm. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57255/57255fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/57255/57255fig4.jpg" /> 
Figure 4: Radiographs after 2 and 5 weeks of bone healing. A. Radiographic analysis of a femur stabilized with the screw after 2 weeks, demonstrating obvious callus formation. B. Radiographic analysis of a femur stabilized with the screw after 5 weeks, demonstrating almost complete healing of the fracture with the remodeling of the callus. Scale bars represent 5 mm. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57255/57255fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/57255/57255fig5.jpg" /> 
Figure 5: Histological sections after 2 and 5 weeks of bone healing. A. Histological analysis of a femur stabilized with the screw after 2 weeks, demonstrating the typical tissue distribution during endochondral bone healing with cartilage (c) and bone (b) tissue within the callus. B. Histological analysis of a femur stabilized with the screw after 5 weeks, demonstrating the almost complete remodeling to lamellar bone. The histological sections were stained according to the trichrome method. Scale bars represent 1000 &#181;m. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57255/57255fig5large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/57255/57255fig6.jpg" /> 
Figure 6: Biomechanical analysis. Biomechanical analysis of the bending stiffness after 2 weeks (white bar, n=9) and 5 weeks (black bar, n=8). Bending stiffness is given in percent to the contralateral non-fractured femur. Data are given as mean &#177; standard error of the mean (SEM), *p&#60;0.05 vs. 2 weeks. After proving the assumption for normal distribution (Kolmogorov-Smirnov-test) and equal variance (F-test), the comparison between the two experimental groups was performed using Student&#180;s t-test. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57255/57255fig6large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about A Minimally Invasive Model to Analyze Endochondral Fracture Healing in Mice Under Standardized Biomechanical Conditions at JoVE.com

A Minimally Invasive Model to Analyze Endochondral Fracture Healing in Mice Under Standardized Biomechanical Conditions

This protocol describes a minimally invasive osteosynthesis technique using an intramedullary screw for standardized stabilization of femur fractures, which can be used to analyze endochondral bone healing in mice.

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an ...

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Nanyang Technological University

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JoVE Journal

Medicine

8.2K Views.  Saarland University. This protocol describes a minimally invasive osteosynthesis technique using an intramedullary screw for standardized stabilization of femur fractures, which can be used to analyze endochondral bone healing in mice.

Video: A Minimally Invasive Model to Analyze Endochondral Fracture Healing in Mice Under Standardized Biomechanical Conditions

Murine Model of Wound Healing

Wound healing and repair are the most complex biological processes that occur in human life. After injury, multiple biological pathways become activated. Impaired wound healing, which occurs in diabetic patients for example, can lead to severe unfavorable outcomes such as amputation. There is, therefore, an increasing impetus to develop novel agents that promote wound repair. The testing of these has been limited to large animal models such as swine, which are often impractical. Mice represent the ideal preclinical model, as they are economical and amenable to genetic manipulation, which allows for mechanistic investigation. However, wound healing in a mouse is fundamentally different to that of humans as it primarily occurs via contraction. Our murine model overcomes this by incorporating a splint around the wound. By splinting the wound, the repair process is then dependent on epithelialization, cellular proliferation and angiogenesis, which closely mirror the biological processes of human wound healing. Whilst requiring consistency and care, this murine model does not involve complicated surgical techniques and allows for the robust testing of promising agents that may, for example, promote angiogenesis or inhibit inflammation. Furthermore, each mouse acts as its own control as two wounds are prepared, enabling the application of both the test compound and the vehicle control on the same animal. In conclusion, we demonstrate a practical, easy-to-learn, and robust model of wound healing, which is comparable to that of humans.

A murine model of cutaneous wound healing that can be used to assess therapeutic compounds in physiological and pathophysiological settings.

Wound healing and repair are the most complex biological processes that occur in human life. After injury, multiple biological pathways become activated. ...

Photothrombotic Ischemia: A Minimally Invasive and Reproducible Photochemical Cortical Lesion Model for Mouse Stroke Studies

The photothrombotic stroke model aims to induce an ischemic damage within a given cortical area by means of photo-activation of a previously injected light-sensitive dye. Following illumination, the dye is activated and produces singlet oxygen that damages components of endothelial cell membranes, with subsequent platelet aggregation and thrombi formation, which eventually determines the interruption of local blood flow. This approach, initially proposed by Rosenblum and El-Sabban in 1977, was later improved by Watson in 1985 in rat brain and set the basis of the current model. Also, the increased availability of transgenic mouse lines further contributed to raise the interest on the photothrombosis model. Briefly, a photosensitive dye (Rose Bengal) is injected intraperitoneally and enters the blood stream. When illuminated by a cold light source, the dye becomes activated and induces endothelial damage with platelet activation and thrombosis, resulting in local blood flow interruption. The light source can be applied on the intact skull with no need of craniotomy, which allows targeting of any cortical area of interest in a reproducible and non-invasive way. The mouse is then sutured and allowed to wake up. The evaluation of ischemic damage can be quickly accomplished by triphenyl-tetrazolium chloride or cresyl violet staining. This technique produces infarction of small size and well-delimited boundaries, which is highly advantageous for precise cell characterization or functional studies. Furthermore, it is particularly suitable for studying cellular and molecular responses underlying brain plasticity in transgenic mice.

Photothrombosis is a quick, minimally-invasive technique for inducing small and well-delimited infarction in areas of interest in highly reproducible manner. It is particularly suitable for studying cellular and molecular responses underlying brain plasticity in transgenic mice.

The photothrombotic stroke model aims to induce an ischemic damage within a given cortical area by means of photo-activation of a previously injected ...

Tibial Nerve Transection - A Standardized Model for Denervation-induced Skeletal Muscle Atrophy in Mice

The tibial nerve transection model is a well-tolerated, validated, and reproducible model of denervation-induced skeletal muscle atrophy in rodents. Although originally developed and used extensively in the rat due to its larger size, the tibial nerve in mice is big enough that it can be easily manipulated with either crush or transection, leaving the peroneal and sural nerve branches of the sciatic nerve intact and thereby preserving their target muscles. Thus, this model offers the advantages of inducing less morbidity and impediment of ambulation than the sciatic nerve transection model and also allows investigators to study the physiologic, cellular and molecular biologic mechanisms regulating the process of muscle atrophy in genetically engineered mice. The tibial nerve supplies the gastrocnemius, soleus and plantaris muscles, so its transection permits the study of denervated skeletal muscle composed of fast twitch type II fibers and/or slow twitch type I fibers. Here we demonstrate the tibial nerve transection model in the C57Black6 mouse. We assess the atrophy of the gastrocnemius muscle, as a representative muscle, at 1, 2, and 4 weeks post-denervation by measuring muscle weights and fiber type specific cross-sectional area on paraffin-embedded histologic sections immunostained for fast twitch myosin.

The tibial nerve transection model is a well-tolerated, validated, and reproducible model of skeletal muscle atrophy. The model surgical protocol is described and demonstrated in C57Black6 mice. &#160;

The tibial nerve transection model is a well-tolerated, validated, and reproducible model of denervation-induced skeletal muscle atrophy in rodents. ...

An Intramedullary Locking Nail for Standardized Fixation of Femur Osteotomies to Analyze Normal and Defective Bone Healing in Mice

Bone healing models are essential to the development of new therapeutic strategies for clinical fracture treatment. Furthermore, mouse models are becoming more commonly used in trauma research. They offer a large number of mutant strains and antibodies for the analysis of the molecular mechanisms behind the highly differentiated process of bone healing. To control the biomechanical environment, standardized and well-characterized osteosynthesis techniques are mandatory in mice. Here, we report on the design and use of an intramedullary nail to stabilize open femur osteotomies in mice. The nail, made of medical-grade stainless steel, provides high axial and rotational stiffness. The implant further allows the creation of defined, constant osteotomy gap sizes from 0.00 mm to 2.00 mm. Intramedullary locking nail stabilization of femur osteotomies with gap sizes of 0.00 mm and 0.25 mm result in adequate bone healing through endochondral and intramembranous ossification. Stabilization of femur osteotomies with a gap size of 2.00 mm results in atrophic non-union. Thus, the intramedullary locking nail can be used in healing and non-healing models. A further advantage of the use of the nail compared to other open bone healing models is the possibility to adequately fix bone substitutes and scaffolds in order to study the process of osseous integration. A disadvantage of the use of the intramedullary nail is the more invasive surgical procedure, inherent to all open procedures compared to closed models. A further disadvantage may be the induction of some damage to the intramedullary cavity, inherent to all intramedullary stabilization techniques compared to extramedullary stabilization procedures.

This protocol describes an osteosynthesis technique using an intramedullary locking nail for standardized fixation of femur osteotomies, which can be used to analyze normal and defective bone healing in mice.

Bone healing models are essential to the development of new therapeutic strategies for clinical fracture treatment. Furthermore, mouse models are becoming ...

Minimally Invasive Transverse Aortic Constriction in Mice

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard open-chest transverse aortic constriction (TAC). Although transverse aortic constriction is a highly functional method for the induction of high pressure in the left ventricle, it is a more difficult and lengthy procedure due to its use of artificial ventilation with tracheal intubation. TAC is oftentimes also less survivable, as the newer method, MTAC, neither requires the cutting of the ribs and intercostal muscles nor tracheal intubation with a ventilation setup. In MTAC, as opposed to a thoracotomy to access to the chest cavity, the aortic arch is reached through a midline incision in the anterior neck. The thyroid is pulled back to reveal the sternal notch. The sternum is subsequently cut down to the second rib level, and the aortic arch is reached simply by separating the connective tissues and thymus. From there, a suture can be wrapped around the arch and tied with a spacer, and then the sternal cut and skin can be closed. MTAC is a much faster and less invasive way to induce left ventricular hypertension and enables the possibility for high-throughput studies. The success of the constriction can be verified using high-frequency trans-thoracic echocardiography, particularly color Doppler and pulsed-wave Doppler, to determine the flow velocities of the aortic arch and left and right carotid arteries, the dimension of the blood vessels, and the left ventricular function and morphology. A successful constriction will also trigger significant histopathological changes, such as cardiac muscle cell hypertrophy with interstitial and perivascular fibrosis. Here, the procedure of MTAC is described, demonstrating how the resulting flow changes in the carotid arteries can be examined with echocardiography, gross morphology, and histopathological changes in the heart.

Minimally invasive transverse aortic constriction (MTAC) conserves the essentials of regular transverse aortic constriction (TAC) while eliminating the use of a ventilator with tracheal intubation. It proves to be a highly desirable method for high-throughput studies on left ventricular overload, particularly in translational studies.

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard ...

Minimally Invasive Muscle Embedding (MIME) - A Novel Experimental Technique to Facilitate Donor-Cell-Mediated Myogenesis

Skeletal muscle possesses regenerative capacity due to tissue-resident, muscle-fiber-generating (myogenic) satellite cells (SCs), which can form new muscle fibers under the right conditions. Although SCs can be harvested from muscle tissue and cultured in vitro, the resulting myoblast cells are not very effective in promoting myogenesis when transplanted into host muscle. Surgically exposing the host muscle and grafting segments of donor muscle tissue, or the isolated muscle fibers with their SCs onto host muscle, promotes better myogenesis compared to myoblast transplantation. We have developed a novel technique that we call Minimally Invasive Muscle Embedding (MIME). MIME involves passing a surgical needle through the host muscle, drawing a piece of donor muscle tissue through the needle track, and then leaving the donor tissue embedded in the host muscle so that it may act as a source of SCs for the host muscle. Here we describe in detail the steps involved in performing MIME in an immunodeficient mouse model that expresses a green fluorescent protein (GFP) in all of its cells. Immunodeficiency in the host mouse reduces the risk of immune rejection of the donor tissue, and GFP expression enables easy identification of the host muscle fibers (GFP+) and donor-cell-derived muscle fibers (GFP-). Our pilot data suggest that MIME can be used to implant an extensor digitorum longus (EDL) muscle from a donor mouse into the tibialis anterior (TA) muscle of a host mouse. Our data also suggest that when a myotoxin (barium chloride, BaCl2) is injected into the host muscle after MIME, there is evidence of donor-cell-derived myogenesis in the host muscle, with approximately 5%, 26%, 26% and 43% of the fibers in a single host TA muscle showing no host contribution, minimal host contribution, moderate host contribution, and maximal host contribution, respectively.

Minimally Invasive Muscle Embedding MIME - A Novel Experimental Technique to Facilitate Donor-Cell-Mediated Myogenesis

We describe a novel experimental technique that we call Minimally Invasive Muscle Embedding (MIME), which is based on the evidence that skeletal muscle tissue contains viable myogenic cells that can facilitate donor-cell-mediated myogenesis when implanted into a host muscle.

Skeletal muscle possesses regenerative capacity due to tissue-resident, muscle-fiber-generating (myogenic) satellite cells (SCs), which can form new ...

Technique of Minimally Invasive Transverse Aortic Constriction in Mice for Induction of Left Ventricular Hypertrophy

Transverse aortic constriction (TAC) in mice is one of the most commonly used surgical techniques for experimental investigation of pressure overload-induced left ventricular hypertrophy (LVH) and its progression to heart failure. In the majority of the reported investigations, this procedure is performed with intubation and ventilation of the animal which renders it demanding and time-consuming and adds to the surgical burden to the animal. The aim of this protocol is to describe a simplified technique of minimally invasive TAC without intubation and ventilation of mice. Critical steps of the technique are emphasized in order to achieve low mortality and high efficiency in inducing LVH.
Male C57BL/6 mice (10-week-old, 25-30 g, n=60) were anesthetized with a single intraperitoneal injection of a mixture of ketamine and xylazine. In a spontaneously breathing animal following a 3-4 mm upper partial sternotomy, a segment of 6/0 silk suture threaded through the eye of a ligation aid was passed under the aortic arch and tied over a blunted 27-gauge needle. Sham-operated animals underwent the same surgical preparation but without aortic constriction. The efficacy of the procedure in inducing LVH is attested by a significant increase in the heart/body weight ratio. This ratio is obtained at days 3, 7, 14 and 28 after surgery (n = 6 - 10 in each group and each time point). Using our technique, LVH is observed in TAC compared to sham animals from day 7 through day 28. Operative and late (over 28 days) mortalities are both very low at 1.7%.
In conclusion, our cost-effective technique of minimally invasive TAC in mice carries very low operative and post-operative mortalities and is highly efficient in inducing LVH. It simplifies the operative procedure and reduces the strain put on the animal. It can be easily performed by following the critical steps described in this protocol.

The aim of this protocol is to describe step-by-step the technique of minimally invasive transverse aortic constriction (TAC) in mice. By elimination of intubation and ventilation which are mandatory for the commonly used standard procedure, minimally invasive TAC simplifies the operative procedure and reduces the strain put on the animal.

Transverse aortic constriction (TAC) in mice is one of the most commonly used surgical techniques for experimental investigation of pressure ...

The Generation of Closed Femoral Fractures in Mice: A Model to Study Bone Healing

Bone fractures impose a tremendous socio-economic burden on patients, in addition to significantly affecting their quality of life. Therapeutic strategies that promote efficient bone healing are non-existent and in high demand. Effective and reproducible animal models of fractures healing are needed to understand the complex biological processes associated with bone regeneration. Many animal models of fracture healing have been generated over the years; however, murine fracture models have recently emerged as powerful tools to study bone healing. A variety of open and closed models have been developed, but the closed femoral fracture model stands out as a simple method for generating rapid and reproducible results in a physiologically relevant manner. The goal of this surgical protocol is to generate unilateral closed femoral fractures in mice and facilitate a post-fracture stabilization of the femur by inserting an intramedullary steel rod. Although devices such as a nail or a screw offer greater axial and rotational stability, the use of an intramedullary rod provides a sufficient stabilization for consistent healing outcomes without producing new defects in the bone tissue or damaging nearby soft tissue. Radiographic imaging is used to monitor the progression of callus formation, bony union, and subsequent remodeling of the bony callus. Bone healing outcomes are typically associated with the strength of the healed bone and measured with torsional testing. Still, understanding the early cellular and molecular events associated with fracture repair is critical in the study of bone tissue regeneration. The closed femoral fracture model in mice with intramedullary fixation serves as an attractive platform to study bone fracture healing and evaluate therapeutic strategies to accelerate healing.

The murine closed femoral fracture model is a powerful platform to study fracture healing and novel therapeutic strategies to accelerate bone regeneration. The goal of this surgical protocol is to generate unilateral closed femoral fractures in mice using an intramedullary steel rod to stabilize the femur.

Bone fractures impose a tremendous socio-economic burden on patients, in addition to significantly affecting their quality of life. Therapeutic strategies ...

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

A Pre-clinical Rat Model for the Study of Ischemia-reperfusion Injury in Reconstructive Microsurgery

Ischemia-reperfusion injury is the main cause of flap failure in reconstructive microsurgery. The rat is the preferred preclinical animal model in many areas of biomedical research due to its cost-effectiveness and its translation to humans. This protocol describes a method to create a preclinical free skin flap model in rats with ischemia-reperfusion injury. The described 3 cm x 6 cm rat free skin flap model is easily obtained after the placement of several vascular ligatures and the section of the vascular pedicle. Then, 8 h after the ischemic insult and completion of the microsurgical anastomosis, the free skin flap develops the tissue damage. These ischemia-reperfusion injury-related damages can be studied in this model, making it a suitable model for evaluating therapeutic agents to address this pathophysiological process. Furthermore, two main monitoring techniques are described in the protocol for the assessment of this animal model: transit-time ultrasound technology and laser speckle contrast analysis.

Here, we describe a pre-clinical animal model for studying the pathophysiology of ischemia-reperfusion injury in reconstructive microsurgery. This free skin flap model based on the superficial caudal epigastric vessels in the rat may also allow for the evaluation of different therapies and compounds to counteract ischemia-reperfusion injury-related damage.

Ischemia-reperfusion injury is the main cause of flap failure in reconstructive microsurgery. The rat is the preferred preclinical animal model in many ...