Three-dimensional confocal images of microdamage in cancellous bone.

The accumulation of microdamage in bone may contribute to loss of bone quality in osteoporosis, and the role of microdamage in the etiology of fatigue fractures is unknown. Microdamage created during testing, ex vivo, can increase the fragility of bone by decreasing the load necessary to cause fracture. Microdamage can also accumulate in vivo, but its influence on bone fragility is unknown. To date, stained microcracks are the only criteria to have been correlated with bone mechanics, leaving the influence of ultrastructural damage on bone fragility open for scrutiny. Staining en bloc has identified three morphological features in the tissue, discrete microcracks, cross-hatch staining, and diffuse staining. The relationship between these features and their identification as microdamage remains equivocal. The purpose of this study was to investigate the three-dimensional nature of microdamage in cancellous bone and also to describe stained microcracks, cross-hatch staining, and diffuse staining and to determine whether they all relate to microdamage in bone. Laser scanning confocal microscopy that provides improved spatial resolution over bright-field microscopy was used to visualize bone damage. It was found that crack surface density was highly correlated with crack density (r = 0.95, p < 0.0001), suggesting that the crack surface of preexisting cracks increases as new cracks are formed or submicroscopic cracks become visible under bright-field microscopy. Cross-hatch staining and diffuse staining included ultra-microcracks about 10 microm in length. The ultra-microcracks in cross-hatch staining were organized in bands and surrounded by diffuse staining. This study demonstrates that damage in bone occurs over a wide range and that discrete microcracks, cross-hatch staining, and diffuse staining are all indicative of bone damage. The diffuse staining still evident in association with the ultra-microcracks seen in cross-hatch staining and diffuse staining is probably due to damage at a still smaller scale than we have been able to investigate.