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Zdero R, Brzozowski P, Schemitsch EH. Biomechanical Design Optimization of Distal Humerus Fracture Plates: A Review. BIOMED RESEARCH INTERNATIONAL 2024; 2024:6015794. [PMID: 38966093 PMCID: PMC11223906 DOI: 10.1155/2024/6015794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/25/2024] [Accepted: 06/08/2024] [Indexed: 07/06/2024]
Abstract
The goal of this article was to review studies on distal humerus fracture plates (DHFPs) to understand the biomechanical influence of systematically changing the plate or screw variables. The problem is that DHFPs are commonly used surgically, although complications can still occur, and it is unclear if implant configurations are always optimized using biomechanical criteria. A systematic search of the PubMed database was conducted to identify English-language biomechanical optimization studies of DHFPs that parametrically altered plate and/or screw variables to analyze their influence on engineering performance. Intraarticular and extraarticular fracture (EAF) data were separated and organized under commonly used biomechanical outcome metrics. The results identified 52 eligible DHFP studies, which evaluated various plate and screw variables. The most common plate variables evaluated were geometry, hole type, number, and position. Fewer studies assessed screw variables, with number and angle being the most common. However, no studies examined nonmetallic materials for plates or screws, which may be of interest in future research. Also, articles used various combinations of biomechanical outcome metrics, such as interfragmentary fracture motion, bone, plate, or screw stress, number of loading cycles to failure, and overall stiffness (Os) or failure strength (Fs). However, no study evaluated the bone stress under the plate to examine bone "stress shielding," which may impact bone health clinically. Surgeons treating intraarticular and extraarticular distal humerus fractures should seriously consider two precontoured, long, thick, locked, and parallel plates that are secured by long, thick, and plate-to-plate screws that are located at staggered levels along the proximal parts of the plates, as well as an extra transfracture plate screw. Also, research engineers could improve new studies by perusing recommendations in future work (e.g., studying alternative nonmetallic materials or "stress shielding"), clinical ramifications (e.g., benefits of locked plates), and study quality (e.g., experimental validation of computational studies).
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Affiliation(s)
- Radovan Zdero
- Orthopaedic Biomechanics LabVictoria Hospital, London, Ontario, Canada
| | - Pawel Brzozowski
- Orthopaedic Biomechanics LabVictoria Hospital, London, Ontario, Canada
| | - Emil H. Schemitsch
- Orthopaedic Biomechanics LabVictoria Hospital, London, Ontario, Canada
- Division of Orthopaedic SurgeryWestern University, London, Ontario, Canada
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Ernstbrunner L, Almond M, Rupasinghe HS, Jo OI, Zbeda RM, Ackland DC, Ek ET. Biomechanical Comparison of Distal Biceps Tendon Repair Techniques: Extracortical Single-Button Inlay Fixation Versus Intracortical Double-Button Onlay Anatomic Footprint Fixation. Am J Sports Med 2023:3635465231171131. [PMID: 37184036 DOI: 10.1177/03635465231171131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND Extracortical single-button (SB) inlay repair is a commonly used distal biceps tendon technique. However, complications (eg, neurovascular injury) and nonanatomic repairs have led to the development of intracortical fixation techniques. PURPOSE To compare the biomechanical stability of extracortical SB repair with an anatomic intracortical double-button (DB) repair technique. STUDY DESIGN Controlled laboratory study. METHODS The distal biceps tendon was transected in 18 cadaveric elbows from 9 donors. One elbow of each donor was randomly assigned to the extracortical SB or anatomic DB group. Both groups were cyclically loaded with 60 N over 1000 cycles between 90° of flexion and full extension. The elbow was then fixed in 90° of flexion and the repair construct loaded to failure. Gap formation and construct stiffness during cyclic loading and ultimate load to failure were analyzed. RESULTS When compared with the extracortical SB technique after 1000 cycles, the anatomic DB technique showed significantly less gap formation (mean ± SD, 2.7 ± 0.8 vs 1.5 ± 0.9 mm; P = .017) and significantly more construct stiffness (87.4 ± 32.7 vs 119.9 ± 31.6 N/mm; P = .023). Ultimate load to failure was not significantly different between the groups (277 ± 93 vs 285 ± 135 N; P = .859). The failure mode in the anatomic DB group was significantly different from that of the extracortical SB technique (P = .002) and was due to fracture avulsion of the cortical button in 7 of 9 specimens (vs none in the SB group). CONCLUSION Our study shows that the intracortical DB technique produces equivalent or superior biomechanical performance to that of the SB technique. The DB technique may offer a clinically viable alternative to the SB repair technique. CLINICAL RELEVANCE This study suggests, at worst, an equivalent and, at best, a superior biomechanical performance of intracortical anatomic DB footprint repair at the time of surgery. However, the mode of failure suggests that this technique should not be used in patients with poor bone quality.
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Affiliation(s)
- Lukas Ernstbrunner
- Melbourne Orthopaedic Group, Melbourne, Australia
- Hand and Wrist Biomechanics Laboratory, O'Brien Institute / St Vincent's Institute, Fitzroy, Australia
- Department of Biomedical Engineering, University of Melbourne, Melbourne, Australia
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Australia
| | - Mitchell Almond
- Department of Biomedical Engineering, University of Melbourne, Melbourne, Australia
| | - Harshi S Rupasinghe
- Department of Biomedical Engineering, University of Melbourne, Melbourne, Australia
| | - Olivia I Jo
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Australia
| | | | - David C Ackland
- Department of Biomedical Engineering, University of Melbourne, Melbourne, Australia
| | - Eugene T Ek
- Melbourne Orthopaedic Group, Melbourne, Australia
- Hand and Wrist Biomechanics Laboratory, O'Brien Institute / St Vincent's Institute, Fitzroy, Australia
- Department of Surgery, Monash Medical Centre, Monash University, Melbourne, Australia
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Farkhondeh Fal M, Junker M, Mader K, Frosch KH, Kircher J. Morphology of the acromioclavicular-joint score (MAC). Arch Orthop Trauma Surg 2023; 143:1523-1529. [PMID: 35381874 PMCID: PMC9957884 DOI: 10.1007/s00402-022-04407-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/27/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION To date there is no generally accepted specific definition or classification of acromioclavicular (AC) joint osteoarthritis. The aim of this study is to analyze morphological parameters using magnetic resonance imaging (MRI) and to develop a scoring system as a basis for decision making to perform an AC-joint resection. MATERIALS AND METHODS In a retrospective-monocentric matched pair study, healthy and affected subjects were investigated using T2 MRI scans in the transverse plane. There were two groups, group 1 (n = 151) included healthy asymptomatic adults with no history of trauma. In group 2, we included n = 99 patients with symptomatic AC joints, who underwent arthroscopic AC-joint resection. The central and posterior joint space width and the AC angle were measured. Morphological changes such as cartilage degeneration, cysts and bone edema were noted. Malalignment of the joint was defined as: posterior joint space width < 2 mm in conjunction with an AC angle > 12°. A scoring system consisting of the measured morphologic factors was developed. RESULTS Symptomatic and asymptomatic patients showed significant differences in all measured items. We observed a significant difference in the MAC score for symptomatic and asymptomatic patients (mean 10.4 vs. 20.6, p = 0.0001). The ROC (receiver operator characteristic) analysis showed an excellent AUC of 0.899 (p = 0.001). The sensitivity of the MAC score was 0.81 and the specificity 0.86. The MAC score shows a significant moderate correlation with age (r = 0.358; p = 0.001). The correlation of age and the development of symptoms was only weak (r = 0.22, p = 0.001). Symptomatic patients showed significantly more frequent malalignment compared to asymptomatic patients (p = 0.001), but the positive predictive value that a patient with malalignment is also symptomatic is only 55%. CONCLUSION Patients with symptomatic AC joints showed a typical pattern of morphological changes on axial MRI scans with early posterior contact of the joint surfaces, reduction of joint space and malalignment as the basis for the development of a scoring system. The MAC score shows excellent test characteristics, and therefore, proved to be both an appropriate guidance for clinical practice as well as an excellent tool for comparative studies and is superior to the assessment of malalignment alone. LEVEL OF EVIDENCE Level IV, retrospective diagnostic study.
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Affiliation(s)
- Milad Farkhondeh Fal
- Department of Trauma and Orthopaedic Surgery, University Hospital Hamburg Eppendorf, Martinistraße 52, 20251, Hamburg, Germany.
| | - Marius Junker
- grid.459906.70000 0001 0061 4027Orthopaedic University Hospital Friedrichsheim, Marienburgerstr. 2, 60528 Frankfurt, Germany
| | - Konrad Mader
- grid.13648.380000 0001 2180 3484Department of Trauma and Orthopaedic Surgery, University Hospital Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Karl Heinz Frosch
- grid.13648.380000 0001 2180 3484Department of Trauma and Orthopaedic Surgery, University Hospital Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Jörn Kircher
- Department of Shoulder and Elbow Surgery, ATOS Klinik Fleetinsel Hamburg, Admiralitätstrasse 3-4, 20459 Hamburg, Germany ,grid.411327.20000 0001 2176 9917Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40255 Düsseldorf, Germany
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Ernstbrunner L, Rupasinghe HS, Almond M, Jo OI, Zbeda RM, Oppy A, Treseder T, Pullen C, Ek ET, Ackland DC. A new all-suture tension band tape fixation technique for simple olecranon fractures versus conventional tension band wire fixation: a comparative biomechanics study. J Shoulder Elbow Surg 2022; 31:1376-1384. [PMID: 35167913 DOI: 10.1016/j.jse.2022.01.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/12/2022] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Simple transverse or short oblique olecranon fractures without articular comminution are classified as Mayo type IIA fractures and are typically treated with a tension band wire construct. Because of the high reoperation rates, frequently because of prominent hardware, all-suture tension band constructs have been introduced. It was the purpose to compare the biomechanical performance of conventional tension band wire fixation with a new all-suture tension band tape fixation for simple olecranon fractures. METHODS Mayo type IIA olecranon fractures were created in 20 cadaveric elbows from 10 donors. One elbow of each donor was randomly assigned to the tension band wire technique (group TBW) or tension band tape (Arthrex, 1.3-mm SutureTape) technique (group TBT). Both groups were cyclically loaded with 500 N over 500 cycles, after which a uniaxial displacement was performed to evaluate load to failure. Data were analyzed for gap formation after cyclic loading, construct stiffness, and ultimate load to failure, where failure was defined as fracture gap formation greater than 4.0 mm. RESULTS There was no significant difference in gap formation after 500 cycles between the TBW (1.8 mm ± 1.3 mm) and the TBT (1.9 mm ± 1.1 mm) groups (P = .854). The TBT showed a tendency toward greater construct stiffness compared with the TBW construct (mean difference: 142 N/mm; P = .053). Ultimate load to failure was not significantly different comparing both groups (TBW: 1138 N ± 286 N vs. TBT: 1126 N ± 272 N; P = .928). In both groups, all repairs failed because of >4.0-mm gap formation at the fracture site and none because of tension band construct breakage. CONCLUSIONS Our study shows that the TBT technique produces equivalent or superior biomechanical performance to the TBW for simple olecranon fractures. The TBT approach reduces the risk of hardware prominence and as a result mitigates against the need for hardware removal. The TBT technique offers a clinically viable alternative to TBW.
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Affiliation(s)
- Lukas Ernstbrunner
- Upper Limb Surgery, Melbourne Orthopaedic Group, Windsor, VIC, Australia; Hand and Wrist Biomechanics Laboratory (HWBL), O'Brien Institute/St. Vincent's Institute, Melbourne, VIC, Australia; Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Biomedical Engineering, University of Melbourne, Parkville, VIC, Australia.
| | | | - Mitchell Almond
- Department of Biomedical Engineering, University of Melbourne, Parkville, VIC, Australia
| | - Olivia I Jo
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Robert M Zbeda
- Upper Limb Surgery, Melbourne Orthopaedic Group, Windsor, VIC, Australia
| | - Andrew Oppy
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Thomas Treseder
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Christopher Pullen
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Eugene T Ek
- Upper Limb Surgery, Melbourne Orthopaedic Group, Windsor, VIC, Australia; Hand and Wrist Biomechanics Laboratory (HWBL), O'Brien Institute/St. Vincent's Institute, Melbourne, VIC, Australia
| | - David C Ackland
- Department of Biomedical Engineering, University of Melbourne, Parkville, VIC, Australia
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