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Pastor T, Zderic I, Pastor T, Drenchev L, Skulev HK, van Knegsel KP, Lenz M, Link BC, Gueorguiev B, Beeres FJP. Helical Plating Compared with Straight Plating and Nailing for Treatment of Proximal Third Humeral Shaft Fractures-A Biomechanical Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2043. [PMID: 38004092 PMCID: PMC10672748 DOI: 10.3390/medicina59112043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 11/04/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: The surgical treatment of proximal humeral shaft fractures usually considers application of either long straight plates or intramedullary nails. By being able to spare the rotator cuff and avoid the radial nerve distally, the implementation of helical plates might overcome the downsides of common fixation methods. The aims of the current study were (1) to explore the biomechanical competence of different plate designs and (2) to compare their performance versus the alternative treatment option of using intramedullary nails. Materials and Methods: Twenty-four artificial humeri were assigned to the following four groups for simulation of an unstable proximal humeral shaft fracture and instrumentation: Group 1 (Straight-PHILOS), Group 2 (MULTILOC-Nail), Group 3 (45°-Helical-PHILOS), and Group 4 (90°-Helical-PHILOS). All specimens underwent non-destructive, quasi-static biomechanical testing under loading in axial compression, torsion in internal/external rotation, and pure bending in four directions, accompanied by motion tracking. Results: Axial stiffness/displacement in Group 2 was significantly higher/smaller than in all other groups (p ≤ 0.010). Torsional displacement in Group 2 was significantly bigger than in all other groups (p ≤ 0.017). Significantly smaller coronal plane displacement was identified in Group 2 versus all other groups (p < 0.001) and in Group 4 versus Group 1 (p = 0.022). Significantly bigger sagittal plane displacement was detected in Group 4 versus all other groups (p ≤ 0.024) and in Group 1 versus Group 2 (p < 0.001). Conclusions: Intramedullary nails demonstrated higher axial stiffness and smaller axial interfragmentary movements compared with all investigated plate designs. However, they were associated with bigger torsional movements at the fracture site. Although 90°-helical plates revealed bigger interfragmentary movements in the sagittal plane, they demonstrated improved resistance against displacements in the coronal plane when compared with straight lateral plates. In addition, 45°-helical plates manifested similar biomechanical competence to straight plates and may be considered a valid alternative to the latter from a biomechanical standpoint.
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Affiliation(s)
- Torsten Pastor
- AO Research Institute Davos, 7270 Davos, Switzerland; (T.P.); (I.Z.); (K.P.v.K.)
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland; (B.-C.L.); (F.J.P.B.)
| | - Ivan Zderic
- AO Research Institute Davos, 7270 Davos, Switzerland; (T.P.); (I.Z.); (K.P.v.K.)
| | - Tatjana Pastor
- AO Research Institute Davos, 7270 Davos, Switzerland; (T.P.); (I.Z.); (K.P.v.K.)
- Department for Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, 3012 Bern, Switzerland
| | - Ludmil Drenchev
- Institute of Metal Science, Equipment and Technologies for Hydro- and Aerodynamics Center “Acad. A. Balevski”, Bulgarian Academy of Sciences, 1000 Sofia, Bulgaria; (L.D.); (H.K.S.)
| | - Hristo Kostov Skulev
- Institute of Metal Science, Equipment and Technologies for Hydro- and Aerodynamics Center “Acad. A. Balevski”, Bulgarian Academy of Sciences, 1000 Sofia, Bulgaria; (L.D.); (H.K.S.)
| | - Kenneth P. van Knegsel
- AO Research Institute Davos, 7270 Davos, Switzerland; (T.P.); (I.Z.); (K.P.v.K.)
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland; (B.-C.L.); (F.J.P.B.)
| | - Mark Lenz
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, 07747 Jena, Germany;
| | - Björn-Christian Link
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland; (B.-C.L.); (F.J.P.B.)
| | - Boyko Gueorguiev
- AO Research Institute Davos, 7270 Davos, Switzerland; (T.P.); (I.Z.); (K.P.v.K.)
| | - Frank J. P. Beeres
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland; (B.-C.L.); (F.J.P.B.)
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Pastor T, Kastner P, Souleiman F, Gehweiler D, Migliorini F, Link BC, Beeres FJP, Babst R, Nebelung S, Ganse B, Schoeneberg C, Gueorguiev B, Knobe M. Anatomical analysis of different helical plate designs for proximal humeral shaft fracture fixation. Eur J Trauma Emerg Surg 2023; 49:411-418. [PMID: 35986752 DOI: 10.1007/s00068-022-02082-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/08/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Helical plates are preferably used for proximal humeral shaft fracture fixation and potentially avoid radial nerve irritation. AIMS Safety of applying four different long plate designs (straight, 45°-, 90°-helical and ALPS) with MIPO technique as well as assessment and comparison of their distances to adjacent anatomical structures. METHODS MIPO was performed in 16 human cadaveric humeri using either a straight (group 1), a 45°-helical (group 2), a 90°-helical (group 3) plate, or an ALPS (group 4). Applying CT angiography, distances between brachial arteries and plates were evaluated. All specimens were dissected and distances to the axillary, radial and musculocutaneous nerve were evaluated. RESULTS No specimens demonstrated injuries of the anatomical structures at risk after MIPO with all investigated plate designs. Closest overall distance (mean (range); mm) between each plate and the radial nerve was 1 (1-3) in group 1, 7 (2-11) in group 2, 14 (7-25) in group 3 and 6 (3-8) in group 4. It was significantly bigger in group 3 and significantly smaller in group 1 compared to all other groups, p < 0.001. Closest overall distance between each plate and the musculocutaneous nerve was 16 (8-28) in group 1, 11 (7-18) in group 2, 3 (2-4) in group 3 and 6 (3-8) in group 4. It was significantly bigger in group 1 and significantly smaller in group 3 compared to all other groups, p < 0.001. CONCLUSIONS MIPO with 45°- and 90°-helical plates as well as with ALPS is safely feasible and demonstrates significantly bigger distances to the radial nerve compared to straight plates. However, the distances remain small and attention must be paid to the musculocutaneous nerve and the brachial artery when MIPO is applied using ALPS, 45°- and 90°-helical implants.
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Affiliation(s)
- Torsten Pastor
- AO Research Institute Davos, Davos, Switzerland.
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Philipp Kastner
- AO Research Institute Davos, Davos, Switzerland
- Department for Orthopaedics and Traumatology, Johannes Kepler University, Linz, Austria
| | - Firas Souleiman
- AO Research Institute Davos, Davos, Switzerland
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | | | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH, University of Aachen Hospital, Aachen, Germany
| | - Björn-Christian Link
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
- Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Sven Nebelung
- Department of Diagnostic and Interventional Radiology, University Hospital Aachen, Aachen, Germany
| | - Bergita Ganse
- Werner Siemens Foundation Endowed Chair for Innovative Implant Development, Clinics and Institutes of Surgery, Saarland University, Homburg, Germany
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Carsten Schoeneberg
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany
| | | | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
- Medical Faculty, RWTH Aachen University Hospital, Aachen, Germany
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Nicolaci G, Maes V, Lollino N, Putzeys G. How to treat proximal and middle one-third humeral shaft fractures: the role of helical plates. Musculoskelet Surg 2022; 107:231-238. [PMID: 35579822 DOI: 10.1007/s12306-022-00748-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the outcomes of patients affected by proximal and middle one-third humeral shaft fractures treated with humeral helical plates. MATERIAL AND METHODS From October 2016 to June 2020, twenty-four (twenty women, four men) underwent humeral reduction and fixation with humeral helical plates (A.L.P.S.® Proximal Humeral Plating System, Zimmer Biomet) that preserve deltoid muscle insertion and reduce the risk of iatrogenic radial nerve injury. At one and six months after surgery, standard antero-posterior and lateral radiographs were obtained, and at last follow-up (eighteen months on average), clinical evaluation was performed through range of motion assessment, Constant score and DASH score questionnaires. Only descriptive statistical analysis was conducted. RESULTS At six months, all fractures have healed. At last follow-up (average eighteen months, 13-28) mean Constant score was 71 (range 33-96), mean Dash score was 19.2 (range 1.7-63). The average range of motion was calculated as follows: flexion 137.8° (range 90-180); abduction 125.8° (range 85-180°); external rotation 55° (range 20-80°), internal rotation at L3 (range between scapulae-trochanter). Three patients experienced temporary radial nerve palsy from injury, while in one case, a temporary iatrogenic palsy occurred. CONCLUSIONS In our opinion, the helical plate may be an effective surgical tool for management of proximal and middle one-third diaphyseal humeral fractures. The humeral helical plate allows stable fixation avoiding the deltoid tuberosity proximally and radial nerve distally, thus increasing the possibility of rapid functional recovery after surgery.
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Affiliation(s)
- G Nicolaci
- Università degli Studi di Torino, Via Gianfranco Zuretti 29, 10126, Turin, Italy.
| | - V Maes
- Department of Orthopaedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - N Lollino
- Ospedale Civile E. Agnelli, SC Ortopedia e Traumatologia, Via Brigata Cagliari 39, 10064, Pinerolo, Italy
| | - G Putzeys
- Department of Orthopaedic Surgery, AZ Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
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One-year follow-up after treatment of proximal and/or middle one-third humeral shaft fractures with a helical plate: healing rates, complications and functional outcome measures. BMC Musculoskelet Disord 2021; 22:890. [PMID: 34670538 PMCID: PMC8529715 DOI: 10.1186/s12891-021-04774-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 10/10/2021] [Indexed: 02/04/2023] Open
Abstract
Background Conventional plate osteosynthesis is a valuable treatment option in displaced proximal and/or middle one-third humeral shaft fractures. Nonetheless, this procedure can be complicated by a radial nerve palsy. To date, many surgical techniques have been developed in an attempt to minimize this high-impact complication. A helical plate has the potential to avoid an iatrogenic radial nerve palsy due to its design. This article aims to evaluate safety and functional outcomes of patients treated with a helical plate compared to conventional plate osteosynthesis. In particular healing rates, complications and functional outcome measures. Methods We retrospectively included all patients with displaced proximal and/or middle one-third humeral shaft fractures who were treated with a helical plate from October 2016 until August 2018 at a single level-1 trauma center (AZ Groeninge, Kortrijk, Belgium). A self-molded long PHILOS plate (DePuy Synthes®) or a pre-contoured A.L.P.S proximal humeral plating system (Zimmer Biomet®) were used. Patient baseline characteristics and standard radiographs were obtained pre- and postoperatively. We retrospectively searched for complications. Patients were reassessed using the Disabilities of the Arm, Shoulder and Hand (DASH), Constant Murley (CMS) and EQ-5D-5L scores with a minimal follow-up of 1 year. Results The humeral shaft fractures of all sixteen patients consolidated within 3 months and no iatrogenic radial nerve palsies were observed. One plate had to be removed after 1 year due to a late deep infection. With a minimum follow up of 1 year, the mean DASH score was 22 ± 19 and the mean normalized CMS was 80 ± 19. Conclusion Operative treatment of proximal and/or middle one-third humeral shaft fractures with a helical plate is a safe procedure with good to excellent shoulder function at one-year follow-up. Contrary to conventional plate osteosynthesis, a helical plate has the potential to completely avoid a radial nerve palsy, while maintaining similar healing rates and functional outcomes. Trial registration Retrospective cohort study. B396201939564. Registered on 10 MAY 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04774-9.
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Nicolaci G, Lollino N. How to treat proximal and middle one-third humeral shaft fractures: The role of helical plates. SURGICAL TECHNIQUES DEVELOPMENT 2021. [DOI: 10.4081/std.2021.9175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Complex proximal third diaphyseal humeral fractures are uncommon patterns of injury mainly caused by high energy trauma. The anatomical shape of the humerus, the presence of the deltoid tuberosity and the close proximity of the radial nerve into the radial groove represent challenge elements to deal with. Historically, straight plates were manually twisted; subsequently, helical plates created for other anatomical sites (as distal tibia) were used in humeral fractures. In both these experiences surgeons observed several disadvantages. More recently, dedicated helical plates have been created. In this study, we expose our surgical technique for using helical humeral plates (A.L.P.S.® Proximal Humeral Plating System, Zimmer Biomet), with its advantages and operative recommendation.
From 2019 to 2021, nine patients who were admitted to our institution for humeral fractures involving the proximal third diaphysis have been treated with humeral helical plates. At one and six months after surgery, standard antero-posterior and lateral radiographs were obtained, and at last follow-up (fourteen months on average) clinical evaluation was performed through range of motion assessment, Constant score and DASH score questionnaires. At six months, all fractures have healed. At last follow-up (fourteen months on average, 6-22) the average range of motion were flexion 135° (90°-180°); abduction 124° (85°-180°); external rotation 52° (20°-80°), internal rotation at L3 (between scapulae-trochanter). Average Constant Shoulder Score was 70 (33-96), average Dash score was 21 (range 1,7-63). Three patients experienced temporary radial nerve palsy from injury, with subsequently improvement at EMG analysis within eight months from surgery. In our opinion this strategy avoids the deltoid tuberosity and reduces the risk of radial nerve injury, increasing the possibility of a rapid functional recovery after surgery.
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Huang Q, Lu Y, Wang ZM, Sun L, Ma T, Wang Q, Li M, Liu HL, Hou MM, Xue HZ, Zhang K, Li Z. Anterolateral approach with two incisions versus posterior median approach in the treatment of middle- and distal-third humeral shaft fractures. J Orthop Surg Res 2021; 16:197. [PMID: 33731159 PMCID: PMC7967943 DOI: 10.1186/s13018-021-02355-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 03/10/2021] [Indexed: 11/24/2022] Open
Abstract
Background The surgical approaches remain controversial for the treatment of middle and distal-third humeral shaft (MDTHS) fractures. This study compared clinical effects of the anterolateral approach with two incisions (AATI) and the posterior median approach (PMA) in the treatment of MDTHS fractures. Methods A retrospective analysis was carried out. One hundred sixty-six patients with MDTHS fractures were selected from January 2015 to January 2017 in Xi’an Hong Hui Hospital. According to surgical approaches, patients were divided into AATI (86 cases) and PMA group (80 cases). All patients were treated with open reduction and plate fixation. Operation indexes were compared, including incision length, operation time, and bleeding. Bryan-Morrey score was used to evaluate elbow joint function. Complication incidence was compared, such as incision infection, iatrogenic radial nerve injury, and nonunion. Results The AATI group showed smaller incision length, less bleeding, lower iatrogenic radial nerve injury rate, and better elbow function than that of PMA group (P<0.05). Conclusions The middle and distal-third humeral shaft fractures can be successfully cured by both approaches. Compared with the posterior median approach, it has better clinical effects of the anterolateral approach with two incisions, which is worthy of clinical application and promotion.
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Affiliation(s)
- Qiang Huang
- Department of Orthopedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Yao Lu
- Department of Orthopedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Zhi Meng Wang
- Department of Orthopedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Liang Sun
- Department of Orthopedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Teng Ma
- Department of Orthopedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Qian Wang
- Department of Orthopedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Ming Li
- Department of Orthopedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Hong Liang Liu
- Department of Orthopedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Ming Ming Hou
- Department of Orthopedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Han Zhong Xue
- Department of Orthopedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Kun Zhang
- Department of Orthopedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China.
| | - Zhong Li
- Department of Orthopedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China.
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Li Y, Tian Q, Leng K, Guo M. Comparison of the Posterior and Anterolateral Surgical Approaches in the Treatment of Humeral Mid-Shaft Fractures: A Retrospective Study. Med Sci Monit 2020; 26:e924400. [PMID: 32639953 PMCID: PMC7366785 DOI: 10.12659/msm.924400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background The aim of this study was to retrospectively assess and compare the functional outcomes and complications following anterolateral versus posterior surgical approaches for the treatment of mid-shaft fractures of the humerus. Material/Methods This study included 107 patients treated for mid-shaft fractures between May 2015 and July 2018. Demographic and surgical data were collected for each patient. During follow-up visits, radiographs were acquired and evaluated. The clinical outcomes of the involved joints were assessed by the Constant scoring system, range of motion (ROM), and the Mayo Elbow Performance Scoring system at the 12-month follow-up. Results The posterior approach was performed in 57 patients with type A fractures (group I, n=28) and type B or C fractures (group III, n=29). The anterolateral approach was performed in 50 patients with type A fractures (group II, n=32) and type B or C fractures (group IV, n=18). There were no significant differences between group I and group II nor between group III and group IV with respect to patient demographic data, surgical data, Constant score, ROM, or Mayo Elbow Performance score. A significant difference in the total complication rate was observed between group I and II. Conclusions The anterolateral approach showed an advantage over the posterior approach for treating simple humeral mid-shaft fractures. However, this advantage was not observed in treating comminuted fractures.
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Affiliation(s)
- Yihan Li
- Orthopedic Department, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
| | - Qingxian Tian
- Orthopedic Department, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
| | - Kungpeng Leng
- Orthopedic Department, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
| | - Meng Guo
- Orthopedic Department, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China (mainland)
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Sezek S, Aksakal B, Gürger M, Malkoc M, Say Y. Biomechanical comparison of straight and helical compression plates for fixation of transverse and oblique bone fractures: Modeling and experiments. Biomed Mater Eng 2016; 27:197-209. [PMID: 27567775 DOI: 10.3233/bme-161576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Total deformation and stability of straight and helical compression plates were studied by means of the finite element method (FEM) and in vitro biomechanical experiments. Fixations of transverse (TF) and oblique (45°) bone (OF) fractures have been analyzed on sheep tibias by designing the straight compression (SP) and Helical Compression Plate (HP) models. The effects of axial compression, bending and torsion loads on both plating systems were analyzed in terms of total displacements. Numerical models and experimental models suggested that under compression loadings, bone fracture gap closures for both fracture types were found to be in the favor of helical plate designs. The helical plate (HP) fixations provided maximum torsional resistance compared to the (SP) fixations. The fracture gap closure and stability of helical plate fixation for transverse fractures was determined to be higher than that found for the oblique fractures. The comparison of average compression stress, bending and torsion moments showed that the FEM and experimental results are in good agreement and such designs are likely to have a positive impact in future bone fracture fixation designs.
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Affiliation(s)
- Sinan Sezek
- Vocational School of Askale, Ataturk University, Erzurum, Turkey
| | - Bunyamin Aksakal
- Department of Metallurgy and Materials Engineering, Faculty of Chemical and Metallurgy, Yildiz Technical University, Istanbul, Turkey
| | - Murat Gürger
- Department of Orthopedics, Faculty of Medicine, Firat University, Elazig, Turkey
| | - Melih Malkoc
- Clinics of Orthopedy and Traumotology, Faculty of Medicine, Medipol University, Istanbul, Turkey
| | - Y Say
- Department of Metallurgy and Materials Engineering, Faculty of Engineering, Tunceli University, Tunceli, Turkey
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