A new volar plate made of carbon-fiber-reinforced polyetheretherketon for distal radius fracture: analysis of 40 cases

Complications after volar plate synthesis for distal radius fractures

Purpose

Distal radius fractures (DRFs) represent up to 18% of all fractures in the elderly population, yet studies on the rate of complications following surgery are lacking in the literature. This systematic review aimed to quantify the rate of complications and reinterventions in patients treated with volar plate for distal radius fractures, and analyze if there was any predisposing factor.

Methods

A comprehensive literature search was performed on three databases up to January 2023, following PRISMA guidelines. Studies describing volar plate complications and hardware removal were included. A systematic review was performed on complications and rate of reintervention. Assessment of risk of bias and quality of evidence was performed with the 'Down and Black's Checklist for measuring quality'.

Results

About112 studies including 17 288 patients were included. The number of complications was 2434 in 2335 patients; the most frequent was carpal tunnel syndrome (CTS), representing 14.3% of all complications. About 104 studies reported the number of reinterventions, being 1880 with a reintervention rate of 8.5%. About 84 studies reported the reason of reintervention; the most common were patient's will (3.0%), pain (1.1%), CTS (1.2%), and device failure (1.1%).

Conclusion

The complication rate after DRFs is 13.5%, with the main complication being CTS (14.3%), followed by pain and tendinopathy. The reintervention rate is 8.5%, mainly due to the patient's willingness, and all these patients had plate removal. Correct positioning of the plate and correct information to the patient before surgery can reduce the number of hardware removal, thereby reducing costs and the risk of complications associated with VLP for distal radius fractures.

Feasibility of 3D-Printed Locking Compression Plates with Polyether Ether Ketone (PEEK) in Tibial Comminuted Diaphyseal Fractures

The applicability of a polyether ether ketone locking compression plate (PEEK LCP) fabricated using FDM (fused deposition modeling)-based 3D printing to treat actual patients was studied. Three different tests-bending, axial compression, and axial torsion-were conducted on tibial non-osteoporotic comminuted diaphyseal fracture samples fixed with the commercial titanium alloy LCP and 3D-printed PEEK LCP. Comparing the outcomes of these tests revealed that the commercial titanium alloy LCP underwent plastic deformation in the bending and axial torsion tests, though the LCP did not fail even when an external force greater than the maximum allowable load of the tibia fixture of the LCP was applied. Elastic deformation occurred in the 3D-printed PEEK LCP in the bending and axial torsion tests. However, deformation occurred even under a small external force, and its stiffness was 10% compared to commercial titanium alloy LCP. Thus, 3D-printed PEEK LCP can be applied to the fracture conditions in non-weight-bearing regions. The experimental results reveal detailed insights into the treatment of actual patients by considering the stiffness and high toughness of 3D-printed PEEK LCP.

Carbon-fiber-reinforced polyetheretherketone orthopedic implants in musculoskeletal and spinal tumors: imaging and clinical features

Carbon-fiber-reinforced polyetheretherketone (CFR-PEEK) orthopedic implants are gaining popularity in oncologic applications as they offer many potential advantages over traditional metallic implants. From an imaging perspective, this instrumentation allows for improved evaluation of adjacent anatomic structures during radiography, computed tomography (CT), and magnetic resonance imaging (MRI). This results in improved postoperative surveillance imaging quality as well as easier visualization of anatomy for potential image-guided percutaneous interventions (e.g., pain palliation injections, or ablative procedures for local disease control). CFR-PEEK devices are also advantageous in radiation oncology treatment due to their decreased imaging artifact during treatment planning imaging and decreased dose perturbation during radiotherapy delivery. As manufacturing processes for CFR-PEEK materials continue to evolve and improve, potential orthopedic applications in the spine and appendicular skeleton increase. An understanding of the unique properties of CFR-PEEK devices and their impact on imaging is valuable to radiologists delivering care to orthopedic oncology patients in both the diagnostic and interventional settings. This multidisciplinary review aims to provide a comprehensive insight into the radiologic, surgical, and radiation oncology impact of these innovative devices.

Fracture fixation in extremity trauma with carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates: evidence today

PURPOSE

To compare the CFR-PEEK plates with conventional plates in fracture fixation with regards to clinical and radiological outcomes and complications.

METHODS

A systematic literature search was conducted in four online databases independently by two reviewers using the Cochrane methodology for systematic reviews. The identified relevant studies were assessed against predetermined inclusion/exclusion criteria. Independent data extraction and assessment of risk of bias and study quality was carried out.

RESULTS

Nine studies (patient n = 361) out of 6594 records were included for analysis: 2 RCTs (n = 63), 3 prospective cohort studies (n = 151), and 4 retrospective cohort studies (n = 147). Studies were grouped per anatomic area of fixation. Four studies (n = 200) examined fixation of proximal humerus fractures. Two studies (n = 74) examined fixation of distal radius fractures. Two studies (n = 53) assessed outcomes of fixation of distal femur fractures. One study (n = 87) assessed the outcomes of fixation of ankle fractures. All nine studies reported very high union rates (from 91% in distal femur to 100% in upper limb) for the CFR-PEEK plate groups and low complication rates. There was no significant difference in clinical outcomes, and rate of complications as compared to the conventional plate groups.

CONCLUSION

CFR-PEEK plates have high union rates in extremity fracture fixation similar to conventional plates with comparable good clinical outcomes and a very low and comparable rate of complications. Considering their advantages, CFR-PEEK plates seem to be valid alternative to conventional plating.

Carbon fibres as potential bone implants with controlled doxorubicin release

This work presents the structural characterisation of carbon fibres obtained from the carbonization of flax tow at 400°C (CFs400°C) and 1000°C (CFs1000°C) and the thermodynamic and kinetic studies of adsorption of Doxorubicin (Dox) on the fibres. The characteristic of carbon fibres and their drug adsorption and removal mechanism were investigated and compared with that of natural flax tow. All fibres were fully characterized by scanning electron microscopy (SEM), Fourier transforms infrared spectroscopy (FT-IR), thermogravimetric analysis (TGA), specific surface area analysis and Boehm titration. The results demonstrated the highest adsorption properties of CFs400°C at 323 K (q_max = 275 mg g⁻¹). The kinetic data followed the pseudo-second-order kinetic model more closely, whereas the Dubinin–Radushkevich model suitably described isotherms for all fibres. Calculated parameters revealed that the adsorption process of Dox ions is spontaneous and mainly followed by physisorption and a pore-filling mechanism. The removal efficiency for carbon fibres is low due to the effect of pore-blocking and hydrophobic hydration. However, presented fibres can be treated with a base for further chemical surface modification, increasing the adsorption capacity and controlling the release tendency.

Palmar plating of distal radius fractures : 3-year follow-up with titanium and PEEK plates give similar outcomes

A variety of different plate designs and materials are available to treat distal radius fractures. This study evaluates clinical results with a carbon fibre- reinforced (CFR)-polyether ether ketone (PEEK) plate in comparison to a standard titanium plate. Thirty-one distal radius fractures were included in this randomised controlled trial. Five fractures were classified as type A, 6 as type B and 20 as type C, in accordance with the AO classification. Patients were randomly allocated into two groups : 15 patients for titanium palmar plating (TPP) and 16 patients for PEEK palmar plating (PPP). Follow-up examinations were set at 2 weeks, 6 weeks, 3 months, 6 months and 3 years postop. In terms of wrist range of motion, radiological evaluation (alignment and fracture healing), DASH score (Disabilities of Arm, Shoulder and Hand), and VAS (visual analogue scale), no statistically significant differences were detected between the two groups, at all follow-up intervals. PEEK palmar plating and titanium plates give equivalent clinical and radiological outcomes up to 3 years follow-up.

SAFETY AND RELIABILITY OF CARBON-PEEK PLATE FOR THE TREATMENT OF DISTAL RADIUS FRACTURES: A REVIEW OF THE LITERATURE

INTRODUCTION

Distal radius fractures are one of the most common injuries. Open reduction and internal fixation (ORIF) are the most diffused between surgical treatments. Carbon-fiber reinforced (CFR) polyetheretherketone (PEEK) plates have been proposed to prevent effects linked to stainless steel or titanium alloy traditional plates, such as radio-opacity, mismatch of bone-plate elasticity modulus, corrosion, limited fatigue life, osseointegration.

OBJECTIVE

This review aims to evaluate the actual safety and reliability of CFR- PEEK plates to treat distal radius fractures.

METHODS

Electronic databases PubMed, Google Scholars, and Cochrane Library were searched in December 2020. Eligible studies were published in peer-reviewed journals. Three authors independently selected relevant articles and discussed those. Searching identified 13 titles and abstracts, 11 manuscripts were considered eligible for the full-text analysis. Of these 11 papers, 7 studies were included in our review.

RESULTS

215 patients were analyzed in this systematic review. The mean age of enrolled patients was 52,8 years. 34% were males and 66% were females. Fractures were classified according to AO/ASIF classification system. We reported 12 cases of complications specific to this device, such as intraoperative plate and screws rupture, erosive flexor tendons synovitis, and loosening.

CONCLUSION

CFR-PEEK distal radius plates are potentially an alternative to traditional ones. But we believe that the use of this device does not entail a significant advantage in the treatment of distal radius fractures, as safe and low-cost traditional devices are available. Further comparative studies are needed to demonstrate the superiority of carbon devices.

A carbon fiber-reinforced polyetheretherketone intramedullary nail improves fracture site visibility on postoperative radiographic images

INTRODUCTION

To evaluate the advantages of a carbon fiber-reinforced polyetheretherketone (CFR/PEEK) intramedullary nail on the diagnosis of fracture healing because of its radiolucency, we retrospectively reviewed radiographs and computed tomography (CT) images of trochanteric femoral fractures that underwent internal fixation with the CFR/PEEK intramedullary nail or a traditional metallic intramedullary nail.

METHODS

Radiographs and CT images from 20 patients with intertrochanteric femoral fractures treated with a CFR/PEEK intramedullary nail and 20 similar patients treated with a metallic intramedullary nail were reviewed. After division of the intertrochanteric region into three zones on anteroposterior and lateral views of the radiographs, the visibilities of the fracture site, fracture line, and bone formation were evaluated in each zone. A three-grade assessment for existence of scattering and effect of scattering on diagnosis of the surrounding bone was performed on three axial slices of the CT images.

RESULTS

In the CFR/PEEK group, the fracture site was visible in all zones for all cases except for the posterior zone on the lateral view in one case. In the cranial and middle zones on anteroposterior views and the middle zone on lateral views of the radiographs, the visible fracture site rates in the CFR/PEEK group were significantly higher than those in the metal group. The grades for existence of scattering and effect of scattering on diagnosis of surrounding bone on the CT images were significantly lower in the CFR/PEEK group compared with the metal group.

CONCLUSION

Superior fracture site visibility on radiographs was demonstrated in cases treated with the CFR/PEEK intramedullary nail compared with cases treated with the traditional metallic intramedullary nail, thereby confirming the advantages of the CFR/PEEK intramedullary nail for evaluation of fracture reduction and bone formation. The CFR/PEEK nail evoked little scattering on CT images, leading to higher diagnostic values for the peri-prosthetic cancellous and cortical bone compared with the metallic nail.

Multimodal imaging of composite carbon fiber-based implants for orthopedic spinal fixation

OBJECTIVE

As cancer treatments continue to improve, the incidence of spinal metastases and the need for surgical management of these with fixation procedures are growing rapidly. Traditionally metallic implants, composed of titanium alloy, have been used in surgical fixation of unstable or symptomatic vertebral metastases or traumatic injuries. Metallic implants, however, cause significant artifact on post-operative imaging, degrading image quality and limiting interpretation, and can also impair the planning and delivery of radiotherapy. Composite carbon fiber-based materials, such as carbon fiber-reinforced polyetheretherketone (PEEK), have been developed to overcome these issues and are now available for spinal fixation procedures. We aimed to review the multimodal imaging features of these new implants.

MATERIALS AND METHODS

Current literature and a case example from our institution were used to describe the multimodal imaging characteristics and considerations of new carbon fiber-based spinal fixation implants.

RESULTS

New carbon fiber-based spinal implants allow far greater visualization of surrounding structures on post-operative cross-sectional imaging, significantly improving diagnostic accuracy and precision of radiotherapy planning, and do not significantly absorb or scatter X-ray photons during radiotherapy delivery. There are, however, important surgical and radiologic considerations associated with the use of carbon fiber-based implants which radiologists must be aware of, such as implications for surgical planning and intra-operative fluoroscopic and post-operative plain radiographic imaging.

CONCLUSION

The use of carbon fiber-based implants, rather than traditional metallic implants, for spinal fixation offers significant advantages for post-operative diagnostic imaging and radiotherapy planning and delivery.

Effects of Bone-Plate Material on the Predicted Stresses in the Tibial Shaft Comminuted Fractures: A Finite Element Analysis

PURPOSE

In this research, low modulus carbon fiber (CF)-reinforced polyetheretherketone composite plates (CF-PEEK plates) were compared with traditional metal plates using finite element analysis to establish a reference for clinical application.

MATERIAL AND METHODS

Plates of stainless steel, titanium alloy (Ti6Al4V), or CF-PEEK with different carbon fiber reinforcement ratios (CF30, CF50, and CF60) were used to fix the tibial shaft comminuted fracture. The maximum stress, the maximum displacement of fracture and the stress shielding of cortex bone were analyzed.

RESULTS

Under 200 N axial compression, the maximum displacement was measured in the CF30 plate (4.62 mm) and the minimum in the stainless steel plate (0.23 mm). The stress shielding rates of stainless steel, titanium, CF30, CF50, and CF60 plates were 59.4%, 54.4%, 23.75%, 48.75% and 66.25%. Under 700 N axial compression, the internal fixation by the CF30 plate failed. Among the other 4 plates, the maximum displacement was measured in the CF50 plate (2.52 mm) and the minimum in the stainless steel plate (0.78 mm). The stress shielding rate of plates made of stainless steel, titanium, CF50, and CF60 were 57.1%, 52.0%, 48.1%, and 67.8%.

CONCLUSIONS

CF50 plates can be safely used in the tibial shaft comminuted fracture. The micromotion in the CF50 and CF60 plate was more beneficial to callus formation and fracture healing. The stress shielding of the cortex bone under the CF50 plate was the lowest. The finite element analysis indicated that the CF-PEEK material is worthy of further study because of its biomechanical advantages.

The advantages of carbon fiber based orthopedic devices in patients who have to undergo radiotherapy

Background and Objectives:

The modern approach to primary and secondary muscular skeletal tumors is multidisciplinary. The right combination of chemotherapy, surgery and radiotherapy (RT) makes obtaining local and distant disease more likely. When surgery is indicated, radiotherapy often has a fundamental role as an adjuvant treatment; however, the titanium alloy instrumentations interfere with Radiotherapy setting, decreasing its effectiveness. It is common opinion that carbon fiber-reinforced devices are convenient in case of adjuvant RT in muscular skeletal oncology. The aim of the study is to support this intuition with experimental data, verifying the more accurate estimation of the delivered dose during RT, comparing Carbon Fiber-Reinforced PEEK (CFRP) plates with titanium-alloy orthopedic devices in order to evaluate their effects on target volume identification and dose distribution for radiation treatment.

Methods:

Phantoms were then irradiated with a linear accelerator Varian 2100 C/D with photon beams of 6 and 15 MV energies. Absorbed dose in the point of interest was verified by EBT3 gafchromic films above and below the two materials. Images from CT simulations were also analyzed in terms of Hounsfield numbers in patients with titanium and carbon fiber orthopedic implants in the spine or in the femur.

Results:

For a 6 MV photon beam, the doses measured just under the titanium-alloy plate were less than approximately 20% of the value calculated by the TPS. For a 15 MV beam energy, these differences were slightly lower. Using CFRP plate, the difference between measured and calculated doses was within ±3% for both energies, which was comparable with the statistical uncertainties. In the cases of simulated treatment of humerus titanium implants, the difference varies in range ± 10% with hot spot of + 10% and cold spot of -15%.

Conclusions:

The use of CFRP for orthopedic devices and implants provides a valuable advantage in identifying the target due to the reduction of artifacts. Clear imaging of the soft tissues surrounding the bone is useful and reduces the discrepancies between calculated/delivered and measured doses, generating a more homogeneous dose distribution. Furthermore, there is a significant benefit in detecting the state of disease in CT imaging during the follow-up of treated patients. In-vivo studies are encouraged to verify whether a more effective radiotherapy leads to a decrease in local recurrence and local progression. (www.actabiomedica.com)

Volar PEEK plate for distal radius fracture: analysis of adverse events

BACKGROUND

The aim of the present retrospective study was to evaluate complications following carbon-fiber-reinforced polyetheretherketon (CFR-PEEK) volar plating in distal radius fracture in a large cohort of patients. As an alternative to conventional metallic devices, CFR-PEEK plates have been introduced over the last few years.

METHODS

We performed a retrospective study including all patients who were treated for distal radius fracture using a volar fixed-angle plate DiPHOS-RM (Lima Corporate, Udine, Italy). All CFR-PEEK plates implanted were reviewed between May 2012 and December 2017. Plate removal, second surgery and adverse events were collected by reviewing medical records. A total of 110 patients were included with a mean follow-up of 4 years.

RESULTS

Adverse side effects were observed in 9 cases (8%), developed during or after treatment. The most frequent complication was represented by intraoperative plate rupture (4%). Infection was reported in one case.

DISCUSSION

The rate of complications of PEEK volar plates seems to be similar to those occurring with plates of different materials. Advantages of PEEK plates are the absence of the cold-welding phenomenon and the absence of exuberant bone callus on the plate, ensuring an easy hardware removal. Intraoperative rupture remains the main complication correlated with PEEK material. These complications can be reduced with an accurate surgical technique, especially at the beginning of the learning curve.

LEVEL OF EVIDENCE

Therapeutic IV.

Carbon/PEEK nails: a case-control study of 22 cases

BACKGROUND

Interest around carbon/PEEK plates and nails has been raising. The elastic modulus close to the bone, the high load-carrying capacity and radiolucency make CFR/PEEK materials a potential breakthrough. In the literature, there are abundant data about CFR/PEEK plates in the treatment of proximal humerus, distal radius and distal fibula fractures. In patients affected by bone metastasis, CFR/PEEK nails were proved effective and safe with 12 months of follow-up. Very little is known about performances of CFR/PEEK nails in patients affected by other pathologies.

PURPOSES

The aim of the study was to evaluate safety and efficacy of CFR/PEEK nails in the treatment of various pathological conditions. It was also investigated whatever radiolucency of this nails could lead to a more objective evaluation of bone callus or disease site.

PATIENTS AND METHODS

In the study group were included 20 patients (22 bone segments) who underwent CFR/PEEK nail implantation (eight humerus, one tibia, nine femur and four knee arthrodesis). They were affected by pathological fractures, and in four cases, they required an arthrodesis of the knee. They were retrospectively evaluated considering nail failures and bone callus or disease progression (RUSH scores). Mean follow-up time was 11 months (min 6.8-max 20.3). In the control group were included patients treated with titanium nails in the same institution for the same pathologies. An interclass correlation coefficient (ICC) analysis was performed in both groups considering RUSH scores by two expert surgeon from two institution to assess whether radiolucency could lead to a more objective evaluation of disease or bone callus site.

RESULTS

The ICC of mean values between RUSH scores was 0.882 (IC 95%: 0.702-0.953) in the CFR/PEEK group, while it was 0.778 (IC 95%: 0.41-0.91) in the titanium group. Observers' evaluation showed a significantly higher obscuration by titanium nails than by CFR/PEEK nails. No osteosynthesis failures were reported in both groups.

CONCLUSIONS

Our results confirm the safety of CFR/PEEK nails in the short-medium term. The radiolucency of these materials led our observers to perform more objective evaluations of bone callus formation or disease progression compared to the titanium group given the higher ICC.

LEVEL OF EVIDENCE

III Case-control therapeutic study.

The use of Carbon-Peek volar plate after distal radius osteotomy for Kienbock's Disease in a volleyball athlete: a case report

Kienbock’s Disease, or lunatomalacia, has uncertain etiopathogenesis, it is more common in male from 20 to 45-year-old. The Lichtman’s classification is the most used by authors and it divides Kienbock’s Disease in 4 stages according to radiographic parameters. In early stages could be performed a conservative treatment, but failure rate is high; various surgical techniques are available in case of failure or higher stages. We report a case of a 26-year-old female volleyball player affected by stage I Kienbock’s Disease who underwent distal radius osteotomy core decompression synthesized with Carbon-Peek plate fixation. Follow-up was performed with clinical evaluation (ROM analysis, VAS score, Quick Dash Score), wrist radiographs and wrist MRI. (www.actabiomedica.it)

Structural stability of a polyetheretherketone femoral component-A 3D finite element simulation

BACKGROUND

Because its mechanical properties are similar to cortical bones of the knee, polyetheretherketone (PEEK) material has been used to make total knee arthroplasty (TKA) components. This study investigated the PEEK femoral component deformation of a TKA system and compared the data with that of a cobalt-chromium (CoCr) component.

METHODS

A 3D finite element knee model was constructed using CT images of a normal subject. A knee prosthesis was installed on the model to simulate a TKA knee. The material properties of the bone were assumed linear and transverse isotropic. The femoral component was modeled using a PEEK or CoCr material. A compressive load was applied to the knee at full extension. Tibiofemoral contact stresses and femoral component deformations were analyzed.

FINDINGS

Under a 3 kN load, the maximal Von-Mises stresses in the femoral component were 14.39 MPa and 30.05 MPa for the PEEK and CoCr components, respectively. At the tibial polyethylene surface, the CoCr femoral component caused higher contact stresses (>2.2%) than the PEEK component. The deformation of the PEEK component was over 3 times larger than that of the CoCr component (0.65 × 10^-3 mm vs 0.2 × 10^-3 mm).

INTERPRETATION

The PEEK femoral component could result in lower contact stresses, but larger deformations in the TKA knee compared to the CoCr component. An increased deformation of the PEEK component indicates a reduction in its structural strength. Future investigation should examine if the reduced structural strength will affect the in-vivo component-bone interface integration and affect the component fatigue life.

Finite element investigation into the use of carbon fibre reinforced PEEK laminated composites for distal radius fracture fixation implants

Carbon fibre reinforced PEEK (CF/PEEK) laminates provide mechanical advantages over homogenous metal osteo-synthesis implants, e.g. radiolucency, fatigue strength and strength to weight ratio. Implants can be designed with custom anisotropic material properties, thus enabling the engineer to tailor the overall stiffness of the implant to the specific loading conditions it will experience in vivo. In the current study a multi-scale computational investigation of idealised distal radius fracture fixation plate (DRP) is conducted. Physiological loading conditions are applied to macro-scale finite element models of DRPs. The mechanical response is compared for several CF/PEEK laminate layups to examine the effect of ply layup design. The importance of ply orientation in laminated DRPs is highlighted. A high number of 0° plies near the outer surfaces results in a greater bending strength while the addition of 45° plies increases the torsional strength of the laminates. Intra-laminar transverse tensile failure is predicted as the primary mode of failure. A micro-mechanical analysis of the CF/PEEK microstructure uncovers the precise mechanism under-lying intra-laminar transverse tensile crack to be debonding of the PEEK matrix from carbon fibres. Plastic strains in the matrix material are not sufficiently high to result in ductile failure of the matrix. The findings of this study demonstrate the significant challenge in the design and optimisation of fibre reinforced laminated composites for orthopaedic applications, highlighting the importance of multi-scale modelling for identification of failure mechanisms.

Preliminary experience with triangular CarboFix "Piccolo" Distal Radius Plate in wrist fractures. Clinical and radiological results

Background and aim o the work: In the recent last years there was a diffusion of new radiolucent plates for the treatment of distal radius fractures. The aim of our study is to evaluate the clinical and radiological outcomes at 12-month-follow-up for the treatment of distal radius fracture with the new triangular CarboFix “Piccolo” Distal Radius Plate. Methods: All consecutive patients aged from 18 or over, who were treated for unstable distal radius fracture with a volar CarboFix “Piccolo” Distal Radius Plate with triangular design between September 2015 and May 2016, have been included in the study. From the original 28 patients, 6 patients were lost to the follow up or did not meet the inclusion criteria and 22 were available for the study. The 22 patients were prospectively reviewed with dynamometric, radiographic and clinical evaluations (ROM, VAS, Quick DASH). Results: The mean follow-up was 15.7 months. All fractures healed, and radiographic union was observed at an average of 5 weeks. All patients have recovery of R.O.M. comparable to the contralateral at the final follow up; with no significant difference (p>0.05) as regards extension, flexion, ulnar deviation, radial deviation, supination and pronation comparing to the unaffected arm. At final follow-up, no patients had a statistically significant difference (p>0.05) of grip strength, comparing to the contralateral side. The mean Quick DASH was 9.3 and the mean VAS score was 2.3. Conclusion: The most important finding of the present study was that the triangular CarboFix “Piccolo” Distal Radius Plate showed good clinical and radiological results in the treatment of distal radial fractures. These results are comparable to those achieved with conventional plates. (www.actabiomedica.it)

A Preliminary Comparison Suggests Poor Performance of Carbon Fiber Reinforced Versus Titanium Plates in Distal Femoral Osteotomy

BACKGROUND

Carbon fiber-reinforced (CFR) polymer implants have theoretical advantages over titanium plates.

QUESTIONS/PURPOSES

The aim of the present study was to assess our early outcomes with CFR plates in lateral opening-wedge distal femoral osteotomy to correct valgus lower limb malalignment. We asked the following: (1) Did the CFR polymer implant change time to union when compared with the titanium implant? (2) Did the incidence of displacement of medial cortical fractures differ between the implants? (3) Did the incidence of complications differ between the two techniques, and did other factors, such as bone graft material used, affect healing?

METHODS

A retrospective review of 16 limbs treated with an opening-wedge distal femoral osteotomy for genu valgum using either titanium (n = 10) or CFR plates (n = 6) was performed. Patient and clinical covariates as well as the primary outcome of time to union and secondary outcome of fracture displacement were collected and analyzed.

RESULTS

Those treated with CFR plates had longer times to union than did those in the titanium-treated group (median, 121.5 vs 81.5 days, respectively). The incidence of fracture displacement was higher in the CFR plate-treated group (CFR, n = 5/6; titanium, n = 1/10). Although the CFR plate-treated group had a 33% nonunion incidence while the titanium group had no nonunions, the study lacked the power to show significance. Bone graft material used did not affect outcome. Complication rates were higher in the CFR plate-treated patients.

CONCLUSION

The CFR plate was associated with a longer time to unite and higher fracture displacement rate than the titanium plate. As this is a retrospective case series, further research is required to confirm these results and clarify best practices in plating of distal femoral osteotomy for deformity correction.

Early Comparative Outcomes of Carbon Fiber-Reinforced Polymer Plate in the Fixation of Distal Femur Fractures

OBJECTIVE

To evaluate the early clinical results of distal femur fractures treated with carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates compared with stainless steel (SS) lateral locking plates.

DESIGN

Retrospective comparative cohort study.

SETTING

ACS Level I trauma center.

PATIENTS/PARTICIPANTS

Twenty-two patients (11 SS, 11 CFR-PEEK) with closed distal femur fractures treated by a single surgeon over a 6-year period.

MAIN OUTCOME MEASUREMENTS

Nonunion, hardware failure, reoperation, time to full weight-bearing, and time union were assessed.

RESULTS

The CFR-PEEK cohort was on average older (71 vs. 57 years, P = 0.03) and more likely to have diabetes (P = 0.02). Nonunion was diagnosed in 4/11 (36%) patients in the SS group and 1/11 (9%) patients in the CFR-PEEK group (P = 0.12). Hardware failure occurred in 2 SS patients (18%) compared with none in the CFR-PEEK group (P = 0.14). Time to full weight-bearing was similar between groups, occurring at 9.9 and 12.4 weeks in the CFR-PEEK and SS groups, respectively (P = 0.23). Time to radiographic union averaged 12.4 weeks in the SS group and 18.7 weeks in the CFR-PEEK group (P = 0.26). There were 4 reoperations in the SS group and 1 in the CFR-PEEK group (P = 0.12).

CONCLUSIONS

CFR-PEEK plates show encouraging short-term results in the treatment of distal femur fractures with a comparable nonunion, reoperation, and hardware failure rates to those treated with SS plates. This data suggest that CFR-PEEK plates may be a viable alternative to SS plates in fixation of these fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evolution of plate design and material composition

The evolution of plate fixation of fracture was accompanied by advances in metallurgy and improvement in understanding of the requirements for successful fracture healing. Locked internal fixation minimizes biologic damage and when used in conjunction with minimally invasive approaches may optimize fracture healing. Some current metal locked plate constructs may actually be too stiff, and various methods including screw modification, plate hole modification, and changes in plate material composition may provide a solution to optimize fracture healing. This paper reviews the evolution of plate design and describes the early clinical experience with the use of carbon fibre reinforced reinforced polyetheretherketone composite plates.

A Retrospective Case Series of Carbon Fiber Plate Fixation of Ankle Fractures

Distal fibula fractures represent a common problem in orthopaedics. When fibula fractures require operative fixation, implants are typically made from stainless steel or titanium alloys. Carbon fiber implants have been used elsewhere in orthopaedics for years, and their advantages include a modulus of elasticity similar to that of bone, biocompatibility, increased fatigue strength, and radiolucency. This study hypothesized that carbon fiber plates would provide similar outcomes for ankle fracture fixation as titanium and steel implants. A retrospective chart review was performed of 30 patients who underwent fibular open reduction and internal fixation (ORIF). The main outcomes assessed were postoperative union rate and complication rate. The nonunion or failure rate for carbon fiber plates was 4% (1/24), and the union rate was 96% (23/24). The mean follow-up time was 20 months, and the complication rate was 8% (2/24). Carbon fiber plates are a viable alternative to metal plates in ankle fracture fixation, demonstrating union and complication rates comparable to those of traditional fixation techniques. Their theoretical advantages and similar cost make them an attractive implant choice for ORIF of the fibula. However, further studies are needed for extended follow-up and inclusion of larger patient cohorts.

LEVELS OF EVIDENCE

Level IV: Retrospective Case series.

A systematic review of volar locking plate removal after distal radius fracture

BACKGROUND

Indication of volar locking plate (VLP) removal after bony healing of distal radius fracture (DRF) is controversial. Studies with various range of removal rate were reported. The purpose of this systematic review was to investigate the frequency and the reasons of hardware removal over the world. We hypothesized that more frequent VLP removal contribute to better clinical outcomes.

METHODS

The authors searched all available literature in the PubMed and EMBASE databases for articles reporting on outcomes of treatment using VLP for DRF. Data collection included hardware removal rate, complication rate, clinical and radiological outcomes. We analyzed correlation between hardware removal rate with clinical and radiological outcomes.

RESULTS

A total of 3472 articles were screened, yielding 52 studies for final review. The mean hardware removal rate was 9%, ranging from 0 to 100%. The mean removal rate in studies from France, Norway, Japan, and Belgium was as high as 19%. The mean removal rate in studies from the US was low (3%). The most frequent reasons for extraction were routine removal (22%), tendon irritation or tenosynovitis (14%), hardware problem (14%), and patient' request (13%). Although routine removal and patient' request were not counted as complication, correlation between removal rate with complication rate was strong (rho=0.64, p<0.001). Correlations between clinical and radiological outcomes were week except for volar tilt (rho=-0.42, p=0.009).

CONCLUSIONS

There was a diversity of removal rate and reasons in the studies over the world. High frequent VLP removal did not contribute to better clinical outcomes.

PEEK radiolucent plate for distal radius fractures: multicentre clinical results at 12 months follow up

INTRODUCTION

Open reduction and internal fixation (ORIF) with plate and screws represents the recommended treatment for unstable intra-articular distal radius fractures. Although significant progresses in surgical technique have been made, anatomical reconstruction of radio-carpal articular surface still represent a difficult task, especially in multifragmentary fractures. Available PEEK reinforced-carbon fiber composite radiolucent devices allow both an easier and more careful assessment of intra-operative reduction of the articular surface of distal radius and prompt correction of any residual step deformity.

MATERIALS AND METHODS

We retrospectively reviewed clinical and radiological multicentre results of 71 consecutive AO B and C fracture pattern of distal radius treated using the same PEEK reinforced-carbon fiber composite radiolucent plate.

RESULTS

Three patients lost at final follow up and 4 cases with incomplete radiological documentations were excluded from the study. 64 patients (38 females, 26 males) were available and formed the basis of this report. Fracture types included 9 patients with 23-B, 13 patients 23-B2,15 patients with 23-B3,10 patients with 23-C1, 7 patients with 23-C2 and 10 patients with 23-C3. Mean Modified Mayo wrist Score was on average 38.11 (SD 10.1; range 24-75, 95%CI 34.7-41.4), 67.22 (SD 9.6, range 50-90, 95%CI 64-70.4), 90.54 (SD 6.3, range 75-100, 95%CI 88.4-92.6) at one, two and twelve months of follow-up, respectively. A statistically significant difference was found between mean scores at different follow-up periods (p = 0.001). We noted 1 case of distal screw fixation aseptic loosening at 5 months post surgical intervention.

CONCLUSIONS

PEEK reinforced-carbon fiber composite radiolucent plate represents a useful device for treatment of complex distal radius fractures in the adult population. It possesses unique biomechanical properties and allows for an easier anatomical reduction during surgical intervention.

Carbon-fiber reinforced intramedullary nailing in musculoskeletal tumor surgery: a national multicentric experience of the Italian Orthopaedic Society (SIOT) Bone Metastasis Study Group

INTRODUCTION

Carbon fiber reinforced (CFR) implants have been proposed for the treatment of fractures or impending fractures of the long bones in the oncology patient. Aim of this study is to present the largest cohort of oncology patients operated by CFR nailing by the Italian Orthopaedic Society (SIOT) Bone Metastasis Study Group.

METHODS

53 adult oncology patients were operated on with a CFR-PEEK nail. All the data from adjuvants therapies were collected. Bone callus formation, response to radiotherapy, relapse or progression of the osteolysis were recorded. Hardware survival and failure, breakage and need for implant revision were also analysed.

RESULTS

Anatomical implantation of nails include humerus (n = 35), femur (n =11) and tibia (n = 7). The most frequent tumors affecting the bone were myeloma (n = 13), breast (n = 11), lung (n = 8), and renal cell cancer (n = 7). Acrylic cement reinforcement was used in 2 patients. One patient was subjected to electrochemotherapy after nail insertion. Intraoperative and early postoperative complications occurred in 13.2% and 7.54% of patients respectively. Eight patients had local progression and one developed a stress fracture proximally to the distal static screw. Radiographic union occurred in 14 patients; one screw loosening was recorded.

DISCUSSION

There is currently a lack of solid evidence on the clinical use of CFR nails in oncologic patients. This is the first and largest study of CFR nailing, with the longest available follow up.

CONCLUSIONS

Implant related complications and surgery-related morbidity should be taken into account in the decision-making process for the surgical management of these patients. These data can improve the surgeon-patient communication and guide further studies on patients' survival and complications with respect to surgery.

Comparison between Carbon-Peek volar locking plates and titanium volar locking plates in the treatment of distal radius fractures

INTRODUCTION

Unstable intra articular fractures of distal radius are frequently being managed with open reduction and internal fixation. Volar locking plate based on polyetheretherketon (PEEK) polymer has developed lately as an alternative to conventional metallic devices. The advantage of this kind of plates include the lack of metal allergies, radiolucency, low artefacts on MRI or imaging scans and the high resistance associated to loading forces. The aim of this study was to evaluate the clinical and radiological results using a new Carbon-PEEK volar locking plate compared with titanium volar locking plates for the treatment of distal radius fractures.

METHODS AND MATERIAL

Thirty patients were included in this study. They all underwent traumatic intra-articular distal radius fractures and were surgically treated with volar locking plates. The patients were randomly divided in two groups: In Group A (15 patients) the fracture was stabilized with a CarboFix volar locking plate whereas in group B (15 patients) with an Acu-Lock Volar Distal Radius Plate. Range of motion (ROM), grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score and X-rays were evaluated. The mean follow up was 12 months.

RESULTS

Analysis of Wrist ROM revealed that there was no statistical significant difference (p > 0.05) in regards to extension, flexion, ulnar deviation, radial deviation, supination and pronation comparing to the unaffected arm and between Group A and Group B. The mean score on the DASH was 15.3 in Group A and 13.2 in Group B (p > 0.05). Patients were able to return to their normal activities of daily living at an average of 4 weeks post-op in both Groups. Overall, the mean VAS score was 3.6 There were no statistically significant differences (p > 0.05) on X-Rays examination between two Groups in regards to alignment and fracture healing.

CONCLUSIONS

Volar locking plates represent the most common procedure for the treatment of displaced distal radius fractures. In our series Carbon-peek volar locking plates seems to be analogue to titanium volar locking plates in terms of radiographic parameters and functional outcome.

Comparison between carbon-peek plate and conventional stainless steal plate in ankle fractures. A prospective study of two years follow up

INTRODUCTION

The aim of our study is to compare the clinical and radiological outcomes of the treatment of distal fibular fracture with the traditional stainless steel or the new radiolucent CFR-PEEK plates. The hypothesis is that there are no differences in clinical and radiological outcomes at the final follow-up between the two fixation devices.

METHODS

All consecutive patients aged from 18 or over, who had undergone operative treatment for malleolar fracture between 2013 and 2014, have been included in the study. 87 were available for the study. The patients were assigned to group A (47 patients, radiolucent plate group) and group B (41 patients, stainless steal plate group). At 6, 12 and 24 months all patients were prospectively reviewed with radiographic and clinical evaluations (OMAS scale, AOFAS, VAS, ROM).

RESULTS

The groups were homogenous with regard to age, gender, BMI, dominance and disease duration. The mean follow-up was 23+/-2 months. The mean waiting time to operation was 2.94days (SD 2.74) (range 0.2-6.8). Statistical analysis showed no difference (p>0.05) about the VAS, OMAS, AOFAS and ROM evaluation at 6, 12 and 24 month follow-up between two groups. Radiographic evaluation showed no difference between two groups at all the follow-up with similar results obtained with the two fixation devices.

DISCUSSION

Our results showed a substantial equivalence of the two fixation devices at 6, 12 and 24 month of clinical and radiographic follow-up. Fixation of the lateral malleolus fractures with a CFR-PEEK plate provides satisfying clinical and radiographic results after 2 years of follow-up. These results are comparable to those achieved with conventional plates.

Debris of carbon-fibers originated from a CFRP (pEEK) wrist-plate triggered a destruent synovitis in human

Application of carbon-fiber-reinforced-polymer (CFRP) artifacts in humans has been promoted in Orthopedic and Trauma Surgery. Literature documents the biocompatibility of materials used, namely carbon fibers (CF) and poly-ether thermoplastics, like poly-ether-ether-ketone (PEEK). A properly designed and accurately implanted composite artifact should not expose its fibers during or after surgery: however this may happen. A white Caucasian woman came to our attention 11 months after surgery for a wrist fracture. She had a severe impairment, being unable to flex the thumb; index finger and distal phalanx of third finger. We retrieved a correctly positioned plate and documented an aggressive erosive flexor tendons synovitis with eroded stumps of flexor tendons. The plate and soft tissues were analyzed by Visible Light and Scanning Electron Microscopy. Histopathology showed granulomatous fibrogenic process with CF engulfed inside multinucleated giant cells. Fibers were unmasked and disrupted inside the holes where screws were tightened and corrugation of the polymer coating led to further unmasking. The mechanism of foreign-body reaction to CF has not been studied in depth yet, particularly at the ultrastructural level and in Humans. This case documents a damage occurred in a clinical application and which was theoretically possible. Our opinion is that a proper way to promote the use of CRFP in the Clinic in the short term is to direct Research towards finding a better way to prevent CF debris to be exposed and released. In the longer term, the biological response to CF deserves a deeper understanding.

Carbon Fiber Biocompatibility for Implants

Carbon fibers have multiple potential advantages in developing high-strength biomaterials with a density close to bone for better stress transfer and electrical properties that enhance tissue formation. As a breakthrough example in biomaterials, a 1.5 mm diameter bisphenol-epoxy/carbon-fiber-reinforced composite rod was compared for two weeks in a rat tibia model with a similar 1.5 mm diameter titanium-6-4 alloy screw manufactured to retain bone implants. Results showed that carbon-fiber-reinforced composite stimulated osseointegration inside the tibia bone marrow measured as percent bone area (PBA) to a great extent when compared to the titanium-6-4 alloy at statistically significant levels. PBA increased significantly with the carbon-fiber composite over the titanium-6-4 alloy for distances from the implant surfaces of 0.1 mm at 77.7% vs. 19.3% (p < 10⁻⁸) and 0.8 mm at 41.6% vs. 19.5% (p < 10⁻⁴), respectively. The review focuses on carbon fiber properties that increased PBA for enhanced implant osseointegration. Carbon fibers acting as polymer coated electrically conducting micro-biocircuits appear to provide a biocompatible semi-antioxidant property to remove damaging electron free radicals from the surrounding implant surface. Further, carbon fibers by removing excess electrons produced from the cellular mitochondrial electron transport chain during periods of hypoxia perhaps stimulate bone cell recruitment by free-radical chemotactic influences. In addition, well-studied bioorganic cell actin carbon fiber growth would appear to interface in close contact with the carbon-fiber-reinforced composite implant. Resulting subsequent actin carbon fiber/implant carbon fiber contacts then could help in discharging the electron biological overloads through electrochemical gradients to lower negative charges and lower concentration.

Carbon fiber intramedullary nails reduce artifact in postoperative advanced imaging

OBJECTIVE

This study assessed whether radiolucent carbon fiber reinforced-polyetheretherketone (CFR-PEEK) intramedullary nails decreased hardware artifact on magnetic resonance imaging (MRI) and computed tomography (CT) in vitro and in an oncologic patient population.

MATERIALS AND METHODS

In vitro and clinical evaluations were done. A qualitative assessment of metal artifact was performed using CFR-PEEK and titanium nail MRI phantoms. Eight patients with a femoral or tibial prophylactic CFR-PEEK nail were retrospectively identified. All patients had postoperative surveillance imaging by MRI, CT, and were followed for a median 20 months (range, 12-28 months). CFR-PEEK images were compared to images from a comparative group of patients with titanium femoral intramedullary nails who had a postoperative MRI or CT. A musculoskeletal-trained radiologist graded visualization of the cortex, corticomedullary junction, and bone-muscle interface, on T1-weighted (T1W), STIR, and contrast-enhanced T1-weighted fat-saturated (T1W FS) sequences of both groups with a five-point scale, performing independent reviews 4 months apart. Statistical analysis used the Wilcoxon rank-sum test and a weighted kappa.

RESULTS

Substantially less MRI signal loss occurred in the CFR-PEEK phantom than in the titanium phantom simulation, particularly as the angle increased with respect to direction of the static magnetic field. CFR-PEEK nails had less MRI artifact than titanium nails on scored T1W, STIR, and contrast-enhanced T1W FS MRI sequences (p ≤ 0.03). The mean weighted kappa was 0.64, showing excellent intraobserver reliability between readings.

CONCLUSIONS

CFR-PEEK intramedullary nail fixation is a superior alternative to minimize implant artifact on MRI or CT imaging for patients requiring long bone fixation.

Treatment of proximal humerus fractures with a CFR-PEEK plate: 2-year results of a prospective study and comparison to fixation with a conventional locking plate

BACKGROUND

A radiolucent carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plate was recently introduced for fixation of proximal humerus fractures. Prospective clinical and radiographic results of patients treated with a CFR-PEEK plate are compared with those of patients treated with a conventional locking plate.

METHODS

Twenty-nine patients (mean age, 66 years) were treated with a CFR-PEEK plate for a 3- or 4-part proximal humerus fracture. Patients were clinically and radiographically re-examined at 6 weeks, 6 months, 12 months, and 24 months with the Simple Shoulder Test, Constant-Murley score (CMS), and Oxford Shoulder Score (OSS) as well as with simple radiographs. In addition, results were compared with a matched group of patients treated with a conventional locking plate.

RESULTS

At the final follow-up examination at 24 months, patients achieved a mean Simple Shoulder Test score of 58%, a mean CMS of 71.3 points (range, 44-97), and a mean OSS of 27.4 points (range, 8-45). Bone union was confirmed in all patients. Compared with patients treated with the conventional locking plate, patients treated with the CFR-PEEK plate achieved significantly better results with regard to the CMS and the OSS (P = .038 and .029, respectively). Furthermore, loss of reduction with subsequent varus deformity was less frequently observed in the CFR-PEEK plate group.

CONCLUSION

Fixation of proximal humerus fractures with a CFR-PEEK plate provides satisfying clinical and radiographic results after 2 years of follow-up. The results are comparable to those achieved with conventional locking plates.