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Liu J, Zhang Z, Ding J, Zhang J, Sheng Q, Piao C. Morphology and novel classification of proximal humeral fractures. Front Bioeng Biotechnol 2024; 12:1366089. [PMID: 39100622 PMCID: PMC11294115 DOI: 10.3389/fbioe.2024.1366089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 07/09/2024] [Indexed: 08/06/2024] Open
Abstract
Background: The morphology of proximal humeral fractures (PHFs) is complex, and the fixation and selection of implants need to be guided by the fracture type and classification, which requires an accurate understanding of the fracture line. This study had three purposes. 1) Define and analyze the fracture lines and morphological features of all types PHFs by three-dimensional (3D) mapping technology. 2) Determine the osteotomy position of the biomechanical model of the PHFs according to the fracture heat map. 3) Based on the analysis of the pathological morphology and distribution of a large number of consecutive cases of PHFs, propose a novel classification of PHFs. Methods: We retrospectively collected 220 cases of PHFs and generated a 3D fracture map and heat map based on computed tomography (CT) imaging. Through analysis of the fracture morphology of the 220 PHFs, a novel classification was proposed. The primary criterion for staging was the continuity between the humeral head and the greater tuberosity and lesser tuberosity, and the secondary criterion was the relationship between the humeral head segment and the humeral shaft. Results: The fracture line was primarily found around the metaphyseal zone of region of the surgical neck, with the most extensive distribution being below the larger tuberosity and on the posterior medial side of the epiphysis. We suggest that the osteotomy gap should be immediately (approximately 5-10 mm) below the lower edge of the articular surface. The most common type of fracture was type I3 (33 cases, 15.0%), followed by type IV3 fracture (23 cases, 10.4%), and type III2 fracture (22 cases, 10.0%). Interobserver and intraobserver reliability analysis for the fracture classification revealed a k value (95% confidence interval) of 0.639 (0.57-0.71) and 0.841, P < 0.01, respectively. Conclusion: In this study, the fracture line and morphological characteristics of PHFs were clarified in detail by 3D mapping technique. In addition, a new classification method was proposed by analysis of the morphological characteristics of 220 PHFs, A two-part fracture model for PHFs is also proposed.
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Affiliation(s)
- Jichao Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Ziyan Zhang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Jie Ding
- Department of Stomatology, The Affiliated Hospital of Changchun University of Traditional Chinese Medicine, Changchun, Jilin Province, China
| | - Jian Zhang
- Radiology Department, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Qian Sheng
- Medical Insurance Office, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Chengdong Piao
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
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Zdero R, Brzozowski P, Schemitsch EH. Biomechanical design optimization of proximal humerus locked plates: A review. Injury 2024; 55:111247. [PMID: 38056059 DOI: 10.1016/j.injury.2023.111247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/15/2023] [Accepted: 11/24/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Proximal humerus locked plates (PHLPs) are widely used for fracture surgery. Yet, non-union, malunion, infection, avascular necrosis, screw cut-out (i.e., perforation), fixation failure, and re-operation occur. Most biomechanical investigators compare a specific PHLP configuration to other implants like non-locked plates, nails, wires, and arthroplasties. However, it is unknown whether the PHLP configuration is biomechanically optimal according to some well-known biomechanical criteria. Therefore, this is the first review of the systematic optimization of plate and/or screw design variables for improved PHLP biomechanical performance. METHODS The PubMed website was searched for papers using the terms "proximal humerus" or "shoulder" plus "biomechanics/biomechanical" plus "locked/locking plates". PHLP papers were included if they were (a) optimization studies that systematically varied plate and screw variables to determine their influence on PHLP's biomechanical performance; (b) focused on plate and screw variables rather than augmentation techniques (i.e., extra implants, bone struts, or cement); (c) published after the year 2000 signaling the commercial availability of locked plate technology; and (d) written in English. RESULTS The 41 eligible papers involved experimental testing and/or finite element modeling. Plate variables investigated by these papers were geometry, material, and/or position, while screw variables studied were number, distribution, angle, size, and/or threads. Numerical outcomes given by these papers included stiffness, strength, fracture motion, bone and implant stress, and/or the number of loading cycles to failure. But, no paper fully optimized any plate or screw variable for a PHLP by simultaneously applying four well-established biomechanical criteria: (a) allow controlled fracture motion for early callus generation; (b) reduce bone and implant stress below the material's ultimate stress to prevent failure; (c) maintain sufficient bone-plate interface stress to reduce bone resorption (i.e., stress shielding); and (d) increase the number of loading cycles before failure for a clinically beneficial lifespan (i.e., fatigue life). Finally, this review made suggestions for future work, identified clinical implications, and assessed the quality of the papers reviewed. CONCLUSIONS Applying biomechanical optimization criteria can assist biomedical engineers in designing or evaluating PHLPs, so orthopaedic surgeons can have superior PHLP constructs for clinical use.
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Affiliation(s)
- Radovan Zdero
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
| | - Pawel Brzozowski
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada.
| | - Emil H Schemitsch
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada; Division of Orthopaedic Surgery, Western University, London, ON, Canada
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Hakiminejad A, Nourani A, Ghias N, Mahmoudi A, Same K, Kamrani RS, Nabian MH. Biomechanical analysis of different osteosynthesis configurations in the pin and plate fixation method for distal humerus fractures. BMC Musculoskelet Disord 2023; 24:579. [PMID: 37460939 DOI: 10.1186/s12891-023-06709-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 07/08/2023] [Indexed: 07/20/2023] Open
Abstract
Distal humerus fractures commonly occur in adults with low bone mineral density causing major technical challenges for orthopedic surgeons. Persian fixation method was introduced as a novel technique to stabilize small fragments in comminuted distal humerus fractures using a set of K-wires and a reconstruction plate. The present study aims to measure this technique's stiffness and stability of this technique and analyze the effect of influential parameters with numerical simulation and biomechanical testing on a cadaveric specimen. Validation of the finite element (FE) model was conducted based on results of experiments. The results indicated that Delta configuration mainly led to a higher stiffness in the case of axial loading and anterior bending compared to L configuration. Analyzing the influential factors of this technique suggests that changes in diameter and number of K-wires have a similarly significant effect on the construct stiffness while the height of plate had a slight influence. Also, the diameter of wires was the most effective parameter for implant failure, particularly in the 3-pin construct, which caused a reduction in failure risk by about 60%. The results revealed that the Persian fixation method would achieve suitable stability compared to the dual-plating technique.
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Affiliation(s)
- Alireza Hakiminejad
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
| | - Amir Nourani
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran.
| | - Narges Ghias
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
| | - Alireza Mahmoudi
- Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran
| | - Kaveh Same
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Shahriar Kamrani
- Department of Orthopedic and Trauma Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Nabian
- Center of Orthopedic Trans-Disciplinary Applied Research (COTAR), Tehran University of Medical Sciences, Tehran, Iran.
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Kaymaz I, Murat F, Korkmaz İH, Yavuz O. A new design for the humerus fixation plate using a novel reliability-based topology optimization approach to mitigate the stress shielding effect. Clin Biomech (Bristol, Avon) 2022; 99:105768. [PMID: 36150287 DOI: 10.1016/j.clinbiomech.2022.105768] [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] [Received: 07/19/2022] [Revised: 09/06/2022] [Accepted: 09/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Due to high stiffness, metal fixation plates are prone to stress shielding of the peri-prosthetic bones, leading to bone loss. Therefore, it has become important to design implants with reduced rigidity but increased load-carrying capacity. Considering the uncertainties in the parameters affecting the implant-bone structure is critical in making more reliable implant designs. In this study, a Response Surface Method based Reliability-based Topology Optimization approach was proposed to design a fixation plate for humerus fracture having less stiffness than the conventional plate. METHODS The design of the fixation plate was described as an Reliability-based Topology Optimization problem in which the probabilistic constraint was replaced with a meta-model generated using the Kriging method. The artificial humerus bone model was scanned, and the 3D simulation model was used in the finite element analysis required in the solution. The optimum plate was manufactured using Selective Laser Melting. Both designs were experimentally compared in terms of rigidity. FINDINGS The volume of the conventional plate was reduced from 2512.5 mm3 to 1667.3 mm3; nevertheless, the optimum plate had almost one-third less rigidity than the conventional plate. The probability of failure of the conventional plate was computed as 0.994. However, this value was almost half for the optimum fixation plate. Interpretation The studies showed that the new fixation plate design was less rigid but more reliable than the conventional one. The computation time required to have the optimum plate was reduced by one-tenth by applying the Response Surface Method for the Reliability-based Topology Optimization problem.
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Affiliation(s)
- Irfan Kaymaz
- Department of Mechanical Engineering, Faculty of Engineering and Architecture, Erzurum Technical University, Erzurum 25050, Turkey; Biomechanics Research Group, Faculty of Engineering and Architecture, Erzurum Technical University, Erzurum 25050, Turkey.
| | - Fahri Murat
- Department of Mechanical Engineering, Faculty of Engineering and Architecture, Erzurum Technical University, Erzurum 25050, Turkey; Biomechanics Research Group, Faculty of Engineering and Architecture, Erzurum Technical University, Erzurum 25050, Turkey.
| | - İsmail H Korkmaz
- Department of Mechanical Engineering, Faculty of Engineering and Architecture, Erzurum Technical University, Erzurum 25050, Turkey; Biomechanics Research Group, Faculty of Engineering and Architecture, Erzurum Technical University, Erzurum 25050, Turkey.
| | - Osman Yavuz
- Department of Mechanical Engineering, Faculty of Engineering and Architecture, Erzurum Technical University, Erzurum 25050, Turkey; Biomechanics Research Group, Faculty of Engineering and Architecture, Erzurum Technical University, Erzurum 25050, Turkey.
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Zhang S, Patel D, Brady M, Gambill S, Theivendran K, Deshmukh S, Swadener J, Junaid S, Leslie LJ. Experimental testing of fracture fixation plates: A review. Proc Inst Mech Eng H 2022; 236:1253-1272. [PMID: 35920401 PMCID: PMC9449446 DOI: 10.1177/09544119221108540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Metal and its alloys have been predominantly used in fracture fixation for
centuries, but new materials such as composites and polymers have begun to see
clinical use for fracture fixation during the past couple of decades. Along with
the emerging of new materials, tribological issues, especially debris, have
become a growing concern for fracture fixation plates. This article for the
first time systematically reviews the most recent biomechanical research, with a
focus on experimental testing, of those plates within ScienceDirect and PubMed
databases. Based on the search criteria, a total of 5449 papers were retrieved,
which were then further filtered to exclude nonrelevant, duplicate or
non-accessible full article papers. In the end, a total of 83 papers were
reviewed. In experimental testing plates, screws and simulated bones or cadaver
bones are employed to build a fixation construct in order to test the strength
and stability of different plate and screw configurations. The test set-up
conditions and conclusions are well documented and summarised here, including
fracture gap size, types of bones deployed, as well as the applied load, test
speed and test ending criteria. However, research on long term plate usage was
very limited. It is also discovered that there is very limited experimental
research around the tribological behaviour particularly on the debris’
generation, collection and characterisation. In addition, there is no identified
standard studying debris of fracture fixation plate. Therefore, the authors
suggested the generation of a suite of tribological testing standards on
fracture fixation plate and screws in the aim to answer key questions around the
debris from fracture fixation plate of new materials or new design and
ultimately to provide an insight on how to reduce the risks of debris-related
osteolysis, inflammation and aseptic loosening.
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Affiliation(s)
- Shiling Zhang
- Aston Institute of Materials Research (AIMR), Aston University, Birmingham, UK
| | - Dharmesh Patel
- Invibio Biomaterial Solutions Limited, Hillhouse International, Thornton-Cleveleys, UK
| | - Mark Brady
- Invibio Biomaterial Solutions Limited, Hillhouse International, Thornton-Cleveleys, UK
| | - Sherri Gambill
- Invibio Biomaterial Solutions Limited, Hillhouse International, Thornton-Cleveleys, UK
| | | | - Subodh Deshmukh
- Sandwell and West Birmingham Hospital NHS Trust, Birmingham, UK
| | - John Swadener
- Aston Institute of Materials Research (AIMR), Aston University, Birmingham, UK
| | - Sarah Junaid
- Aston Institute of Materials Research (AIMR), Aston University, Birmingham, UK
| | - Laura Jane Leslie
- Aston Institute of Materials Research (AIMR), Aston University, Birmingham, UK
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Ott N, Hackl M, Prescher A, Scaal M, Lanzerath F, Müller LP, Wegmann K. The effect of long calcar screws on the primary stability of 3-part, varus impacted proximal humeral fractures compared to short calcar screws: a real fracture simulation study. Arch Orthop Trauma Surg 2022; 143:2485-2491. [PMID: 35635575 PMCID: PMC10110638 DOI: 10.1007/s00402-022-04473-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 04/27/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Complex proximal humeral fracture ranks among the most common fracture types, especially in elderly patients. In locked plate fixation of proximal humerus fractures, the calcar is deciding for screws providing further medial column support. To date, the biomechanical effect of the length of these calcar screws is not well known. The purpose of this study was to analyze the effect of long calcar screws on fresh frozen prefractured cadaveric specimens. METHODS In the present biomechanical study, 8 pairs of cadaveric proximal humeri were fractured identically using a custom-made fracture simulator. ORIF was performed using a locking plate (PHILOS; Fa. Synthes). The specimens were tested in a biomechanical setup under increased axial load without any calcar screws installed, with short calcar screws and long calcar screws installed. Strain gages (4-wire-120 Ohm, Fa. Vishay) mounted on the locking plate were used to evaluate the fixation strain and to give an estimate for primary stability.. RESULTS The measured strain of the locking plate without calcar screws (804,64 µm/m) at maximum load (200 N) was significantly higher than with short (619,07 µm/m; p = 0.02) or long calcar screws (527,31 µm/m; p = 0.007). Additionally, strain with short calcar screws was noticeably higher in comparison to long calcar screws (619,07 µm/m vs. 527,31 µm/m; p = 0.03). CONCLUSION Use of calcar screws improves the stability of realistically impacted 3-part varus humeral fractures. Long calcar screws that are positioned as close as possible to the joint provide further primary stability compared to short calcar screws. LEVEL OF EVIDENCE Basic science study.
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Affiliation(s)
- Nadine Ott
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Street 62, 50937, Cologne, Germany.
| | - Michael Hackl
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Andreas Prescher
- Institute of Molecular and Cellular Anatomy -Prosektur, RWTH Aachen, Aachen, Germany
| | - Martin Scaal
- Department of Anatomy, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Fabian Lanzerath
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Lars Peter Müller
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Kilian Wegmann
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Street 62, 50937, Cologne, Germany.,Orthopädische Chirurgie München, OCM Clinic, Steinerstrasse 6, 81369, Munich, Germany
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Optimization of Locking Plate Screw Angle Used to Treat Two-Part Proximal Humerus Fractures to Maintain Fracture Stability. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12094739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Proximal humerus fractures increase with the aging of the population. Due to the high failure rates of surgical treatments such as open reduction and internal fixation (ORIF), biomechanical studies seek to optimize the treatments and intervening factors to improve the quality of life of people undergoing these treatments. The aim of the present study was to determine the optimal insertion angle configuration of screws used in a two-part proximal humerus fracture-locking plate osteosynthesis treatment based on finite element analysis (FEA). A series of 3D models of PHILOS locking plates with different screw insertion angle configurations were designed using a matrix system for screw angulation. The locking plate models were evaluated in a two-part proximal humerus fracture with surgical neck fracture under bending and compressive loading conditions using FEA and statistically analyzed using a design of experiments (DOE). The optimal screw insertion angle setting showed an improvement in relation to the interfragmentary strain value of the fracture. Moreover, calcar screws were the most significant feature in fracture stability throughout the tests, followed by the divergence of the most proximal screws and the proximal–distal alignment of the locking plate.
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Zhang H, Xu X, Wu S, Liu Y, Mei J. A finite element analysis study based on valgus impacted femoral neck fracture under diverse stances. Comput Methods Biomech Biomed Engin 2022; 25:475-486. [PMID: 35373661 DOI: 10.1080/10255842.2021.1921165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The aim of the study was to determine the biomechanical environment of patients who suffer from valgus impacted femoral neck fracture. With the help of computational modeling, both of finite element hip fracture and normal three-dimensional model were reconstructed from a patient with hip fracture. The predicted stress distribution was compared between before and after fracture. After the fracture, during standing and the gait, the fracture site has a greater change in stress distribution due to the shortening of the femoral neck. The largest stress occurs at the middle and lower end of the femoral shaft, which occurs from toe off to deceleration during the whole gait. After the fracture, greater stress on the femoral head will result in a worse mechanical environment for the femur. The stress peak value of the femoral shaft is larger than the unfractured side and the stress distribution is uneven. From the results of gait analysis, it is concluded that the increase of concentrated stress and the change of stress distribution will cause the possibility of secondary fractures at the middle and lower ends of the femoral shaft when there is an accident in the case of existing fracture.
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Affiliation(s)
- Haowei Zhang
- Department of Biomedical Engineering, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Xinsheng Xu
- Department of Biomedical Engineering, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Shenghui Wu
- Department of Orthopedics, Shanghai Sixth Peoples Hospital, Shanghai, China
| | - Ying Liu
- Department of Biomedical Engineering, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Jiong Mei
- Department of Orthopedics, Shanghai Sixth Peoples Hospital, Shanghai, China
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Abstract
PURPOSE OF REVIEW Fracture fixation aims to provide stability and promote healing, but remains challenging in unstable and osteoporotic fractures with increased risk of construct failure and nonunion. The first part of this article reviews the clinical motivation behind finite element analysis of fracture fixation, its strengths and weaknesses, how models are developed and validated, and how outputs are typically interpreted. The second part reviews recent modeling studies of the femur and proximal humerus, areas with particular relevance to fragility fractures. RECENT FINDINGS There is some consensus in the literature around how certain modeling aspects are pragmatically formulated, including bone and implant geometries, meshing, material properties, interactions, and loads and boundary conditions. Studies most often focus on predicted implant stress, bone strain surrounding screws, or interfragmentary displacements. However, most models are not rigorously validated. With refined modeling methods, improved validation efforts, and large-scale systematic analyses, finite element analysis is poised to advance the understanding of fracture fixation failure, enable optimization of implant designs, and improve surgical guidance.
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Affiliation(s)
- Gregory S Lewis
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, Hershey, PA, USA.
| | | | - Hwabok Wee
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, Hershey, PA, USA
| | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, Hershey, PA, USA
| | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland
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Biomechanical Comparison of a Novel Implant and Commercial Fixation Devices for AO/OTA 43-C1 Type Distal Tibial Fracture. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11104395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study compares the novel Asia Distal Lateral Tibial Locking Plate mechanical stability to that of the current anterolateral and medial tibial plates based on finite element analysis. Four-part fracture fragment model of the distal tibia was reconstructed using CAD software. A load was applied to simulate the swing phase of gait. The implant stress and the construct stiffness were compared. The results of the anterolateral plate and the medial plate were similar and the displacement values were determined lower than those in the medial plate. In the simulated distal tibia fracture, the Aplus Asia Distal Lateral Tibial Locking Plate and medial distal tibial plate tibia fixations will lead to a stiffer bone-implant construct compared to the anterolateral distal tibial plate. Moreover, the stress in the Aplus Asia Distal Lateral Tibial Locking Plate was lower than those for the medial distal tibial plate and anterolateral bone plates. The Aplus Asia Distal Lateral Tibial Locking Plate has better stabilization and is an anterolateral plate that avoids more soft tissue damage than other bone plates. The Aplus Asia Distal Lateral Tibial Locking Plate could be one of a suitable design in tibia distal fracture fixation.
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Kim H, Lee W, Choi S, Kholinne E, Lee E, Alzahrani WM, Koh KH, Jeon IH, Kim S. Role of Additional Inferomedial Supporting Screws in Osteoporotic 3-Part Proximal Humerus Fracture: Finite Element Analysis. Geriatr Orthop Surg Rehabil 2020; 11:2151459320956958. [PMID: 33224551 PMCID: PMC7649924 DOI: 10.1177/2151459320956958] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/08/2020] [Accepted: 08/18/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Importance of inferomedial supporting screws in preventing varus collapse has been investigated for the proximal humerus fracture. However, few studies reported the results of osteoporotic complex fracture. This study aimed to demonstrate the stress distribution pattern, particularly in osteoporotic 3-part proximal humerus fractures involving greater tuberosity (GT) with different screw configurations. MATERIALS AND METHODS Using the computed tomography (CT) images of 2 patients, who had osteoporosis and the other had normal bone density, 3-part fractures involving the GT, without medial support were reconstructed. To reflect the osteoporosis or real bone density, Hounsfield unit of CT scans were utilized. A force of 200 N was applied in 30° varus direction. The proximal screws were set in 2 ways: 6 screws without inferomedial supporting screws and 9 screws with inferomedial supporting screws. Qualitative and quantitative analysis of internal stress distribution were performed. RESULTS The most proximal part area near humeral head vertex and near the 1st screw's passage and tip had more stress concentrated in osteoporotic 3-part fractures. The stress distribution around the proximal screws was found near the GT fracture line and its lateral side, where the local max values located. Inferomedial supporting screws decreased these effects by changing the points to medial side from the GT. The ratio in osteoporotic bone model decreased to that in normal bone model when inferomedial supporting screws were applied (normal bone, 2.97%-1.30%; osteoporosis bone, 4.76%-1.71%). CONCLUSIONS In osteoporotic 3-part proximal humerus fracture, the stress distribution was concentrated on the area near the humeral vertex, 1st row screw tips, and lateral side region from the GT fracture line. Moreover, inferomedial supporting screws ensured that the stress distribution is similar to that in normal bone setting, particularly in osteoporotic condition.
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Affiliation(s)
- Hyojune Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | | | - Erica Kholinne
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Orthopedic Surgery, St. Carolus Hospital, Jakarta, Indonesia
| | - Euisop Lee
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wael Mohammed Alzahrani
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Orthopaedic Surgery, Najran University Hospital, Najran, Saudi Arabia
| | - Kyoung Hwan Koh
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Ho Jeon
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shinseok Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Mischler D, Windolf M, Gueorguiev B, Nijs S, Varga P. Computational optimisation of screw orientations for improved locking plate fixation of proximal humerus fractures. J Orthop Translat 2020. [DOI: 10.1016/j.jot.2020.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
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13
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Trends in the Characterization of the Proximal Humerus in Biomechanical Studies: A Review. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10186514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Proximal humerus fractures are becoming more common due to the aging of the population, and more related scientific research is also emerging. Biomechanical studies attempt to optimize treatments, taking into consideration the factors involved, to obtain the best possible treatment scenario. To achieve this, the use of finite element analysis (FEA) is necessary, to experiment with situations that are difficult to replicate, and which are sometimes unethical. Furthermore, low costs and time requirements make FEA the perfect choice for biomechanical studies. Part of the complete process of an FEA involves three-dimensional (3D) bone modeling, mechanical properties assignment, and meshing the bone model to be analyzed. Due to the lack of standardization for bone modeling, properties assignment, and the meshing processes, this article aims to review the most widely used techniques to model the proximal humerus bone, according to its anatomy, for FEA. This study also seeks to understand the knowledge and bias behind mechanical properties assignment for bone, and the similarities/differences in mesh properties used in previous FEA studies of the proximal humerus. The best ways to achieve these processes, according to the evidence, will be analyzed and discussed, seeking to obtain the most accurate results for FEA simulations.
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Tilton M, Armstrong AD, Wee H, Hast MW, Manogharan G, Lewis GS. Finite Element-Predicted Effects of Screw Configuration in Proximal Humerus Fracture Fixation. J Biomech Eng 2020; 142:081005. [PMID: 31913444 DOI: 10.1115/1.4045907] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Indexed: 11/08/2022]
Abstract
Internal fixation with the use of locking plates is the standard surgical treatment for proximal humerus fractures, one of the most common fractures in the elderly. Screw cut-out through weak cancellous bone of the humeral head, which ultimately results in collapse of the fixed fracture, is the leading cause of failure and revision surgery. In an attempt to address this problem, surgeons often attach the plate with as many locking screws as possible into the proximal fragment. It is not thoroughly understood which screws and screw combinations play the most critical roles in fixation stability. This study conducted a detailed finite element analysis to evaluate critical parameters associated with screw cut-out failure. Several clinically relevant screw configurations and fracture gap sizes were modeled. Findings demonstrate that in perfectly reduced fracture cases, variation of the screw configurations had minor influence on mechanical stability of the fixation. The effects of screw configurations became substantial with the existence of a fracture gap. Interestingly, the use of a single anterior calcar screw was as effective as utilizing two screws to support the calcar. On the other hand, the variation in calcar screw configuration had minor influence on the fixation stability when all the proximal screws (A-D level) were filled. This study evaluates different screw configurations to further understand the influence of combined screw configurations and the individual screws on the fixation stability. Findings from this study may help decrease the risk for screw cut-out with proximal humerus varus collapse and the associated economic costs.
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Affiliation(s)
- Maryam Tilton
- Department of Mechanical Engineering, Pennsylvania State University, 230 Innovation Blvd., University Park, PA 16803
| | - April D Armstrong
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, 500 University Dr., Hershey, PA 17033
| | - Hwabok Wee
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, 500 University Dr., Hershey, PA 17033
| | - Michael W Hast
- Biedermann Lab for Orthopaedic Research, Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, 10th Floor, Suite 1050, Philadelphia, PA 19104
| | - Guha Manogharan
- Department of Mechanical Engineering, Pennsylvania State University, 230 Innovation Blvd., University Park, PA 16803
| | - Gregory S Lewis
- Department of Orthopaedics & Rehabilitation, Center for Orthopaedic Research and Translational Science, Pennsylvania State University, 500 University Dr., Hershey, PA 17033; Department of Mechanical Engineering Center for Orthopaedic Research and Translational Science, Pennsylvania State University, 500 University Dr., Hershey, PA 17033
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15
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Feng X, Qi W, Wang C, Leung F, Chen B. Effect of the screw tightening sequence on the stress distribution of a dynamic compression plate: A pilot finite element study. J Orthop Surg (Hong Kong) 2020; 27:2309499019876073. [PMID: 31554466 DOI: 10.1177/2309499019876073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Although the optimal screw tightening sequence is a common question orthopaedists encounter during fractures fixation with a dynamic compression plate (DCP), the effect of the screw tightening sequence on the stability of the plate has never been explored. This study explores the effect of the screw tightening sequence on the stress distribution of a DCP using a finite element method. METHODS Idealized finite element analysis models of the femoral diaphysis with six-hole or eight-hole DCPs were constructed. The screw tightening preload was simulated using 'bolt load' in ABAQUS. Two screw tightening sequences were studied for the six-hole plate and six sequences were studied for the eight-hole plate. U magnitude and Von Mises stress were used to evaluate the deformation and stress distribution of the plate, respectively. Deformation and stress distribution plots from different sequences were compared. RESULTS The different screw tightening sequences showed different deformation processes, while all had the same final deformation after all the screws were tightened. Each screw tightening step of different tightening sequences showed different stress distributions in the plate, while all had the same stress distribution after all the screws were tightened. CONCLUSION Using different screw tightening sequences to fix the same DCP can produce the same stability, which means in terms of fixation stability, after the two screws nearest to the fracture line are tightened, surgeons do not need to hesitate about the order in which the rest screws should be inserted during the surgery.
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Affiliation(s)
- Xiaoreng Feng
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Weichen Qi
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Chengyong Wang
- Institute of Manufacturing Technology, Guangdong University of Technology, Guangzhou, China
| | - Frankie Leung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Bin Chen
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Fang R, Ji A, Zhao Z, Long D, Chen C. A regression orthogonal biomechanical analysis of internal fixation for femoral shaft fracture. Biocybern Biomed Eng 2020. [DOI: 10.1016/j.bbe.2020.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Finite Element- and Design of Experiment-Derived Optimization of Screw Configurations and a Locking Plate for Internal Fixation System. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2019; 2019:5636528. [PMID: 31531124 PMCID: PMC6721095 DOI: 10.1155/2019/5636528] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/12/2019] [Accepted: 07/03/2019] [Indexed: 11/20/2022]
Abstract
Objectives The optimization for the screw configurations and bone plate parameters was studied to improve the biomechanical performances such as reliable internal fixation and beneficial callus growth for the clinical treatment of femoral shaft fracture. Methods The finite element analysis (FEA) of internal fixation system under different screw configurations based on the orthogonal design was performed and so was for the different structural parameters of the locking plate based on the combination of uniform and orthogonal design. Moreover, orthogonal experiment weight matrixes for four evaluation indexes with FEA were analyzed. Results The analytical results showed the optimal scheme of screw configuration was that screws are omitted in the thread holes near the fracture site, and single cortical screws are used in the following holes to the distal end, while the double cortical screws are fixed in thread holes that are distal to the fracture; in the other words, the length of the screws showed an increasing trend from the fracture site to the distal end in the optimized configuration. The plate structure was optimized when thread holes gap reached 13 mm, with a width of 11 mm and 4.6 mm and 5 mm for thickness and diameter of the screw, respectively. The biomechanical performance of the internal fixation construct was further improved by about 10% based on the optimal strain range and lower stress in the internal fixation system. Conclusions The proposed orthogonal design and uniform design can be used in a more efficient way for the optimization of internal fixation system, which can reduce the simulation runs to about 10% compared with comprehensive test, and the methodology can be also used for other types of fractures to achieve better internal fixation stability and optimal healing efficiency, which may provide a method for an orthopedist in choosing the screw configurations and parameters for internal fixation system in a more efficient way.
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18
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Antoniac IV, Stoia DI, Ghiban B, Tecu C, Miculescu F, Vigaru C, Saceleanu V. Failure Analysis of a Humeral Shaft Locking Compression Plate-Surface Investigation and Simulation by Finite Element Method. MATERIALS 2019; 12:ma12071128. [PMID: 30959903 PMCID: PMC6479305 DOI: 10.3390/ma12071128] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 03/28/2019] [Accepted: 04/03/2019] [Indexed: 12/11/2022]
Abstract
A case study of a failed humeral shaft locking compression plate is presented, starting with a clinical case where failure occurred and an implant replacement was required. This study uses finite element method (FEM) in order to determine the failure modes for the clinical case. Four loading scenarios that simulate daily life activities were considered for determining the stress distribution in a humeral shaft locking compression plate (LCP). Referring to the simulation results, the failure analysis was performed on the explant. Using fracture surface investigation methods, stereomicroscopy and scanning electron microscopy (SEM), a mixed mode failure was determined. An initial fatigue failure occurred followed by a sudden failure of the plate implant as a consequence of patient's fall. The fracture morphology was mostly masked by galling; the fractured components were in a sliding contact. Using information from simulations, the loading was inferred and correlated with fracture site and surface features.
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Affiliation(s)
- Iulian Vasile Antoniac
- Department of Metallic Materials Science, Physical Metallurgy, University Politehnica of Bucharest, 313 SplaiulIndependentei, J Building, District 6, 060042 Bucharest, Romania.
| | - Dan Ioan Stoia
- Department of Mechanics and Strength of Materials, Politehnica University of Timisoara, 1 Mihai Viteazul Avenue, 300222 Timisoara, Romania.
| | - Brandusa Ghiban
- Department of Metallic Materials Science, Physical Metallurgy, University Politehnica of Bucharest, 313 SplaiulIndependentei, J Building, District 6, 060042 Bucharest, Romania.
| | - Camelia Tecu
- Department of Metallic Materials Science, Physical Metallurgy, University Politehnica of Bucharest, 313 SplaiulIndependentei, J Building, District 6, 060042 Bucharest, Romania.
| | - Florin Miculescu
- Department of Metallic Materials Science, Physical Metallurgy, University Politehnica of Bucharest, 313 SplaiulIndependentei, J Building, District 6, 060042 Bucharest, Romania.
| | - Cosmina Vigaru
- Department of Mechanics and Strength of Materials, Politehnica University of Timisoara, 1 Mihai Viteazul Avenue, 300222 Timisoara, Romania.
| | - Vicentiu Saceleanu
- Faculty of Medicine, University Lucian Blaga of Sibiu, 2A Lucian Blaga Str., 550169 Sibiu, Romania.
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Jabran A, Peach C, Zou Z, Ren L. Parametric Design Optimisation of Proximal Humerus Plates Based on Finite Element Method. Ann Biomed Eng 2018; 47:601-614. [PMID: 30386950 PMCID: PMC6342901 DOI: 10.1007/s10439-018-02160-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 10/22/2018] [Indexed: 10/30/2022]
Abstract
Optimal treatment of proximal humerus fractures remains controversial. Locking plates offer theoretical advantages but are associated with complications in the clinic. This study aimed to perform parametric design optimisation of proximal humerus plates to enhance their mechanical performance. A finite element (FE) model was developed that simulated a two-part proximal humerus fracture that had been treated with a Spatial Subchondral Support (S3) plate and subjected to varus bending. The FE model was validated against in vitro biomechanical test results. The predicted load required to apply 5 mm cantilever varus bending was only 0.728% lower. The FE model was then used to conduct a parametric optimisation study to determine the orientations of inferomedial plate screws that would yield minimum fracture gap change (i.e. optimal stability). The feasible design space was automatically identified by imposing clinically relevant constraints, and the creation process of each FE model for the design optimisation was automated. Consequently, 538 FE models were generated, from which the obtained optimal model had 4.686% lower fracture gap change (0.156 mm) than that of the manufacturer's standard plate. Whereas its screws were oriented towards the inferomedial region and within the range of neck-shaft angle of a healthy subject. The methodology presented in this study promises future applications in patient-specific design optimisation of implants for other regions of the human body.
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Affiliation(s)
- Ali Jabran
- School of Mechanical, Aerospace and Civil Engineering, University of Manchester, Sackville Street, Manchester, M13 9PL, UK
| | - Chris Peach
- School of Mechanical, Aerospace and Civil Engineering, University of Manchester, Sackville Street, Manchester, M13 9PL, UK.,Department of Shoulder and Elbow Surgery, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK
| | - Zhenmin Zou
- School of Mechanical, Aerospace and Civil Engineering, University of Manchester, Sackville Street, Manchester, M13 9PL, UK
| | - Lei Ren
- School of Mechanical, Aerospace and Civil Engineering, University of Manchester, Sackville Street, Manchester, M13 9PL, UK.
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20
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Theopold J, Schleifenbaum S, Müller M, Werner M, Hammer N, Josten C, Hepp P. Biomechanical evaluation of hybrid double plate osteosynthesis using a locking plate and an inverted third tubular plate for the treatment of proximal humeral fractures. PLoS One 2018; 13:e0206349. [PMID: 30372476 PMCID: PMC6205804 DOI: 10.1371/journal.pone.0206349] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 10/11/2018] [Indexed: 01/31/2023] Open
Abstract
Background Treating proximal humerus fractures can be challenging because of large metaphyseal defects that conceal anatomical landmarks. In such cases, medial cortical support with, for example, calcar screws, is mandatory. Nevertheless, varus dislocations and implant failures in patients with impaired bone quality persist. Thus, the need for effective treatment of these patients exists. Hybrid double plate osteosynthesis was introduced as an alternative, yielding similar results as calcar screws. However, a biomechanical comparison of the stability of these two techniques is pending. Methods Cadaveric humeral specimens were treated with plate osteosynthesis and calcar screws (group 1, n = 9) or hybrid double plate osteosynthesis (group 2, n = 9) using a proximal humerus fracture model with a two-part fracture. Displacement, stiffness, failure mode, and ultimate load were examined biomechanically in a cyclic compressive-loading scenario. Results Although the hybrid double plate osteosynthesis (group 2) tended to confer higher stiffnesses than the medial support screws at higher cycles (group 1), this trend was below the level of significance. The displacement revealed non-significantly lower values for group 1 as compared with group 2 for cycles 50 and 2000, but at 5000 cycles, group 2 offered non-significantly lower displacement values than group 1. The ultimate load tended to be non-significantly higher in the hybrid double plate osteosynthesis group (group 2: 1342±369 N, group 1: 855±408 N). Both groups yielded similar failure rates, with the majority of failures in group 2 being gap closures (n = 8), whereas those in group 1 being plate dislocations (n = 4). Conclusions The use of an additive plate osteosynthesis in the region of the bicipital groove may be a potential alternative to the previously-established method of using calcar screws. The biomechanical data obtained in this study suggests that hybrid double plate osteosynthesis is as rigid and robust as calcar screws.
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Affiliation(s)
- Jan Theopold
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
- * E-mail:
| | - Stefan Schleifenbaum
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
- ZESBO–Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Leipzig, Germany
| | - Mirijam Müller
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Michael Werner
- Fraunhofer Institute for Machine Tools and Forming Technology, Dresden, Germany
| | - Niels Hammer
- Department of Anatomy, University of Otago, Dunedin, New Zealand
| | - Christoph Josten
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Pierre Hepp
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
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21
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Varga P, Inzana JA, Gueorguiev B, Südkamp NP, Windolf M. Validated computational framework for efficient systematic evaluation of osteoporotic fracture fixation in the proximal humerus. Med Eng Phys 2018; 57:29-39. [PMID: 29728330 DOI: 10.1016/j.medengphy.2018.04.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 02/20/2018] [Accepted: 04/19/2018] [Indexed: 12/24/2022]
Abstract
The high rate of fixation failure in osteoporotic proximal humerus fractures indicate the need for improved solutions. Computer simulations may help to overcome the limitations of the gold standard biomechanical testing in evaluating the performance of new implants and enhance the effectivity and outcome of the design process. This study presents a framework for automated computational analysis that facilitates efficient and systematic evaluation of proximal humerus fracture plating under a variety of conditions including bone quality, fracture pattern, implant configuration and loading regime. The underlying finite element methodology was previously validated. The capabilities of the software tool are demonstrated by virtually reproducing a previously published biomechanical study on the effect of screw augmentation and showing that the models capture the essence of the experimental results. Due to the modular design of the framework, the currently available set of angle-stable plate implants can be readily expanded to include other fixations such as intramedullary nails. Besides the capability to compare already existing solutions, the tool can provide rapid feedback on novel ideas. Therefore, it is expected to efficiently complement and partially replace expensive experimental tests and aid development and optimization of implant designs for improved fixation of osteoporotic proximal humerus fractures.
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Affiliation(s)
- Peter Varga
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland.
| | - Jason A Inzana
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Norbert P Südkamp
- Orthopedics and Trauma Department, University Hospital Freiburg, Breisacher Str. 86, 79110 Freiburg im Breisgau, Germany
| | - Markus Windolf
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
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Biomechanical analysis of plate systems for proximal humerus fractures: a systematic literature review. Biomed Eng Online 2018; 17:47. [PMID: 29703261 PMCID: PMC5923007 DOI: 10.1186/s12938-018-0479-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 04/18/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Proximal humerus fractures are the third most common in the human body but their management remains controversial. Open reduction and internal fixation with plates is one of the leading modes of operative treatment for these fractures. The development of technologies and techniques for these plates, during the recent decades, promise a bright future for their clinical use. A comprehensive review of in vitro biomechanical studies is needed for the comparison of plates' mechanical performance and the testing methodologies. This will not only guide clinicians with plate selection but also with the design of future in vitro biomechanical studies. This review was aimed to systematically categorise and review the in vitro biomechanical studies of these plates based on their protocols and discuss their results. The technologies and techniques investigated in these studies were categorised and compared to reach a census where possible. METHODS AND RESULTS Web of Science and Scopus database search yielded 62 studies. Out of these, 51 performed axial loading, torsion, bending and/or combined bending and axial loading while 11 simulated complex glenohumeral movements by using tendons. Loading conditions and set-up, failure criteria and performance parameters, as well as results for each study, were reviewed. Only two studies tested four-part fracture model while the rest investigated two- and three-part fractures. In ten studies, synthetic humeri were tested instead of cadaveric ones. In addition to load-displacement data, three-dimensional motion analysis systems, digital image correlation and acoustic emission testing have been used for measurement. CONCLUSIONS Overall, PHILOS was the most tested plate and locking plates demonstrated better mechanical performance than non-locking ones. Conflicting results have been published for their comparison with non-locking blade plates and polyaxial locking screws. Augmentation with cement [calcium phosphate or poly(methyl methacrylate)] or allografts (fibular and femoral head) was found to improve bone-plate constructs' mechanical performance. Controversy still lies over the use of rigid and semi-rigid implants and the insertion of inferomedial screws for calcar region support. This review will guide the design of in vitro and in silico biomechanical tests and also supplement the study of clinical literature.
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Numerical investigation of fracture impaction in proximal humeral fracture fixation with locking plate and intramedullary nail. INTERNATIONAL ORTHOPAEDICS 2017; 41:1471-1480. [DOI: 10.1007/s00264-017-3401-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 01/03/2017] [Indexed: 10/20/2022]
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