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Chancharoen W, Pansai J, Boonchuay T, Saeya S, Das R, Chobpenthai T, Aimmanee S. Performance parametric formulation of carbon fiber-reinforced composite locking bone implant plates based on finite-element analysis. Comput Methods Biomech Biomed Engin 2024:1-17. [PMID: 38808689 DOI: 10.1080/10255842.2024.2358362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 05/17/2024] [Indexed: 05/30/2024]
Abstract
The treatment of Giant Cell Tumor (GCT) in the distal radius poses challenges due to the intricate anatomical features of the bone. It often necessitates the use of long implant plates or the interconnection of multiple short plates after tumor excision. However, the deployment of metal plates may increase the risk of screw loosening and various complications. To address these challenges, this study proposes the adoption of carbon fiber-reinforced PEEK (CFRP) as the base material. As a unique strategy, performance parameters (PP) were developed to compare CFRP implant plates with a Ti-6Al-4V plate using the Finite-element Method. The focus was on four elements: the screw axial force, bone growth, callus formation, and bone resorption. The investigation into the screw axial force involved analyzing the internal force of the screw. The remaining parameters were evaluated using the stress, strain, or elastic energy induced in the bones. The findings showed that the second screw endured the largest screw axial force, measuring 10.16 N under a 90-degree 10-N loading at the translocated bone. The model without a callus exerted a significantly greater force on the screw than the model with a callus, leading to screw loosening in the early stage of treatment. The maximum PP, reached 1.62, was achieved with an angle-ply [456/-456] laminate, featuring a weighting fraction of 0.7 for bone growth and 0.1 for the other parameters. This study provides a generalized methodology for assessing the performances of CFRP implants and offers guidelines for future development in composite implant plate technology.
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Affiliation(s)
- Wares Chancharoen
- Laboratory of Artificial Intelligence and Innovation in Medicine (AIIM), Princess Srisavangavadhana College of Medicine, Chulabhorn Royal Academy, LakSi, Thailand
| | - Jirapong Pansai
- Advanced Materials and Structures Laboratory (AMASS), Center for Lightweight Materials Design and Manufacturing, Department of Mechanical Engineering, Faculty of Engineering, King Mongkut's University of Technology Thonburi, Thung Khru, Thailand
| | - Teeravut Boonchuay
- Advanced Materials and Structures Laboratory (AMASS), Center for Lightweight Materials Design and Manufacturing, Department of Mechanical Engineering, Faculty of Engineering, King Mongkut's University of Technology Thonburi, Thung Khru, Thailand
| | - Somchart Saeya
- Advanced Materials and Structures Laboratory (AMASS), Center for Lightweight Materials Design and Manufacturing, Department of Mechanical Engineering, Faculty of Engineering, King Mongkut's University of Technology Thonburi, Thung Khru, Thailand
| | - Raj Das
- School of Engineering, RMIT University, Melbourne, Australia
| | - Thanapon Chobpenthai
- Laboratory of Artificial Intelligence and Innovation in Medicine (AIIM), Princess Srisavangavadhana College of Medicine, Chulabhorn Royal Academy, LakSi, Thailand
| | - Sontipee Aimmanee
- Advanced Materials and Structures Laboratory (AMASS), Center for Lightweight Materials Design and Manufacturing, Department of Mechanical Engineering, Faculty of Engineering, King Mongkut's University of Technology Thonburi, Thung Khru, Thailand
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Mischler D, Gueorguiev B, Windolf M, Varga P. On the importance of accurate elasto-plastic material properties in simulating plate osteosynthesis failure. Front Bioeng Biotechnol 2023; 11:1268787. [PMID: 38107614 PMCID: PMC10725216 DOI: 10.3389/fbioe.2023.1268787] [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: 07/28/2023] [Accepted: 11/15/2023] [Indexed: 12/19/2023] Open
Abstract
Background: Plate osteosynthesis is a widely used technique for bone fracture fixation; however, complications such as plate bending remain a significant clinical concern. A better understanding of the failure mechanisms behind plate osteosynthesis is crucial for improving treatment outcomes. This study aimed to develop finite element (FE) models to predict plate bending failure and validate these against in vitro experiments using literature-based and experimentally determined implant material properties. Methods: Plate fixations of seven cadaveric tibia shaft fractures were tested to failure in a biomechanical setup with various implant configurations. FE models of the bone-implant constructs were developed from computed tomography (CT) scans. Elasto-plastic implant material properties were assigned using either literature data or the experimentally derived data. The predictive capability of these two FE modelling approaches was assessed based on the experimental ground truth. Results: The FE simulations provided quantitatively correct prediction of the in vitro cadaveric experiments in terms of construct stiffness [concordance correlation coefficient (CCC) = 0.97, standard error of estimate (SEE) = 23.66, relative standard error (RSE) = 10.3%], yield load (CCC = 0.97, SEE = 41.21N, RSE = 7.7%), and maximum force (CCC = 0.96, SEE = 35.04, RSE = 9.3%), when including the experimentally determined material properties. Literature-based properties led to inferior accuracies for both stiffness (CCC = 0.92, SEE = 27.62, RSE = 19.6%), yield load (CCC = 0.83, SEE = 46.53N, RSE = 21.4%), and maximum force (CCC = 0.86, SEE = 57.71, RSE = 14.4%). Conclusion: The validated FE model allows for accurate prediction of plate osteosynthesis construct behaviour beyond the elastic regime but only when using experimentally determined implant material properties. Literature-based material properties led to inferior predictability. These validated models have the potential to be utilized for assessing the loads leading to plastic deformation in vivo, as well as aiding in preoperative planning and postoperative rehabilitation protocols.
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Affiliation(s)
- Dominic Mischler
- AO Research Institute Davos, Davos, Switzerland
- Graduate School for Cellular and Biomedical Sciences (GCB), University of Bern, Bern, Switzerland
| | | | | | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland
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Yoo J, Kwak D, Kim J, Kwon S, Kwon J, Hwang J. Risk Factors of Proximal Screw Breakage of Locking Plate (ZPLP ®) after MIPO for Distal Femur Fractures -Analysis of Patients with Plate Removal after Bony Union. J Clin Med 2023; 12:6345. [PMID: 37834989 PMCID: PMC10573958 DOI: 10.3390/jcm12196345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Locking a compression plate is a more favorable surgical technique than intramedullary nailing in the treatment of distal femur fractures. This study analyzed the risk factors of proximal screw breakage retrospectively, which was confirmed in the patients with plate removal after bony union. METHODS A total of 140 patients who were fixed by MIPO using ZPLP from 2009 to 2019 were identified. A total of 42 patients met the inclusion criteria and were included. The screw breakage group (12 patients) and the non-breakage group (30 patients) were compared. RESULTS Approximately 12 (28.6%) of 42 plate-removal patients showed proximal screw breakage. The breakage of proximal screws developed at the junction of the screw head and neck. The number of broken proximal screws averaged 1.4 (1~4). The breakage of the proximal screw even after the bony union is more frequent in older patients (p = 0.023), the dominant side (p = 0.025), the use of the cortical screw as the proximal uppermost screw (p = 0.039), and the higher plate-screw density (p = 0.048). CONCLUSIONS Advanced age, dominant side, use of the cortical screw as the uppermost screw, and higher plate-screw density were related to proximal screw breakage. When the plate is removed after bony union or delayed union is shown in these situations, the possibility of proximal screw breakage should be kept in mind.
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Affiliation(s)
- Jehyun Yoo
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Anyang-si 14068, Republic of Korea; (J.Y.); (D.K.)
| | - Daekyung Kwak
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Anyang-si 14068, Republic of Korea; (J.Y.); (D.K.)
| | - Joongil Kim
- Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1 Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea; (J.K.); (S.K.); (J.K.)
| | - Seungcheol Kwon
- Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1 Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea; (J.K.); (S.K.); (J.K.)
| | - Junhyuk Kwon
- Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1 Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea; (J.K.); (S.K.); (J.K.)
| | - Jihyo Hwang
- Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1 Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea; (J.K.); (S.K.); (J.K.)
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Askin A, Aldemir C, Duygun F, Nabi V. The Relation between the Radial Collapse and the Number of Metaphyseal Screws for Distal Radius Fractures. Malays Orthop J 2022; 16:30-35. [PMID: 36589376 PMCID: PMC9791896 DOI: 10.5704/moj.2211.006] [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: 08/27/2021] [Accepted: 03/28/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction The purpose of this study is the evaluation of radial collapse, based on the number of screws used in the metaphyseal region and by distal dorsal distance (DDD) and lunate facet distance (LFD) measurement. Materials and methods Between 2015 and 2019, 60 patients who were being treated with volar locking plates due to isolated distal radius fracture were evaluated. Control radiographs were taken on the first day and at 3rd-, 6th- and 12th-month follow-ups. Distal dorsal cortex distance and lunate facet distance were measured in the lateral radiographs. The number of screws used in the metaphyseal region was also evaluated. According to the number of screws, the amount of collapse was analysed based on both the LFD and the DDD. Results The mean age of patients was 43.5±12.7 years. Thirty-three of the patients included in the study were male and 27 were female, and the minimum follow-up period was one year. According to the mean number of screws, groups were defined as up to 6 screws or 7 screws and above. There was a statistically significant difference between the groups in terms of DDD collapse at the 6th-month and 12th-month follow-ups (p<0.005). It was observed that the radial collapse and decrease in DDD and LFD were lower in plates with seven screws and above. Conclusion Decreases in either DDD or LFD, or radial collapse were observed less in patients who had seven or more metaphyseal screws inserted. These findings might be useful for surgeons treating distal radius fractures to reduce radial collapse.
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Affiliation(s)
- A Askin
- Department of Orthopaedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkiye,Corresponding Author: Aydogan Askin, Department of Orthopaedics and Traumatology, Antalya Training and Research Hospital, Varlik, Kazim Karabekir Cd, 07100 Muratpasa/Antalya, Turkiye Phone: +902422491300
| | - C Aldemir
- Department of Orthopaedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkiye
| | - F Duygun
- Department of Orthopaedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkiye
| | - V Nabi
- Department of Orthopaedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkiye
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Muthusamy B, Chao CK, Su SJ, Cheng CW, Lin J. Effects of merged holes, partial thread removal, and offset holes on fatigue strengths of titanium locking plates. Clin Biomech (Bristol, Avon) 2022; 96:105663. [PMID: 35550943 DOI: 10.1016/j.clinbiomech.2022.105663] [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: 01/06/2022] [Revised: 04/30/2022] [Accepted: 05/03/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study investigated the effects of screw hole merging, thread removal, and screw hole offset on the mechanical properties of locking plates. METHODS Finite element models were used to develop the optimal design of the merged holes. Four titanium locking plates with different hole designs were analyzed. Type I had threaded round holes. Type II had merged holes. Type III had merged holes with partial thread removal. Type IV had threaded offset holes. Mechanical experiments similar to finite element analyses were conducted and compared. Screw bending tests were used to assess the screw holding power. FINDINGS Finite element analyses showed the optimal merging distance between two round screw holes was 3.5 mm with 2/3 circumferences in each hole. The stresses of types II and III were respectively 6.42% and 7.33%, lower than that of type I. The stress of type IV was 1.66% higher than that of type I. In the mechanical tests, the fatigue lives of types II and III were respectively 3.86 and 7.16 times higher than that of type I. The fatigue life of type IV was 37% lower than that of type I. The differences in the bending strengths of screws were insignificant. INTERPRETATION Merging holes could mitigate screw hole stress and increase the fatigue lives of the plates significantly. Partial thread removal could further improve the fatigue life. Merging holes and thread removal did not decrease the screw holding power significantly. The fatigue lives were significantly decreased in plates with offset holes.
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Affiliation(s)
- Balraj Muthusamy
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Ching-Kong Chao
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Shinyen Jason Su
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Cheng-Wen Cheng
- Department of Orthopedic Surgery, Sijhih Cathay General Hospital, No. 2, Ln. 59, Jiancheng Rd., Xizhi Dist., New Taipei 221037, Taiwan
| | - Jinn Lin
- Department of Orthopedic Surgery, Sijhih Cathay General Hospital, No. 2, Ln. 59, Jiancheng Rd., Xizhi Dist., New Taipei 221037, Taiwan.
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Ovesy M, Silva-Henao JD, Fletcher JWA, Gueorguiev B, Zysset PK, Varga P. Non-linear explicit micro-FE models accurately predict axial pull-out force of cortical screws in human tibial cortical bone. J Mech Behav Biomed Mater 2021; 126:105002. [PMID: 34894498 DOI: 10.1016/j.jmbbm.2021.105002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/22/2021] [Accepted: 11/24/2021] [Indexed: 11/30/2022]
Abstract
Screws are the most frequently used implants for treatment of bone fractures and play an essential role in determining fixation stability. Robust prediction of the bone-screw interface failure would enable development of improved fixation strategies and implant designs, ultimately reducing failure rates and improving outcomes of bone fracture treatments. This study aimed to compare the accuracy of micro-computed tomography image based bone volume measures, linear micro-finite element (FE) and non-linear micro-FE simulations in predicting pull-out force of 3.5 mm screws in human cadaveric tibial cortical bone. Axial pull-out experiments were performed in forty samples harvested from a single human tibia to measure ultimate force, which was correlated with bone volume around the screw and the predictions by both linear micro-FE and non-linear explicit micro-FE models. Correlation strength was similar for bone volume around the screw (R2 = 0.866) and linear micro-FE (R2 = 0.861), but the explicit non-linear micro-FE models were able to capture the experimental results more accurately (R2 = 0.913) and quantitatively correctly. Therefore, this technique may have potential for future in silico studies aiming at implant design optimization.
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Affiliation(s)
- Marzieh Ovesy
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Juan Diego Silva-Henao
- AO Research Institute Davos, Davos, Switzerland; Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
| | | | | | - Philippe K Zysset
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland.
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Meyers KN, Achor TS, Prasarn ML, Ahn J, Khalsa K, Wellman DS, Lorich DG, Helfet DL. The effects of locking inserts and overtorque on the mechanical properties of a large fragment locking compression plate. J Exp Orthop 2021; 8:106. [PMID: 34817734 PMCID: PMC8613322 DOI: 10.1186/s40634-021-00424-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 11/08/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The study was to determine the effect of locking hole inserts and their insertion torque on the fatigue life of a large fragment Locking Compression Plate (LCP) under bending forces. METHODS Fatigue strength of the LCP was examined using cyclic three-point bend testing at 80% yield strength of the construct. Locking hole inserts were used in 2, 4, and 6-hole of a 12-hole plate to simulate three different working lengths. Within each working length, plates were tested without locking inserts serving as the control group. In the experimental groups, inserts were tightened to manufacturer recommendations (4 Nm) and using overtorque (8 Nm). RESULTS Significantly fewer cycles to failure were observed in control groups versus the locking hole insert groups for all working lengths (2-hole: 4 Nm p = 0.003, 8 Nm p = 0.003; 4-hole: 4 Nm p = 0.02, 8 Nm p < 0.001; 6-hole: 4 Nm p = 0.004, 8 Nm p < 0.001). There was a statistically significant increase in fatigue strength when using overtorque in the 4-hole (p = 0.04) and 6-hole (p = 0.01) defect groups. This was not shown in the 2-hole defect group (p = 0.99). CONCLUSIONS By placing locking inserts in the empty locking regions of Combi holes along the working length, the number of cycles to failure was increased. Tightening inserts to twice the recommended insertion torque further increased cycles to failure in longer working length models. A longer fatigue life has the potential to decease the incidence of plate failure especially in the setting of delayed union due to poor intrinsic healing capacity, fractures in the geriatric population, osteoporosis and periprosthetic fractures.
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Affiliation(s)
- Kathleen N Meyers
- Department of Biomechanics, Hospital for Special Surgery, New York, NY, USA
| | - Timothy S Achor
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Mark L Prasarn
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Jaimo Ahn
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - Kevin Khalsa
- Orethopaedic Trauma Service, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - David S Wellman
- Orethopaedic Trauma Service, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Dean G Lorich
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA
| | - David L Helfet
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 535 East 70th Street, New York, NY, 10021, USA.
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Patterson BM, Breslin MA, Wadenpfuhl LK, Vallier HA. New versus old: 95 degree angled blade plate versus distal femoral locking plate. A randomized clinical trial. Injury 2021; 52:1563-1568. [PMID: 33279173 DOI: 10.1016/j.injury.2020.11.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/19/2020] [Accepted: 11/22/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose was to compare the locking condylar plate (LCP) with the 95° angled blade plate (ABP) for distal femoral fracture patterns amenable to either device. Our hypothesis was that LCP would outperform ABP with primary outcome of nonunion and secondary outcomes of reoperation and malunion. METHODS 78 adult patients with 79 eligible fractures and mean age of 60 years were prospectively randomized to LCP (n = 45) or ABP (n = 34). Mean ISS was 16. 22% fractures were open. Patient-reported functional outcomes were assessed with the Musculoskeletal Function Assessment (MFA). RESULTS All patients were followed to union, and mean follow-up was 25 months. There were no differences in age, sex, fracture pattern, co-morbidities or mechanism for the two groups. Three patients had infections, one superficial after LCP and one deep infection each after ABP and LCP. Three patients developed nonunion after LCP versus none after ABP (p = 0.06). Nine patients healed with minor deformity after LCP versus 5 following ABP. One fracture had major deformity after ABP versus two after LCP. Eight patients had a secondary procedure following LCP versus two after ABP (p = 0.05). CONCLUSIONS The investigation failed to support newer technology being better. Evidence did not indicate the LCP was superior to the ABP. Trends for primary union and fewer secondary procedures suggest that ABP may have superior performance to LCP for fracture patterns which may be treated with either implant.
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Affiliation(s)
- Brendan M Patterson
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, United states
| | - Mary A Breslin
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, United states
| | - Leanne K Wadenpfuhl
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, United states
| | - Heather A Vallier
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, United states.
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Grzeskowiak RM, Freeman LR, Harper DP, Anderson DE, Mulon P. Effect of cyclic loading on the stability of screws placed in the locking plates used to bridge segmental bone defects. J Orthop Res 2021; 39:516-524. [PMID: 32844515 PMCID: PMC7984344 DOI: 10.1002/jor.24838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/04/2020] [Accepted: 08/18/2020] [Indexed: 02/04/2023]
Abstract
The objective of this study was to evaluate the ex vivo effect of cyclic loading on the stability of screws placed in locking plates used to bridge segmental bone defects. The primary interface stability was assessed using peak reverse torque. Eighteen, 8-hole stainless-steel 4.5 mm locking plates and 4.0-mm self-tapping locking-head screws were used to stabilize 40-mm segmental defects in goat tibiae. Treatment groups included control constructs without cyclic loading (n = 6) and constructs tested to 5000 (n = 6) and 10,000 cycles (n = 6) of 600 N compressive axial loading. The insertion of all screws was standardized to 400 N-cm insertion torque. Peak reverse torque was measured immediately after screw placement (control), or after the completion of the respective loading cycles. The difference between treatment groups was compared using univariate analysis of variance. The analysis revealed a significant difference in peak reverse torque of the screws among the treatment groups (p = .000). The mean reverse torque values equaled 343.5 ± 18.3 N-cm for non-cycled controls, 303.3 ± 25.9 and 296.0 ± 42.9 N-cm after 5000 and 10,000 cycles, respectively. Among all treatment groups, screws placed in the distal bone segment tended to have lesser peak reverse torque reduction than those placed in the proximal segment and the difference was proportional to the number of cycles (p = .562; p = .255; p = .013 in control, and after 5000 and 10,000 cycles, respectively). Cyclic loading may have a negative effect on the primary stability of screws placed in locking plate constructs used to bridge segmental bone defects and could contribute to the risk of screw loosening.
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Affiliation(s)
- Remigiusz M. Grzeskowiak
- Large Animal Clinical SciencesUniversity of Tennessee College of Veterinary MedicineKnoxvilleTennesseeUSA
| | - Laura R. Freeman
- Large Animal Clinical SciencesUniversity of Tennessee College of Veterinary MedicineKnoxvilleTennesseeUSA
| | - David P. Harper
- The Center for Renewable Carbon, Institute of AgricultureUniversity of TennesseeKnoxvilleTennesseeUSA
| | - David E. Anderson
- Large Animal Clinical SciencesUniversity of Tennessee College of Veterinary MedicineKnoxvilleTennesseeUSA
| | - Pierre‐Yves Mulon
- Large Animal Clinical SciencesUniversity of Tennessee College of Veterinary MedicineKnoxvilleTennesseeUSA
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10
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The relation between fracture activity and bone healing with special reference to the early healing phase - A preclinical study. Injury 2021; 52:71-77. [PMID: 33131796 DOI: 10.1016/j.injury.2020.10.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fracture healing outcome is to a great extent steered by the mechanical environment. The importance of early phase mechanical fracture stimulation is still controversially discussed, both clinically and scientifically. Furthermore, the role of fracture activity, defined as the number of stimulatory events per time, is particularly for the direct postoperative phase unknown. METHODS Tibial defects of seven Swiss mountain sheep were stabilized with a dynamizable bone fixator, which allowed for defined interfragmentary motion by limiting the maximum axial displacement. The fixator was further equipped with a telemetric measuring unit to continuously log all occurring displacement events above a predefined amplitude threshold over an 8-weeks observation period. Callus size was measured over time from X-rays. Ultimate torsional strength of the healed defects was assessed after euthanasia. RESULTS One animal had to be excluded from the experiment due to technical reasons. The remaining six animals exhibited consistently the highest fracture activity in week 1 post-operation with 6'029 displacement events per week for the animal with the lowest activity and 21'866 events per week for the most active animal. Afterwards fracture activity gradually decreased over time. Strong and significant correlations were found for fracture activity in week 1 and 2 with torsional strength of the healed bone (R ≥ 0.881, p ≤ 0.02). No significant correlations were observed at later timepoints. Fracture activity in week 1 and 2 also correlated strongly with the maximum callus area as measured from X-rays (R ≥ 0.846, p ≤ 0.034). CONCLUSIONS The data demonstrates a positive effect of, within limits, frequent fracture stimulation on bone healing and suggests the importance of the mechanical environment in the direct post-operative healing phase. Clinically, the findings may advocate for the concept of direct post-operative weight bearing. This, however, requires clinical validation and must be considered within the full clinical context including the risk for fixation failure from overloading.
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Sandra ML, Johnson MD, Daniel LD. Reply to Plate Stress Does Not Decrease When Working Length is Increased. Vet Comp Orthop Traumatol 2020; 33:458-460. [PMID: 33181859 DOI: 10.1055/s-0040-1718727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- MacArthur L Sandra
- Pitt County Animal Services/Spay Today, Greenville, North Carolina, United States
| | - Matthew D Johnson
- Department of Small Animal Clinical Sciences, American College of Veterinary Surgeons-Small Animal, College of Veterinary Medicine, University of Florida, Gainesville, Florida, United States
| | - Lewis D Daniel
- Department of Small Animal Clinical Sciences, American College of Veterinary Surgeons-Small Animal, College of Veterinary Medicine, University of Florida, Gainesville, Florida, United States
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Abstract
PURPOSE OF REVIEW Fractures of osteoporotic bone in elderly individuals need special attention. This manuscript reviews the current strategies to provide sufficient fracture fixation stability with a particular focus on fractures that frequently occur in elderly individuals with osteoporosis and require full load-bearing capacity, i.e., pelvis, hip, ankle, and peri-implant fractures. RECENT FINDINGS Elderly individuals benefit immensely from immediate mobilization after fracture and thus require stable fracture fixation that allows immediate post-operative weight-bearing. However, osteoporotic bone has decreased holding capacity for metallic implants and is thus associated with a considerable fracture fixation failure rate both short term and long term. Modern implant technologies with dedicated modifications provide sufficient mechanical stability to allow immediate weight-bearing for elderly individuals. Depending on fracture location and fracture severity, various options are available to reinforce or augment standard fracture fixation systems. Correct application of the basic principles of fracture fixation and the use of modern implant technologies enables mechanically stable fracture fixation that allows early weight-bearing and results in timely fracture healing even in patients with osteoporosis.
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Affiliation(s)
- Marianne Hollensteiner
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Sabrina Sandriesser
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Emily Bliven
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Christian von Rüden
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
- Department of Trauma Surgery, BG Klinikum Murnau, Murnau, Germany
| | - Peter Augat
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany.
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria.
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13
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Panagiotopoulou VC, Varga P, Richards RG, Gueorguiev B, Giannoudis PV. Late screw-related complications in locking plating of proximal humerus fractures: A systematic review. Injury 2019; 50:2176-2195. [PMID: 31727401 DOI: 10.1016/j.injury.2019.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2019] [Indexed: 02/07/2023]
Abstract
Locking plating is a common surgical treatment of proximal humeral fractures with satisfactory clinical results. Implant-related complications, especially screw-related, have been reported, however, the lack of information regarding their onset, used surgical technique, complexity of the fracture, bone quality etc., prevents from understanding the causes for them. The aim of this systematic review is to identify the potential risk factors for late screw complications by gathering information about the patient characteristics, comorbidities, fracture types, surgical approaches and implant types. A PubMed search was performed using humerus, fractures, bone and locking as keywords in clinical papers written in English. All abstracts and manuscripts on distal or humerus shaft fractures, and those on proximal humerus fractures without any or with only iatrogenic complications were excluded. One hundred studies met the inclusion criteria, resulting in 33% of the reported cases having at least one complication, with 11% of all complications being screw-related. Most of the latter were secondary screw perforations and screw cut-outs, being predominantly linked to poor bone quality, while screw loosening and retraction were found less frequently as a result of locking mechanism failure. Overall, the amount of information for complications was limited and screw perforation was the most frequent screw-related complication, mostly reported in female patients older than 50 years, following four-part or AO/OTA type C fractures and detected four weeks postoperatively. The sparse information in the literature could be an indicator that the late screw complications might have been under-reported and under-described, making the understanding of the screw-related complications even more challenging.
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Affiliation(s)
- Vasiliki C Panagiotopoulou
- AO Research Institute Davos, Davos, Switzerland; School of Chemical and Processing Engineering, Engineering Building, University of Leeds, UK.
| | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland
| | | | | | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
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14
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Tuminoh H, Afandi MHM, Gan HS, Kadir MRA, Ramlee MH. Number of Screws Affecting the Stability and Stress Distributions of Conventional and Locking Compression Plate: A Finite Element Study. ACTA ACUST UNITED AC 2019. [DOI: 10.1088/1742-6596/1372/1/012038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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15
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Raina DB, Larsson D, Sezgin EA, Isaksson H, Tägil M, Lidgren L. Biomodulation of an implant for enhanced bone-implant anchorage. Acta Biomater 2019; 96:619-630. [PMID: 31301423 DOI: 10.1016/j.actbio.2019.07.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/14/2019] [Accepted: 07/04/2019] [Indexed: 12/23/2022]
Abstract
Aseptic loosening of implants is the major cause for revision surgery. By modulating the bone-implant interface, early bone-implant anchorage could be improved. Implant surface manipulation by the addition of osteopromotive molecules locally and systemically to promote implant integration has been described with limited success. This study describes a novel approach by making the implant capable of biologically modulating its surroundings. It was hypothesized that the early implant fixation would improve by filling the interior of the implant with a carrier providing spatio-temporal release of bone active drugs with known osteogenic effect. The implant consisted of a threaded polyether ether ketone (PEEK) hollow chamber with holes at the bottom. The implant was filled with a calcium sulphate (CaS)/hydroxyapatite (HA) carrier, delivering two bone active molecules; zoledronic acid (ZA) and bone morphogenic protein-2 (BMP-2). At first, a rat abdominal muscle pouch model indicated a sustained in-vivo release of both 125I-rhBMP-2 (57%) and 14C-ZA (22%) from the CaS/HA carrier over a period of 4-weeks. The biomodulated implant was then inserted in the proximal tibia in rats with the following experimental groups: G1) Empty implant, G2) Implant + CaS/HA, G3) Implant + CaS/HA + ZA and G4) Implant + CaS/HA + ZA + rhBMP-2. Significantly higher bone volume (BV) was seen around the implant in groups G3 (3.3 ± 0.7 mm3) and G4 (3.1 ± 0.7 mm3) compared to the control (1.3 ± 0.4 mm3) using micro-computed tomography and qualitative histology. Group G3, also exhibited significantly higher pull-out force and absorbed energy when compared to the control group G1. These findings indicate that a low dose of ZA alone, released in a controlled manner from within a fenestrated implant is enough to improve implant anchorage without the need of adding rhBMP-2. This simple method of using a fenestrated implant containing a ceramic carrier releasing bone active molecules improved bone anchorage and could clinically reduce prosthetic failure. STATEMENT OF SIGNIFICANCE: Aseptic loosening remains as a major cause for implant revisions and early reaction of surrounding bone to the prosthesis is important for longevity. A novel approach to enhance early bone-implant anchorage is presented. The implant is filled with a carrier providing controlled release of bone active molecules. In an animal model, a calcium sulphate (CaS)/hydroxyapatite (HA) carrier was used to provide a spatio-temporal release of bone morphogenic protein-2 (BMP-2) and zoledronic acid (ZA). Significantly better bone-implant integration was achieved using ZA alone, thereby eliminating the need for adding BMP-2. The developed method of implant biomodulation holds potential to prevent implant loosening and is an alternative to prosthetic coatings or systemic drug treatment. Importantly, all constituents are approved for clinical use.
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16
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Wilson M, Stirling E. Humeral plate failure following trauma – A case report. Trauma Case Rep 2019; 21:100203. [PMID: 31080866 PMCID: PMC6505028 DOI: 10.1016/j.tcr.2019.100203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- M. Wilson
- Corresponding author at: 26 Cathcart Road, London SW10 9NN, United Kingdom of Great Britain and Northern Ireland.
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17
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Locking Hole Inserts: Effect of Insertion Torque on Fatigue Performance and Insert Loosening in Locking Plates. J Orthop Trauma 2019; 33:120-124. [PMID: 30768531 DOI: 10.1097/bot.0000000000001387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the effect of locking hole inserts (LHIs) and their insertion torque on locking plate fatigue life. METHODS Eighteen standard 3.5-mm locking plates were instrumented with LHIs (Smith & Nephew, Memphis, TN) of 1.70 or 3.96 Nm insertion torque, or without LHIs, whereas eleven 4.5-mm locking plates were instrumented with LHIs at 3.96 Nm insertion torque or without LHIs. Plates were cyclically loaded to failure (ie, plate fracture) in four-point bending. Number of cycles to plate failure were measured. RESULTS The 3.5-mm plates with 1.70 Nm LHI insertion torque had a 52% increase in cycles to failure compared with plates without LHIs (114,300 ± 23,680 vs. 75,487 ± 15,746 cycles; P = 0.01). Increasing insertion torque to 3.96 Nm led to a further increase of 36% in fatigue life (155,177 ± 32,493 cycles; P = 0.02) and a 106% increase compared with plates without LHIs (P = 0.001). The 4.5-mm plates with 3.96 Nm insertion torque had a 48% increase in cycles to failure when compared with plates without LHIs (74,369 ± 10,181 vs. 50,214 ± 5544 cycles; P = 0.001). CONCLUSIONS LHIs significantly extend plate fatigue length, which would be advantageous in the setting of delayed fracture healing. We recommend the use of LHIs in round locking holes over bony gaps whenever possible; however, we recognize that these findings are limited to implants manufactured by Smith & Nephew.
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18
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Pitfalls and limits of locking plates. Orthop Traumatol Surg Res 2019; 105:S103-S109. [PMID: 30130659 DOI: 10.1016/j.otsr.2018.04.031] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 04/06/2018] [Accepted: 04/12/2018] [Indexed: 02/02/2023]
Abstract
The use of locking plates relies on novel mechanical and biological concepts: the bone healing is endochondral because of the elasticity of the constructs. Preoperative planning is required to determine the fracture reduction strategy and select the implants. The type of plate and the type of screws and their position determine the mechanical properties of the construct. Failure of locking plate fixation is a new phenomenon that differs from conventional plate fixation. These are brought on by inadequate planning, which is made worse when minimally invasive surgery is performed. Often, the fracture is not reduced correctly (leading to malunion), the implant length is incorrect, or the screw type, number, location and implantation sequence are inappropriate. Together these can result in an overly rigid construct with poor healing and implant failure or the opposite, an overly flexible construct that can compromise healing. The return to weight bearing after fracture fixation must be adapted to the type of fracture and construct. While locking plates provide better bone purchase, especially in osteoporotic bone, "en bloc" pulling out of the implant is possible. Delayed fractures at the end of the plates are also possible but can be avoided by making the correct biomechanical choices during fixation. For epiphyseal fractures, there are risks of cut-out and impaction of locking screws in cancellous bone related to the fracture pathology. In the long-term, locking plates can be difficult to remove; however, specialized instrumentation can make this easier.
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Hung LW, Chao CK, Huang JR, Lin J. Screw head plugs increase the fatigue strength of stainless steel, but not of titanium, locking plates. Bone Joint Res 2019; 7:629-635. [PMID: 30662709 PMCID: PMC6318752 DOI: 10.1302/2046-3758.712.bjr-2018-0083.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objectives Screw plugs have been reported to increase the fatigue strength of stainless steel locking plates. The objective of this study was to examine and compare this effect between stainless steel and titanium locking plates. Methods Custom-designed locking plates with identical structures were fabricated from stainless steel and a titanium alloy. Three types of plates were compared: type I unplugged plates; type II plugged plates with a 4 Nm torque; and type III plugged plates with a 12 Nm torque. The stiffness, yield strength, and fatigue strength of the plates were investigated through a four-point bending test. Failure analyses were performed subsequently. Results For stainless steel, type II and type III plates had significantly higher fatigue strength than type I plates. For titanium, there were no significant differences between the fatigue strengths of the three types of plates. Failure analyses showed local plastic deformations at the threads of screw plugs in type II and type III stainless steel plates but not in titanium plates. Conclusion The screw plugs could increase the fatigue strength of stainless steel plates but not of titanium plates. Therefore, leaving screw holes open around fracture sites is recommended in titanium plates. Cite this article: L-W. Hung, C-K. Chao, J-R. Huang, J. Lin. Screw head plugs increase the fatigue strength of stainless steel, but not of titanium, locking plates. Bone Joint Res 2018;7:629–635. DOI: 10.1302/2046-3758.712.BJR-2018-0083.R1.
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Affiliation(s)
- L-W Hung
- Department of Orthopedic Surgery, Cardinal Tien Hospital, Fun Jen Catholic University, New Taipei City, Taiwan and Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - C-K Chao
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan
| | - J-R Huang
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan
| | - J Lin
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
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20
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Aklilu S, Barei DP, Chew FS. Disengagement and intrapelvic migration of a dynamic helical hip screw. Radiol Case Rep 2018; 14:291-297. [PMID: 30533168 PMCID: PMC6279990 DOI: 10.1016/j.radcr.2018.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 11/26/2022] Open
Abstract
Some proximal femur fractures may be treated surgically with the use of fracture fixation hardware such as the sliding hip screw and its variants. These devices allow the femoral head and neck fragment to compress against the trochanteric or shaft fragment as the hip screw telescopes into the barrel of the side plate. We describe an unusual complication in which the hip screw disengaged in the opposite direction, migrated through the hip joint, and came to rest inside the pelvic cavity. The separated components of the device were surgically removed without further complication.
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Affiliation(s)
- Segen Aklilu
- University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA 98195 USA
| | - David P Barei
- University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA 98195 USA
| | - Felix S Chew
- University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA 98195 USA
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21
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Triana M, Gueorguiev B, Sommer C, Stoffel K, Agarwal Y, Zderic I, Helfen T, Krieg JC, Krause F, Knobe M, Richards RG, Lenz M. LagLoc-a new surgical technique for locking plate systems. J Orthop Res 2018; 36:2886-2891. [PMID: 29917270 DOI: 10.1002/jor.24069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/04/2018] [Indexed: 02/04/2023]
Abstract
Treatment of oblique and spiral fractures remains challenging. The aim of this study was to introduce and investigate the new LagLoc technique for locked plating with generation of interfragmentary compression, combining the advantages of lag screw and locking-head-screw techniques. Oblique fracture was simulated in artificial diaphyseal bones, assigned to three groups for plating with a seven-hole locking compression plate. Group I was plated with three locking screws in holes one, four, and seven. The central screw crossed the fracture line. In group II the central hole was occupied with a lag screw perpendicular to fracture line, whereas holes one and seven were occupied with locking screws. Group III was instrumented applying the LagLoc technique as follows. Hole four was predrilled perpendicularly to the plate, followed by overdrilling of the near cortex and insertion of a locking screw-crossing the fracture line-whose head was covered by a holding sleeve to prevent temporarily the locking in the plate hole and generate interfragmentary compression. Subsequently, the screw head was released and locked in the plate hole. Holes one and seven were occupied with locking screws. Interfragmentary compression in the fracture gap was measured using pressure sensors. All screws in the three groups were tightened with 4 Nm torque. Interfragmentary compression in group I (167 ± 25 N) was significantly lower in comparison to groups II (431 ± 21 N) and III (379 ± 59 N), p ≤ 0.005. The difference in compression between groups II and III remained not significant (p = 0.999). The new LagLoc technique offers an alternative tool to generate interfragmentary compression with the application of locking plates by combining the biomechanical advantages of lag screw and locking screw fixations. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2886-2891, 2018.
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Affiliation(s)
- Miguel Triana
- AO Research Institute Davos, Davos, Switzerland.,Department of Orthopaedic Surgery, Fundación Cardioinfantil, Bogotá, Colombia.,Hospital Infantil San José, Bogotá, Colombia.,Universities of Bosque, Bogotá, Colombia.,Fundación Universitaria Ciencias de la salud, Bogotá, Colombia
| | | | - Christoph Sommer
- Department of General and Trauma Surgery, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Karl Stoffel
- University of Basel, Basel, Switzerland.,Cantonal Hospital Baselland, Orthopedic and Musculoskeletal Traumatology Clinic, Bruderholz, Switzerland
| | | | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | - Tobias Helfen
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - James C Krieg
- Division of Orthopaedic Trauma and Fracture Care, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Fabian Krause
- Department of Orthopaedic Surgery, Inselspital, University of Berne, Bern, Switzerland
| | - Matthias Knobe
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Aachen, Germany
| | | | - Mark Lenz
- Department of Trauma, Hand and Reconstructive Surgery, Friedrich Schiller University Jena, Jena, Germany
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22
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MacLeod AR, Pankaj P. Pre-operative planning for fracture fixation using locking plates: device configuration and other considerations. Injury 2018; 49 Suppl 1:S12-S18. [PMID: 29929685 DOI: 10.1016/s0020-1383(18)30296-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Most locked plating failures are due to inappropriate device configuration for the fracture pattern. Several studies cite screw positioning variables such as the number and spacing of screws as responsible for occurrences of locking plate breakage, screw loosening, and peri-prosthetic re-fracture. It is also widely accepted that inappropriate device stiffness can inhibit or delay healing. Careful preoperative planning is therefore critical if these failures are to be prevented. This study examines several variables which need to be considered when optimising a locking plate fixation device for fracture treatment including: material selection; screw placement; the effect of the fracture pattern; and the bone-plate offset. We demonstrate that device selection is not straight-forward as many of the variables influence one-another and an identically configured device can perform very differently depending upon the fracture pattern. Finally, we summarise the influence of some of the key parameters and the influence this can have on the fracture healing environment and the stresses within the plate in a flowchart.
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Affiliation(s)
| | - Pankaj Pankaj
- School of Engineering, The University of Edinburgh, UK.
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23
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Abstract
Locking plates have led to important changes in bone fracture management, allowing flexible biological fracture fixation based on the principle of an internal fixator. The technique has its indications and limitations. Most of the typical failure patterns arise from basic technical errors. Types of locking plates, material properties and the general principles of locking plate applications are reviewed together with their misapplication.
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Affiliation(s)
| | - Mark Lenz
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Jena, Germany
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24
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Lin CH, Chao CK, Ho YJ, Lin J. Modification of the screw hole structures to improve the fatigue strength of locking plates. Clin Biomech (Bristol, Avon) 2018; 54:71-77. [PMID: 29567519 DOI: 10.1016/j.clinbiomech.2018.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/11/2018] [Accepted: 03/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The fatigue fracture of locking plates can substantially threaten fracture treatment results. In the present study, three measures for modifying the screw hole structures of plates were implemented to improve their fatigue strength. MATERIALS Custom-made identical titanium locking plates, except the screw hole configurations, were tested using four-point bending load. The three measures were partial removal of screw threads on the tension side of the plates, reduction of screw hole size, and modification of the thread radii. There were six types of plates: control (Type I), half of the threads removed (Type II) or one-third of the threads (Type III), smaller screw holes (Type IV), and increase of the thread root radii (Type V) or crest radii (Type VI). FINDINGS Compared with the control, Types II and III significantly improved the fatigue strength (14.5 and 10.1 times, respectively). Decreasing the size of the screw hole (Type IV) also yielded a higher fatigue strength (17.6%). Type VI significantly improved the fatigue strength (9.8 times). However, Type V decreased the fatigue strength (14%). For cyclic stiffness, Type IV was significantly higher than other types statistically. Failure analyses showed typical fatigue fracture in all plates and the cracks were always initiated at the thread crest. INTERPRETATIONS The fatigue strength of titanium locking plates can be significantly improved by structural changes in the screw holes. Removing the threads of the plates and increasing the crest radii of the threads were more effective measures than decreasing the size of the screw holes.
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Affiliation(s)
- Chen-Huei Lin
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Ching-Kong Chao
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Yu-Jou Ho
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Section 4, Taipei, Taiwan
| | - Jinn Lin
- Department of Orthopedics, National Taiwan University Hospital, No. 7, Chung-Shan S. Rd., Taipei, Taiwan.
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25
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Pilz S, Geissler D, Calin M, Eckert J, Zimmermann M, Freudenberger J, Gebert A. Thermomechanical processing of In-containing β-type Ti-Nb alloys. J Mech Behav Biomed Mater 2018; 79:283-291. [DOI: 10.1016/j.jmbbm.2017.12.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 12/15/2017] [Accepted: 12/28/2017] [Indexed: 11/28/2022]
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26
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Ulusoy R, Bilge A, Akalin Y, Akinci M, Ermutlu S. Placing a threaded plug in the hole of a locking plate at the fracture level can increase the resistance of the plate: A biomechanical study. SANAMED 2018. [DOI: 10.24125/sanamed.v13i3.256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objectives: This study aimed to evaluate whether placing a threaded plug in the hole of a locking plate at the fracture level is beneficial for increasing the resistance of the plate. Methods: This experimental study analyzed load and compression forces in sheep tibia bone models. The following groups were assessed: Group 1 (n = 4), control bone samples; Group 2 (n = 4), samples of screw plate fixation without threaded plug in the hole at the fracture level; and Group 3 (n = 4), samples of screw plate fixation with a threaded plug in the hole at the fracture level. Elastic force, bending moment, elastic compression, and rigidity were evaluated using a three-point bending test. Results: Group 1 showed the greatest elastic force and the least amount of compression. The rigidity and elastic force were better in Group 3 than in Group 2. The mean elastic force in Group 3 was 22.4% of that in Group 1, whereas the mean elastic force in Group 2 was 19% of that in Group 1. Rigidity in Group 3 was 24.7% of that in Group 1, whereas rigidity in Group 2 was 18.3% of that in Group 1. Improved results were obtained in Group 3 when compared with Group 2. Conclusions: Our results suggest that placing a threaded plug in the hole of the plate at the fracture level provides additional rigidity and stability by improving resistance to loading forces, but the differences were not statistically significant.
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27
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Slobogean GP, Soswa L, Rotunno G, O’Brien PJ, Lefaivre KA. Digital blinding of radiographs to mask allocation in a randomized control trial. World J Orthop 2017; 8:785-789. [PMID: 29094009 PMCID: PMC5656494 DOI: 10.5312/wjo.v8.i10.785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 08/30/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To demonstrate the effectiveness of a digital radiographic altering technique in concealing treatment allocation to blind outcome assessment of distal femur fracture fixation.
METHODS Digital postoperative anteroposterior and lateral radiographs from a sample of 33 randomly-selected patients with extra-articular distal femur fractures treated by surgical fixation at a Level 1 trauma center were included. Using commercially available digital altering software, we devised a technique to blind the radiographs by overlaying black boxes over the implant hardware while preserving an exposed fracture site for assessment of fracture healing. Three fellowship-trained surgeons evaluated a set of blinded radiographs twice and a control set of unblinded radiographs once. Each set of radiographs were reviewed independently and in a randomly-assigned order. The degrees of agreement and disagreement among evaluators in identifying implant type while reviewing both blinded and unblinded radiographs were assessed using the Bang Blinding Index and James Blinding Index. The degree of agreement in fracture union was assessed using kappa statistics.
RESULTS The assessment of blinded radiographs with both the Bang Blinding Index (BBI) and James Blinding Index (JBI) demonstrated a low degree of evaluator success at identifying implant type (Mean BBI, far cortical locking: -0.03, SD: 0.04; Mean BBI, standard screw: 0, SD: 0; JBI: 0.98, SD: 0), suggesting near perfect blinding. The assessment of unblinded radiographs with both blinding indices demonstrated a high degree of evaluator success at identifying implant type (Mean BBI, far cortical locking: 0.89, SD: 0.19; Mean BBI, standard screw: 0.87, SD: 0.04; JBI: 0.26, SD: 0.12), as expected. There was moderate agreement with regard to assessment of fracture union among the evaluators in both the blinded (Kappa: 0.38, 95%CI: 0.25-0.52) and unblinded (Kappa: 0.35, 95%CI: 0.25-0.45) arms of the study. There was no statistically significant difference in fracture union agreement between the blinded and unblinded groups.
CONCLUSION The digital blinding technique successfully masked the surgeons to the type of implant used for surgical treatment of distal femur fractures but did not interfere with the surgeons’ ability to reliably evaluate radiographic healing at the fracture site.
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Affiliation(s)
- Gerard P Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Lukasz Soswa
- Department of Orthopaedics, University of British Columbia, Vancouver V5Z 1M9, Canada
| | - Giuliana Rotunno
- University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Peter J O’Brien
- Department of Orthopaedics, University of British Columbia, Vancouver V5Z 1M9, Canada
| | - Kelly A Lefaivre
- Department of Orthopaedics, University of British Columbia, Vancouver V5Z 1M9, Canada
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28
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Wittkowske C, Raith S, Eder M, Volf A, Kirschke JS, König B, Ihle C, Machens HG, Döbele S, Kovacs L. Computer assisted evaluation of plate osteosynthesis of diaphyseal femur fracture considering interfragmentary movement: a finite element study. BIOMED ENG-BIOMED TE 2017; 62:245-255. [PMID: 27574854 DOI: 10.1515/bmt-2015-0176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 07/15/2016] [Indexed: 11/15/2022]
Abstract
A semi-automated workflow for evaluation of diaphyseal fracture treatment of the femur has been developed and implemented. The aim was to investigate the influence of locking compression plating with diverse fracture-specific screw configurations on interfragmentary movements (IFMs) with the use of finite element (FE) analysis. Computed tomography (CT) data of a 22-year-old non-osteoporotic female were used for patient specific modeling of the inhomogeneous material properties of bone. Hounsfield units (HU) were exported and assigned to elements of a FE mesh and converted to mechanical properties such as the Young's modulus followed by a linear FE analysis performed in a semi-automated fashion. IFM on the near and far cortex was evaluated. A positive correlation between bridging length and IFM was observed. Optimal healing conditions with IFMs between 0.5 mm and 1 mm were found in a constellation with a medium bridging length of 80 mm with three unoccupied screw holes around the fracture gap. Usage of monocortical screws instead of bicortical ones had negligible influence on the evaluated parameters when modeling non-osteoporotic bone. Minimal user input, automation of the procedure and an efficient computation time ensured quick delivery of results which will be essential in a future clinical application.
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Volar Locking Plate Breakage after Nonunion of a Distal Radius Osteotomy. Case Rep Med 2016; 2016:6836190. [PMID: 28003828 PMCID: PMC5149625 DOI: 10.1155/2016/6836190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/09/2016] [Indexed: 11/18/2022] Open
Abstract
We report a 38-year-old male with a nonunion followed by plate breakage after volar plating of a distal radius osteotomy. Volar locking plates have added a new approach to the treatment of distal radius malunions, due to a lower morbidity of the surgical approach and the strength of the final construction, allowing early mobilization and return to function. Conclusion. Plate breakage is an uncommon complication of volar locking plate fixation. To our knowledge, few cases have been described after a distal radius fracture and no case has been described after a distal radius corrective osteotomy. In the present case, plate breakage appears to have occurred as a result of a combination of multiple factors as the large corrective lengthening osteotomy, the use of demineralized bone matrix instead of bone graft, and the inappropriate fixation technique as an unfilled screw on the osteotomy site, rather than the choice of plate.
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Abstract
Stress modulation is the concept of manipulating bridge plate variables to provide a flexible fixation construct that allows callus formation through uneventful secondary bone healing. Obtaining absolute stability through the anatomic reduction of all fracture fragments comes at the expense of fracture biology, whereas intramedullary nailing, which is more advantageous for diaphyseal fractures of the lower extremity, is technically demanding and often may not be possible when stabilizing many metaphyseal fractures. Overly stiff plating constructs are associated with asymmetric callus formation, early implant failure, and fracture nonunion. Numerous surgeon-controlled variables can be manipulated to increase flexibility without sacrificing strength, including using longer plates with well-spaced screws, choosing titanium or stainless steel implants, and using locking or nonlocking screws. Axially dynamic emerging concepts, such as far cortical locking and near cortical overdrilling, provide further treatment options when bridge plating techniques are used.
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Abstract
OBJECTIVES We compared the postoperative complication rates between the less invasive stabilization system (LISS) plating and locking compression plate for open and closed distal femoral fracture fixation for superiority. DESIGN Retrospective Review. SETTING Multicenter. PARTICIPANTS Patients identified through a hospital database who were treated for supracondylar femur fractures using LISS or LCP techniques between January 2005 and July 2010. INTERVENTION Medical history, patient demographics, injury characteristics, presence of polytrauma, and surgical characteristics were collected for each patient. MAIN OUTCOME MEASUREMENTS χ and logistic regression analysis was performed to compare postoperative infection and nonunion/reoperation regarding both plating techniques. RESULTS Of 339 distal femoral fractures, 185 (54.6%) were repaired with a LISS plate and 154 (45.4%) were repaired with a LCP. Multivariate analysis revealed only open fractures to be a risk factor for nonunion (Odds ratio 2.42, P = 0.01) and infection (Odds ratio 3.47, P = 0.02), regardless of device used. No difference was seen between either plate type in infection, plate failure, or nonunion. CONCLUSIONS Postoperative infection and nonunion rates are comparable between LISS and LCP for both open and closed distal femoral fracture fixation. As no difference was detected between plates, either may be used to treat distal femur fractures. Nonunion rate was higher than expected based on previous reports. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Wiewiorski M, Barg A, Schlemmer T, Valderrabano V. Ankle Joint Fusion With an Anatomically Preshaped Anterior Locking Plate. J Foot Ankle Surg 2015; 55:414-7. [PMID: 25998475 DOI: 10.1053/j.jfas.2015.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Indexed: 02/03/2023]
Abstract
We present a novel fixation plate for primary ankle joint fusion. A single anatomically preshaped angular stable plate was used with an anterior approach. An excellent result with good bone consolidation was present at the 1-year follow-up examination.
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Affiliation(s)
- Martin Wiewiorski
- Surgeon, Osteoarthritis Research Center Basel, University Hospital Basel, Basel, Switzerland.
| | - Alexej Barg
- Assistant Professor, Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Thomas Schlemmer
- Resident, Osteoarthritis Research Center Basel, University Hospital Basel, Basel, Switzerland
| | - Victor Valderrabano
- Professor, Orthopaedic Department, Schmerzklinik Basel, Genolier Swiss Medical Network GSMN, Basel, Switzerland
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Affiliation(s)
- William M Ricci
- Department of Orthopaedic Surgery, Washington University School of Medicine, Campus Box 8233, 660 South Euclid Avenue, St. Louis, MO 63110
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Boretto JG, Pacher N, Giunta D, Gallucci GL, Alfie V, De Carli P. Comparative clinical study of locking screws versus smooth locking pegs in volar plating of distal radius fractures. J Hand Surg Eur Vol 2014; 39:755-60. [PMID: 24401740 DOI: 10.1177/1753193413517806] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The present study was performed to test the null hypothesis on no difference in stability of fixation after volar plating of intra-articular distal radius fractures (AO C2-C3) with either locking smooth pegs or locking screws in a clinical setting. A retrospective evaluation included adult patients with C2-C3 AO fractures treated with a volar plate with locking smooth pegs or locking screws. Radiographic assessment was performed to evaluate extra- and intra-articular parameters in the early postoperative period and after bone union. Twenty-seven consecutive patients were included. Thirteen cases had fixation with locking screws and 14 had fixation with locking smooth pegs. Both groups had bone fragment displacement after fixation. However, there were no significant differences between the groups either in extra- or intra-articular parameters defined by Kreder et al. (1996). Our study shows that, in a clinical setting, there is no difference in stability fixation between locking screws or smooth locking pegs in C2-C3 distal radius fractures.
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Affiliation(s)
- J G Boretto
- Hand and Upper Extremity Surgery Department, Prof. Dr. Carlos Ottolenghi Institute, Orthopedics and Traumatology Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - N Pacher
- Hand and Upper Extremity Surgery Department, Prof. Dr. Carlos Ottolenghi Institute, Orthopedics and Traumatology Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - D Giunta
- Internal Medicine Research Unit, Internal Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - G L Gallucci
- Hand and Upper Extremity Surgery Department, Prof. Dr. Carlos Ottolenghi Institute, Orthopedics and Traumatology Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - V Alfie
- Hand and Upper Extremity Surgery Department, Prof. Dr. Carlos Ottolenghi Institute, Orthopedics and Traumatology Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - P De Carli
- Hand and Upper Extremity Surgery Department, Prof. Dr. Carlos Ottolenghi Institute, Orthopedics and Traumatology Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Vandenbussche E, LeBaron M, Ehlinger M, Flecher X, Pietu G. Blade-plate fixation for distal femoral fractures: a case-control study. Orthop Traumatol Surg Res 2014; 100:555-60. [PMID: 25129706 DOI: 10.1016/j.otsr.2014.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 06/30/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND The blade-plate is the earliest of the contemporary internal fixation devices introduced for distal femoral fractures. The recent development of dedicated, fixation devices has considerably limited its use. The objective of this study was to evaluate outcomes after blade-plate fixation and after fixation using other devices. HYPOTHESIS Outcomes after blade-plate fixation are similar to those after condylar screw-plate, distal femoral nail, or locking condylar plate fixation. MATERIAL AND METHODS We reviewed outcomes after 62 patients managed with blade-plate fixation and included in a multicentre retrospective study (n=57) or a multicentre prospective study (n=5) and we compared them to outcomes after fixation using condylar screw-plates (n=82), distal femoral nail (n=219), or locking condylar plates (n=301). The four groups were comparable for age, gender distribution, occupational status, prevalence of skin wounds, patient-related factors, type of accident, and type of fracture. The evaluation relied on the clinical International Knee Society (IKS) score and on radiographs. RESULTS No significant differences existed across the four groups for operative time, blood transfusion use, complications, need for bone grafting, non-union rate, or IKS score values. The early surgical revision rate for removal of the fixation material was 4% with the blade-plate and 16% with the other three fixation devices (P=0.02). Post-operative fracture deformity was similar in the four groups with, however, a higher proportion of residual malalignment in the screw-fixation group. The final anatomic axis was 3.3±1.4° with the blade-plate versus 2.3±3.7° with the other three fixation devices. The blade-plate group had few patients with axial malalignment, and the degree of malalignment was limited to 3° of varus and 10° of valgus at the most, compared to 10° and 18° respectively, with the other three fixation devices. CONCLUSION Despite the now extremely limited use and teaching of blade-plate fixation, as well as the undeniable technical challenges raised by the implantation of this device, the blade-plate is a simple, strong, and inexpensive fixation method. It remains reliable for the fixation of distal femoral fractures. The disfavour into which the blade-plate is currently falling is not warranted. LEVEL OF EVIDENCE III, case-control study.
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Affiliation(s)
- E Vandenbussche
- Service de chirurgie orthopédique et traumatologique, université René-Descartes, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France.
| | - M LeBaron
- Service de chirurgie orthopédique, hôpital Nord, Assistance Publique des Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France
| | - M Ehlinger
- Service de chirurgie orthopédique et traumatologie, université de Strasbourg, hôpital Hautepierre, Strasbourg University Hospitals, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - X Flecher
- Service de chirurgie orthopédique, hôpital Nord, Assistance Publique des Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France
| | - G Pietu
- Service de chirurgie orthopédique et traumatologique, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
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Schwartz BE, Amirouche FML, Choi KW, Mejia A, Gonzalez M, Seiler JR. A Finite Element Model of Locked Plating in Femoral Shaft Fractures. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojo.2014.44018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Hanschen M, Aschenbrenner IM, Fehske K, Kirchhoff S, Keil L, Holzapfel BM, Winkler S, Fuechtmeier B, Neugebauer R, Luehrs S, Liener U, Biberthaler P. Mono- versus polyaxial locking plates in distal femur fractures: a prospective randomized multicentre clinical trial. INTERNATIONAL ORTHOPAEDICS 2013; 38:857-63. [PMID: 24326361 DOI: 10.1007/s00264-013-2210-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 11/15/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE Treatment of complex fractures of the distal femur utilizing monoaxial locking plates (e.g. Less Invasive Stabilisation System, LISS®, Synthes) is considered to be superior to conventional plating systems. Due to the limitation that the thread forces the screw into pre-determined positions, modifications have been made to allow screw positioning within a range of 30° (Non Contact Bridging, NCB®-DF, Zimmer). For the first time, this multicenter prospective randomized clinical trial (RCT) investigates the outcome of LISS® vs. NCB®-DF treatment following complex fractures of the distal femur. METHODS Since June 2008, 27 patients with a fracture of the distal femur (AO ASIF 33-A-C and periprosthetic fractures) were enrolled in this study by four university trauma centres in southern Germany. Clinical (e.g. range of motion, Oxford knee score, Tegner score) and radiological (e.g. axis deviation, secondary loss of realignment) follow-ups were conducted one and six weeks, as well as three, six, and 12 months after the operation. RESULTS This study comprises data of 27 patients (8 male, 19 female; 15 NCB®-DF, 12 LISS®). Polyaxial osteosynthesis using the NCB® system tended to result in better functional knee scores and a higher range of motion. Interestingly, fracture union tended to be more rapid using the polyaxial plating system. CONCLUSIONS We present the analysis of a multicenter prospective RCT to compare the monoaxial LISS® vs. the polyaxial NCB®-DF treatment following complex fractures of the distal femur. NCB®-DF treatment tended to result in better functional and radiological outcomes than LISS® treatment. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Marc Hanschen
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany,
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Foo TL, Gan AWT, Soh T, Chew WYC. Mechanical failure of the distal radius volar locking plate. J Orthop Surg (Hong Kong) 2013; 21:332-6. [PMID: 24366795 DOI: 10.1177/230949901302100314] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To review 9 cases of mechanical failure of the volar locking plate for distal radial fractures. METHODS Records of 374 consecutive patients who underwent volar locking plating for distal radial fractures were reviewed. Mechanical failures of the volar locking plate were defined as plate breakage or bending, screw breakage or loosening, or collapse of articular fragments resulting in intra-articular screw extrusion. RESULTS Nine mechanical failures occurred between 2 weeks and 3 months in 8 (2.4%) of the patients aged 25 to 82 (median, 74) years with AO fracture types of A3 (n=4), C1 (n=1), C2 (n=1), and C3 (n=3). Mechanical failures included screw pullout (n=5), locking plate bending (n=2), locking screws breakage (n=1), and loosening of locked variable angle screws (n=1). One patient underwent revision of fixation and 2 underwent implant removal. The remainder were treated conservatively. All patients were followed up for a minimum of 12 months; their mean flexion arc was 87 degrees (standard deviation [SD], 17) and the mean rotation arc was 136 degrees (SD, 29 degrees). According to the Green and O'Brien score, their outcomes were good (n=1), fair (n=4), and poor (n=3). CONCLUSION Although mechanical failure of volar locking plate is uncommon, some are potentially preventable.
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Affiliation(s)
- Tun-Lin Foo
- Department of Hand and Reconstructive Microsurgery, National University Health System, Singapore
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Xu GH, Liu B, Zhang Q, Wang J, Chen W, Liu YJ, Peng AQ, Zhang YZ. Biomechanical comparison of gourd-shaped LCP versus LCP for fixation of comminuted tibial shaft fracture. JOURNAL OF HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY. MEDICAL SCIENCES = HUA ZHONG KE JI DA XUE XUE BAO. YI XUE YING DE WEN BAN = HUAZHONG KEJI DAXUE XUEBAO. YIXUE YINGDEWEN BAN 2013; 33:250-257. [PMID: 23592139 DOI: 10.1007/s11596-013-1106-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to compare monotonic biomechanical properties of gourd-shaped LCP fixation with LCP fixation of human tibial shaft in gap fracture mode. Twenty paired fresh cadaveric human tibias were randomly divided into 4 groups (5 pairs each): (1) axial loading single cycle to failure testing, (2) torsion single cycle to failure testing, (3) 4-point bending single cycle to failure testing, and (4) dynamic 4-point bending testing. A 7-hole 4.5 mm gourd-shaped LCP was secured on the anteromedial surface of 1 randomly selected bone from each pair, respectively, using 6 locking screws in the 1st, 2nd, 3rd, 5th, 6th and 7th hole with the middle hole unfilled and just located at the mid-diaphysis of the tibia. A 7-hole 4.5 mm LCP was secured on the other bone with the same method. Standard AO/ASIF techniques were used. After fixation finished, a 10 mm gap in the mid-diaphysis of tibia was created, centrally located at the unfilled hole. The axial, torsional, and bending stiffness and failure strengths were calculated from the collected data in static testings and statistically compared using paired Student's t-test. The 4-point bending fatigue lives of the two constructs were calculated from the dynamic testing data and also statistically compared using paired Student's t-test. Failure modes were recorded and visually analyzed. P<0.05 was considered significant. Results showed that the axial, torsional and bending stiffness of gourd-shaped LCP construct was greater (4%, 19%, 12%, respectively, P<0.05) than that of the LCP construct, and the axial, torsional and bending failure strengths of gourd-shaped LCP construct were stronger (10%, 46%, 29%, respectively, P<0.05) than those of the LCP construct. Both constructs failed as a result of plate plastic torsional deformation. After axial loading and 4-point bending testings, LCP failed in term of an obvious deformation of bent apex just at the unfilled plate hole, while the gourd-shaped LCP failed in term of a deformation of bent arc between the 3rd and 5th holes, which indicated a more consistent stress distribution on gourd-shaped LCP. Fatigue life of gourd-shaped LCP construct was significantly greater than LCP construct (153 836±2 228 vs. 132 471±6 460 cycles, P<0.01). All constructs failed as a result of fracture of the plate through the compression hole of the unfilled combination screw hole. The biomechanical testing showed that gourd-shaped LCP can provide greater stiffness and strength, and longer fatigue life than LCP. The gourd-shaped LCP may be more advantageous mechanically and may reduce the plate breakage rate clinically.
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Affiliation(s)
- Guo-Hui Xu
- Department of Trauma Emergency Center, the Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Bo Liu
- Department of Trauma Emergency Center, the Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Qi Zhang
- Department of Trauma Emergency Center, the Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Juan Wang
- Department of Trauma Emergency Center, the Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Wei Chen
- Department of Trauma Emergency Center, the Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Yue-Ju Liu
- Department of Trauma Emergency Center, the Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - A-Qin Peng
- Department of Trauma Emergency Center, the Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China
| | - Ying-Ze Zhang
- Department of Trauma Emergency Center, the Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China.
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Nassiri M, Macdonald B, O'Byrne JM. Computational modelling of long bone fractures fixed with locking plates - How can the risk of implant failure be reduced? J Orthop 2013; 10:29-37. [PMID: 24403745 DOI: 10.1016/j.jor.2013.01.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 01/01/2013] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND AND PURPOSE The Locking Compression Plate (LCP) is part of a new plate generation requiring an adapted surgical technique and new thinking about commonly used concepts of internal fixation using plates. Knowledge of the fixation stability provided by these new plates is very limited and clarification is still necessary to determine how the mechanical stability and the risk of implant failure can best be controlled. METHODS Upon validation, a finite element model of an LCP attached to a cylinder was developed to simulate and analyse the biomechanics of a transverse long bone fracture fixed with a locking plate. Of special interest were the factors influencing the mechanical conditions at the fracture site, the control of interfragmentary movement and implant failure. RESULTS Several factors were shown to influence stability in compression. Increasing translation and/or fracture angle post fixation reduced construct stability. Axial stiffness was also influenced by the working length and plate-bone distance. The fracture gap had no effect on the construct stability when no bone contact occurred during loading. Stress analysis of the LCP demonstrated that the maximum Von Mises stresses were found in the innermost screws at the screw-head junction. INTERPRETATION For the clinical use of the LCP as a locked internal fixator in fractures with an interfragmentary gap of 1 mm, at least two to four plate holes near the fracture gap should be omitted to allow fracture motion and bone contact to occur. This will also achieve a larger area of stress distribution on the plate and reduce the likelihood of fatigue failure due to cyclic loading.
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Affiliation(s)
- M Nassiri
- Cappagh National Orthopaedic Hospital, Finglas, Dublin, Ireland
| | - B Macdonald
- School of Mechanical Engineering, Dublin City University, Dublin, Ireland
| | - J M O'Byrne
- Cappagh National Orthopaedic Hospital, Finglas, Dublin, Ireland
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Selection of Plate in Internal Fixation of Fractures: Locking Plate and Compression Plate. ACTA ACUST UNITED AC 2013. [DOI: 10.12671/jkfs.2013.26.1.92] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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The effect of locked screw angulation on the biomechanical properties of the S.P.S. Free-Block plate. Vet Comp Orthop Traumatol 2012; 26:117-22. [PMID: 23154447 DOI: 10.3415/vcot-12-03-0045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Accepted: 09/13/2012] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Among the locked internal fixators is one denominated S.P.S. (Synthesis Pengo System) Free-Block, which was designed with a locking ring that allows the screw to be locked and positioned obliquely. Due to the paucity of biomechanical studies on this system, the present work aimed to evaluate the influence of locked screw angulation on the resistance of the S.P.S. Free-Block plate. METHODS Forty synthetic bone cylinders with 10 mm fracture gap were used. Forty seven-hole 3.5 mm stainless steel plates (two AO-like dynamic compression holes and five locked holes) were assembled according to the orientation of the locked screws: monocortical screws were positioned at 90º to the long axis of the cylinder (Group 1), and monocortical screws were positioned at 70º to its cylinder long axis (Group 2). In both groups, AO-like dynamic compression hole screws were positioned bicortically and neutrally. For each group, six specimens were tested until failure, three in bending and three in compression, to determine the loads for fatigue testing. Subsequently, for each group, 14 specimens were tested for failure - seven by bending and seven in compression. RESULTS No significant failure differences were observed between Groups 1 and 2 under static-loading or fatigue test. CLINICAL SIGNIFICANCE In a fracture gap model the orientation of the locked monocortical screws did not show any influence on the mechanical performance of the S.P.S. Free-Block to tests of axial compression and four-point bending.
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Rigid versus flexible plate fixation for periprosthetic femoral fracture—Computer modelling of a clinical case. Med Eng Phys 2012; 34:1041-8. [DOI: 10.1016/j.medengphy.2011.11.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 11/02/2011] [Accepted: 11/03/2011] [Indexed: 01/14/2023]
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Chao P, Lewis DD, Kowaleski MP, Pozzi A. Biomechanical Concepts Applicable to Minimally Invasive Fracture Repair in Small Animals. Vet Clin North Am Small Anim Pract 2012; 42:853-72, v. [DOI: 10.1016/j.cvsm.2012.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Hoerdemann M, Gédet P, Ferguson SJ, Sauter-Louis C, Nuss K. In-vitro comparison of LC-DCP- and LCP-constructs in the femur of newborn calves - a pilot study. BMC Vet Res 2012; 8:139. [PMID: 22909337 PMCID: PMC3514370 DOI: 10.1186/1746-6148-8-139] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 08/15/2012] [Indexed: 11/10/2022] Open
Abstract
Background To compare the biomechanical in-vitro characteristics of limited-contact dynamic compression plate (LC-DCP) and locking compression plate (LCP) constructs in an osteotomy gap model of femoral fracture in neonatal calves. Pairs of intact femurs from 10 calves that had died for reasons unrelated to the study were tested. A 7-hole LC-DCP with six 4.5 mm cortical screws was used in one femur and a 7-hole LCP with four 5.0 mm locking and two 4.5 mm cortical screws was used in the corresponding femur. The constructs were tested to failure by cyclic compression at a speed of 2 mm/s within six increasing force levels. Results The bone-thread interface was stripped in 21 of 80 cortical screws (26.3%) before a pre-set insertion torque of 3 Nm was achieved. Only 3 corresponding intact pairs of constructs could be statistically compared for relative structural stiffness, actuator excursion and width of the osteotomy gap. Relative structural stiffness was significantly greater, actuator excursion and width of the osteotomy gap were significantly smaller in the LCP constructs. While failure occurred by loosening of the screws in the LC-DCP constructs, locking constructs failed by cutting large holes in the soft distal metaphyseal bone. Conclusions An insertion torque sufficient to provide adequate stability in femurs of newborn calves could not be achieved reliably with 4.5 mm cortical screws. Another limiting factor for both constructs was the weak cancellous bone of the distal fracture fragment. LCP constructs were significantly more resistant to compression than LC-DCP constructs.
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Comparison of the 95-degree angled blade plate and the locking condylar plate for the treatment of distal femoral fractures. J Orthop Trauma 2012; 26:327-32. [PMID: 22183200 DOI: 10.1097/bot.0b013e318234d460] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES In the distal femur, locked plating is efficacious when coronal fractures preclude the use of a conventional fixed-angle device. However, minimal comparative data exist for supracondylar fracture patterns, which could be treated with other devices. The purpose of this study was to compare the 95-degree angled blade plate (ABP) versus the Locking Condylar Plate (LCP) by assessing complications and secondary procedures in fractures amenable to treatment with either implant. DESIGN Retrospective review. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Seventy patients with 71 distal femoral fractures (OTA 33-A, 33-C1, 33-C2) amenable to either ABP or LCP with a mean age of 59.5 years (range, 20-92 years) were included. Seventeen fractures (24%) occurred adjacent to a previous knee arthroplasty (10 ABP and 7 LCP). The 2 groups were similar with respect to age, fracture pattern, and the presence of open fracture. Most injuries were the result of high-energy trauma, and 21% were open fractures. INTERVENTION Thirty-two fractures (45%) were treated with an ABP, and 39 (55%) were treated with the LCP. MAIN OUTCOME MEASURES Complications, including infection, nonunion, and malunion, and secondary operations were determined. RESULTS After a mean of 26-month follow-up, 4 patients (6.0%) were treated for infections. Malunions occurred in 11% of LCP patients and in 1 ABP patient (3.4%, P = 0.14). All patients with malunions were older than 55 years. Seven patients (11%) were treated for nonunions. Six of the nonunions occurred after LCP (16% vs. 3.4%, P = 0.11) Complications were more frequent in LCP patients (35%) versus ABP patients (10%, P = 0.001). Complications were not related to fracture pattern, periprosthetic fracture, or open fracture. Mean age of patients with complications was 64 years (vs. 53 years, P = 0.01), and they were more likely to have lower energy mechanisms (P = 0.017). Overall, 18 patients (27%) underwent secondary procedures, including treatment of infection, nonunion, malunion, or prominent implant removal. Secondary procedures were more common after LCP (43%) versus ABP (6.9%, P = 0.0008) patients. Painful prominent implants were removed from 7 LCP patients (18%) and no ABP patients (P = 0.01). CONCLUSIONS Distal femur fractures are often associated with prolonged healing and rehabilitation times, which increase substantially when complications occur. Internal fixation of these fractures may be performed successfully with ABP or LCP. In our review of fractures that could be treated with either implant, patients treated with locking plates had more complications and nonunions, requiring more secondary procedures to treat complications and to remove prominent implants. Furthermore, locking plates are substantially more expensive than conventional fixed-angle devices. Future investigation is needed in the form of a large randomized prospective study to clearly define clinical differences, functional outcomes, and costs of care. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
OBJECTIVE To determine whether locking plates offer an advantage in fixation of fractures in osteoporotic humeral bone. DESIGN Biomechanical testing of 18 matched pairs of osteoporotic human cadaver humeri plated posteriorly with either all locked or all nonlocked screws. An established protocol was used to test the constructs with torque applied to a peak of ±10 Nm for 1000 cycles at 0.3 Hz or until failure. Eighteen pairs were tested for failure, 11 pairs were tested for cycles survived, and 10 pairs were tested for stiffness. SETTING University biomechanical laboratory. MAIN OUTCOME MEASUREMENTS Percentage surviving testing, mean cycles survived, and stiffness. RESULTS We observed catastrophic failure of the constructs in 47% of the samples. Humeri plated with nonlocking plates failed at a higher rate than those with locking plates (67% nonlocking vs 28% locking, n = 18 pairs, P = 0.008). Locking constructs also outperformed nonlocking constructs in mean cycles survived (707 cycles locking, 345 cycles nonlocking, n = 11 pairs, P < 0.05) and stiffness at 10 cycles (0.853 Nm/degree locking vs 0.416 Nm/degree nonlocking, n = 10 pairs, P < 0.001). CONCLUSIONS Locking plates were shown to provide improved mechanical performance over nonlocking plates in torsional cyclic loading in a osteoporotic cadaveric fracture model. Our results confirm general conclusions of previous work that used a synthetic bone model of osteoporosis, but we found a high rate of catastrophic failure, questioning the validity of the previously published synthetic model of osteoporosis (overdrilling of synthetic bone) for this application.
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Yasuda M, Ando Y. A NEW VARIABLE ANGLED LOCKING VOLAR PLATE SYSTEM FOR COLLES' FRACTURE: OUTCOME STUDY AND TIME-COURSE IMPROVEMENT OF OBJECTIVE CLINICAL VARIABLES. ACTA ACUST UNITED AC 2011; 14:93-8. [DOI: 10.1142/s021881040900430x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 04/30/2009] [Accepted: 09/15/2009] [Indexed: 11/18/2022]
Abstract
Our purposes were to report the radiographic outcomes and complications of patients with Colles' fracture treated with the Nakashima locking volar plate system (variable angled distal screw locking mechanism) prospectively and to report the results of objective clinical variables such as grip strength and range of motion of the wrist prospectively at up to one year. This study consisted of eight men and 32 women for analysis of radiographic parameters (volar tilt, radial inclination and radial length) and complications. Radiographic parameters were measured pre-operatively, immediately post-operatively and at final follow-up visit. The average age at operation was 60.3 years old. Among them, we selected 25 cases (6 men and 19 women) whom we followed up at six weeks, three months, six months and one year post-operatively. The average age at operation in this group was 62 years old. We measured objective clinical variables (grip strength, forearm rotation, wrist extension/flexion) at each visit. Except for volar tilt, radiographic parameters revealed no significant changes between immediately post-operative radiographs and radiographs at final follow-up visit. Complications included loss of reduction in two cases. Objective clinical variables other than pronation measurement showed significant increase at each visit up to one year post-operatively. Satisfactory clinical and radiographic results were obtained by using this system. The variable angled distal fragment plating system appears to be a reliable construct for rigid fixation of Colles' fractures; however, technical errors can occur, as with other fixation systems. We demonstrated that the follow-up of Colles' fracture treated by our volar locking plate less than one year post-operative may be insufficient.
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Affiliation(s)
- Masataka Yasuda
- Department of Orthopaedic Surgery, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Yoshiyuki Ando
- Department of Orthopaedic Surgery, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
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Fitzpatrick N, Nikolaou C, Yeadon R, Hamilton M. String-Of-Pearls Locking Plate and Cerclage Wire Stabilization of Periprosthetic Femoral Fractures after Total Hip Replacement in Six Dogs. Vet Surg 2011; 41:180-8. [DOI: 10.1111/j.1532-950x.2011.00870.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Goswami T, Patel V, Dalstrom DJ, Prayson MJ. Mechanical evaluation of fourth-generation composite femur hybrid locking plate constructs. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2011; 22:2139-2146. [PMID: 21769628 DOI: 10.1007/s10856-011-4388-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 07/04/2011] [Indexed: 05/31/2023]
Abstract
Locking compression plates are routinely used for open reduction and internal fixation of fractures. Such plates allow for locking or non-locking screw placement in each hole. A combined use of both types of screw application for stabilization of a fracture is commonly applied and referred to as hybrid internal fixation. Locking screws improve the stability of the fixation construct but at the expense of significant additional cost. This study experimentally analyzes various combinations of locking and non-locking screws under simultaneous axial and torsional loading to determine the optimal hybrid locking plate-screw construct in a fourth generation composite femur. Clinically it is necessary to ensure adequate fixation stability in a worse case fracture-bone quality scenario. A locking screw near the fracture gap increased the axial and torsional strength of the locked plate system. Greater removal torque remained in non-locked screws adjacent to locked screws compared to an all non-locking screws control group.
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Affiliation(s)
- Tarun Goswami
- Department of Biomedical, Industrial and Human Factor Engineering, Wright State University, Dayton, USA.
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