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Wardle B, Lynch JT, Staniforth T, Ward T, Smith P. Weightbearing versus non-weight bearing in geriatric distal femoral fractures: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02550-7. [PMID: 38777887 DOI: 10.1007/s00068-024-02550-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 05/09/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Demographics of patients who sustain geriatric distal femoral fractures (DFF) match those of patients with neck-of-femur fractures but have limited evidence with which to support post-operative weightbearing protocols. PURPOSE This systematic review sought to identify any difference in outcomes for elderly patients with DFF who were allowed early versus delayed weightbearing postoperatively. METHODS DATA SOURCES: PubMed, Medline, Embase and The Cochrane Library, reference lists of retrieved articles. STUDY SELECTION English language papers published between January 2010 and February 2023 with AO-OTA type 33A, B and C femoral fractures as well as Lewis and Rorabeck Type I and II periprosthetic DFF surgically treated with either a lateral locking plate or retrograde intramedullary nail and an average patient age of ≥ 60 years. DATA EXTRACTION Studies were assessed for inclusion by two authors and quality was assessed using the MINORS tool. DATA SYNTHESIS Sixteen studies were included, Meta-analysis of non-union, malunion, infection, delayed union and implant complications was performed using Microsoft Excel and the MetaXL extension. The data on return to mobility were presented in narrative form. The analyses demonstrated no difference between the early and delayed weightbearing groups. CONCLUSIONS There are no significant differences in complication rates between early versus delayed weightbearing after surgery for DFF in an elderly population. The study results are limited by high heterogeneity and low-quality studies. High quality, prospective studies are needed to determine the ideal postoperative weightbearing protocol. LEVEL OF EVIDENCE Level III, Systematic Review and Meta-analysis of Level III studies. International Prospective Register of Systematic Reviews registration-Prospero CRD42022371460.
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Affiliation(s)
- Blaise Wardle
- Trauma and Orthopaedic Research Unit, Yamba Drive, Canberra, Australian Capital Territory, 2605, Australia.
- Canberra Hospital Orthopaedic Department, Canberra, Australian Capital Territory, Australia.
- The Australian National University, Canberra, Australian Capital Territory, Australia.
| | - Joseph T Lynch
- Trauma and Orthopaedic Research Unit, Yamba Drive, Canberra, Australian Capital Territory, 2605, Australia
- The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Thomas Staniforth
- Canberra Hospital Orthopaedic Department, Canberra, Australian Capital Territory, Australia
| | - Thomas Ward
- Trauma and Orthopaedic Research Unit, Yamba Drive, Canberra, Australian Capital Territory, 2605, Australia
- Canberra Hospital Orthopaedic Department, Canberra, Australian Capital Territory, Australia
- The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Paul Smith
- Trauma and Orthopaedic Research Unit, Yamba Drive, Canberra, Australian Capital Territory, 2605, Australia
- Canberra Hospital Orthopaedic Department, Canberra, Australian Capital Territory, Australia
- The Australian National University, Canberra, Australian Capital Territory, Australia
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Gurung R, Terrill A, White G, Windolf M, Hofmann-Fliri L, Dlaska C, Schuetz M, Epari DR. Severity of Complications after Locking Plate Osteosynthesis in Distal Femur Fractures. J Clin Med 2024; 13:1492. [PMID: 38592416 PMCID: PMC10934512 DOI: 10.3390/jcm13051492] [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: 02/09/2024] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Locked plating for distal femur fractures is widely recommended and used. We systematically reviewed clinical studies assessing the benefits and harms of fracture fixation with locked plates in AO/OTA Type 32 and 33 femur fractures. Methods: A comprehensive literature search of PubMed, Embase, Cinahl, Web of Science, and the Cochrane Database was performed. The studies included randomized and non-randomized clinical trials, observational studies, and case series involving patients with distal femur fractures. Studies of other fracture patterns, studies conducted on children, pathological fractures, cadaveric studies, animal models, and those with non-clinical study designs were excluded. Results: 53 studies with 1788 patients were found to satisfy the inclusion and exclusion criteria. The most common harms were nonunion (14.8%), malunion (13%), fixation failure (5.3%), infection (3.7%), and symptomatic implant (3.1%). Time to full weight-bearing ranged from 5 to 24 weeks, averaging 12.3 weeks. The average duration of follow-up was 18.18 months, ranging from 0.5 to 108 months. Surgical time ranged between 40 and 540 min, with an average of 141 min. The length of stay in days was 12.7, ranging from 1 to 61. The average plate length was ten holes, ranging from 5 to 20 holes. Conclusion: This review aimed to systematically synthesize the available evidence on the risk associated with locked plating osteosynthesis in distal femur fractures. Nonunion is the most common harm and is the primary cause of reoperation. The overall combined risk of a major and critical complication (i.e., requiring reoperation) is approximately 20%.
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Affiliation(s)
- Roshan Gurung
- School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane City, QLD 4000, Australia
- Centre for Biomedical Technologies, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia
| | - Alexander Terrill
- School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane City, QLD 4000, Australia
- Centre for Biomedical Technologies, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia
| | - Gentry White
- School of Mathematical Sciences, Queensland University of Technology, Brisbane City, QLD 4000, Australia
| | | | | | - Constantin Dlaska
- The Orthopaedic Research Institute of Queensland, Townsville, QLD 4812, Australia
| | - Michael Schuetz
- School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane City, QLD 4000, Australia
- Centre for Biomedical Technologies, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia
- Jamieson Trauma Institute, Metro North Hospital and Health Services, Herston, QLD 4006, Australia
| | - Devakara R. Epari
- School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane City, QLD 4000, Australia
- Centre for Biomedical Technologies, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia
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Upadhyay P, Syed F, Ramoutar DN, Ward J. The missing piece of the trauma armoury-medial femoral condyle plate. Injury 2022; 53:1237-1240. [PMID: 34839895 DOI: 10.1016/j.injury.2021.11.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 10/16/2021] [Accepted: 11/14/2021] [Indexed: 02/02/2023]
Abstract
Fixation of distal femoral fractures is often challenging due to the fracture configuration and associated poor bone quality. Dual plating (lateral and medial) has become an acceptable option to provide improved stability versus a single plate fixation. Though there are several commercially available anatomically designed plates for the lateral femoral condyle, there is no anatomic plate available in UK specifically for medial fixation of distal femur fractures. Our aim is to determine the best suited pre-contoured plate for stabilising the medial femoral condyle (MFC). Right sided femur sawbones were used to determine how well 18 different pre-contoured anatomical plates (Depuy Synthes, Leeds, UK) fit the medial femoral condyle. Some of these had variable angle (VA) option. Lift off, fit and notch penetration were assessed and recorded independently by 4 orthopaedic trauma surgeons. The number and distribution of screws in the MFC that each plate allowed was also determined. To do this the MFC was divided into quadrants: Proximal anterior (PA), distal anterior (DA), proximal posterior (PP) and distal posterior (DP). The ipsilateral anterolateral proximal tibial (VA and 4.5 mm non-VA), PHILOS, posteromedial proximal tibial and ipsilateral lateral extra-articular distal humeral plate offered good sagittal fit, less than 2 mm lift off at the condyles and no diaphyseal lift off. Plate positioning in the PA quadrant offered the best fit. The ipsilateral anterolateral proximal tibial plates (VA) and PHILOS allowed at least 4 screws to be placed in the PA and 2 in the PP quadrant with no notch penetration. The Tomofix provided good fit, but all 4 screws were in PA quadrant, with distal screws causing notch penetration. The non-VA and PHILOS plates did not offer the VA advantage. The ipsilateral anterolateral proximal tibial VA plates provided the best anatomical fit for the MFC with the greatest number of screws in the condylar quadrants with the option of variable angle screw placement.
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Affiliation(s)
- Piyush Upadhyay
- University Hospital of Coventry & Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK; School of Engineering, University of Warwick, Coventry CV4 7AL
| | - Farhan Syed
- University Hospital of Coventry & Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK.
| | - Darryl N Ramoutar
- University Hospital of Coventry & Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Jayne Ward
- University Hospital of Coventry & Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK
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Biphasic plating improves the mechanical performance of locked plating for distal femur fractures. J Biomech 2020; 115:110192. [PMID: 33385868 DOI: 10.1016/j.jbiomech.2020.110192] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/18/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
Internal fixation by plate osteosynthesis is the gold standard treatment for distal femur fractures. Despite improvements that preserve the biological conditions for bone healing, there are concerns standard locked plating constructs may be overly stiff. Biphasic plating is a novel concept designed to provide suitable fracture motion and increased implant strength to support early full weight-bearing. This study aims to demonstrate that the Biphasic Plate can be incorporated into a pre-contoured distal femur plate while providing adequate flexibility and increased implant strength. The mechanical performance of the Biphasic Plate (BP) was investigated in comparison to a standard locking plate for the distal femur (LCP-DF). Constructs were formed by mounting the implants on a bone substitute. The construct stiffness and strength under axial loading and the magnitude of interfragmentary movement were determined using finite element analysis. The Biphasic Plate exhibited a bi-linear stiffness response; at low loads, the BP construct was 55% more compliant and at high loads 476% stiffer than the LCP-DF. The Biphasic Plate provided more consistent interfragmentary movement over a wider loading range. At partial weight-bearing loads, the Biphasic Plate produced larger interfragmentary movements (0.18 vs. 0.04 mm). However, at loads equivalent to full weight-bearing, the maximum movements were substantially smaller than the LCP-DF construct (1.5 vs. 3.5 mm). The increased flexibility at low loads was provided without sacrificing implant strength with peak stress in the Biphasic Plate 63% lower than the LCP-DF construct. The biphasic plating concept can be successfully incorporated into anatomically contoured distal femur plates while providing adequate flexibility and increasing implant strength.
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Hofmann-Fliri L, Epari DR, Schwyn R, Zeiter S, Windolf M. Biphasic Plating - In vivo study of a novel fixation concept to enhance mechanobiological fracture healing. Injury 2020; 51:1751-1758. [PMID: 32536529 DOI: 10.1016/j.injury.2020.04.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fracture fixation has advanced significantly with the introduction of locked plating and minimally invasive surgical techniques. However, healing complications occur in up to 10% of cases, of which a significant portion may be attributed to unfavorable mechanical conditions at the fracture. Moreover, state-of-the-art plates are prone to failure from excessive loading or fatigue. A novel biphasic plating concept has been developed to create reliable mechanical conditions for timely bone healing and simultaneously improve implant strength. This paper introduces the novel fixation concept and presents preclinical results from a large animal study. METHODS Twenty-four sheep underwent a mid-diaphyseal osteotomy stabilized with either the novel biphasic plate fixator or a control locking plate. Different fracture patterns regarding orientation and localization were investigated. Animals were free to fully bear weight during the post-operative period. After 12 weeks, the healing fractures were evaluated for bone formation using micro-computer tomography and strength and stiffness using biomechanical testing. Additionally, histological evaluation of soft tissue samples with respect to metal wear debris was performed. RESULTS No plate deformation or failures were observed under full weight bearing with the biphasic plate. Defects stabilized with the biphasic plate demonstrated robust callus formation compared to control group. Torsion tests after plate removal revealed no statistical difference in peak torsion to failure and stiffness for the different fracture patterns stabilized with the biphasic plate. However, the biphasic plate group specimens were 45% stronger (p=0.002) and 48% stiffer (p=0.007) than the controls. No histological signs of metal wear due to the biphasic feature could be found. CONCLUSIONS The biphasic plate concept is aimed at improving the biomechanics of locked plating. The results of this large animal study demonstrate the feasibility and clinical potential of this novel stabilization concept.
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Affiliation(s)
| | - Devakara R Epari
- Queensland University of Technology (QUT), 2 George Street, Brisbane, Queensland 4001, Australia.
| | - Ronald Schwyn
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland.
| | - Stephan Zeiter
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland.
| | - Markus Windolf
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland.
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Wright DJ, DeSanto DJ, McGarry MH, Lee TQ, Scolaro JA. Supplemental Fixation of Supracondylar Distal Femur Fractures: A Biomechanical Comparison of Dual-Plate and Plate-Nail Constructs. J Orthop Trauma 2020; 34:434-440. [PMID: 32032183 DOI: 10.1097/bot.0000000000001749] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This biomechanical study compares the effectiveness of dual-plate (DP) and plate-nail (PN) constructs for fixation of supracondylar distal femur fractures in synthetic and cadaveric specimens. METHODS Twenty-four synthetic osteoporotic femurs were used to compare 4 constructs in an extra-articular, supracondylar fracture gap model (OTA/AO type 33-A3). Constructs included: (1) distal lateral femoral locking plate (DLFLP), (2) retrograde intramedullary nail (rIMN), (3) DLFLP + medial locking compression plate (DP construct), and (4) DLFLP + rIMN (PN construct). DP and PN constructs were then directly compared using 7 matched pairs of cadaveric femurs. Specimens underwent cyclic loading in torsion and compression. Biomechanical effectiveness was measured by quantifying the load-dependent stiffness of each construct. RESULTS In synthetic osteoporotic femurs, the DP construct had the greatest torsional stiffness (1.76 ± 0.33 Nm/deg) followed by the rIMN (1.67 ± 0.14 Nm/deg), PN construct (1.44 ± 0.17 Nm/deg), and DLFLP (0.68 ± 0.10 Nm/deg) (P < 0.01). The DP construct also had the greatest axial stiffness (507.9 ± 83.1 N/mm) followed by the PN construct (371.4 ± 41.9 N/mm), DLFLP (255.0 ± 45.3 N/mm), and rIMN (109.2 ± 47.6 N/mm) (P < 0.05). In cadaveric specimens, the DP construct was nearly twice as stiff as the PN construct in torsion (8.41 ± 0.58 Nm/deg vs. 4.24 ± 0.41 Nm/deg, P < 0.001), and over one-and-a-half times stiffer in compression (2148.1 ± 820.4 vs. 1387.7 ± 467.9 N/mm, P = 0.02). CONCLUSIONS DP constructs provided stiffer fixation than PN constructs in this biomechanical study of extra-articular distal femur fractures. In the clinical setting, fracture morphology, desired healing mode, surgical approach, and implant cost should be considered when implementing these fixation strategies.
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Affiliation(s)
- David J Wright
- University of California, Irvine, Department of Orthopaedic Surgery, Orange, CA; and
| | - Donald J DeSanto
- University of California, Irvine, Department of Orthopaedic Surgery, Orange, CA; and
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA
| | - John A Scolaro
- University of California, Irvine, Department of Orthopaedic Surgery, Orange, CA; and
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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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Kim SM, Yeom JW, Song HK, Hwang KT, Hwang JH, Yoo JH. Lateral locked plating for distal femur fractures by low-energy trauma: what makes a difference in healing? INTERNATIONAL ORTHOPAEDICS 2018; 42:2907-2914. [PMID: 29549401 DOI: 10.1007/s00264-018-3881-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 03/05/2018] [Accepted: 03/07/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE The objective of this study is to investigate healing outcome of lateral locked plating for distal femoral fractures caused by low-energy trauma. In addition, we sought to determine predictable factors associated with fracture healing time. METHODS Seventy-three patients (73 fractures) with distal femur fractures (AO/OTA type 33) caused by low-energy trauma were recruited. The mean age of patients was 69.8 years (range, 43-87 years). All fractures were stabilized by less invasive osteosynthesis with anatomical periarticular locking system. Patients were followed up for mean 17.3 months (range, 6-44 months). RESULTS Of the 73 fractures, 52 (71.2%) fractures showed bony union within 6 months after the index surgery while the remaining 21 (28.8%) fractures showed delayed union or received revision surgery prior to complete healing. Although overall healing rate from the initial surgery was 93.2% (68/73), which seems to be satisfactory, the rate of surgical complications was 11.0% (8/73). Of all 73 fractures, seven received further surgery including three re-osteosynthesis. On multivariable analysis, plate-screw density at the fracture site was an independent predictable factor associated with the problematic healing. CONCLUSIONS Our findings suggest that complications related to increased healing time and fixation construct are not infrequent and ongoing problems in managing low-energy distal femur fractures. Specifically, plate-screw density at the fracture site has a significant influence on healing time in these fractures.
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Affiliation(s)
- Sang-Min Kim
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University School of Medicine, Seoul, South Korea
| | - Jae-Woo Yeom
- Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, South Korea
| | - Hyung Keun Song
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Kyu-Tae Hwang
- Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, South Korea
| | - Ji-Hyo Hwang
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Je-Hyun Yoo
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 896 Pyeongchon-dong, Dongan-gu, Anyang, 14068, South Korea.
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Biomechanics-Hot Topics Part II. J Orthop Trauma 2018; 32 Suppl 1:S29-S32. [PMID: 29461400 DOI: 10.1097/bot.0000000000001126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Orthopaedic surgery and biomechanics are intimately partnered topics in medicine. Biomechanical principles are used to design implants and fashion treatment protocols. Although it would seem that biomechanical principles in the design of fixation devices and fracture repair constructs have been already finalized, there are several points of controversy remaining. New technology has raised new questions, while at the same time, we still do not fully understand simple clinical principles such as time of fracture healing depending on the construct used. This review looks at several of these current controversies to better understand what work is needed in fracture care going forward.
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MacLeod A, Simpson AHRW, Pankaj P. Experimental and numerical investigation into the influence of loading conditions in biomechanical testing of locking plate fracture fixation devices. Bone Joint Res 2018; 7:111-120. [PMID: 29363522 PMCID: PMC5805837 DOI: 10.1302/2046-3758.71.bjr-2017-0074.r2] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objectives Secondary fracture healing is strongly influenced by the stiffness of the bone-fixator system. Biomechanical tests are extensively used to investigate stiffness and strength of fixation devices. The stiffness values reported in the literature for locked plating, however, vary by three orders of magnitude. The aim of this study was to examine the influence that the method of restraint and load application has on the stiffness produced, the strain distribution within the bone, and the stresses in the implant for locking plate constructs. Methods Synthetic composite bones were used to evaluate experimentally the influence of four different methods of loading and restraining specimens, all used in recent previous studies. Two plate types and three screw arrangements were also evaluated for each loading scenario. Computational models were also developed and validated using the experimental tests. Results The method of loading was found to affect the gap stiffness strongly (by up to six times) but also the magnitude of the plate stress and the location and magnitude of strains at the bone-screw interface. Conclusions This study demonstrates that the method of loading is responsible for much of the difference in reported stiffness values in the literature. It also shows that previous contradictory findings, such as the influence of working length and very large differences in failure loads, can be readily explained by the choice of loading condition. Cite this article: A. MacLeod, A. H. R. W. Simpson, P. Pankaj. Experimental and numerical investigation into the influence of loading conditions in biomechanical testing of locking plate fracture fixation devices. Bone Joint Res 2018;7:111–120. DOI: 10.1302/2046-3758.71.BJR-2017-0074.R2.
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Affiliation(s)
| | - A H R W Simpson
- Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - P Pankaj
- The University of Edinburgh, School of Engineering, Institute for Bioengineering, Faraday Building, Edinburgh EH9 3DW, UK
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Factors predicting admission to extended care facility after distal femoral fracture. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVES To evaluate outcomes and complications using cemented modular distal femoral replacement in elderly patients with distal femoral fractures. DESIGN Retrospective chart review, case series. SETTING A Level 1 and Level 2 trauma center, both tertiary referral hospitals. PATIENTS/PARTICIPANTS Eighteen patients older than 60 years (average age 77 years) who had cemented distal femoral replacement for distal femoral fractures (comminuted, intraarticular, osteoporotic, arthritic) between 2005 and 2013. Patients with previous knee surgery were excluded. INTERVENTION Cemented modular distal femoral replacement. MAIN OUTCOME MEASURES Implant status, complications, Knee Society Score, Musculoskeletal Tumor Society score, and Western Ontario and McMaster Osteoarthritis Index. RESULTS All patients were extremely or very satisfied with their outcomes. For patients with functional outcome data, Knee Society Score averaged 85.7 with a functional score of 35, Musculoskeletal Tumor Society score averaged 19.2, and Western Ontario and McMaster Osteoarthritis Index score averaged 23.1 at an average follow-up of 2.3 years. Range of motion was 1-99 degrees. Implant-related complications occurred in 2 patients (11%); one required revision to total femoral replacement because of periprosthetic fracture and the other had a deep infection that required exchange of the components. No patient had aseptic loosening or patellar maltracking. There were no perioperative deaths or late amputations. CONCLUSIONS Cemented modular distal femoral replacement is a viable treatment option in elderly patients that permits immediate full weight-bearing, with most patients returning to preoperative functional status. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Mechanical Construct Characteristics Predisposing to Non-union After Locked Lateral Plating of Distal Femur Fractures. J Orthop Trauma 2016; 30:403-8. [PMID: 27027801 DOI: 10.1097/bot.0000000000000593] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To identify discrete construct characteristics related to overall construct rigidity that may be independent predictors of nonunion after lateral locked plate (LLP) fixation of distal femur fractures. DESIGN Retrospective case-control study. SETTING Three level-1 urban trauma centers. PATIENTS/PARTICIPANTS Two hundred and seventy-one supracondylar femoral fractures treated with LLP at 3 affiliated level 1 urban trauma centers between August 2004 and December 2010. METHODS Nonunion was defined as a secondary procedure for poor healing. Construct variables included: (1) combined plate design and material variable, (2) Plate length, (3) # screws proximal to fracture, (4) total screw density (TSD), (5) proximal screw density (PSD), (6) presence of a screw crossing the main fracture, and (7) rigidity score multivariable analysis was performed using logistic regression to identify independent risk factors for nonunion. INTERVENTION LLP fixation. MAIN OUTCOME MEASURE Nonunion. RESULTS Nonunion rate was 13.3% (n = 36). There was a significant association between plate design/material and nonunion with 41% of stainless constructs and 10% of titanium constructs resulting in a nonunion (P < 0.001). Rigidity scores reached significance (P = 0.001) with constructs resulting in a nonunion having higher scores. No significant univariate differences with respect to number of proximal screws, plate length, total screw density, or proximal screw density were observed between healed fractures and those with nonunion. Results of the multivariate analysis confirmed that the primary significant independent predictor of nonunion was plate design/material (odds ratio, 6.8; 95% CI, 2.9-16.1; P < 0.001). CONCLUSIONS When treating distal femur fractures with LLP, combined plate design and material variable has a highly significant influence on the risk of nonunion independent of any other construct variable. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Retrograde dynamic locked intramedullary nailing for aseptic supracondylar femoral nonunion after dynamic condylar screw treatment. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:625-31. [PMID: 27314842 DOI: 10.1007/s00590-016-1800-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/19/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Supracondylar femoral nonunions after dynamic condylar screw (DCS) treatment are uncommon, and few studies have addressed an optimal treatment technique for this disorder. Re-insertion of a new plate may not be secure because of bony defects in the distal fragment, created by the lag screw of the DCS. MATERIALS AND METHODS Forty-two consecutive adult patients with 42 supracondylar femoral nonunions were treated with removal of the DCS, re-alignment of the knee axis, and insertion of a retrograde dynamic traditional femoral locked nail. When necessary, a humeral plate was augmented to reinforce rotational stability. RESULTS A final group of 36 patients with 36 nonunions were followed for an average of 2.8 years (range 1.1-6.2 years). All nonunions healed with a union rate of 100 %, and the average time to union was 4.2 months (range 2.5-5.5 months). Complications included two malunions. There were no instances of nonunion or deep infection. Satisfactory knee function among 36 patients improved from 8.2 % preoperatively to 86.1 % at the last follow-up (p < 0.001). All 36 patients could walk without aids. CONCLUSION The described technique may be an excellent alternative treatment for an aseptic supracondylar femoral nonunion after DCS treatment. The technique is not difficult, and the union rate and satisfactory rate are high.
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Wu CC. Retrograde locked intramedullary nailing for aseptic supracondylar femoral nonunion following failed locked plating. J Orthop Surg (Hong Kong) 2015; 23:155-9. [PMID: 26321540 DOI: 10.1177/230949901502300207] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE To review the outcome of retrograde locked nailing for aseptic supracondylar femoral nonunions following failed locked plating. METHODS Records of 20 men and 4 women aged 20 to 57 (mean, 39) years who underwent retrograde locked intramedullary nailing for aseptic supracondylar femoral nonunion following failed locked plating were reviewed. There were 20 closed and 4 open Gustilo type II or IIIA fractures secondary to motor vehicle accidents (n=21) or falls (n=3). Patients had undergone one to 3 operations. The mean time from injury to the present revision surgery was 1.3 years. No patient had a flexion contracture. The locked plate was removed and replaced with a retrograde dynamic locked nail (with or without buttress plate augmentation) followed by bone grafting. RESULTS 17 men and 4 women were followed up for a mean of 3.4 years. The rest were lost to follow-up. The 21 patients achieved bone union after a mean of 4.3 months. The mean maximal knee flexion improved from 97.1º to 107.6º (p=0.03). Knee function was excellent in one, good in 15, and fair in 5 knees. The fair outcome was due to extension contracture, varus knee deformity, or knee pain. There were 3 malunions with varus deformity of 7º, 8º, and 9º each. No patient had deep infection causing a nonunion. All 21 patients could walk without aids. CONCLUSION Retrograde locked intramedullary nailing for aseptic supracondylar femoral nonunions following failed locked plating achieved a high union rate.
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Affiliation(s)
- Chi-Chuan Wu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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