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PubMed1994

A biomechanical analysis of four humeral fracture fixation systems.

A biomechanical study was initiated to compare four fracture fixation devices: the AO dynamic compression plate, a distal fin locking nail, a solid locked intramedullary nail, and paired flexible nails for humeral fracture fixation. Eighteen pairs of fresh-frozen, intact humeri were harvested, standardized midshaft transverse osteotomies were created in each specimen, and left and right specimens were fixed with plates and nails, respectively. The bending properties of the plate-fixed humeri were significantly greater than the nailed humeri in both the anteroposterior and mediolateral planes on a paired basis. The distal fin nail and solid locked nail had comparable bending properties, and both had bending properties superior to those measured for the paired flexible nails. The torsional properties of humeri fixed with plates and solid locked nails were equivalent, except for rigidity and stiffness, which were superior for the nail. Both fixation methods resulted in torsional properties significantly greater to those measured for humeri fixed with paired flexible nails or a distal fin nail.

Biomechanical Phenomena↗
PubMed1998

Timing of fracture fixation in blunt trauma patients with severe head injuries.

BACKGROUND: Early fracture fixation in blunt trauma patients is suggested to decrease postoperative morbidity by allowing early mobilization and reducing the release of harmful inflammatory mediators. Some studies have challenged this concept in the presence of severe associated injuries, and especially head trauma. METHODS: The records of 47 consecutive blunt trauma patients with severe head injuries, as defined by a Glasgow Coma Score (GCS) < or =8 and a head Abbreviated Injury Score (AIS) > or =3, and long bone fractures requiring surgical fixation were reviewed. The study population was divided into the early fixation (EF) group, consisting of 22 patients who underwent fracture fixation within 24 hours of admission (mean time 17 +/- 8.5 hours); and the late fixation (LF) group, consisting of 25 patients, who had orthopedic repair at a later time (mean 143 +/- 178 hours). RESULTS: The two groups were similar in terms of overall injury severity, neurologic injuries, hemodynamic and neurologic status on admission, and operations received. Patients in the EF group had a higher injury severity of extremity fractures (extremity AIS: 2.9 +/- 0.2 versus 2.4 +/- 0.5, P = 0.0002) and a higher incidence of open fractures (72% versus 36%, P = 0.02). There was no difference in intraoperative and postoperative hypoxic and hypotensive episodes. Neurologic, orthopedic, and general complications were the same between the two groups. The mean GCS on discharge was 12 +/- 3 for both groups with equal distribution among patients. Although there was a trend toward longer hospital stay (25 +/- 17 versus 17 +/- 10 days, P = 0.057) among LF patients, mechanical ventilation days, length of stay, and mortality were not different. CONCLUSIONS: Timing of fracture fixation in this group of blunt trauma patients with severe head injuries did not influence morbidity, mortality, or neurologic outcome.

Adolescent↗
PubMed2000

[Biodegradable implants in fracture fixation: state of the art].

Operative fracture repair in trauma surgery is currently performed using metal implants. These metal implants often are removed during a second, retrieval operation. Biodegradable fracture fixation devices have been used clinically since the late seventies. Most bioresorbable implants are manufactured from polymers. The polylactides, polyglycolides and co-polymers slowly degrade into small components that are excreted from the human body via natural pathways and removal operations after fracture surgery are not necessary. Due to the limited mechanical properties, the polymer screws and pins are mostly used in the treatment of non weight-baring simple fractures of the ankle, elbow, hand and foot. In view of the progressing technical developments, new materials will be developed and tested for clinical use in the coming decades.

Absorbable Implants↗
PubMed1998

Biomechanical evaluation of transverse acetabular fracture fixation.

The purpose of this two-part biomechanical study was to evaluate various fixation methods for transverse acetabular fractures in a synthetic pelvic model. In Part 1, 40 transverse acetabular fractures were repaired with anterior column plating using 10-hole curved reconstructions plates with one of four screw configurations to evaluate the effect of screw placement and number on fracture fixation stiffness. In Part 2, 36 transverse acetabular fractures were repaired with one of six fixation methods using combinations of contoured plates and column screws to stabilize the anterior column, the posterior column, or both. Each repaired acetabulum was loaded via a hemiarthroplasty in a direction consistent with stance phase. Fixation stiffness was measured from the force-displacement curve for each construct. In Part 1, there was no significant difference in fixation stiffness afforded by any of the constructs. However, the stiffest construct resulted from two screws on each side of the fracture site: one placed as close to the fracture site as allowed (one empty screw hole adjacent to the fracture) and the second at the end of the plate. In Part 2, the constructs that concomitantly stabilized anterior and posterior columns were significantly stiffer than were those addressing either the anterior or posterior column alone, regardless of the number of plates applied. The stiffest construct combined a posterior column plate with an anterior column screw. Because no significant change in stiffness occurred with the addition of a third set of screws, two screws on each side of the fracture site appear to provide sufficient stability with acetabular plating. Concurrent fixation of anterior and posterior columns of transverse acetabular fractures provides the greatest resistance to postoperative loss of reduction in this model.

Acetabulum↗
PubMed1995

Is the timing of fracture fixation important for the patient with multiple trauma?

OBJECTIVE: The effect of timing of femur fracture fixation for patients with multiple trauma was studied to determine the effect of operative timing on eventual outcome. METHODS: The relationship between timing of intramedullary rod (IMR) placement, degree of injury, and pulmonary complications was studied in 424 consecutive patients. The authors focused on 105 patients undergoing IMR placement with an Injury Severity score (ISS) of greater than or equal to 18. The effects of timing of IMR placement on various pulmonary complications, organ failure, intensive care unit (ICU) admission, and ventilatory assistance were studied for various time intervals. RESULTS: Of the 424 patients, pulmonary complications increased slightly in the more seriously injured group (ISS > 18) but were not influenced by the timing of IMR placement. Of the 105 patients undergoing IMR placement with an ISS > or = 18, only 2 patients died. Both patients had an IMR placed in less than 24 hours and died later of head injury and delayed hemorrhage. The incidence of organ failure, number of ventilator days, and length of ICU stay did not differ between the groups based on timing of fracture fixation. The incidence of severe head injuries was higher in the group undergoing delayed IMR placement (> 48 hours). CONCLUSIONS: Modest delays in IMR placement did not adversely affect patient outcome. Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation. In a well-integrated trauma system, clinical judgment regarding the timing of IMR placement was the most important determinant of outcome. Delays that were made to stabilize the patient, treat associated injuries, and plan orthopedic reconstruction did not adversely affect patient outcome.

Adult↗
PubMed1992

Lower extremity fracture fixation in head-injured patients.

Compared with nonsurgical management or delayed repair, early fracture fixation can reduce the incidence of pulmonary complications in patients with long-bone fractures of the lower extremities. Blunt trauma victims often have multiple nonskeletal injuries that might influence the risk of pulmonary complications, and when head injuries are present it has been a common practice to delay nonemergent operations for several days to protect the injured brain. We conducted a retrospective review of 114 patients with multiple trauma whose injuries included head trauma and a fracture of the neck or shaft of the femur or shaft of the tibia to determine if delayed stabilization of lower extremity fractures increased the risk of pulmonary complications or reduced the risk of cerebral complications. Forty-six patients underwent surgical fixation of their fractures within 24 hours of injury (early fixation), 26 patients had their fractures repaired more than 24 hours after injury (late fixation), and 42 patients did not undergo surgical fracture fixation. The risk of pulmonary complications was not related to the timing of surgical fracture fixation but was strongly influenced by the severity of injuries to the head and to the chest (p less than 0.001). Furthermore, a delay in fracture fixation did not protect the injured brain; the risk of CNS events was determined by the severity of the head injury (p less than 0.0001). Early fracture fixation in patients with head injury may be appropriate because it simplifies patient care and does not seem to worsen the head injury, but it does not prevent pulmonary complications in these high-risk patients.

Adolescent↗
PubMed1992

[Development of synthetic bone models for the evaluation of fracture fixation devices].

Mechanical tests are indispensable for the research and development of internal devices used for fracture fixation. It is ideal to use fresh human bones even for in vitro experiments. However, fresh human bones are difficult to access, so that alternative materials have been developed. In this study, the applicability of synthetic tibia or femur models made from polyurethane resin (Hiprox) was studied, comparing the mechanical properties of both the synthetic models and the fresh human bones under fracture-fixation conditions using various fixation devices. When the models were designed to simulate the cortical bone with solid resin and the cancellous bone with porous resin, the mechanical properties can be fairly approximated to those of the fresh human bones. It was concluded that the Hiprox models are useful in for preliminary testing of fracture fixation devices.

Biomechanical Phenomena↗
PubMed2000

Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation.

BACKGROUND: The presence of persistent occult hypoperfusion (OH) is associated with higher morbidity and mortality rates after trauma. Early femur fracture fixation in trauma patients with multiple injuries is associated with decreased morbidity and mortality. Association of OH and incidence of postoperative complications after intramedullary (IM) fixation in patients with femur fractures was investigated. METHODS: A retrospective study design was used. All patients with femur fractures admitted to the trauma service of a Level I trauma center between January 1, 1995, and August 1, 1998, who were older than 18 years of age and who had IM fracture fixation within 24 hours of admission and serum lactate determinations on admission and at proscribed intervals, were included in the study. Patients with lactic acid levels > or = 2.5 mmol/L were determined to have OH. No patients had clinical signs of shock (hypotension, tachycardia, decreased urine output) on transfer to the operating room. Complete resuscitation was defined as a lactic acid level < 2.5 mmol/L. Patients were divided into two groups based on presence/absence of OH determined from the lactic acid level immediately before surgery. The incidence of all postoperative organ complications was recorded, and complication rates were compared between groups. Total hospital costs were also compared. RESULTS: One hundred seventy-seven patients with femur fractures were admitted to the trauma service during this period. Seventy-nine patients met initial criteria for inclusion in the study. Further review excluded 32 patients. Occult hypoperfusion was present in 20 patients before early IM fixation (group 2). Twenty-seven patients were completely resuscitated before early IM fixation (group 1). Injury Severity Scores were similar in both groups. Group 2 had 35 complications in 20 patients, and group 1 had 11 complications in 27 patients. A significant difference was found in incidence of postoperative complications in group 1 (20%) versus group 2 (50%). Group 2 also had a significantly higher proportion of postoperative infections than group 1 (72% vs. 28%, respectively) and higher total hospital costs ($46,469 vs. $23,139). CONCLUSION: The presence of OH in trauma patients undergoing early IM fixation of a femur fracture is associated with a twofold higher incidence of postoperative complications. Clinical judgment, not surgical dogma, should guide the timing of IM fixation in these patients. Identifying and correcting OH through relatively simple resuscitative measures may be advantageous in reducing morbidity in the patient with multiple injuries.

Adult↗
PubMed1993

Biomechanics of odontoid fracture fixation. Comparison of the one- and two-screw technique.

Direct anterior screw fixation of odontoid fractures has become more prevalent clinically. No biomechanical study, however, has determined whether one or two screws should be used. This study measured the stability of the odontoid process after fracture and internal fixation with one or two screws. Internal fixation of Type II odontoid fractures did not restore the original stability of the intact specimen, direct internal fixation with one or two screws provided 50% of the stability of the unfractured odontoid, and no significant differences between the one- and two-screw technique was found under loading to failure, although the two-screw technique provided increased stiffness in extension loading.

Biomechanical Phenomena↗
PubMed1989

Implant materials for fracture fixation: a clinical perspective.

The optimum management of traumatic skeletal fractures may involve the installation of high quality surgical implants by a skilled orthopedic surgeon. Satisfactory clinical results are very dependent on the ability to maintain stable fracture fixation. Well designed contemporary implants rely on precise control of material composition and properties to achieve a well tolerated level of biological response. Metallic materials, such as 316L stainless steel, pure titanium, and titanium alloys, demonstrate an acceptable combination of strength, ductility, corrosion resistance, and biocompatibility. Polymers, composites, and biodegradable materials may offer selected opportunities for fracture fixation. An understanding of relevant clinical factors is essential to evaluate potential applications for advanced materials.

Biocompatible Materials↗
PubMed1982

[Experimental studies on "less rigid" polyacetal plates for fracture fixation (author's transl)].

UNLABELLED: It is a well known fact that rigid and prolonged internal fixation of a fracture with a stiff plate yields osteoporosis. In order to solve this problem, so called "less rigid" plates made of various plastic materials have been tested by some workers experimentally, but they are not widely accepted yet for clinical use, for the plastic material used lacked sufficient strength to secure stable osteosynthesis. This paper presents a series of experimental studies using polyacetal (polyoxymethylene--POM) materials which have relatively larger strength, for the fixation of canine fractures. MATERIALS AND METHODS: Experiment I--Alteration of material strength in vivo: Dumb-bell shaped test pieces were made of three different POM plastics; 1, acetal copolymer alone (M90), 2, acetal copolymer reinforced with 20% carbon fiber (CR20) and 3. acetal copolymer with 20% fluorine (YF20). Tensile strength was measured after imbedding the test piece between the vastus lateralis and the biceps femoris of dogs for eight months. The results were compared with those before imbedding. Experiment II--Fracture healing study: After applying a POM plate or a stainless-steel plate (AO one-third tubular plate) on an adult canine femur with four stainless-stell screws, the femur was osteotomized at the center with a Gigli saw to produce a transverse fracture. Postoperative roentgenograms were taken periodically. After sufficient bone union on roentgenogram, the animal was sacrificed to excise the femur for three point bending test applying up to 30 kg load posteriorly to the femur to measure ultimate strength, deflexion at the center and strains at the anterior portion of the bone. RESULTS: Experiment I: A certain decrease in tensile strength was noted in the three tested materials. Experiment II: 1) With M90 plates, there was considerable tendency toward delayed union, which would have been due to insufficient strength of the plate. 2) No significant difference in the period required for bone union was noted between the CR20 and the AO plate groups, while the former tended to produce larger callus. 3) The ultimate strength of the united bone following CR20 of AO plate fixation ranged from 50 to 55% of that of the contralateral non-osteotomized femur. There was no significant difference between the two plate groups. 4) The deflexion at the center was significantly less in the CR20 group under low load, irrespective to the difference in the amount of the ultimate strength. 5) The strain at the fracture site was extremely large in the AOI group compared to those at the other sites, which would indicate uneven strength distribution, while the strains were relatively even in the CR20 group as in the non-osteotomized femur. The results of the experiments suggest possibilities of using reinforced polyacetal plates for better fracture fixation.

Animals↗
PubMedDate not supplied

Internal fracture fixation in patients with osteoporosis.

Because of the decreased holding power of plate-and-screw fixation in osteoporotic bone fractures, internal fixation can have a high failure rate, ranging from 10% to 25%. Screws placed into cortical bone have better resistance to pullout than do those placed into adjacent trabecular bone. Plates should not be used to bridge unstable regions of bony comminution in osteoporotic patients. Fixation stability is optimized by securing stable bone contact across the fracture site and by placing screws both as close to and as far from the fracture as possible. Intentional shortening can improve stability and load sharing of the fracture construct. Structural bone graft or other types of fillers can be used to fill voids when comminution prevents stable contact. Load-sharing fixation devices such as the sliding hip screw, intramedullary nail, antiglide plate, and tension band constructs are better alternatives for osteoporotic metaphyseal locations. Proper planning is essential for improved fracture fixation in this high-risk patient group.

Fracture Fixation, Internal↗
PubMed1997

Bioresorbable fracture fixation in orthopedics: a comprehensive review. Part I. Basic science and preclinical studies.

Metal alloys are currently the most popular materials for manufacture of fracture-fixation devices. Two major disadvantages of these materials are their extreme stiffness, which causes stress shielding of the underlying bone, and the necessity, in a significant number of cases, of removing metallic implants after fracture healing is complete. These shortcomings of metal alloys have led to the study of bioresorbable materials for use in fracture fixation. Currently, polylactic acid, polyglycolic acid, and polydioxanone implants are available to the orthopedic surgeon for the fixation of small cancellous bone fractures. Part I of this article provides an overview of the basic science of bioresorbable materials and presents a comprehensive review of preclinical studies reported in the orthopedic literature. Clinical studies will be reviewed in Part II.

Alloys↗
PubMed1994

Tissue-implant interface at an absorbable fracture fixation plug made of polylactide in cancellous bone of distal rabbit femur.

The tissue-implant interface at a self-reinforced poly-L-lactide (SR-PLLA) expansion plug implanted in distal rabbit femoral cancellous bone was studied histologically, histomorphometrically, and microradiographically in 35 rabbits during consolidation of a transverse transcondylar osteotomy fixed with the SR-PLLA expansion plug. The absorbable plug for internal fixation of fractures and osteotomies measured 4.5 mm in diameter and 30 mm in length and had an expandable distal locking blade system. The femoral specimens were harvested in groups of 5-10 rabbits after a follow-up time of 3, 6, 12, and 24 weeks. The intact contralateral femur served as a control. Vigorous osteogenic response to the implant was already observed at 3 weeks postoperatively, and the osteoid surface fraction at 24 weeks was still significantly higher than in the unoperated contralateral femur. Incomplete union of the osteotomy seemed to result in increased fibrous tissue formation at the tissue-implant boundary. No signs of degradation of the SR-PLLA was observed within the entire follow-up period. The number of inflammatory cells at the tissue-implant interface was low. Consequently, the short-term biocompatibility of the implant was deemed acceptable. Clinical application of the expansion plug is being planned.

Animals↗
PubMed1992

Principles of fracture fixation in growing animals.

Changes in bone structure and conformation can occur very rapidly in growing animals. Injury to the bones or articular surfaces warrant special consideration because of the potential devastating consequences of secondary growth deformities in the animal. Disturbance of normal growth plate activity, imperfect fixation of an articular fracture, and conformational defects in long bones may create lifelong problems for the animal.

Animals↗
PubMed1994

Audit of ankle fracture fixation in the elderly.

To assess the results of operative treatment of ankle fractures in the elderly, we have reviewed the results of ankle fracture fixation in 76 patients aged over 50 years. This was carried out with special reference to the early complications. Our series had a 1.8% incidence of infection and a 5.2% incidence of delayed healing and wound necrosis. Malunion occurred in 7.9% of patients, and was due in all cases to either imperfect peroperative reduction or inadequate fixation. In no case did fixation fail because of poor bone quality. We conclude that internal fixation of ankle fractures in the elderly carries acceptable risks, so long as careful attention is paid to surgical technique, and fixation is in accordance with AO/ASIF principles.

Age Factors↗
PubMed1998

Biodegradable interlocking nails for fracture fixation.

Serious problems such as stress shielding, allergic reactions, and corrosion are associated with the use of metallic fracture fixation devices in fractured long bones. Metal implants often are removed during a second retrieval operation after fracture healing has completed. A biocompatible implant that degrades slowly during implantation would obviate the need for a second operation and save the patient from considerable physical, psychologic, and financial discomfort. The biodegradable implant must provide the fractured limb sufficient support for a certain time, allowing early loading. A gradual transfer of load from the biodegradable implant to the bone would result in a better product of bone healing and avoid stress shielding. In an animal model using adult sheep, two types of biodegradable polymer interlocking nails were tested in comparison with a stainless steel interlocking nail. Fracture healing, mechanical properties of the bones, degradation behavior in vivo and in vitro, and tissue response were monitored during a 2 1/2-year followup study. To detect shifts in acid base relations caused by the release of acid compounds, pH measurements were performed. Fracture healing was unimpaired, and the mechanical test results of all three groups were excellent. Histologic analysis showed a mild inflammatory response, but no pH shifts were observed. The results of this study justify additional research on these promising materials.

Absorbable Implants↗