High failure rate of trochanteric fracture osteosynthesis with proximal femoral locking compression plate

INTRODUCTION Stable reconstruction of proximal femoral (PF) fractures is especially challenging due to the peculiarity of the injury patterns and the high load-bearing requirement. Since its introduction in 2007, the PF-locking compression plate (LCP) 4.5/5.0 has improved osteosynthesis for intertrochanteric and subtrochanteric fractures of the femur. This study reports our early results with this implant. METHODS Between January 2008 and June 2010, 19 of 52 patients (12 males, 7 females; mean age 59 years, range 19-96 years) presenting with fractures of the trochanteric region were treated at the authors' level 1 trauma centre with open reduction and internal fixation using PF-LCP. Postoperatively, partial weight bearing was allowed for all 19 patients. Follow-up included a thorough clinical and radiological evaluation at 1.5, 3, 6, 12, 24, 36 and 48 months. Failure analysis was based on conventional radiological and clinical assessment regarding the type of fracture, postoperative repositioning, secondary fracture dislocation in relation to the fracture constellation and postoperative clinical function (Merle d'Aubigné score). RESULTS In 18 patients surgery achieved adequate reduction and stable fixation without intra-operative complications. In one patient an ad latus displacement was observed on postoperative X-rays. At the third month follow-up four patients presented with secondary varus collapse and at the sixth month follow-up two patients had 'cut-outs' of the proximal fragment, with one patient having implant failure due to a broken proximal screw. Revision surgeries were performed in eight patients, one patient receiving a change of one screw, three patients undergoing reosteosynthesis with implantation of a condylar plate and one patient undergoing hardware removal with secondary implantation of a total hip prosthesis. Eight patients suffered from persistent trochanteric pain and three patients underwent hardware removal. CONCLUSIONS Early results for PF-LCP osteosynthesis show major complications in 7 of 19 patients requiring reosteosynthesis or prosthesis implantation due to secondary loss of reduction or hardware removal. Further studies are required to evaluate the limitations of this device.

Computational simulation of the early stage of bone healing under different configurations of locking compression plates

Flexible fixation or the so-called ‘biological fixation’ has been shown to encourage the formation of fracture callus, leading to better healing outcomes. However, the nature of the relationship between the degree of mechanical stability provided by a flexible fixation and the optimal healing outcomes has not been fully understood. In this study, we have developed a validated quantitative model to predict how cells in fracture callus might respond to change in their mechanical microenvironment due to different configurations of locking compression plate (LCP) in clinical practice, particularly in the early stage of healing. The model predicts that increasing flexibility of the LCP by changing the bone–plate distance (BPD) or the plate working length (WL) could enhance interfragmentary strain in the presence of a relatively large gap size (.3 mm). Furthermore, conventional LCP normally results in asymmetric tissue development during early stage of callus formation, and the increase of BPD or WL is insufficient to alleviate this problem.

New eight node serendipity quadrilateral plate bending element for thin and moderately thick plates using Integrated Force Method

A new 8-node serendipity quadrilateral plate bending element (MQP8) based on the Mindlin-Reissner theory for the analysis of thin and moderately thick plate bending problems using Integrated Force Method is presented in this paper. The performance of this new element (MQP8) is studied for accuracy and convergence by analyzing many standard benchmark plate bending problems. This new element MQP8 performs excellent in both thin and moderately thick plate bending situations. And also this element is free from spurious/zero energy modes and free from shear locking problem.

New twelve node serendipity quadrilateral plate bending element based on Mindlin-Reissner theory using Integrated Force Method

The Integrated Force Method (IFM) is a novel matrix formulation developed for analyzing the civil, mechanical and aerospace engineering structures. In this method all independent/internal forces are treated as unknown variables which are calculated by simultaneously imposing equations of equilibrium and compatibility conditions. This paper presents a new 12-node serendipity quadrilateral plate bending element MQP12 for the analysis of thin and thick plate problems using IFM. The Mindlin-Reissner plate theory has been employed in the formulation which accounts the effect of shear deformation. The performance of this new element with respect to accuracy and convergence is studied by analyzing many standard benchmark plate bending problems. The results of the new element MQP12 are compared with those of displacement-based 12-node plate bending elements available in the literature. The results are also compared with exact solutions. The new element MQP12 is free from shear locking and performs excellent for both thin and moderately thick plate bending situations.

A field-consistent and variationally correct representation of transverse shear strains in the nine-noded plate element

We present a biquadratic Lagrangian plate bending element with consistent fields for the constrained transverse shear strain functions. A technique involving expansion of the strain interpolations in terms of Legendre polynomials is used to redistribute the kinematically derived shear strain fields so that the field-consistent forms (i.e. avoiding locking) are also variationally correct (i.e. do not violate the variational norms). Also, a rational method of isoparametric Jacobian transformation is incorporated so that the constrained covariant shear strain fields are always consistent in whatever general quadrilateral form the element may take. Finally the element is compared with another formulation which was recently published. The element is subjected to several robust bench mark tests and is found to pass all the tests efficiently.

New nine-node Lagrangian quadrilateral plate element based on Mindlin-Reissner theory using IFM

This paper presents a new nine-node Lagrangian quadrilateral plate bending element (MQP9) using the Integrated Force Method (IFM) for the analysis of thin and moderately thick plate bending problems. Three degrees of freedom: transverse displacement w and two rotations theta(x) and theta(y) are considered at each node of the element. The Mindlin-Reissner theory has been employed in the formulation which accounts the effect of shear deformation. Many standard plate bending benchmark problems have been analyzed using the new element MQP9 for various grid sizes via Integrated Force Method to estimate defections and bending moments. These results of the new element MQP9 are compared with those of similar displacement-based plate bending elements available in the literature. The results are also compared with exact solutions. It is observed that the presented new element MQP9 is free from shear locking and produced, in general, excellent results in all plate bending benchmark problems considered.

Finite element analysis of free vibration of the delaminated composite plate with variable kinematic multilayered plate elements

Composite laminates are prone to delamination. Implementation of delamination in the Carrera Unified Formulation frame work using nine noded quadrilateral MITC9 element is discussed in this article. MITC9 element is devoid of shear locking and membrane locking. Delaminated as well as healthy structure is analyzed for free mode vibration. The results from the present work are compared with the available experimental or/and research article or/and the three dimensional finite element simulations. The effect of different kinds and different percentages of area of delamination on the first three natural frequencies of the structure is discussed. The presence of open-mode delamination mode shape for large delaminations within the first three natural frequencies is discussed. Also, the switching of places between the second bending mode, with that of the first torsional mode frequency is discussed. Results obtained from different ordered theories are compared in the presence of delamination. Advantage of layerwise theories as compared to equivalent single layer theories for very large delaminations is stated. The effect of different kinds of delamination and their effect on the second bending and first torsional mode shape is discussed. (C) 2014 Elsevier Ltd. All rights reserved.

Damage assessment of composite plate structures with material and measurement uncertainty

Composite materials are very useful in structural engineering particularly in weight sensitive applications. Two different test models of the same structure made from composite materials can display very different dynamic behavior due to large uncertainties associated with composite material properties. Also, composite structures can suffer from pre-existing imperfections like delaminations, voids or cracks during fabrication. In this paper, we show that modeling and material uncertainties in composite structures can cause considerable problein in damage assessment. A recently developed C-0 shear deformable locking free refined composite plate element is employed in the numerical simulations to alleviate modeling uncertainty. A qualitative estimate of the impact of modeling uncertainty on the damage detection problem is made. A robust Fuzzy Logic System (FLS) with sliding window defuzzifier is used for delamination damage detection in composite plate type structures. The FLS is designed using variations in modal frequencies due to randomness in material properties. Probabilistic analysis is performed using Monte Carlo Simulation (MCS) on a composite plate finite element model. It is demonstrated that the FLS shows excellent robustness in delamination detection at very high levels of randomness in input data. (C) 2016 Elsevier Ltd. All rights reserved.

A simple displacement-based quadrilateral laminated composite plate element - part I : linear analysis

Based on the first-order shear deformation theory (FSDT) and Timoshenko's laminated composite beam functions, a simple displacement-based 4-node, 24-dof quadrilateral laminated plate element is proposed in this paper for linear analysis of thin to moderately thick laminates. The deflection and rotation functions of the element boundary are obtained from the Timoshenko's laminated composite beam functions, hence convergence to the thin plate solution can be achieved theoretically and shear-locking problem is avoided naturally. The in-plane displacement functions of a quadrilateral plane element with drilling degrees of freedom are taken as the in-plane displacements of the proposed quadrilateral element. Some numerical examples of linear analysis of composite laminated plates are calculated, and the results show that the proposed element is convergent, shear-locking free, efficient, accurate and not sensitive to mesh distortion.

A simple displacement-based quadrilateral laminated composite plate element : Part II : linear analysis

The 4-node, 24-dof quadrilateral displacement-based element (Zhang et al. 2004), which have been developed successfully for linear analysis of thin to thick laminated composite plates, is extended further for geometrically nonlinear analysis in this paper. The proposed element is based on the first-order shear deformation theory (FSDT) and von-Karman's large deflection theory, and the total Lagrangian approach is employed to formulate the element. The deflection and rotation functions of the element boundary are obtained from Timoshenko's laminated composite beam functions. The developed element is simple in formulation, free from shear-locking, and include conventional engineering degrees of freedom. Numerical examples demonstrate that the element is accurate and efficient for large deformation, small rotation geometrically nonlinear analysis of thin to moderately thick laminated composite plates.

Effect of the number of screws on the stability of locking mandibular reconstruction plates

Atrophic mandible fractures are frequently a challenge to stabilize. This study evaluated, through mechanical testing in vitro, the number of locking screws that is sufficient to withstand loading when applied with a locking reconstruction plate in the fixation of atrophic mandible fractures. Polyurethane mandibles with a simulated linear fracture at the midline were used as substratum. Results show that resistance of the fixation is poor when one and two screws are used on each side of the fracture. Three screws on each side of the fracture significantly increases the resistance to displacement. However, no additional strength is added to the construct when more than three screws per side are used. © 2013 International Association of Oral and Maxillofacial Surgeons.

The effect of locked screw angulation on the biomechanical properties of the S.P.S. Free-Block plate

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: mono cortical screws were positioned at 90° to the long axis of the cylinder (Group 1), and monocortical screws were positioned at 70° 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. © Schattauer 2013.

Evidence Based Development of a Novel Lateral Fibula Plate (VariAx Fibula) Using a Real CT Bone Data Based Optimization Process During Device Development

Development of novel implants in orthopaedic trauma surgery is based on limited datasets of cadaver trials or artificial bone models. A method has been developed whereby implants can be constructed in an evidence based method founded on a large anatomic database consisting of more than 2.000 datasets of bones extracted from CT scans. The aim of this study was the development and clinical application of an anatomically pre-contoured plate for the treatment of distal fibular fractures based on the anatomical database. 48 Caucasian and Asian bone models (left and right) from the database were used for the preliminary optimization process and validation of the fibula plate. The implant was constructed to fit bilaterally in a lateral position of the fibula. Then a biomechanical comparison of the designed implant to the current gold standard in the treatment of distal fibular fractures (locking 1/3 tubular plate) was conducted. Finally, a clinical surveillance study to evaluate the grade of implant fit achieved was performed. The results showed that with a virtual anatomic database it was possible to design a fibula plate with an optimized fit for a large proportion of the population. Biomechanical testing showed the novel fibula plate to be superior to 1/3 tubular plates in 4-point bending tests. The clinical application showed a very high degree of primary implant fit. Only in a small minority of cases further intra-operative implant bending was necessary. Therefore, the goal to develop an implant for the treatment of distal fibular fractures based on the evidence of a large anatomical database could be attained. Biomechanical testing showed good results regarding the stability and the clinical application confirmed the high grade of anatomical fit.

The influence of different osteosynthesis configurations with locking compression plates (LCP) on stability and fracture healing after an oblique 45° angle osteotomy

Background Locking compression plates are used in various configurations with lack of detailed information on consequent bone healing. Study design In this in vivo study in sheep 5 different applications of locking compression plate (LCP) were tested using a 45° oblique osteotomy simulating simple fracture pattern. 60 Swiss Alpine sheep where assigned to 5 different groups with 12 sheep each (Group 1: interfragmentary lag screw and an LCP fixed with standard cortex screws as neutralisation plate; Group 2: interfragmentary lag screw and LCP with locking head screws; Group 3: compression plate technique (hybrid construct); Group 4: internal fixator without fracture gap; Group 5: internal fixator with 3 mm gap at the osteotomy site). One half of each group (6 sheep) was monitored for 6 weeks, and the other half (6 sheep) where followed for 12 weeks. Methods X-rays at 3, 6, 9 and 12 weeks were performed to monitor the healing process. After sacrifice operated tibiae were tested biomechanically for nondestructive torsion and compared to the tibia of the healthy opposite side. After testing specimens were processed for microradiography, histology, histomorphometry and assessment of calcium deposition by fluorescence microscopy. Results In all groups bone healing occurred without complications. Stiffness in biomechanical testing showed a tendency for higher values in G2 but results were not statistically significant. Values for G5 were significantly lower after 6 weeks, but after 12 weeks values had improved to comparable results. For all groups, except G3, stiffness values improved between 6 and 12 weeks. Histomorphometrical data demonstrate endosteal callus to be more marked in G2 at 6 weeks. Discussion and conclusion All five configurations resulted in undisturbed bone healing and are considered safe for clinical application.

Proximal Femoral Osteotomies with the Paediatric Hip Plate (LCP): Valgus osteotomy.

OBJECTIVE Proximal femoral osteotomy with stable fixation and sufficient correction. Low complication rates due to exact preoperative planning. INDICATIONS Congenital or traumatic femoral neck pseudarthrosis. Coxa vara. CONTRAINDICATIONS None. In severe deformities, a single femoral osteotomy may not solve the problem; thus, additional correction, e.g., a pelvic osteotomy, is required. SURGICAL TECHNIQUE Correct planning of the correction angle. Lateral approach. Subperiosteal detachment of vastus lateralis muscle. Place guide wire on the femoral neck to judge anteversion. Insert positioning wire 5 mm distal to trochanteric physis. Insert 2.8 mm Kirschner wire in the femoral neck. Osteotomy of the femur after marking the rotation by Kirschner wires or oscillating saw. Slide LC plate over Kirschner wires. Replace Kirschner wires with screws. Reduction of the femoral shaft to the plate with bone forceps. Definitive fixation of the plate to the femoral shaft by cortex or locking screws. Readaptation of vastus lateralis muscle over the plate. POSTOPERATIVE MANAGEMENT Partial weightbearing for 4-6 weeks depending on the age of the patient without any external fixation (e. g. cast) is possible. RESULTS Recent studies support the authors' findings of sufficient correction and stable fixation after proximal femoral osteotomy with the LCP pediatric hip plate. Low complication rates and stable fixation.