Abstract. Introduction. Surgery in patients with high body mass index (BMI) is more technically challenging and associated with increased complications post-operatively. Inferior clinical and functional mid-term results for high BMI patients undergoing high tibial osteotomy (HTO) relative to normal weight patients have been reported. This study discusses the clinical, radiological and functional outcomes of HTO surgery in patients with a high BMI. Method. This is a retrospective study on patients undergoing HTO surgery using the Tomofix anatomical MHT plate between 2017 and 2022, with follow-up period of up to 5 years. The cohort was divided: non-obese (BMI <30 kg/m2) and obese (BMI>30 kg/m2). Pre and post operative functional scores were collected: Oxford Knee Score (OKS), EuroQol-5D and Tegner. Complications, plate survivorship and Mikulicz point recorded. Results. 32 HTO procedures; 19 patients BMI <30 (average 27.0) and 14 patients BMI >30 (average 36.1). In BMI<30 cohort, one readmission for investigation of venous thromboembolism, doppler negative; two complications: hinge fracture and stitch abscess. The five year survivorship of the plate was 100%. In BMI>30 cohort, one readmission for pulmonary embolism; one complication: hinge fracture. The 5 year survivorship of the plate was 93%, 1 conversion to unicompartmental knee replacement. The average OKS improvement was 17 and 18 for BMI <30 and >30 respectively. Mikulicz point change was identical. Conclusion. The Tomofix anatomical MHT plate achieves good outcomes and minimal complications irrespective of BMI. Reduced plate survivorship, thus earlier conversion may be required in the obese, however higher cohort numbers are needed to confirm this

Objectives. Opening wedge high tibial osteotomy (HTO) is an established surgical procedure for the treatment of early-stage knee arthritis. Other than infection, the majority of complications are related to mechanical factors – in particular, stimulation of healing at the osteotomy site. This study used finite element (FE) analysis to investigate the effect of plate design and bridging span on interfragmentary movement (IFM) and the influence of fracture healing on plate stress and potential failure. Materials and Methods. A 10° opening wedge HTO was created in a composite tibia. Imaging and strain gauge data were used to create and validate FE models. Models of an intact tibia and a tibia implanted with a custom HTO plate using two different bridging spans were validated against experimental data. Physiological muscle forces and different stages of osteotomy gap healing simulating up to six weeks postoperatively were then incorporated. Predictions of plate stress and IFM for the custom plate were compared against predictions for an industry standard plate (TomoFix). Results. For both plate types, long spans increased IFM but did not substantially alter peak plate stress. The custom plate increased axial and shear IFM values by up to 24% and 47%, respectively, compared with the TomoFix. In all cases, a callus stiffness of 528 MPa was required to reduce plate stress below the fatigue strength of titanium alloy. Conclusion. We demonstrate that larger bridging spans in opening wedge HTO increase IFM without substantially increasing plate stress. The results indicate, however, that callus healing is required to prevent fatigue failure. Cite this article: A. R. MacLeod, G. Serrancoli, B. J. Fregly, A. D. Toms, H. S. Gill. The effect of plate design, bridging span, and fracture healing on the performance of high tibial osteotomy plates: An experimental and finite element study. Bone Joint Res 2018;7:639–649. DOI: 10.1302/2046-3758.712.BJR-2018-0035.R1

The ideal treatment method regarding various defect sizes after local aggressive tumor resection is unknown. We investigated the biomechanical properties of metaphyseal defect filling regarding different defect sizes and fixation methods.

Ninety-one sheep tibias were divided into five groups as 21 tibias per four study groups and 7 tibias in the control group. Study groups were further divided into three subgroups according to 25%, 50% and 75% metaphyseal defect size. Control group tibias were left intact. In study group 1, a metaphyseal defect was created and no further process was applied. Metaphyseal defects were filled with cement without fixation in group 2. Cement filling and fixation with 2 screws were performed in group 3. In addition to cement filling, plate-screw fixation was performed in group 4. Axial loading test was applied to all tibias and the results were compared between study subgroups and control group.

Plate-screw fixation was found to have the best biomechanical properties in all defect sizes. Load to failure for screw fixation was found to be significantly decreased between 25% and 50% defect size (P<0.05). However, load to failure for isolated cement filling was not affected from defect size (p>0.05).

In conclusion, size of the defect predicts the fixation method in addition to filling with cement. Filling with cement in metaphyseal defects was found to be biomechanically insufficient. In addition to filling with cement, additional screw fixation in less than 25% defects and plate-screw fixation in more than 25% defects may decrease tibial plateau fracture or metaphyseal fracture risk after local aggressive tumor resection.

Introduction and Objective. Plating of geriatric distal femoral fractures with Locking Compression Plate Distal Femur (LCP–DF) often requires augmentation with a supplemental medial plate to achieve sufficient stability allowing early mobilization. However, medial vital structures may be impaired by supplemental medial plating using a straight plate. Therefore, a helically shaped medial plate may be used to avoid damage of these structures. Aim of the current study was to investigate the biomechanical competence of augmented LCP–DF plating using a supplemental straight versus helically shaped medial plate. Materials and Methods. Ten pairs of human cadaveric femora with poor bone quality were assigned pairwise for instrumentation using a lateral anatomical 15-hole LCP–DF combined with a medial 14-hole LCP, the latter being either straight or manually pre-contoured to a 90-degree helical shape. An unstable distal femoral fracture AO/OTA 33–A3 was simulated by means of osteotomies. All specimens were biomechanically tested under non-destructive quasi-static and destructive progressively increasing combined cyclic axial and torsional loading in internal rotation, with monitoring by means of optical motion tracking. Results. Initial axial stiffness and torsional stiffness in internal and external rotation for straight double plating (548.1 ± 134.2 N/mm, 2.69 ± 0.52 Nm/° and 2.69 ± 0.50 Nm/°) was significantly higher versus helical double plating (442.9 ± 133.7 N/mm, 2.07 ± 0.32 Nm/° and 2.16 ± 0.22 Nm/°), p≤0.04. Initial interfragmentary axial displacement and flexural rotation under 500 N static loading were significantly smaller for straight plating (0.11 ± 0.14 mm and 0.21 ± 0.10°) versus helical plating (0.31 ± 0.14 mm and 0.68 ± 0.16°), p<0.01. However, initial varus deformation under this loading remained not significantly different between the two fixation methods (straight: 0.57 ± 0.23°, helical: 0.75 ± 0.34°), p=0.08. During dynamic loading, within the course of the first 4000 cycles the movements of the distal fragment in flexion were significantly bigger for helical over straight plating (1.03 ± 0.33° versus 0.40 ± 0.20°), p<0.01. However, no significant differences were observed between the two fixation methods in terms of varus, internal rotation, axial and shear displacements at the fracture site, and number of cycles to failure. Conclusions. Augmented lateral plating of unstable distal femoral fractures with use of supplemental helically shaped medial plate was associated with more elastic bone-implant construct behavior under static and dynamic loading compared to straight double plating. Both fixation methods resulted in comparable number of cycles to failure. From a biomechanical perspective, the more elastic helical double plating may be considered as useful alternative to straight plating, potentially reducing stress risers at the distal bone-implant interface due to its ameliorated damping capacities

Helical plates potentially bypass the medial neurovascular structures of the thigh. Recently, two plate designs (90°- and 180°-helix) proved similar biomechanically behaviour compared to straight plates. Aims of this study were: (1) Feasibility of MIPO-technique with 90°- and 180°-helical plates on the femur, (2) Assessment of distances to adjacent anatomical structures at risk, (3) Comparison of these distances to using medial straight plates instead, (4) Correlation of measurements performed in anatomic dissection with CT-angiography. MIPO was performed in ten cadaveric femoral pairs using either a 90°-helical 14-hole-LCP (Group1) or a 180°-helical 15-hole-LCP-DF (Group2). CT angiography was used to evaluate the distances between the plates and the femoral arteries as well as the distances between the plates and the perforators. Subsequently, the specimens were dissected, and the distances were determined again manually. Finally, all helical plates were removed, and all measurements were repeated after application of straight medial plates (Group3). Closest overall distances between plates and femoral arteries were 15 mm (11 − 19 mm) in Group1, 22 mm (15 − 24 mm) in Group2 and 6 mm (1 − 8 mm) in Group3 with a significant difference between Group1 and Group3 (p < 0.001). Distances to the nearest perforators were 24 mm (15 − 32 mm) in Group1 and 2 mm (1 − 4 mm) in Group2. Measurement techniques (visual after surgery and CT-angiography) demonstrated a strong correlation of r. 2. = 0.972 (p < 0.01). MIPO with 90°- and 180°-helical plates is feasible and safe. Attention must be paid to the medial neurovascular structures with 90°-helical implants and to the proximal perforators with 180°-helical implants. Helical implants can avoid medial neurovascular structures compared to straight plates although care must be taken during their distal insertion. Measurements during anatomical dissection correlate with CT-angiography

Dual plate constructs have become an increasingly common fixation technique for midshaft clavicle fractures and typically involve the use of mini-fragment plates. The goal of this technique is to reduce plate prominence and implant irritation, as these are common reasons for revision surgery. However, limited biomechanical data exist for these lower-profile constructs. The study aim was to compare dual mini-fragment orthogonal plating to traditional small-fragment clavicle plates for biomechanical non-inferiority and to determine if an optimal plate configuration could be identified, using a cadaveric model. Twenty-four cadaveric clavicles were randomized to one of six groups (n=4 per group), stratified by CT-based bone mineral content (BMC). The six different plating configurations compared were: pre-contoured superior or anterior fixation using a single 3.5-mm LC-DC plate, and four different dual-plating constructs utilizing 2.4-mm and 2.7-mm reconstruction or LC-DC plates. The clavicles were plated and then osteotomized to create an inferior butterfly fracture, which was then fixed with a single interfragmentary screw (OTA 15.2B). Axial, torsional, and bending (anterior and superior surface loading) stiffness were determined for each construct through non-destructive cyclic testing, using an MTS 858 Bionix materials testing system. This was followed by a load-to-failure test in three-point superior-surface bending. Kruskal-Wallace H and Mann-Whitney U were used to test for statistical significance. There were no significant differences in BMC (median 7.9 g, range 4.2-13.8 g) for the six groups (p=1.000). For axial stiffness, the two dual-plate constructs with a superior 2.4-mm and anterior 2.7-mm plate (either reconstruction or LC-DC) were significantly stiffer than the other four constructs (p=0.021). For both superior and anterior bending, the superior 2.4-mm and anterior 2.7-mm plate constructs were significantly stiffer when compared to the 3.5-mm superior plate (p=0.043). In addition, a 3.5-mm plate placed anterior was a stiffer construct than a superior 3.5-mm plate (p=0.043). No significant differences were found in torsional stiffness or load-to-failure between the different constructs. Dual plating using mini-fragment plates is biomechanically superior for fixation of midshaft clavicle fractures when compared to a single superior 3.5-mm plate and has similar biomechanical properties to a 3.5-mm plate placed anteriorly. With the exception of axial stiffness, no significant differences were found when different dual plating constructs were compared to each other. However, placing a 2.4-mm plate superiorly in combination with a 2.7-mm plate anteriorly might be the optimal construct, given the biomechanical superiority over the 3.5-mm plate placed superior

Helical plates are preferably used for proximal humeral shaft fracture fixation and potentially avoid radial nerve irritation as compared to straight plates. Aims:(1) to investigate the safety of applying different long plate designs (straight, 45°-, 90°-helical and ALPS) in MIPO-technique to the humerus. (2) to assess and compare their distances to adjacent anatomical structures at risk. MIPO was performed in 16 human cadaveric humeri using either a straight plate (group1), a 45°-helical (group2), a 90°-helical (group3) or an ALPS (group4). Using CT-angiography, distances between brachial arteries and plates were evaluated. Following, all specimens were dissected, and distances to the axillary, radial and musculocutaneous nerve were evaluated. None of the specimens demonstrated injuries of the anatomical structures at risk after MIPO with all investigated plate designs. Closest overall distance (mm(range)) between each plate and the radial nerve was 1(1-3) in group1, 7(2-11) in group2, 14(7-25) in group3 and 6(3-8) in group4. It was significantly longer in group3 and significantly shorter in group1 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the musculocutaneous nerve was 16(8-28) in group1, 11(7-18) in group2, 3(2-4) in group3 and 6(3-8) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the brachial artery was 21(18-23) in group1, 7(6-7) in group2, 4(3-5) in group3 and 7(6-7) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.021. MIPO with 45°- and 90°-helical plates as well as ALPS is safely feasible and showed a significant greater distance to the radial nerve compared to straight plates. However, distances remain low, and attention must be paid to the musculocutaneous nerve and the brachial artery when MIPO is used with ALPS, 45°- and 90°-helical implants. Anterior parts of the deltoid insertion will be detached using 90°-helical and ALPS implants in MIPO-technique

Abstract. Introduction. Compared to the standard Tomofix plate, the anatomical Tomofix medial high tibial (MHT) plate has been shown to improve anatomical fit and post correction tibial contour, following high tibial osteotomy (HTO). Clinical data on surgical complications, osteotomy union rates and survivorship with the anatomical Tomofix MHT plate however remain limited. This study reports mid-term results of HTO surgery, using the anatomical Tomofix MHT plate. Methods. All patients undergoing HTO surgery using the anatomical Tomofix MHT plate between 2017 and 2022 were included in the study. Data on complications, osteotomy union rates and survivorship were collected prospectively and retrospectively analysed. Results. 78 HTO procedures were performed using the anatomical Tomofix plate in 68 patients. Follow-up ranged between 6 weeks and 5 years. Postoperative complications included 5 hinge fractures that united without further intervention, 1 deep vein thrombus and 1 subclinical pulmonary embolism. There were no wound problems and no returns to theatre, other than for planned removal of metalwork at 1 year. All osteotomies united with no loss of correction. Only 1 HTO was successfully revised to a partial medial knee replacement 2.5 years following osteotomy. The 5-year survivorship was 98.7%. Conclusion. The anatomical Tomofix MHT plate achieves excellent biomechanical stability and union rates in HTO surgery, with minimal complications and excellent mid-term HTO survivorship

Aims. The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients. Methods. In this multicentre study, 120 patients aged ≥ 60 years with an acute unstable AO/OTA type 44-B fracture of the ankle were randomized to fixation with either a nail or a plate and followed for 24 months after surgery. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. Secondary outcome measures were the Manchester-Oxford Foot Questionnaire, the Olerud and Molander Ankle score, the EuroQol five-dimension questionnaire, a visual analogue score for pain, complications, the quality of reduction of the fracture, nonunion, and the development of osteoarthritis. Results. At 24 months, the median AOFAS score was equivalent in the two groups (nail 90 (interquartile range (IQR) 82 to 100), plate 95 (IQR 87 to 100), p = 0.478). There were statistically more complications and secondary operations after nail than plate fixation (p = 0.024 and p = 0.028, respectively). There were no other significant differences in the outcomes between the two groups. Conclusion. The functional outcome after nail and plate fixation was equivalent; however, the complication rate and number of secondary operations was significantly higher after nail fixation. These results suggest that plate fixation should usually be the treatment of choice for unstable ankle fractures in the elderly. Cite this article: Bone Joint J 2023;105-B(1):72–81

The ITS volar radial plate (Implant Technology Systems, Graz/Austria) is a fixation device that allows for the distal locking screws to be fixed at variable angles (70°-110°). This occurs by the different material properties, with the screws (titanium alloy) cutting a thread through the plate holes (titanium). We present our experience with the ITS plate. We retrospectively studied 26 patients who underwent ITS plate fixation for unstable multifragmentary distal radial fractures (AO types A3, B2, B3, C2, C3). The surgery was performed either by a consultant orthopaedic hand surgeon or senior registrar. A volar approach was used every time and 10 cases required synthetic bone grafting. Post-operatively they were immobilised for an average of 2.5 weeks. The 26 patients had a mean age of 58 and the dominant side was affected in 46% of cases. 5 cases were open fractures and 10 cases followed failed manipulation under general anaesthesia. The average interval between injury and surgery was 7 days. Union was achieved in all cases. No implant infections, failure or tendon rupture/irritation occurred. There were two fractures which loss reduction, of which one required revision surgery. There was one case of CRPS. The six month average DASH score was 27.5. We consider the ITS plate a technically easy plate to use and a reliable implant at early follow-up. We value the versatility of its variable angle screw fixation ability for complex intra-articular distal radial fractures

A finite element study was carried out to compare the performance of a three-hole locking plate with angled screws to the ‘gold-standard’ four-hole hip plate. Two cases of the three-hole hip plate were examined; (a) three screws and (b) two screws (most proximal and most distal). A 3D model of the proximal femur was constructed from CT scans. A 3D CAD model of the four-hole hip plate was also created. The three-hole hip plate was then created from the four-hole implant in a way that it was possible to switch between all three models by activating/deactivating sections and/or switching material properties. A single common finite element model was generated, and a static analysis of each model variation was then performed in two steps using ABAQUS/standard. In the first, screws were pre-tensioned up to 150N. In the second, loads corresponding to stair climbing were applied. Forces in the screws, permitted to change in the second step, were examined and compared. Maximum principal stresses in the bone were also examined, with a focus on the stresses in the bone at the end of the plate in each model. The highest tensile force was in the proximal screw of the three-hole plate with three screws, followed by the most distal screw in the standard four-hole plate. This suggests that the risk of screw pull-out is highest at the proximal screw of the three-hole hip plate with three screws. A comparison of the forces in the distal screws for all cases shows that the highest tensile force was in the four-hole plate, followed by the three-hole plate with two screws. The lowest was the three-hole plate with three screws, which was in compression at full load. The maximum tensile stresses in the bone at the end of the plate were greatest for the standard four-hole hip plate, followed by the three-hole plate with two screws and then the three-hole plate with three screws. This indicates that the risk of bone fracture at the end of the plate is lowest for the three-hole hip plate with three screws. The risk of bone fracture is significantly lower for the three-hole hip plate, with either two or three screws, compared to the ‘gold-standard’ four-hole hip plate. This is partially offset by a small increase in the risk of screw pull out (in the proximal rather than the distal screw)

Aims. Osteoarthritis (OA) is the most prevalent systemic musculoskeletal disorder, characterized by articular cartilage degeneration and subchondral bone (SCB) sclerosis. Here, we sought to examine the contribution of accelerated growth to OA development using a murine model of excessive longitudinal growth. Suppressor of cytokine signalling 2 (SOCS2) is a negative regulator of growth hormone (GH) signalling, thus mice deficient in SOCS2 (Socs2. -/-. ) display accelerated bone growth. Methods. We examined vulnerability of Socs2. -/-. mice to OA following surgical induction of disease (destabilization of the medial meniscus (DMM)), and with ageing, by histology and micro-CT. Results. We observed a significant increase in mean number (wild-type (WT) DMM: 532 (SD 56); WT sham: 495 (SD 45); knockout (KO) DMM: 169 (SD 49); KO sham: 187 (SD 56); p < 0.001) and density (WT DMM: 2.2 (SD 0.9); WT sham: 1.2 (SD 0.5); KO DMM: 13.0 (SD 0.5); KO sham: 14.4 (SD 0.7)) of growth plate bridges in Socs2. -/-. in comparison with WT. Histological examination of WT and Socs2. -/-. knees revealed articular cartilage damage with DMM in comparison to sham. Articular cartilage lesion severity scores (mean and maximum) were similar in WT and Socs2. -/-. mice with either DMM, or with ageing. Micro-CT analysis revealed significant decreases in SCB thickness, epiphyseal trabecular number, and thickness in the medial compartment of Socs2. -/-. , in comparison with WT (p < 0.001). DMM had no effect on the SCB thickness in comparison with sham in either genotype. Conclusion. Together, these data suggest that enhanced GH signalling through SOCS2 deletion accelerates growth plate fusion, however this has no effect on OA vulnerability in this model. Cite this article: Bone Joint Res 2022;11(3):162–170

Many two-part fractures of the proximal humerus are treated conservatively due to the frequent failure of internal fixation. The current investigation examines the biomechanical properties of a unique plate versus a standard plate for internal fixation of proximal humerus fractures. The unique plate employs screws that thread into the plate, creating a multi-planer, fixed angle device. A cadaveric model was developed that relied on the rotator cuff musculature as the primary deforming force. The locking plate displayed significantly greater holding power on the humeral head (p=0.007). This may lead to more consistent results in two-part fractures treated with internal fixation. The current investigation evaluates a unique plate designed to treat fractures of the proximal humerus. The plate employs screws that thread into the plate creating a fixed angle device. This plate was tested versus a standard cloverleaf plate. The locking plate displayed greater holding power on the humeral head in the model tested. This may lead to decreased failure rates in two-part fractures treated with internal fixation. Many two-part fractures of the proximal humerus are treated conservatively due to the frequent failure of common internal fixation modalities. This is done with the acceptance of possible non-union and loss of function. A more reliable method for stable internal fixation is therefore desirable. A significant difference was found (p=0.007) with the locking plate displaying greater holding capability on the humeral head. Eight pairs of preserved, cadaveric humeri were dissected and plated with either the locking plate or standard cloverleaf plate followed by an osteotomy at the surgical neck. A servo-hydraulic testing machine was then used to pull on the rotator cuff musculature until failure was achieved. Failure of the plate-head interface was reached in five of the eight pairs. Previous biomechanical studies have not taken into account the clinical mode of failure when testing internal fixation modalities for proximal humerus fractures. The current study has reproduced failure into varus by relying on the rotator cuff musculature as the primary deforming force. Funding: All implants donated by Synthes, Canada

Aims. Fixation of scaphoid nonunion with a volar locking plate and cancellous bone grafting has been shown to be a successful technique in small series. Few mid- or long-term follow-up studies have been reported. The aim of this study was to report the mid-term radiological and functional outcome of plate fixation for scaphoid nonunion. Methods. Patients with a scaphoid nonunion were prospectively enrolled and treated with open reduction using a volar approach, debridement of the nonunion, and fixation using a locking plate and cancellous bone grafting, from the ipsilateral iliac crest. Follow-up included examination, functional assessment using the patient-rated wrist/hand evaluation (PRWHE), and multiplanar reformation CT scans at three-month intervals until union was confirmed. Results. A total of 49 patients with a mean age of 31 years (16 to 74) and a mean duration of nonunion of 3.6 years (0.4 to 16) were included. Postoperatively, the nonunion healed in 47 patients (96%) as shown on CT scans. The mean time to union was 4.2 months (3 to 12). Due to impingement of the plate on the volar rim of the radius and functional limitation, the hardware was removed in 18 patients. At a median follow-up of 38 months in 34 patients, the mean active range of motion (ROM) improved significantly from 89° to 124° (SD 44°; p = 0.003). The mean grip strength improved significantly from 52% to 79% (SD 28%; p < 0.001) of the contralateral side. The mean PRWHE score improved significantly from 66 to 17 points (SD 25; p < 0.001). Conclusion. Locking plate fixation supplemented with autologous cancellous bone grafting is a successful form of treatment for scaphoid nonunion. Functional outcomes improve with the passage of time, and mid-term results are excellent with a significant improvement in ROM, grip strength, and functional outcome as measured by the PRWHE. Cite this article: Bone Joint J 2020;102-B(12):1697–1702

The purpose of this study is to determine the re-operation rate following plate fixation of the olecranon with contoured anatomic plates. Plate fixation of the olecranon allows for management of different fracture patterns as well as osteotomies with anatomic reduction and stable fixation for early elbow mobilization. However, olecranon hardware prominence can be troublesome. Our hypothesis was with the newer generation of low profile contoured anatomic plates, the rate of hardware removal should be lower compared to previously described literature. Retrospective review for patients treated with operative fixation of the olecranon between 2010 and 2015 in the Edmonton zone was identified using population level administrative data. Radiographic screening of these patients was then carried out to identify those who received plate fixation. Fracture patterns were also characterized. Chart reviews followed to determine the indications for re-operation and other post-operative complications. Main outcome measures were re-operation rate and their indications, including hardware prominence. During the screening process, 600 surgically treated olecranon patients were identified and 321 patients were found to have plate fixation of the olecranon. Chart review determined 90 patients had re-operations demonstrating a 28% re-operation rate. Re-operation due to hardware prominence was found to be 15.6%. Other indications included hardware failure (5.3%), infection (2.8%), or contracture (2.8%). Compared to patients that did not require re-operation, the re-operation group had a higher incidence of Type III olecranon fractures (17.4% vs 8.4%, p = 0.036) and Monteggia pattern injuries (13.5% vs 4.9%, p = 0.008). Recent heteregenous data suggests the hardware removal rate related to implant prominence is between 17–54%. Compared to the literature, this study demonstrated a lower rate at 15.6% with contoured anatomic plating. Also, those with more complex fracture patterns were more likely to require re-operation

Surgical education of fracture fixation biomechanics relies mainly on simplified illustrations to distill the essence of the underlying principles. These mostly consist of textbook drawings or hands-on exercises during courses, both with unique advantages such as broad availability and haptics, respectively. Computer simulations are suited to bridge these two approaches; however, the validity of such simulations must be guaranteed to teach the correct aspects. Therefore, the aim of this study was to validate finite element (FE) simulations of bone-plate constructs to be used in surgical education in terms of fracture gap movement and implant surface strain. The validation procedure was conducted in a systematic and hierarchical manner with increasing complexity. First, the material properties of the isolated implant components were determined via four-point bending of the plate and three-point bending of the screw. Second, stiffness of the screw-plate interface was evaluated by means of cantilever bending to determine the properties of the locking mechanism. Third, implant surface strain and fracture gap motion were measured by testing various configurations of entire fixation constructs on artificial bone (Canevasit) in axial compression. The determined properties of the materials and interfaces assessed in these experiments were then implemented into FE models of entire fixation constructs with different fracture width and screw configurations. The FE-predicted implant surface strains and fracture gap motions were compared with the experimental results. The simulated results of the different construct configurations correlated strongly with the experimentally measured fracture gap motions (R. 2. >0.99) and plate surface strains (R. 2. >0.95). In a systematic approach, FE model validation was achieved successfully in terms of fracture gap motion and implant deformation, confirming trustworthiness for surgical education. These validated models are used in a novel online education tool OSapp (. https://osapp.ch/. ) to illustrate and explain the biomechanical principles of fracture fixations in an interactive manner

Aims. To determine whether half-threaded screw holes in a new titanium locking plate design can substantially decrease the notch effects of the threads and increase the plate fatigue life. Methods. Three types (I to III) of titanium locking plates were fabricated to simulate plates used in the femur, tibia, and forearm. Two copies of each were fabricated using full- and half-threaded screw holes (called A and B, respectively). The mechanical strengths of the plates were evaluated according to the American Society for Testing and Materials (ASTM) F382-14, and the screw stability was assessed by measuring the screw removal torque and bending strength. Results. The B plates had fatigue lives 11- to 16-times higher than those of the A plates. Before cyclic loading, the screw removal torques were all higher than the insertion torques. However, after cyclic loading, the removal torques were similar to or slightly lower than the insertion torques (0% to 17.3%), although those of the B plates were higher than those of the A plates for all except the type III plates (101%, 109.8%, and 93.8% for types I, II, and III, respectively). The bending strengths of the screws were not significantly different between the A and B plates for any of the types. Conclusion. Removing half of the threads from the screw holes markedly increased the fatigue life of the locking plates while preserving the tightness of the screw heads and the bending strength of the locking screws. However, future work is necessary to determine the relationship between the notch sensitivity properties and titanium plate design. Cite this article: Bone Joint Res 2020;9(10):645–652

To determine the outcome of Clavicle Hook Plate fixation in terms of level of function achieved, healing of the fracture and the need for removal of the hook plate. Review of patient records and radiographs of all the fractured clavicles and acromioclavicular dislocations that were surgically treated with a Clavicle Hook Plate. The study population was identified using the operating theatre data. A total of 24 patients (19 lateral third-Neer type II-fractures and 5 type III acromioclavicular dislocations) were treated from January 1998 to December 2003. Eighteen of the 24 plates (75%) had been removed at the time of the study. In 72% restriction of the range of movement and pain due to plate impingement were the main causes for removal of the plate. Two of the plates (11%) were removed due to ‘mechanical failure’; the plate being levered off the bone or eroding the acromion. Mechanical failure of the plate was significantly associated with an older age group (P=0.01). At the time of discharge from the clinic 57% had more than 50% of their shoulder movements, while 55.5% had minimal or no pain. We suggest that Clavicle Hook Plates should be routinely removed as they cause impingement symptoms and they be used with caution (if at all) in the older age group given the tendency for the plate to lever off the bone

Biomechanical stability is important for fracture healing. With standard plate and screw constructs, longer plates with screws well spaced, near and far from the fracture site, are biomechanically superior. Newer locked plates have been shown to be superior to conventional plating for difficult fractures. The ideal screw configuration for fixation with locked plates has yet to be addressed. This study investigates the effects of screw position on construct stiffness as well as strain in both the plate and bone during fixation of a diaphyseal comminuted fracture using a locking plate with bicortical fixation. A composite cylinder (Sawbones) was machined to produce two models:. (a) comminuted model (4mm gap) and. (b) whole model (no gap) to simulate the remodelling phase. Five strain gauges were mounted to the bone models and one between the center holes of the locking plate. Four different configurations of screw number and position were evaluated using a twelve-hole locking plate (Smith & Nephew Perilock). Plate holes were numbered on each side of the gap from one to six. Screw configuration 654321, 621, 654 and 321 were tested in four-point bending on an MTS 858 Mini-Bionix. Force (N) and displacement (mm) as well as strain readings were recorded at 10 Hz. Plate strain in the gap model did not vary significantly for the different configurations. Construct stiffness of the 654 model (all screws far from gap) showed a 30% decrease in stiffness as compared to other screw configurations (p< 0.001). In the whole bone model, the maximal bone strain was outside the farthest screw from the center of the plate (stress shielding) and bone strain at the fracture site in 654 was significantly higher than in 621 (p< 0.001). Results showed that three screw fixation produced similar construct stiffness to a six screw construct when well spaced. Three screws placed far from the fracture gap (654) as compared to three screws evenly spaced (621) showed decreased stability in the comminuted model but resulted in increased bone strain at the fracture site in the whole bone model. All configurations produced similar plate strain

Introduction. Distal femur fracture fixation in elderly presents significant challenges due to osteoporosis and associated comorbidities. There has been an evolution in the management of these fractures with a description of various surgical techniques and fixation methods; however, currently, there is no consensus on the standard of care. Non-union rates of up to 19% and mortality rates of up to 26 % at one year have been reported in the literature. Delay in surgery and delay in mobilisation post-operatively have been identified as two main factors for high rate of mortality. As biomechanical studies have proved better stability with dual plating or nail-plate combination, a trend has been shifting for past few years towards rigid fixation to allow early mobilisation. Our study aims to compare outcomes of distal femur fractures managed with either single plate (SP), dual plating (DP) or nail-plate construct (NP). Methods. A retrospective review of patients aged above 65 years with distal femur fractures (both native and peri-prosthetic) who underwent surgical management between June 2020 and May 2023 was conducted. Patients were divided into three groups based on mode of fixation - single plate or dual plating or nail-plate construct. AO/OTA classification was used for non-periprosthetic, and Unified classification system (UCS) was used for periprosthetic fractures. Data on patient demographics, fracture characteristics, surgical details, postoperative complications, re-operation rate, radiological outcomes and mortality rate were evaluated. Primary objective was to compare re-operation rate and mortality rate between 3 groups at 30 days, 6 months and at 1 year. Results. A cohort of 32 patients with distal femur fractures were included in this study. 91% were females and mean age was 80.97 (range 68–97). 18 (53%) were non-periprosthetic fracture and 14 (47%) were periprosthetic fractures.18 patients underwent single plate fixation (AO/OTA 33A – 8, 33B/C – 2, UCS V3B – 5, V3C – 3),10 patients had dual plate fixation (AO/OTA 33A – 1, 33B/C – 4, UCS V3B – 3, V3C – 2) and 4 patients underwent nail-plate combination fixation (AO/OTA 33A – 4). 70.5% patients had surgery within 36 hours of admission and 90% within 48 hours. Analysis showed no re-operation at 30 days, 6 months in all 3 groups. At 1 year one patient had re-operation in dual-plating periprosthetic group (Distal femur replacement done for failed fixation). Three patients (16%) in single plate group had re-operation at 2 years (2 for peri-implant fracture and 1 for infection). None of the patients treated with Nail-plate combination had re-operation. Mortality rate at 30 days was 0% in among all the 3 groups. At 6 months, it was 16% in single plate group and 0% in DP and NP groups at 6 months and at 1 year mortality rate was 27% in SP group, 10% in DP and 0% in NP group. Combined mortality rate was 0% at 30 days, 9% at 6 months and 18.7% at one year. Conclusion. Our analysis provides insights into fixation methods of distal femur fractures in elderly patients. We conclude that a lower re-operation rate and mortality rate can be achieved with early surgery and rigid fixation with either dual plating or nail-plate construct to allow early mobilisation. Further prospective studies are warranted to confirm these findings and guide the selection of optimal surgical strategies for these challenging fractures