A systematic review of the use of titanium versus stainless steel implants for fracture fixation.

BACKGROUND: Controversy exists regarding the use of titanium and stainless steel implants in fracture surgery. To our knowledge, no recent, comprehensive review on this topic has been reported. PURPOSE: To perform a systematic review of the evidence in the current literature comparing differences between titanium and stainless steel implants for fracture fixation. METHODS: A systematic review of original research articles was performed through the PubMed database using PRISMA guidelines. Inclusion criteria were English-language studies comparing titanium and stainless steel implants in orthopaedic surgery, and outcome data were extracted. RESULTS: The search returned 938 studies, with 37 studies meeting our criteria. There were 12 clinical research articles performed using human subjects, 11 animal studies, and 14 biomechanical studies. Clinical studies of the distal femur showed the stainless steel cohorts had significantly decreased callus formation and an increased odds radio (OR 6.3, 2.7-15.1; P < .001) of nonunion when compared with the titanium plate cohorts. In the distal radius, 3 clinical trials showed no implant failures in either group, and no difference in incidence of plate removal, or functional outcome. Three clinical studies showed a slightly increased odds ratio of locking screw breakage with stainless steel intramedullary nails compared with titanium intramedullary nails (OR 1.52, CI 1.1-2.13). CONCLUSION: Stainless steel implants have equal or superior biomechanical properties when compared with titanium implants. However, there is clinical evidence that titanium plates have a lower rate of failure and fewer complications than similar stainless steel implants in some situations. Although our review supports the use of titanium implants in these clinical scenarios, we emphasize that further prospective, comparative clinical studies are required before the conclusions can be made.

Does Greater Trochanter Decortication Affect Suture Anchor Pullout Strength in Abductor Tendon Repairs? A Biomechanical Study.

BACKGROUND: Greater trochanter decortication is frequently performed at the time of abductor tendon repair to theoretically increase healing potential. No previous studies have determined the effect that greater trochanter decortication has on the pullout strength of suture anchors. Hypothesis/Purpose: The purpose of this study is to determine whether greater trochanter decortication and bone mineral density affect suture anchor pullout strength in abductor tendon repair. The authors hypothesize that both will have a significant detrimental effect on suture anchor pullout strength. STUDY DESIGN: Controlled laboratory study. METHODS: Nineteen cadaveric proximal femurs with accompanying demographic data and computed tomography scans were skeletonized to expose the greater trochanter. Bone density measurements were acquired by converting Hounsfield units to T-score, based on a standardized volumetric sample in the intertrochanteric region of the femur. The gluteus medius insertion site on the lateral facet of the greater trochanter was evenly divided into 2 regions, anterior-distal and posterior-proximal, and each region was randomly assigned to receive either no decortication or 2 mm of bone decortication. A single biocomposite anchor was implanted in each region and initially tested with cyclic loading for 10 cycles at 0-50 N, 0-100 N, 0-150 N, and 0-200 N, followed by load to failure (LTF) tested at 1 mm/s. For each trial, the number of cycles endured, LTF, mechanism of failure, and stiffness were recorded. RESULTS: Greater trochanters with no decortication and 2 mm of decortication survived a mean ± SD 35.1 ± 6.4 and 28.5 ± 10.6 cycles, respectively ( P < .01). Load to failure for nondecorticated specimens was 206.7 ± 75.0 N versus 152.3 ± 60.2 N for decorticated specimens ( P < .001). In a multivariate analysis, decortication and bone density were determinants in LTF ( P < .05). CONCLUSION: Decortication and decreased bone mineral density significantly decreased the pullout strength of suture anchors in the lateral facet of the greater trochanter. CLINICAL RELEVANCE: Bone density should be considered when determining whether to perform greater trochanter decortication in abductor tendon repairs.

The Halo Effect: An Unintended Benefit of Care Pathways.

The objective of this study was to determine if implementation of a simplified care pathway for total knee arthroplasty (TKA) would affect outcomes of total hip arthroplasty (THA) patients in the same health care system. Data were collected from a total of 5,095 consecutive THA patients in the year before and 2 years after implementation of the care pathway for TKA patients. Postimplementation increases were observed in both early activity (p < 0.0001) and continuous urinary catheter avoidance (p < 0.0001) among THA patients. These improvements in protocol adherence were associated with decreased complications (p < 0.0001), fewer 30-day readmissions (p < 0.0019), and decreased hospital length of stay (p < 0.0001). Based on these results, the implementation of a simplified care pathway for TKA patients can also improve outcomes for THA patients in the same health care system.