Biomechanical evaluation of current patella fracture fixation techniques.

OBJECTIVE: To compare the mechanical effectiveness of three different techniques for stabilization of transverse fractures of the patella. DESIGN: Cadaveric knees were used to model acute fractures of the patella. To test three treatment techniques in pairs of knees, specimen pairs were assigned randomly to a set of predetermined treatment pairs so as to provide equal numbers of paired and unpaired data sets. Results then were analyzed using a two-way analysis of variance. SETTING: The treatment techniques used are widely applicable in the clinical setting for the treatment of transverse fractures of the patella. No specialized equipment or training is required for the general or subspecialized orthopaedic surgeon. PATIENTS/PARTICIPANTS: None. INTERVENTIONS: Fractures were created in eighteen knees (nine pairs) and repaired by one of three techniques: (a) modified tension band (AO technique); (b) two parallel 4.5-millimeter interfragmentary lag screws; or (c) a new technique using four-millimeter cannulated lag screws with a tension band wired through the screws. MAIN OUTCOME MEASURES: In mechanical testing, the amount of interfragmentary separation in simulated knee extension and the maximum load to failure at 45 degrees of flexion were measured. RESULTS: Fractures stabilized with a modified tension band were found to displace significantly more than those fixed with screws alone or screws plus a tension band in simulated knee extensions (p < 0.05). The fractures fixed with the cannulated screws plus the tension band failed at higher loads (mean = 732 newtons) than those stabilized with screws alone (mean = 554 newtons, p = 0.06) or those with a modified tension band (mean = 395 newtons, p < 0.05). CONCLUSIONS: Combining interfragmentary screw fixation with the tension band principle appears to provide improved stability over the modified tension band or screws alone for transverse patella fractures. Cannulated screws allow for simple, reliable addition of a tension band to screw fixation.

Comparison of the effects of compression plates and external fixators on early bone-healing.

We used two mechanically dissimilar devices, compression bone-plates and unilateral-frame external fixators, in a standard canine osteotomy model; both methods were highly successful in achieving mature bone union. Bone union was studied by histological, physiological, and biomechanical means. At 120 days after injury, union was biomechanically less mature on the external fixator side. These tibiae had less intracortical new-bone formation (p less than 0.01), more bone resorption (p less than 0.045), and more bone porosity (p less than 0.04) when compared with paired tibiae that had been treated with compression plates. This higher level of bone turnover on the external fixator side was accompanied by an increase in blood flow (measured by clearance of 85Sr) (p less than 0.04). At the osteotomy site, pre-experimental or unlabeled bone and porosity were greater on the external fixator side and endosteal new-bone formation was greater on the plated side. Since the in vitro stiffness of the external fixator was less in all modes tested (compression, distraction, torsion, and anteroposterior bending) except lateral bending, it may be that the rigidity of the fixation is an important factor in early bone-remodeling of a healing osteotomy.

Fatigue performance of external fixator pins.

The fatigue performance of several types of commonly used external fixator pins was examined. The pins were tested under a cyclic bending mode. A strength reduction factor (SRF) was defined to quantify the effect of stress concentration caused by the pin threads as compared with the smooth portion of the pin. The half pins tested had much higher SRF values than the corresponding full pins because of the smaller root diameter of the threaded regions. The use of finer threads and a cold rolling process appeared to increase the pin fatigue strength. In some pins, the depth markers on the smooth portion and the self-tapping fluted region were sites of significant stress concentration. When certain half pins are severely loaded under clinical conditions, they may fracture because of fatigue.

Comparison of mechanical performance in four types of external fixators.

The Hoffmann-Vidal triangular apparatus for fracture fixation of the femur, the Volkov-Oganesian device with Steinmann pins in tension, the Kronner device with a plastic elliptic frame, and the Roger-Anderson apparatus (both standard and compression-distraction designs) were studied based on loading and analytic methods established previously. The results were compared with those for the standard Hoffmann-Vidal quadrilateral configuration. The Kronner device, with five connecting bars, was the stiffest under most loading modes, closely followed by the Hoffmann-Vidal quadrilateral apparatus. The standard Roger-Anderson device demonstrated average rigidity; its new design with compression-distraction capability was relatively weak. All devices showed an apparent weakness in antero-posterior bending. The Volkov-Oganesian design demonstrated low overall stiffness but was the most effective apparatus in resisting anteroposterior bending. External fixators provide effective compression at the fracture site, and the amount of compression is proportional to the stiffness of the apparatus.

Rigidity and stress analyses of external fracture fixation devices--a theoretical approach.

The rigidity and stresses in external fracture fixation devices were studied by means of the finite element method. Different geometries and material parameters were simulated using a beam element model. Axial, bending and torsional loads were applied through the bone ends and the displacement obtained at the fracture sites was used to calculate the fracture fixation stiffness. The key parameters which increased fixation rigidity were identified. High pin stresses were predicted under certain application conditions. Possible clinical implications for the use of such apparatus are discussed in the light of bone fracture healing. The present results are expected to have a significant impact on future design modifications and clinical applications of this popular instrument in orthopedic surgery and traumatology.