Biomechanical Analysis of Operative Methods in the Treatment of Extra-Articular Fracture of the Proximal Tibia

Abstract

BackgroundTo determine relative fixation strengths of a single lateral locking plate, a double construct of a locking plate, and a tibial nail used in treatment of proximal tibial extra-articular fractures.MethodsThree groups of composite tibial synthetic bones consisting of 5 specimens per group were included: lateral plating (LP) using a locking compression plate-proximal lateral tibia (LCP-PLT), double plating (DP) using a LCP-PLT and a locking compression plate-medial proximal tibia, and intramedullary nailing (IN) using an expert tibial nail. To simulate a comminuted fracture model, a gap osteotomy measuring 1 cm was created 8 cm below the knee joint. For each tibia, a minimal preload of 100 N was applied before loading to failure. A vertical load was applied at 25 mm/min until tibial failure.ResultsUnder axial loading, fixation strength of DP (14,387.3 N; standard deviation [SD], 1,852.1) was 17.5% greater than that of LP (12,249.3 N; SD, 1,371.6), and 60% less than that of IN (22,879.6 N; SD, 1,578.8; p < 0.001, Kruskal-Wallis test). For ultimate displacement under axial loading, similar results were observed for LP (5.74 mm; SD, 1.01) and DP (4.45 mm; SD, 0.96), with a larger displacement for IN (5.84 mm; SD, 0.99). The median stiffness values were 2,308.7 N/mm (range, 2,147.5 to 2,521.4 N/mm; SD, 165.42) for the LP group, 4,128.2 N/mm (range, 3,028.1 to 4,831.0 N/mm; SD, 832.88) for the DP group, and 5,517.5 N/mm (range, 3,933.1 to 7,078.2 N/mm; SD, 1,296.19) for the IN group.ConclusionsDuring biomechanical testing of a simulated comminuted proximal tibial fracture model, the DP proved to be stronger than the LP in terms of ultimate strength. IN proved to be the strongest; however, for minimally invasive osteosynthesis, which may be technically difficult to perform using a nail, the performance of the DP construct may lend credence to the additional use of a medial locking plate.

Finite element analysis of intramedullary nailing and double locking plate for treating extra-articular proximal tibial fractures

“…In the viewpoint of biomechanics, the structures of DLP and IMN primarily supply with support in lateral and axial directions respectively. For construct stability, the IMN fixation provided the higher stiffness, which was similar to that of Lee et al [ 19 ] who found that intramedullary nail provided a stronger stress compared with the double plates fixation. And Lee also mentioned that IMN was an ideal load sharing implant with respect to the concepts of minimally invasive surgery.…”

Nailing Versus Plating in the Management of Proximal Extra-Articular Tibial Fractures: A Systematic Review

“…Lack of comparable control group with identical or at least similar baseline data, the IMN and plate groups in this study could have different average age, gender ratio, injury severity and et al, and therefore, the result of inter-group comparison could be misleading [11]. This could be the reason for the highest implant failure rate for IMN compared with plate and even with external fixator in this systematic review, which was hard to explain, for according to most of the biomechanical studies, IMN has the strongest stability [16][17][18].…”

Intramedullary Nailing with a Suprapatellar Approach and Condylar Bolts for the Treatment of Bicondylar Fractures of the Tibial Plateau

“…Of the 3 studies that have confirmed the biomechanical advantages of the proposed technique, 2 investigated proximal tibial fractures with a metaphyseal-diaphyseal gap 14 , 15 , whereas the third 16 , with the participation of the author of the present study, involved the fixation technique described in the current report. The models in the third study were commercially prepared plastic bones with fracture planes that could be reduced with excellent contact; these models lacked articular or fracture-plane impaction or comminution.…”