Clin Orthop Surg.  2014 Sep;6(3):312-317. 10.4055/cios.2014.6.3.312.

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

• Lee SM
• Oh CW
• Oh JK
• Kim JW
• Lee HJ
• Chon CS
• Lee BJ
• Kyung HS

• KMID: 1794713
• DOI: http://doi.org/10.4055/cios.2014.6.3.312

Abstract

BACKGROUND
To 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.
METHODS
Three 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.
RESULTS
Under 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.
CONCLUSIONS
During 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.

Keyword

Proximal tibial fracture; Locking plate; Nail; Biomechanical study

MeSH Terms

Biomechanical Phenomena
Bone Nails
Bone Plates
Fracture Fixation, Internal/*instrumentation
Fractures, Comminuted/physiopathology/*surgery
Humans
Models, Anatomic
Tibial Fractures/physiopathology/*surgery

Figure

• 

  Fig. 1 Three types of instruments were used in the proximal tibia fracture models with a gap osteotomy measuring 1 cm (LP, DP, and IN from the left). Typical experimental set-ups for mechanical testing are also shown alongside the radiographic constructs. LP: lateral plating, DP: double plating, IN: intramedullary nailing.

• 

  Fig. 2 Failures after axial load testing for all constructs and resulting radiographs. Development of bone cracks at the bone-proximal locking screw interface was observed in four of the five LP constructs. Bone cracks were observed at the bone-proximal locking screw interface in all five DP constructs, and four of them showed bending of plates at the osteotomy gap. Failure at interlocking screws, without bending of the nail was observed in all IN constructs. LP: lateral plating, DP: double plating, IN: intramedullary nailing.

• 

  Fig. 3 Comparison of axial load to failure for all construct groups. The intramedullary nailing (IN) was found to be the strongest construct. In terms of axial loading, the average load to failure of the double plating (DP) construct was 17.5% greater than that of the lateral plating (LP) construct (p < 0.001).

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