Malaysian Journal of Medicine & Health Sciences

CORRELATION BETWEEN THE CLOSEST PIN DISTANCE OF

THE FRACTURE LINE TO THE STABILITY OF THE EXTERNAL
FIXATION: A BIOMECHANICAL STUDY ON BOVINE TIBIA

Journal: Malaysian Journal of Medicine & Health Sciences

Manuscript ID Draft
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Manuscript Type: Original Article

Axial Compression, Closest Pin Distance, Bovine Tibia, External Fixation

Keywords:
Stability
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Page 1 of 13 Malaysian Journal of Medicine & Health Sciences

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2 ABSTRACT
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6 Introduction: The use of external fixation with a uniplanar frame has the disadvantage of
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8 stability to axial compression forces. A way to increase external fixation stability is to locate
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the first pin as close to the fracture as possible. Aims: To determine the effect of the closest
11 pin distance from the fracture line on the stability of the external fixation which is applied axial
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13 compression force. Material and Methods: This study was an experimental study with a
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post-test only controlled group design, using bovine tibia. It was conducted in the Laboratory
16 of Sebelas Maret University from June to September 2020. There were three treatment
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18 groups with different closest pin spacing (2 cm, 3 cm, 4 cm). Results: This study used 10
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bones for each treatment groups. The closest 2 cm pin distance group has the largest mean
21 value of compressive strength 7036.56 ± 453.37 Newton. Linear regression analysis shows
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23 the value of p = 0.000 with a regression coefficient of -912.55. The significant relationship
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proves the near-far law theory, where the pins are placed as close as possible from the
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26 fracture line could give the greater amount of external fixation stability. Conclusion: There is
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28 a significant relationship between the closest pin distance and the compressive strength of
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the external fixation.
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33 Key-words: Axial Compression; Closest Pin Distance ; Bovine Tibia; External Fixation
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35 Stability
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2 INTRODUCTION
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6 External fixation is a common practice for the management of trauma patients with
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8 fractures. It indicated as damage control measures, especially in patients with severe soft
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tissue damage. External fixation used as a definitive treatment for fractures. Considerations
11 about the rigidity and biomechanical aspects of the implant influence bone healing, and the
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13 vascularity of the fracture area.1-3
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15 Stability is the fundamental characteristic of external fixation. The stability required
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must be precise, allowing micro-movement for the bone consolidation process, without
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18 compromising the strength of the external fixation stability. One way to increase the rigidity of
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20 the external fixation device is to increase the number of pins. Biomechanical studies reveal
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that the 6 pin construction is more rigid and has better stability than the 4 pin construction.
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23 This is due to the smaller distance F0 on the external 6 pin fixation compared to the 4 pin
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construction. The smaller the distance F0, the greater the stiffness and the smaller the flexor
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moment.4
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Use of external fixation with a unilateral frame that is often used has the
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30 disadvantage of stability to bending, compression, and torsion forces. The displacement of
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33 The stability of the external fixation is influenced by many things, one of which is the distance
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35 of the pin to the fracture line.5 Ideally, to gain stability in the 6 pin construction, the location of
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the first pin is as close as possible to the fracture, and the other pins are as far as possible to
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38 the fracture.6,7 However, the literature has not been stated at what distance from the fracture
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40 line the maximum stability is obtained.
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42 This study was conducted to compare the results of biomechanical tests on the
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44 external technique of unilateral frame fixation on tibia fractures with 6 pin construction at
45 several locations measured from the fracture line by assessing the resistance to
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47 compression forces. This study aims to get the most ideal pin distance from the fracture line
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49 in order to obtain the maximum stability of the tibial fracture, which is attached externally to
50 the unilateral frame.
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Page 3 of 13 Malaysian Journal of Medicine & Health Sciences

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2 MATERIAL AND METHODS
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6 This research is a laboratory experimental research. The research design used was
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8 a randomized post-test only control group design. After being given the treatment, the
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experimental group will be given a posttest, to determine the condition of the group after
11 giving the treatment. This research was conducted in the Orthopedic and Traumatology
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13 Department of dr. Moewardi Surakarta and the Engineering Laboratory of Sebelas Maret
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University, Sebelas Maret University from June to September 2020.
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The research sample in this study used 30 bovine tibial bones that met the inclusion
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18 and exclusion criteria. Inclusion criteria include the following a) using the bovine tibia, b) age
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20 of the bovine tibial bone of 20-24 months, c) bone length 25-30 cm, mid-shaft diameter ± 6
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cm, d) bone weight 2000 grams, e) bone condition normal bovine leg. Fractures occurring
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23 prior to treatment and spiral, oblique, or comminuted fracture patterns were excluded from
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the sample group. After collecting 30 tibia bones, they will then be divided into three groups,
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namely the control group (the closest pin distance group is 4 cm), the closest pin spacing
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28 group is 3 cm, and the closest pin spacing group is 2 cm, 10 bones each. In each research
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30 group, the same diameter, size pins and sidebar will be used. The distance between the pins
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outside the closest point is 5 cm, the distance between the sidebar and the bone is 50 mm.
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33 The process of measuring the external stabilization test on the bovine tibial bone in
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35 this study is described: a) preparation of the tool and installation of external fixation by
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providing a gap between fracture fragments of 10 mm, placing the bone in the Universal
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38 Testing Machine, the compression test is carried out so that there is no fragment gap
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40 fracture, a measurement of the axial compression force in Newtons / mm.
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42 This research uses univariate analysis and bivariate analysis. Univariate analysis is
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44 used to explain and describe the characteristics of each research variable and is presented
45 in tabular form. Bivariate analysis is used to determine the direction of the relationship
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47 between the pin distance closest to the fracture line to the stability of the external fixation that
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49 is given axial compression force. The data will be analyzed using a linear regression test.
50 Statistical data processing will be carried out using the Statistical Product and Service
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52 Solution (SPSS) program version 25.0 for Windows. In this study, a power of 90% was used
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54 with a 95% confidence interval. All analytical tests used p <0.05.
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2 RESULTS
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6 Based on table 1, a distance of 2 cm pin has a minimum compressive strength of
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8 6241.79 newtons, a maximum compressive strength of 7596.15 newtons, and a mean value
9 of 7036.56 ± 453.37. A distance of 3 cm has a compressive strength value of 6009.75
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11 newtons, a maximum compressive strength of 6760.01 newtons, and a mean value of
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13 6377.83 ± 231.71. For a distance of 4 cm, it has a minimum compressive strength of 4267.16
14 newtons, a maximum strength of 5871.35 newtons, and a mean value of 5211.47 ± 481.18.
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18 From Fig. 1, the highest compressive strength value is the 2 cm pin distance and the
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20 lowest compressive strength value is the 4 cm pin distance.
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24 The data normality test in this study used Shapiro-Wilk because the data were less
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27 distance of 3 cm, and a distance of 4 cm, has a p value> 0.05, which means the data is
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The results of the regression analysis table 3. shows the value of p = 0.000 <0.05, so
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34 there is a significant difference between the pin distance and the compressive strength of the
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36 external fixation that is given axial compression force. The regression coefficient value of -
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912.55 shows that with each additional 1 cm pin distance from the fracture line, the fixation
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39 pressure strength decreases by 912.55 newtons.
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43 Table 4 shows the linear regression coefficient of determination of 0.775. This shows
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45 that the compressive strength of 77.5% is influenced by the variable of the closest pin
46 distance, while 22.5% is influenced by other variables not examined.
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2 DISCUSSION
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6 The results showed that there was a significant difference in the compressive
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8 strength of the external fixation between all groups. The most influential thing is the 2 cm pin
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distance to the external fixation press output. This result is consistent with the near-far law
11 theory, where the pins are placed as close as possible from the fracture line and placed as
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13 far as possible on each side of the fracture. The closest pin is placed as close as possible
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from the fracture line to stabilize the fracture segment.11,16 The 2 cm pin distance group has a
16 compressive value of 7036 newtons, this group made the greatest value of the compressive
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18 strength of all groups.
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20 In this study, besides the factor of the distance between the pins closest to the
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fracture line, the number of pins can also influence the results of the study. According to
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23 Bojrab M et al., increasing the number of pins will distribute forces against the pins and
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increase the stiffness of the construction as a whole. However, increasing the number of pins
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can increase the risk of damage to the surrounding anatomical structures and increase the
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28 portal of infection. Increasing the diameter of the pin core will increase the torsional strength,
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30 as a 6mm diameter pin is five times stronger than a 4mm pin. The larger the pin diameter,
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the maximum construction stiffness can be achieved, but the pin diameter should not be
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33 more than one-third of the bone diameter to avoid pin-hole fracture.7
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35 According to Moss DP et al., external fixation can be used as a definitive treatment
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for fractures. The location of the first pin is as close as possible to the fracture and the other
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38 pins as far as possible with the fracture. Considerations about the rigidity and biomechanical
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40 aspects of implants greatly influence bone healing, besides the vascularity of the fracture
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42 area.13 In certain fractures, external fixation has advantages over other fixation models, such
43 as Open Reduction Internal Fixation (ORIF) and intramedullary (IM) nailing. External fixation
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45 can be used in high-energy multiple trauma patients who may have open wounds, severe
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47 soft tissue damage, comminuted fractures, or bone loss incompatible with the use of ORIF or
48 IM nailing.
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50 There are several factors that affect the stability of the construction on external
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52 fixation, including maximizing the size of the pins, the number of pins, the distance between
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54 pins, the closeness of the pins to the fracture line, the bar for clamping the bone to the
55 clamp, and the diameter of the pin / connecting rod.11 Ideal position for placement is based to
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57 near-far law where the pin is placed as close as possible to the fracture line and placed as
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59 far as possible on each side of the fracture. The stiffness can also be increased by a double
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2 The results showed that there was a significant effect on the distance of the closest
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4 pin from the fracture line to the stability of the external fixation that was given axial
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compression force. External fixation is a method of obtaining alignment to the bone using a
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7 combination of pins, wire, clamp, and bar/ring. This type of fixation was first introduced by
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9 Lambotte in the early 20th century.1,16,17 Anderson and Hoffman modified Lambotte’s
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invention by developing and customizing pin clamps that could manipulate fractures in all 3
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12 dimensions (a precursor to many modern external fixations currently in use).17
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14 This study was successful in proving a significant relationship between the closest
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16 pin distance and the compressive strength of external fixation. The closer the pin distance to
17 the fracture line will increase the compressive strength of the external fixation. Further
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19 research is needed to test other stability measurement tools such as tension, shear, and
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21 bending tests.
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CONCLUSION
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There is a significant relationship between the closest pin distance and the compressive
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32 ACKNOWLEDGMENTS
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34 None
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40 CONFLICT OF INTEREST
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All authors declare that they have no conflict of interest.
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2 REFERENCES
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5 1. Roberts C, Pape H, Jones A, Malkani A, Rodriguez J, Giannoudis P. Damage Control
6 Orthopaedics: evolving concepts in the treatment of patients who have sustained
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8 orthopaedic trauma. The Journal of Bone & Joint Surgery 2005;54:447-62.
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10 2. Cao Y, Zhang Y, Huang L, Huang X. The impact of plate length, fibula integrity and
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plate placement on tibial shaft fixation stability: a finite element study. Journal of
13 Orthopaedic Surgery and Research 2019;14(52):1-7.
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15 3. Fragomen A, Rozbruch S. The Mechanics of External Fixation. HSS Journal.
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17 2006;3(1):13-29.
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4. Sternick M, Dallacosta D, Bento D, Reis M. Relação entre rigidez de fixador externo e
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20 quantidade de pinos: análise computacional por elementos finitos. Revista Brasileira
21
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22 de Ortopedia. 2012;47(5):646-650.
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24 5. Haryadi D, Prijambodo B. Unilateral external Fixation Frame And Modified Bilateral
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25 External Fixation Frame Using Model Of Tibial Fracture Of A Java Goat (Capra
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27 Aegagrus Hircus): A Biomechanical Test. Surabaya: Medical Faculty of Airlangga
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29 University; 2019 1-10.

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6. Moss DP, Tejwani N. Biomechanics of external fixation: a review of the literature. Bull
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32 NYU Hosp Jt Dis. 2007;65(4):294-9.

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34 7. Karunakar MA, Bosse MJ. Principles of external fixation. In: Bucholz RW, Heckman
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36 JD (eds): Rockwood and Green’s Fractures in Adults. (5th ed). Philadelphia: Lippincott
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Williams & Wilkins, 2001, 231-44.
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39 8. Greene W, Netter F. Netter's orthopaedics. 1st ed. Philadelphia, PA: Saunders
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Elsevier; 2006.
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43 9. Behrens F. A primer of fixator devices and configurations. Clin Orthop Relat Res.
44 1989;(241):5-14.
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46 10. Höntzsch D. Safe Zone for Tibial Pin Insertion : Wheeless' Textbook of Orthopaedics
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48 [Internet]. Wheeless' Textbook of Orthopaedics 2018 [cited 2020 Apr 4]; Available
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from: https://www.wheelessonline.com/bones/safe-zone-for-tibial-pin-insertion/
51 11. Bojrab M, Waldron D, Toombs J. Current techniques in small animal surgery. 1st ed.
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53 CRC Press; 2014.
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55 12. Behrens F, Johnson WD, Kock TW, et al. Bending stiffness of unilateral and bilateral
56 fixator frames. Clin Orthop Relat Res. 1983;(178):103-10.
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58 13. Aro HT, Hein TJ, Chao EYS. Mechanical performance of pin clamps in external
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60 fixators. Clin Orthop Relat Res.1989;(248):246-53.

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14. Matthews LS, Green CA, Goldstein SA. The thermal effects of skeletal fixation-pin
3 insertion in bone. J Bone Joint Surg Am. 1984;66(7):1077-83.
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5 15. Kowalski M, Schemitsch EH, Harrington RM, et al. Comparative biomechanical
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7 evaluation of different external fixation sidebars: Stainless-steel tubes versus carbon
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fiber rods. J Orthop Trauma. 1996;10:470-5.
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10 16. Parvizi J, Kim G. External Fixation. High Yield Orthopaedics. 2010;171-72.
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12 17. Grubor P, Grubor M, Asotic M. Comparison of Stability of Different Types of External
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14 Fixation. Medical Archives. 2011;65(3):157.
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3 Tabel 1. Baseline Characteristics
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7 Pin Distance Minimum Maximum Mean Std. Deviation
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9 2 cm 6241.79 7596.15 7036.56 453.37
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3 cm 6009.75 6760.01 6377.83 231.71
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12 4 cm 4267.16 5871.35 5211.47 481.18
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14 Total 4267.16 7596.15 6208.62 861.06
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3 Table 2. Normality Test
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7 Pin Distance Shapiro-Wilk
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9 Statistic df Sig.
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Compressive 2 cm 0.948 10 0.644
12 Strength 3 cm 0.972 10 0.907
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14 4 cm 0.947 10 0.633
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3 Table 3. Bivariate Analysis
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7 Variable Pin N Mean±SD CI 95% P-value
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9 Distance (Confidence Interval)
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Compressive 2 cm 10 7036.56±453.37 6712.24-7360.89 0.000
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12 Strength 3 cm 10 6377.83±231.71 6212.07-6543.58
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14 4 cm 10 5211.47±481.18 4867.25-5555.68
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3 Table 4. Regression Linear Analysis
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7 Variable Regression Coefficient P-value
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9 Pin Distance -912,55 0.000
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40 Figure 1. External Fixation 6 Pin Construction Model A) Before being given treatment B) After being given
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