I

Plate Fixation
in
Orthopaedics
Basic Concepts and Clinical Applications
II
 III

Plate Fixation
in
Orthopaedics
Basic Concepts and Clinical Applications

Authors:
Hamid Reza Seyyed Hosseinzadeh MD
Assistant Professor of Orthopaedic Surgery
Akhtar Orthopaedic Hospital
Shahid Beheshti University of Medical Sciences
Tehran, Iran

Mehrnoush Hassas Yeganeh MD

Resident of Pediatrics
Mofid’s Pediatric Hospital
Shahid Beheshti University of Medical Sciences
Tehran, Iran

Hamed Reza Seyyed Hosseinzadeh

PhD Candidate in Metallurgy
Amirkabir University of Technology
Tehran, Iran
IV
 V

Dedicated to

The memory of our father

Yaaghoub

Whose love will forever be in our heart

VI
 VII

Preface:
This book is intended to comprehensively cover the subject of plate fixation in orthopaedic surgery. There are
many articles and books on this subject around the world, but each of them has approached this, from a particular
point of view. A surgeon who wants to study multiple aspects of a particular plate, especially its metallurgical and
biomechanical features, altogether, finding a book covering all these concepts, seems nearly impossible. So, we
intended to gather a wide range of information together inside a single book, about the basic concepts and the
clinical applications of plate fixation in orthopaedics, to fulfill this need. Strictly speaking, metallurgical aspects of
plates are not fully discussed in orthopaedic literature, may be due to the coverage of this concept by a specialty in
engineering and materials science, which has no apparent relationship to orthopaedics and medicine. But as every
orthopaedic surgeon knows, plate failures predominantly result from some engineering misconception and mistake
in production or application of plates. In this book, we have tried to cover this special aspect of this clinical concept.
With respect to the growing number of plates used in orthopaedic surgery and as, many companies are producing
a large number of plates in different designs and materials, the surgeons must have the basic knowledge of the
plates to be able to choose the best and fittest one for his/her special patient and to choose the best plate with
respect to its geometry, biomechanics, material and technology used to produce it.
This book consists of seven sections, each discussing a particular aspect of plate fixation. In section I, we described
a brief history of “fixation in orthopaedics”, to mention our appreciation toward all, not only those who have been
named in the book, that have worked in the past to open the horizon of orthopaedics for us. In the sections II-IV, we
have discussed the basic concepts of bone tissue and healing, bone and plate biomechanics and plate metallurgical
aspects, which we think will be relatively unique to this book. In the sections V-VI, the designs, functions and
indications of different plates are discussed. Finally, in last section, the clinical applications of different plates have
been discussed.
One of us (Hamid RSH) wants to thank a special person who has always been his leader in all his life and has been
the founder of his success, his uncle, Mansour Seyyed Hosseinzadeh, MD, Professor emeritus of vascular surgery and
the head of surgey department of mashhad university of medical sciences.
Beside thanking all those who have a role, even small, in our education, and thanking all the patients who have
been both the interest and the material for our education, we must remember and thank our professors who have
had a close role in our specialty education:
Abrishami S, MD Farahmandi M, MD
Alizadeh K, MD Haerian A, PhD
Aslani HR, MD Hosseini M, MD
Azarbal M, MD Kazemian GH, MD
Badi’a Zadeh K, MD Khatibi H, MD
Bagheri S, MD Mahboubi F, PhD
Ebrahinpour A, MD Madadi F, MD
Farahanchi MR, MD Shafaghi T, MD

At last, we hope that our goal, although ambitious, has been met.

Hamid R Seyyed Hosseinzadeh MD

M Hassas Yeganeh MD
Hamed R Seyyed Hosseinzadeh PhD candidate
VIII
 IX

Contributors:

Dara Moridpour MD Mohammad Ali Amiri MD

Assistant Professor (Emeritus) Resident
Orthopaedic Surgery Orthopaedic Surgery
SBMU SBMU

Seyyed Morteza Kazemi MD Salman Azarsina MD

Associate Professor Resident
Orthopaedic Surgery Orthopaedic Surgery
SBMU SBMU

Mostafa Sharifian MD Mehdi Bahari MD

Professor Resident
Pediatric Nephrologist Orthopaedic Surgery
SBMU SBMU

Farivar Lahiji MD Amir Bisadi MD

Resident
Assistant Professor
Orthopaedic Surgery
Orthopaedic Surgery
SBMU
SBMU
Seyyed Mohammad Ghoreshi MD
Mohammad Emami MD Resident
Assistant Professor Orthopaedic Surgery
Orthopaedic Surgery SBMU
SBMU
Arash Maleki MD
Ali Akbar EsmaeeliJah MD Resident
Associate Professor Orthopaedic Surgery
Orthopaedic Surgery SBMU
SBMU
Seyyed Rouhollah Mosavi MD
Seyyed Mohammad Jazayery MD Resident
Associate Professor Orthopaedic Surgery
Orthopaedic Surgery SBMU
SBMU

Mohammad Reza Bigdeli MD Reza Zandi MD

Resident Resident
Orthopaedic Surgery Orthopaedic Surgery
SBMU SBMU

Ali Reza Amani MD

Resident
Orthopaedic Surgery
SBMU
X
 XI

Table of Contents

Section 1: History of Plate Fixation in Section 5: Conventional Plates and

Orthopaedics 1 Screws 233
1.1 A brief review of development in fracture fixation 5.1Structure and Design 235
methods 3 5.2Types 239
5.3Functions 253

Section 2: Biology of Bone and joint Section 6: Locking plates 269

tissue 15 6.1 Evolution of locking screws and plates 265
2.1 Bone tissue 17 6.2 Philosophy of locking plates 269
2.2 Bone formation 31 6.3 Development of locking plates 273
2.3 Biology of bone healing 39 6.4 Biomechanics of locking screws and plates 277
2.4 Mechanobiology of fracture healing 45 6.5 Types of locking head screws 289
2.5 Molecular mechanisms of fracture healing 53 6.6 Types of locking plates 295
2.6 Failure of Fracture healing 57 6.7 MIPO 299
2.7 Joint tissue 65 6.8 Indications for locking screws and plates 315
2.8 Synovial joint healing 71 6.9 Failure and complication of locking plates 319
2.9 Enhancement of fracture healing 75
Section 7: Clinical application of Screws
Section 3: Biomechanics of Bone tissue and Plates 311
and Orthopaedic Hardwares 89 7.1 Perioperative considerations 333
3.1 Basic concepts in biomechanics 91 7.2 Basic techniques of application of screws 349
3.2 Biomechanics of bone tissue 99 7.3 Basic techniques of application of conventional
3.3 Mechanobiology 119 plates 355
3.4 Biomechanics of hardwares for fracture fixation 127 7.4 Basic techniques of application of locking plates and
3.5 Biomechanical aspects of fracture fixation in specific screw 359
locations 155 7.5 Clinical techniques of application of plates in
different anatomic sites 375
7.6 Clinical techniques of MIPO 403
Section 4: Metallurgy and its Application
in Orthopaedics 159
4.1 Basic concepts 161
4.2 Structure of metals 165
4.3 Metal processing 171
4.4 Corrosion 175
4.5 Stress-Strain relationship 189
4.6 Corrosion resistant orthopaedic alloys 197
4.7 Role of kidney in handling metal ions 213
4.8 Surface coating of metals for orthopaedics 221
XII
 History of Fixation 1

SECTION 1
HISTORY OF PLATE
FIXATION IN
ORTHOPAEDICS
SECTION OUTLINE

CHAPTER 1
A brief review of development in fracture fixation methods 3
2 Plate Fixation in Orthopaedics
 History of Fixation 3

CHAPTER 1
HISTORY
CHAPTER OUTLINE

Early fracture repair theories 4

The evolution of fracture fixation methods
Evolution of plate fixation
The evolution of locking plates
Development of locking head screws
Development of liss
Development of the locking compression plate (LCP)
Development of minimally invasive plate osteosynthesis (MIPO)
A brief review of development in fracture fixation methods
From open reduction internal fixation (ORIF) to minimal invasive plate osteosynthesis (MIPO)
From dynamic contact plates (DCP) to low contact dynamic compression plates (LCDCP)
From round hole to polyaxial combihole
From generic to pre-formed implants
From iliac crest bone graft (ICBG) to bone morphogenetic proteins (BMPs)

In 1159, John Salisbury in his Metalogicon wrote:
“Bernard of Chartres used to say that we are like
dwarfs on the shoulders of giants, so that we can
see more than they, and things at a greater
distance, not by virtue of any sharpness on sight
on our part, or any physical distinction, but
because we are carried high and raised up by
their giant size.” As orthopedic surgeons, we
need to remember the work and concepts of
those who led us this far.
INTRODUCTION
Orthopaedic surgeons and their patients continue to
benefit from rapidly improving orthopaedic
technology. Devices and instruments available today
allow surgical treatment of conditions that were
difficult to treat, or were untreatable, just 20 years
ago.
Each year, orthopaedic surgeons are presented
with numerous new devices, technologies, and
implants. However, little is known regarding what
proportion of these new devices will become
important parts of the orthopaedic armamentarium
and what proportion will be on the market for a
short time. Examples include hip arthroscopy,
locked plating of fractures, and bone morphogenetic
protein for adjunctive fracture healing. These
beneficial new technologies come from the complex
symbiotic relationship between orthopaedic
surgeons and industry. However, each new
technology introduced can result in new problems.
Much attention has been given to the careful
introduction of new technology to the orthopaedic
4 Plate Fixation in Orthopaedics
marketplace. It is necessary to balance excitement
over new surgical options and protection of patients.
In orthopaedic trauma, the energy that causes
fractures generates a zone of injury owing to the
injury to both the bone and the surrounding soft
tissue. In the resultant inflammatory reaction,
vasoactive substances are released that mediate a
beneficial increase in the local circulation as well as
the detrimental effects of edema and pain.
Additionally, these inflammatory substances and
neural reflexes cause involuntary contraction of
skeletal muscle groups around the fracture to splint
the injured extremity, reduce painful motion, and
facilitate fracture healing. As a result, early
observations of the pain relief associated with
external splinting led to the belief that fractures
were best treated by immobilization and prolonged
rest of the injured part. In this way, optimal cast
immobilization included the joints both above and
below the affected bone. Fractures of the spine,
pelvis, and femur were often treated with bed rest
and traction for many weeks, followed by months of
spica or body cast immobilization. Unfortunately,
this approach focused on the achievement of bony
union. Although fractures usually healed with these
nonoperative treatments, the inability to directly
control the position of fracture fragments within the
soft tissue envelope led to problems with malunion
and nonunion. Additionally, long periods of
immobilization required profound restriction of
muscle activity, joint mobilization, and weight-
bearing. In turn, the patients experienced
considerable muscle atrophy, joint stiffness, disuse
osteoporosis, and persistent edema—a complex of
problems termed fracture disease. At the same time,
prolonged periods of immobilization sometimes led
to psychologic changes, including depression,
dependency, and perceived disability.
In light of these phenomena, it became clear that
fracture treatment must focus on both fracture
healing and restoration of preinjury function.
Therefore, the ideal method should achieve the
desired bony alignment and stabilization while
permitting early function, mobilization, weight-
bearing, and independence. Fracture care has
matured over the last 40 years to the point where
orthopaedic traumatology has become a recognized
subspecialty within orthopaedic surgery. The recent
advances in surgery, imaging, anesthesia, and
computerization have made this possible. Since the
beginnings of fracture treatment, however, the
implantation of plates and screws as well as
intramedullary devices and the application of
external fixation have been the standard treatment
of surgical stabilization. Each of these methods has
gained a distinct place in our treatment algorithms
once the implant was seen to provide reproducible
results in our published literature. When this occurs,
the implant is greeted with a wave of enthusiasm,
and perhaps overuse. Subsequent reports and a
better understanding of the benefits and limitations
of the device then result in a clear delineation of the
role of the implant, and its use becomes
standardized.
EARLY FRACTURE REPAIR
THEORIES
John Hunter (1728–1793) is credited with the 4-
stage classification of callus repair in fractures
(inflammation, soft callus, hard callus, remodeling).
Hunter also supported Albrecht Haller’s (1708–
1777) theory that bone was deposited in response
to injury from the vascularity around the reparative
zone. This early understanding of the importance of
the vascular network in fracture repair is one of the
cornerstones to minimally invasive fracture surgery.
The opposing theory advocated by H.L. Duhamel
was that all bone was formed from the periosteum
and used the term “cambium layer” for the
osteogenic layer of periosteum as an analogy to tree
growth.
A contemporary of Macewen, Louis Xavier Ollier, a
surgeon and proponent of Duhamel, was convinced
that the periosteum, bone marrow, and lastly bone
were the sources of osteogenesis and argued for
preservation of the periosteum with surgical
approaches. These respective theories are still
evident in our surgical practices today; however, the
dominant theorist for the twentieth century was
that of Robert Danis (1880–1962). His work in
plating with his discoveries of interfragmentary
compression and compression plating resulting in
Soudure Autoge`ne (Primary Bone Healing) was
promulgated and taught through Dr. Maurice Muller
and the A.O. Group.
The cellular contribution to fracture repair has
focused on the osteoblast since John Belchier in
1736 developed the technique of vital staining of
osteoblastic new bone with a precursor to alizarin
dye (the red stain we all recognize in microscopic
slides of new bone formation). John Goodsir (1814 –
1867) of the University of Edinburgh described
osteoblasts as the actual builders of bone.
Figure 1-1: John Hunter (1728–1793); Scottish surgeon

Figure 1-2: Albrecht Haller (1708–1777); Swiss anatomist
and physiologist
Figure 1-3: John Belchier (1706–1785); British surgeon
William Macewen from the University of Glasgow as
an active proponent of Goodsir’s osteoblastic
formation relegated the periosteum to insignificance
in surgical approaches for fracture repair.
Raoul Hoffman (1881–1972), although best known
for his external fixator designs, actually contributed
the concept of closed reduction of fractures with the
use of external devices through attachment with
percutaneous pins, which he termed osteotaxis in
1938. Gerhard Küntscher in 1939 presented his
preliminary series of nonreamed intramedullary
nailing using the principles of closed reduction and
intramedullary fixation with a long nail introduced
remote to the fracture site preserving the
vascularity of the fracture periosteal environment.
Gavril A. Ilizarov (1921–1992) introduced the
techniques of osteoreparative osteosynthesis with
nonrigid external fixation and temporal sequential
distraction that was diametrically opposed to the
philosophy of Danis. The complexity of interactions,
which lead to successful reparative osteogenesis,
can now be viewed as a synthesis of these authors’
contributions. A recently proposed model of
reparative osteogenesis in metaphyseal-diaphyseal
fractures pictures callus as a component structure
consisting of the adjacent fracture components, the
respective viable periosteum, the void at the
History of Fixation 5
fracture site, which acutely and in the inflammatory
phase is filled with hematoma and necrotic debris,
and the adjacent viable soft tissue envelope. These
components give rise to a regenerative organ for
reparative osteogenesis. In this model, vascular
preservation is mandatory to allow
revascularization of the zone of injury bringing in
stem cells and regional cell lines with the capability
of metaplasia and cell mitogenesis to form new
osteoblasts. As the callus structure develops, it
forms a toroidal shaped region of matrix and active
cellular infiltration and metaplasia. This area is
anchored to the adjacent periosteum and its
respective bone. The Torus structure is a three-
dimensional representation of the osteogenic
reparative zone described by Brighton and
Heppenstall as the Delta Zone. As the reparative
process continues, the center of the torus is actually
segregated to contain platelet derived growth
factors and a high potassium concentration forcing
the cellular proliferation peripherally. As Kenwright
and Goodship and G De Bastiani have shown, the
callus or torus structure is sensitive to mechanical
manipulation of the fixation construct during the
reparative cycle. The growth and maturity of the cell
lines in the torus are controlled by a negative
feedback loop terminating their growth phase once
mechanical stability is obtained, after which the
consolidation phase of Hunter begins. This type of
model allows for integration of all biologic factors
and mechanical behaviors of the fracture repair
mechanism. It also explains the benefits of
minimally invasive techniques and gives us potential
design modification goals of our surgical implant
constructs. More importantly this may serve the
surgeon in understanding the principles behind the
various surgical techniques that have proven
successful and predict new concepts for invention.
Historically, the most notable development in the
treatment of diaphyseal fractures has been a shift
away from the mechanical aspects of internal
fixation toward the biological aspects.
Figure 1-4: Robert Danis (1880-1962)
6 Plate Fixation in Orthopaedics

limited the use of Küntscher’s contribution. The

addition of locking bolts, once a novel concept, has
been so completely refined that the technique of
using an intramedullary splint to stabilize a long
bone fracture is now commonplace. As the wave of
enthusiasm grew, attempts by “nailers” to indicate
this device for even periarticular fractures, by
cutting the tips off nails to allow the locks to go
lower to obtain purchase, demonstrated the
limitations of these devices.
Finally, while all this was taking place, Prof. G.A.
Ilizarov showed us that tensioned wire frames could
address many problem fractures that were difficult
to treat using conventional methods. As a result of
Figure 1-5: Gavril A. Ilizarov (1921–1992); Russian his work, an entire school of treatment has emerged.
Orthopaedic Surgeon Although many surgeons find this technique difficult
and have abandoned the common use of this device,
its place in orthopaedic traumatology cannot be
denied and further refinements such as hybrid and
THE EVOLUTION OF FRACTURE spatial frames continue to be popular treatment
FIXATION METHODS devices.

Coincidental with the biologic concepts of fracture Evolution of plate fixation

repair, the concept of open reduction of the fracture The first dynamic compression plate (the modified
to prevent deformity began its debate. C. Hansmann Collison plate) was introduced by George Bagby in
is credited with the first successful plate and screw 1956. This plate had oval holes with the distal end of
design in 1886. It was a flat plate made of nickel, the hole having a vertical slot allowing for motion of
copper, and tin alloy with unicortical tapered screws the plate relative to the conical screw head. In 1958,
that drilled into the bone and locked to the plate. 15 Swiss general and orthopedic surgeons met to
This design has obvious similarities to the LISS discuss the status of the poor results obtained with
system. The first totally implanted plate and screws both nonoperative and operative methods of
were by Halsted in 1893 using a silver plate and fracture treatment in their country.This meeting led
Lane in 1894 with a steel plate. Lane’s plate was flat to the formation of the Arbeitsgemeinschaft fur
and used “wood-type” screws which were the Osteosynthesefragen/Association for the Study of
precursor of our current cancellous thread forms. In Internal Fixation (AO/ASIF).The meeting was
the early 1900s, Albin Lambotte (1866–1955) initiated by Maurice Muller, who had spent time
articulated the 4 components of surgical fracture with Danis and was impressed by his concept of
technique: (1) fracture exposure, (2) fracture compression and rigid fixation. Four principles
reduction, (3) provisional fixation, and (4) definitive seemed clearly instrumental for obtaining optimal
fixation. He also was the first to curve plates results and were accepted as a "working
transversely to better fit the curved bone and hypothesis."
advocated “metal thread screws,” the precursor of
our current cortical thread forms. Sherman
developed the first self-tapping screws before 1915.
Interestingly, the first locked plate design, which we
would recognize as a contemporary design, was
invented by Ernest Hey Groves of Bristol, England.
He described the devices mechanism as such: “The
screw may instead be threaded into the plate, and
there fixed by the grip of metal against metal in such
a way that it never can become loose from the plate”.
Dr. Paul Reinhold in Paris, France, patented a very
similar plate design to Hey-Groves in 1931, and it
was commercialized by Collin (a sales company in
France) in 1935. Although many surgeons were
skeptical about these devices, teaching and training
ultimately made plates the standard of care for most
fractures. Over time, although many surgeons were
successful “platers,” long bone fractures treated with
plates continued to pose a problem.
Although intramedullary nails were a reasonable Figure 1-6: Carl Hansmann is credited with the first
alternative, shortening and rotational deformities successful plate and screw design in 1886

Figure 1-7: Albin Lambotte (1866-1956); the father of
osteosynthesis
Figure 1-8: Gerhardt Kuntscher (1900-1972); the father of
intramedullary nailing
These were anatomical reduction, rigid internal
fixation, atraumatic technique on the soft tissue and
bone and early pain-free active mobilization during
the first 10 postoperative days. Three years later, E.
Muller described the outboard compression plate
device. A round-hole bone plate was screwed into
the bone on one side of the fracture. On the other
side of the fracture, a tension/compression device
was screwed into the bone and hooked onto the
plate. A nut was then tightened on the device,
causing compression across the fracture. Since the
inception of the AO/ASIF, plates and plating have
evolved significantly with the aim of providing for
improved healing. Prof. S.M. Perren developed and
presented dynamic compression plating to the
orthopaedic community. But the first self-
compression plate devised by the AO was reported
in 1963s. In 1969, the Dynamic Compression Plate
(DCP) was designed and introduced for fracture
treatment. The plate was similar in design to the
History of Fixation 7
Bagby plate, but with several marked
improvements. These features allowed the use of the
DCP as a tension band, neutralization, compression,
and buttress plate. Other techniques such as
prebending and lag screw fixation were introduced
to improve fracture compression and load contact
sharing. These methods resulted in rigid fixation and
healing occurred by direct bone formation, with
scarce radiographic callus formation. The lack of
callus in rigidly fixed fractures was described by
Bagby and others in animal experiments. At that
time, callus was most often viewed as a direct sign of
instability, implant overload, and/or fretting
corrosion. Using the principles of exact anatomical
reduction and absolute stabilization, a wide surgical
exposure was necessary. Fracture fragments were
often stripped of their soft tissues to achieve precise
reconstruction of the bone. Furthermore, the
stability of the plate-fracture construct using
bicortical screws depends on the friction between
the undersurface of the plate and the cortical surface
of the underlying bone. This friction increases as the
torque of the screw increases. A common
observation after plate osteosynthesis is
radiographic bone loss under the plate. Although
this phenomenon has been attributed to implant-
related stress protection, it has also been linked to
transient bone necrosis and internal remodeling
beneath the plates. Perren et al showed that porosis
is present in areas of disturbed circulation between
the plate and the bone. They hypothesized that
improved circulation beneath the plate would
decrease osteoporosis. (Fig 1-6)
During the early 1970s, investigators began to
study the pressures exerted by plates on bones
following compression plate osteosynthesis. They
found that the plate exerts an average pressure to
the bone of 7000 N/cm2. Some postulated that that
these findings would be useful in the development of
more optimal systems for osteosynthesis.
Subsequent to this work, the Zespol system was
developed in Poland and reported on by
Ramotowski and Granowski.
This system represented the first internal fixator
for stabilizing long bones. It used screw heads that
locked into a plate, which offset from the bone and
could be used as either an internal or external
fixator.
The plate did not apply any direct pressure to the
underlying bone, thereby preserving the vascularity
and avoiding porosis. In the early 1980s, Brunner
and Weber introduced the wave plate, and
Heitemeyer and Hierholzer developed the bridge
plate. These plates were designed to span the
fracture site, with a plate fixed proximally and
distally to the fracture. The wave plate provided the
theoretical advantage of avoiding vascular
disruption to the injured bone, allowing for the
placement of corticocancellous bone graft at the
fracture site, and altering the load of the plate to
provide pure tension forces.
8 Plate Fixation in Orthopaedics
Figure 1-6: The disturbance of circulation in the foot print
area of the plate, leading to local osteoporosis
These findings led to the development of plates
with more limited plate-bone contact. The Limited
Contact Dynamic Compression Plate (LC-DCP)
(Synthes, Paoli, Pennyslvania), introduced by Perren
in 1990, was designed to provide less than
50%contact between the plate and the bone.
Through this decreased contact, it was postulated
that the blood supply to the underlying bone would
be better preserved, thereby improving rates of
fracture healing, decreasing the need for bone
grafting, decreasing the incidence of infection and
refracture, and decreasing implant-related stress
risers following plate removal. The design of the
plate also has other features, including uniform
spacing of the screw holes, a trapezoidal cross
section, and symmetric plate holes. These
modifications of the dynamic compression plate
allow for a more evenly distributed force along the
plate, a 40 degree tilt of each screw within the hole
and an ability to change more easily to a plate of
different length. Further, the plate was constructed
of titanium to improve its tissue tolerance. Most
recently, plating methods have focused on the
principles of "biological fixation." The Point Contact
Fixator (PC-Fix) (Synthes, Paoli. Pennsylvania) was
introduced in 1994. The plate was designed to
contact the bone on pointed areas of its
undersurface with significantly less plate-bone
contact than the LC-DCP. The plate also utilized
unicortical screws that locked into the plate and
were less disruptive of the intramedullary blood
supply than bicortical screws. Clinical trials using
the PC-Fix titanium plates have suggested that the
plates are associated with decreased rates of
infection. PCFix-stabilized sheep tibia fractures have
been shown to heal faster and with similar strengths
to those treated with a DCP. Other mechanical
studies have shown that the fixation achieved with
the PC-Fix (locked screw-plate-bone construct) is
stronger than the DCP(nonlocked conventional
screw-plate-bone construct) when applied to
cadaveric human femurs.
The evolution of locking plates
Locking plates re-emerged in Europe with the
Wolter system (Litos) in 1974 and the Zespol
System from Poland in 1982. It functions
mechanically as an external fixator, and the locked
plate is above the skin. The A.O. designed and
repopularized locked plating in the United States
with the LISS with its first implantation in 1995.
This was a major departure for the A.O. away from
the Danis theories of fracture repair. The results
were very impressive and have led the way to a
revitalization of plate and screw osteosynthesis
especially in lower extremity fractures.
Several 95° fixed-angle devices, such as the blade
plate or dynamic condylar screw, have been used
successfully to manage many injuries; however,
these devices cannot be used in all situations. This
shortcoming necessitated the development of other
methods to achieve fixed-angle or “locked” internal
fixation constructs. Early attempts to gain angular
stability of conventional screws placed through
commercially available plates led to the
development of the Schuhli nut (Synthes, Paoli, PA).
This device, essentially a threaded washer, served
two purposes: it allowed screws to lock into the
plate, thereby preventing screw toggle, and it
limited the contact of the plate with the underlying
bone in an attempt to preserve periosteal
perfusion.(Fig 1-7) The results of biomechanical
studies and clinical series have documented the
improved stability and clinical utility of these
devices in managing difficult nonunions and
malunions.
Development of locking head screws
PC-Fix was the first type of plate fixator in which
angular stability was achieved by establishing a
conical connection between the screw heads and
screw holes. However, the tapered screw–plate
connection does not provide axial anchorage of the
screw in the plate, so that point contact between the
plate and the bone is still required to achieve
stability. A new type of thread connection between
the screw head and screw hole, resulting in angular
and axial stability, was therefore developed so that
no contact at all is required for stability. The screw
simply functions as a Schanz screw. Angular stable
implants and especially angular stable noncontact
plates are called locked internal fixators (LIFs). So a
new great advancement in orthopaedic
traumatology happens. These devices were carefully
developed over the years by Drs. S. M. Perren and R.
Frigg and others and are the result of a great amount
of experimentation in the laboratory in Davos,
Switzerland. The development of locking combined
with percutaneous insertion as popularized by Prof.
Krettek completed the cycle. These evolutionary
plates, with their ability to stabilize and fix
periarticular fractures, have become so popular
among orthopaedic surgeons that the technique is
now truly a “revolution” among those orthopaedists
who treat fractures.
Their distinguishing mechanical feature lies mainly
in the fact that stability is not achieved by friction
between the undersurface of the plate and the bone,
with all the associated disadvantages, but rather by
connecting elements between the extramedullary
load carrier and the main fragments of the bone. The
rigid connection of the pins, blades, or bolts/screws
to the load carrier facilitates the mechanical

bridging of the fracture zone without creating
friction between the load carrier and the bone. This
mechanical concept is similar to external fixators.
This type of thread connection has been
incorporated into the new internal fixation
systems—the less invasive stabilization system
(LISS) and the locking compression plate (LCP). The
aim of the basic locked internal fixation technique is
to achieve flexible elastic fixation to trigger
spontaneous healing, including the induction of
callus formation, supporting the principle of
minimally invasive plate osteosynthesis (MIPO).
Development of LISS
The combination of locking plate concept,
anatomical preshaped plates and minimally invasive
surgery lead to the development of LISS (Less
Invasive Stabilizing System).
LISS for the distal femur (LISS DF) and the proximal
lateral tibia (LISS-PLT) are implants that act as
splints. LISS acts mechanically as an internal fixator.
This device is a 100 percent locked internal fixator
because only locking head screws (LHSs) are used.
LISS is designed for percutaneous insertion. A less
invasive approach also is possible. Closed indirect
reduction and pure splinting of the fracture zone are
important.
Development of the locking compression
plate (LCP)
LISS was originally designed as a device that would
provide angular stability and accommodate only
locking head screws; all of the plate holes are
threaded. However, clinicians found that this
technology was too restrictive in some cases and
that an all-purpose implant system would offer
greater flexibility. Research and development work
in this area—with multidisciplinary collaboration
among clinicians, researchers, developers, and
manufacturers—ultimately led to the concept of a
combination hole, which has been incorporated into
the most recent type of plate—the locking
compression plate, or LCP—a single-plate system
that allows the surgeon more choices.
Figure 1-7: Schuhli nut converts a dynamic compression
device to a fixed angle device
History of Fixation 9
The LCP hole also makes it possible to insert
different screw types into the same plate so that the
surgeon can choose the type depending on
intraoperative requirements. In retrospect,
combining two completely different anchorage
techniques into a single implant was a logical
approach and a straightforward, practical solution.
Development of minimally invasive
plate osteosynthesis (MIPO)
The other great stride over the last 20 years has
been the development of percutaneous and soft
tissue–sparing surgical techniques. Our knowledge
of the biology of fracture care has again evolved
through past misunderstandings and an analysis of
failure.
Drs. H. Rosen, J. Mast, and R. Ganz have shown us
that protection of the blood supply and minimal
“stable” fixation rather than “rigid” fixation would
result in significant improvements in healing rates.
These teachings have permeated our thinking, with
surgeons again taking minimal incision surgery
perhaps a bit too far. A 2-inch incision is an obvious
improvement over a 10-inch incision. If one needs a
3-inch incision, however, struggling instead of
extending the wound 1 inch may be a true example
of the triumph of “technique” over “reason.”
The development of indirect methods of fracture
reduction for diaphyseal fractures using the
principle of Iigamentotaxis led to the avoidance of
further damage to the blood supply of the fracture
fragments, which accompanied direct manipulation
of the fracture ends. Furthermore, it was shown that
internal fixation based only on reducing the mobility
of the fracture fragments, without contact between
the bone fragments, could result in solid healing.
Thus, multifragmentary fractures fixed with
bridging plates demonstrated high union rates
without the need for bone grafting. The explanation
for this was based on the concept of
interfragmentary strain. Fracture reduction in
multifragmentary diaphyseal fractures became
simpler and consisted mainly of regaining length,
rotation, and axial alignment. Thus the stage was set
for the progression to more biological methods of
fracture fixation, namely minimally invasive
osteosynthesis (MIO). MIO is not a new concept in
orthopedic surgery. Closed intramedullary nailing,
and percutaneous fixation of fractures using screws
and K-wires had been performed with satisfactory
results. The application of plates using minimally
invasive surgical techniques, however, was not
carried out until the advent of the internal fixator
system which had as its main objective the
elimination of the ill effects of plate-bone contact.
Further developments in the field of M IPO included
the introduction of new types of LCP designed for
use in specific anatomical regions such as the
proximal and distal humerus, distal femur, proximal
and distal tibia.
10 Plate Fixation in Orthopaedics
A BRIEF REVIEW OF
DEVELOPMENT IN FRACTURE
FIXATION METHODS
During the 1950s, the AO (Arbeitsgeminschaft fur
Osteosynthesefragen) group in Switzerland
introduced standardised surgical treatment of
fractures. This approach allowed the early
mobilisation of patients with all the associated
benefits (reduction of the fat embolism syndrome,
decrease of joint stiffness and muscle wasting, early
return to function and reduced length of hospital
stay). This philosophy of fracture fixation has
evolved over the years and together with the
advances made in every discipline in medicine, the
overall care of the trauma patient has been
improved substantially leading to reduced
morbidity and mortality rates. A number of
innovations have contributed to this revolution of
fracture fixation including the following:
From open reduction internal fixation
(ORIF) to minimal invasive plate
osteosynthesis (MIPO)
From 1954 onwards, the AO group developed the
concept of absolute stability to treat fractures.
Osteosynthesis allowed early mobilisation and
prevented fracture disease and the formation of
callus, which was initially felt to be associated with
joint stiffness. Failure of osteosynthesis due to the
development of irritation callus was a harbinger of
loss of stability.
Further research resulted in the discovery of the
different types of bone healing with the realization
that callus was beneficial in some fracture patterns,
giving rise to the concepts of relative stability and
secondary bone healing.
The good results of the AO group were not initially
reproduced, with non-union and infective non-union
and wound breakdown being big problems.
Schatzker reviewed the results of osteosynthesis
and showed that there were good results when the
AO recommended techniques were applied and poor
results when they were not, proving that ‘‘if you do
an operation badly, you get a bad result’’.
In the early days of modern osteosynthesis, surgery
was delayed following initial traction and it was
often recommended that osteosynthesis should not
be performed until callus had begun to form.
Further work by the AO group led to a
comprehensive fracture classification system
allowing assessment of the soft tissue envelope.
Thus, surgeons were able to evaluate the personality
of the fracture and make informed decisions about
the timing of surgery, the mechanics of fixation and
the type of bone healing required. The assessment of
the soft tissue envelope was a concept that was slow
in being adopted by many surgeons, and in many
fractures (especially of the lower limbs), wound
breakdown remained a problem. Consequently,
minimal surgery with spanning external fixators and
percutaneous screw fixation of periarticular
fractures came into vogue, followed closely by the
use of circular frames. Circular frames came with
their own problems such as the lack of generally
available expertise, problems with pin site sepsis
and problems associated with hybrid frames with
opposing biomechanics.
Prolonged delay before internal fixation and the
desire to manipulate fractures before soft tissue
rigidity prevented reduction of fragments led to
minimally invasive techniques with tunnel plates.
The concept of biological fixation with secondary
bone healing and callus was a necessary first step
when applying this technique. Initially, minimally
invasive plate osteosynthesis was performed with
standard plates. Good soft tissue results were
obtained but malalignment resulted in many
malunions but with good results with regards to
union. These implants, however, remained bulky
around the metaphysis. Precontouring of the plate
was necessary using either Xrays or plastic models,
and consequently, anatomical plates pre-designed
for certain regions, such as the tibial plateau or
pilon, were developed with bullet-shaped ends so as
to aid percutaneous insertion. Special instruments
were developed to aid the tunnelling process and
the bulkiness associated with certain anatomical
regions has been minimised by the development of
metaphyseal plates, with a standard bulk for the
diaphyseal end and flattened, thinned out ends for
the metaphysis.
The development of locking plates with threaded
screw heads turning the construct into a fixed angle
device was developed with the realisation that
angulation of the screw within the plate was the sine
qua non of failure of osteosynthesis, resulting in
increased strength of osteosynthesis (especially in
porotic bone), and giving rise to a fixateur interne
which improved vascularity and reduced the so-
called dead bone footprint of standard plates,
thereby allowing surgeons to achieve and maintain
percutaneous fracture reduction (and not to
subsequently lose it by apposition of the bone to the
plate, as the reduction would be held in situ by such
locking plates). The purchase on the metaphyseal
region of the bone was enhanced using multiple
small locking screws, which also allowed purchase
on very distal or proximal metaphyseal fractures.
The pioneering implant for this technique was the
less invasive skeletal stabilisation system (LISS,
Synthes, Paoli, PA) for the treatment of periarticular
fractures of the distal femur. Percutaneous
placement was enhanced by the use of a jig attached
to the plate, and with diaphyseal screws and guide
wire alignment to restore anatomical axis. Devices
were developed to allow secondary reduction onto
an anatomically pre-contoured plate, thus helping
surgeons restore alignment, but rotation still
remained a subjective assessment, based on a
surgeon’s visual estimation and the matching of
cortical width and shape on image intensification.

It has come to our attention that some cases of
MIPO fracture fixation do not behave according to
the principles of biological fixation, especially in
periarticular fractures where diaphyseal and
metaphyseal junction non-unions (which were
initially treated with spanning MIPO techniques)
would only unite with the addition of lag screws.
From dynamic contact plates (DCP) to
low contact dynamic compression plates
(LCDCP)
Fracture care became an active operative process
following the principles of fracture fixation
described in the early 1950s by the AO group. The
mechanical principle that lay behind successful
osteosynthesis was that of absolute stability in
primary bone healing, as a consequence of
interfragmentary compression (IFC). IFC was
achieved either by the use of lag screws —protected
by a neutralisation plate to span the compressed
fragments — or by the plate itself, which could be
made to slide and pull one fixed end of the bone into
the other by eccentric drilling of an oval hole in the
plate, with the head of the screw thus driving the
plate axially, thereby providing inter-fragmentary
compression. These plates were held tightly against
the bone resulting in avascular dead bone footprints
that were perceived as conducive to non-union.
This problem was counteracted by the
development of plates that contacted the bone only
via pseudopodia in close relation to the screw holes
and so the concept of low contact dynamic
compression plates was developed to minimise the
avascular impact of plate osteosynthesis.
The concept was further developed via the use of
Schooley screws, producing the so-called ‘fixateur
interne’, with the ‘internal’ external fixator. This,
however, led to bulky fixations and technically
demanding procedures.
Analysis of the mechanics of failure of plate
osteosynthesis led to the realisation that screw pull-
out required angulation of the screw relative to the
plate and so screw heads with threads that locked
into the threads of the holes of the plate,
transformed the implant into a fixed angle device,
thus preventing this mode of failure. Consequently,
it was no longer necessary to contour the plate to
the bone or indeed compress the plate to the bone
or even reduce the bone to the plate, and stable
fixation could be produced analogous to the ‘fixateur
interne’ with limited or no dead bone footprint.
From round hole to polyaxial combihole
Original early plates came with round holes, and
fracture stabilisation depended merely on the
friction between the plates and the bone.
Compression relied either on lag screws or an
external tensioning device, the latter requiring
extension of the incision to an extent greater than
would otherwise be necessary, although enormous
History of Fixation 11
compression forces could be generated across the
fracture site and the use of this device became
established in the formation of osteotomy.
The first innovation in modern plate development
was the oval hole, which had a dual effect in
increasing the angle available to the surgeon for
placing the screw, and also allowed eccentric
placement of the drill hole within the oval hole,
thereby squeezing the plate to move longitudinally
on bedding down of the screw head, and thus
creating a mechanism to compress the fracture,
using the plate itself to achieve absolute stability.
The oval hole applied to the DCP and LCDCP
remained the mainstay of plate osteosynthesis until
the last 5 years, when the understanding of the
biomechanics of plate failure led to the development
of fixed angle plate osteosynthesis by locking screws
to the plate, using a threaded head of the screw in a
threaded hole in the plate. The result is that the
screw-plate angle is pre-determined, the
consequences being limitation of surgeon choice,
but giving the ability to treat periarticular fractures
by lining the distal screws parallel to the joint, and
bringing the bone to the plate to restore axial
alignment, assuming the plate was anatomically pre-
contoured.
The development of locking plates enhanced the
hold in osteoporotic bone to the extent of
overconfidence in recommending only unicortical
screws in the diaphysis. This was, however, not
bourne out in clinical practice and biocortical screws
are now regarded as advisable in porotic bone.
The enhanced fixation provided by locked screws
has further led to the concept of ‘small but lots’, with
the aim of trapping a block of bone within a
metaphysis making it more difficult to rip out and so
further enhancing fixation in periarticular fractures.
Locking holes alone limited the application of these
plates, and dynamic compression and bone to plate
reduction were also lost. Consequently, the option of
a hole that could allow a locked screw option or the
angular and dynamic compression choices of an oval
hole has led to the ‘combihole’, thus further
enhancing the surgeon’s choice in extending the
application of these implants. Where new methods
of fixation are invented, new complications will
result and the performance of these plates has not
yet been fully evaluated in clinical practice.
From generic to pre-formed implants
The original large, small and mini fragment sets
were largely applicable to diaphyseal fractures with
trespass into the metaphysis with the use of high
surface area cancellous screws, but metaphyseal
purchase was limited numerically by the size of the
screws and the inline arrangement of screw holes in
the plate.
The indications for periarticular fractures were
extended by L- and hockey stick-shaped pre-
contoured plates in the proximal tibia, clover leaf
plates on the distal tibia and T-plates for the distal
radius and these plates remained generic, with
12 Plate Fixation in Orthopaedics
surgeons contouring them to fit periarticular
fractures in other bones.
Whilst certain implants were developed for the
application of certain specific fractures, such as the
dynamic hip screw (DHS), it was not until the
principles of fracture fixation became applicable to
small bones, together with the subspecialisation of
surgery, such as hand surgery, that need has driven
the development of regional specific implants.
Surgeons who developed a specialist interest in
distal radial fractures, and who extended the same
principles of fracture fixation to the distal radius as
to other periarticular fractures, helped create
anatomically pre-contoured and trimable
reconstruction plates, such as the Jupiter locking
plates (Pi plates), which allowed the stabilisation of
wrist fractures into an anatomical shape that was
hitherto not possible. The development of MIPO
techniques added pressure to the development of
anatomically pre-contoured plates aiding apposition
of the plate to the bone with the use of combiholes
to reduce the bone to the plate. The concept of a raft
of small locked screws to hold porotic periarticular
fractures was developed.
The early anatomical plates suffered from
bulkiness on the metaphyseal side, which led to a
huge inventory of implants. Thus, generic
metaphyseal plates with the thinner, broader
metaphyseal side, allowing moulding to specific sites
with a raft of small locked screws on the
metaphyseal side and combihole options on the
diaphyseal side, are the most recent developments.
From iliac crest bone graft (ICBG) to
bone morphogenetic proteins (BMPs)
Non-union is still a problem that dogs
osteosynthesis. Sometimes this is due to the severity
of the soft tissue injury, sometimes it is due to
patient related factors and co-morbidity, sometimes
it may be iatrogenic, or sometimes it is simply due to
segmental bone loss.
Iliac crest bone graft (ICBG) has long been the bone
graft of choice and has the advantages of coming
sterile, being immunoneutral and having both
osteoconductive and osteoinductive properties, as
well as being a space occupier. Nevertheless, this is
not without its problems, which include donor site
morbidity, a limited supply (especially in elderly and
osteoporotic skeletons), as well as giving rise to
limited quality bone in the treatment of segmental
diaphyseal defects.
Attempts were made to overcome this by the use of
freeze dried and sterilised allografts, largely from
femoral heads, but supplies are limited, processing
is expensive and products have a limited shelf-life.
There is also the problem of transmission of disease,
especially with regards to prions.
Bone mineral substitutes, largely calcium-
hydroxyapatite-based, have been used but they have
neither osteoconductive or osteoinductive
properties although they can be produced easily in
large quantities, they do have long shelf-lives and
they have found a role in replacing lost bone in
metaphyseal fractures. They come either as a putty
that can be used to pack into defects, just like ICBG,
or injected into defects following osteosynthesis
where they subsequently harden and help to
support the subchrondral plate. They are then
gradually replaced by bone over 3—4 years by the
process of creeping substitution .Their role has now
become well established in the management of
plateau fractures and in the distal radius.
ICBG has limited application in segmental defects
as gaps greater than 4 or 5 cm appear to be the
upper limit that will reliably ossify and non-unions
and re-fractures are not uncommon. Advances in
microvascular techniques have led to vascularised
bone grafts, either local, such as pronator quadrates
for the scaphoid, or DCMIA for the femoral neck, or
free fibulas, either with or without a
musculocutaneous soft tissue paddle as a free tissue
transfer. The blood supply to the fibula is segmental
which allows multilevel osteotomies and hence
shaping to local anatomical needs such as in the
mandible. In the axial skeleton, fixation is a problem
and non-union at one end or the other is seen
regularly and when the fibula is used to replace
tibial segmental defects it takes 3—4 years until
hypertrophy. There is also the issue of donor site
morbidity which is minor in the sedentary patient
but may be significant in the fit and active.
Ilizarov techniques have gone a long way to
treating non-unions by the mechanical stimulation
and modulation of callus and segmental defects well
in excess of that which ICBG can fill, which has
resulted in this technique giving rise to spectacular
limb salvage with superior quality regenerate bone.
The discovery of bone stimulating cytokines by Dr.
Marshall Urist initiated research into the roles of
members of the TGFa family and the development of
human recombinant technology which has led to the
production of different bone morphogenic proteins
for which the clinical drive came initially from
recalcitrant spinal fusions. The supraphysiological
dosing of BMP2 and BMP7 has led to increased
fusion rates in spinal surgery which has encouraged
its applications in other areas. Unfortunately, it has
been applied in many heterogeneous fracture types
in clinical research and non-unions of a variety of
causes and so clear conclusions about its efficacy are
difficult to draw especially as its use has been
initially limited to salvage situations and so its
potential as a bone stimulator has been clouded by
multiple external factors. Cost is another problem,
varying from £2500 to £3000 per dose, together
with its relatively short shelf-life and the need for
refrigerated storage and its poor handling
characteristics. Furthermore, the BMPs have little in
the way of space occupying properties by
themselves but are readily combined with ICBG to
enhance its efficacy. Its lack of space occupying
properties had led to the development of
combinations with scaffolds to help the filling of
defects and to enhance ossification but its efficacy is
 History of Fixation 13

called into doubt as dosages are non-
supraphysiological.
Research has also established that BMPs do not
work in isolation but as part of an orchestrated
cascade, spanning the mobilisation and
differentiation of mesenchymal stem cells (MSCs)
into chondro and osteoprogenitor cells and future
research is likely to be targeted to the best
combinations and the differential slow release of the
different elements of the cascade. Nevertheless,
there is an established role for BMPs as there is no
donor site morbidity, production is theoretically
unlimited and its efficacy in stimulating union has
been reported as being equivalent to ICBG. The
future holds the hope of genetic manipulation of
recalcitrant non-unions as clinicians recognized that
some patients failed to unite despite all the factors
being in their favour whilst others united despite
many reasons why they should not, with the
tantalising hint of the underlying mechanism yet to
be clearly defined in patients with pathological bone
formation in head injury and myositis ossificans.

References:
Bhattacharyya T, Blyler C, Shenaq D: The Natural History
of New Orthopaedic Devices. CORR. 451: 263–266, 2006

Colton CL: The History of Fracture Treatment, in:

Browner: Skeletal trauma, 4th edit. 2008, Chapter 1

Kubiak N, Fulkerson E, Strauss E, Egol KA: The Evolution

of Locked Plates. J Bone Joint Surg Am.;88:189-200, 2006

Kurokawa T, Orthopedic philosophy, J Orthop Sci 8:127–

131, 2003

Miclau T, Remiger A, et al : A mechanical comparison of

the DCP, LC-DCP and PCF. JOT. Vol. 9, 1, 17-22. 1995

Sanders R: When Evolution Begets Revolution. JOT, Vol 18,

8, 2004

Schütz M, Südkamp NP: Revolution in plate

osteosynthesis: new internal fixator systems. J Orthop Sci
8:252–258, 2003

Strauss EJ, Schwarzkopf R, et al: The Current Status of

Locked Plating: The Good, the Bad, and the Ugly. JOT, 22:
479-86. 2008
14 Plate Fixation in Orthopaedics
 Biomechanics of Bone Tissue & Orthopaedic Hardwares 89

SECTION 3
BIOMECHANICS OF
BONE TISSUE
AND
ORTHOPAEDIC
HARDWARES
SECTION OUTLINE

CHAPTER 3.1 CHAPTER 3.4

Basic concepts in biomechanics 91 Biomechanics of hardwares for
fracture fixation 127
CHAPTER 3.2
Biomechanics of bone tissue 99 CHAPTER 3.5
Biomechanical aspects of fracture
CHAPTER 3.3 fixation in specific locations 155
Mechanobiology 119
90 Plate Fixation in Orthopaedics
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
CHAPTER
BASIC CONCEPTS IN
BIOMECHANICS
CHAPTER OUTLINE
Moment
Pressure
Mechanical work, energy and power
Translation and Rotation in a Plane
Translation
Rotation
Combined Translation and Rotation
Stress/Strain
Biomechanics is the science concerned with the
action of forces, internal or external, on the living
body.
Biomechanics (from Ancient Greek: βίος "life" and
μηχανική "mechanics") is the application of
mechanical principles to living organisms, such as
humans, animals, plants and the functional basic
units of life, the cells.
Biomechanics includes bioengineering, the
research and analysis of the mechanics of living
organisms and the application of engineering
principles to and from biological systems. This
research and analysis can be carried forth on
multiple levels, from the molecular, wherein
biomaterials such as collagen and elastin are
91
3.1
considered, all the way up to the tissue and organ
level.
Aristotle wrote the first book on biomechanics, De
Motu Animalium, or On the Movement of Animals.
He not only saw animals' bodies as mechanical
systems, but pursued questions such as the
physiological difference between imagining
performing an action and actually doing it. Some
simple examples of biomechanics research include
the investigation of the forces that act on limbs, the
aerodynamics of bird and insect flight, the
hydrodynamics of swimming in fish, and locomotion
in general across all forms of life, from individual
cells to whole organisms. The biomechanics of
human beings is a core part of kinesiology.
92 Plate Fixation in Orthopaedics
Applied mechanics, most notably
thermodynamics and continuum mechanics, and
mechanical engineering disciplines such as fluid
mechanics and solid mechanics, play prominent
roles in the study of biomechanics. By applying the
laws and concepts of physics, biomechanical
mechanisms and structures can be simulated and
studied. Such concepts are found in the field of
“Sports Biomechanics” where we apply the laws of
mechanics and physics to human performance in
order to gain a greater understanding of
performance in athletic events through modeling,
computer simulation and measurement.
The study of biomaterials is of crucial importance
to biomechanics. For example, the various tissues
within the body's organs, such as skin, bone, and
arteries each possess unique material properties.
The passive mechanical response of a particular
tissue can be attributed to characteristics of the
various proteins, such as elastin and collagen, living
cells, ground substances such as proteoglycans, and
the orientations of fibers within the tissue. For
example, if human skin were largely composed of a
protein other than collagen, many of its mechanical
properties, such as its elastic modulus, would be
different.
It has been shown that applied loads and
deformations can affect the properties of living
tissue. There is much research in the field of growth
and remodeling as a response to applied loads. For
example, the effects of elevated blood pressure on
the mechanics of the arterial wall, the behavior of
cardiomyocytes within a heart with a cardiac
infarct, and bone growth in response to exercise,
and the acclimative growth of plants in response to
wind movement, have been widely regarded as
instances in which living tissue is remodelled as a
direct consequence of applied loads.
The study of biomechanics ranges from the inner
workings of a cell to the movement and
development of limbs, to the mechanical properties
of soft tissue, and bones. As we develop a greater
understanding of the physiological behavior of
living tissues, researchers are able to advance the
field of tissue engineering, as well as develop
improved treatments for a wide array of
pathologies.
Biomechanics is also applied in studying human
musculoskeletal systems. In recent years, research
applied force platform to study human joint
reaction forces and 3D human movement. Human
motion is also captured through the human motion
capture to study human 3D motion.
Biomechanics is widely used in orthopedic
industry to design orthopedic implants for human
joints, external fixations and other medical
purposes. Biotribology is a very important part of it.
It is a study of the performance and function of
biomaterials used for orthopedic implants. It plays a
vital role in order to improve the design and
produce successful biomaterials for medical and
clinical purposes.
Bone is a remarkable material with complex
mechanical properties and a unique ability for self-
repair, making it a fascinating structural material
from both clinical and engineering perspectives.
Bone fails when overloaded, initiating a complex
series of biological and biomechanical events
directed toward repair and restoration of function.
There are now tools that can help predict if a bone
is likely to fail, with particular relevance to the
problem of osteoporotic or pathologic fractures.
Once a fracture has occurred, both the biological
and mechanical environments must be controlled to
optimize the healing process. Tremendous progress
is being made toward understanding, controlling,
and enhancing the biological aspects of fracture
healing. The mechanical environment will always be
a crucial element of fracture healing, with strong
interactions between biological and mechanical
factors. Clinical management of fractures must
influence both the biological and mechanical
conditions so that the original load-bearing capacity
of the bone is restored as quickly as possible. There
are thus three principal aspects to the biomechanics
of fractures and their treatment: (1) the
biomechanical factors that determine when and
how a bone will fracture, (2) the biomechanical
factors that influence fracture healing, and (3)
control of the biomechanical environment by
fracture treatments.
The biomechanical factors that determine
whether a bone will fracture include the loads
applied and the mechanical properties of bone and
bone tissue. For normal bone, the loads that result
in fracture are typically extremes, whereas severely
osteoporotic or pathologic bone may fracture
during normal activities of daily living. In addition,
the mechanical properties of bone vary over a wide
range, and several pathological processes can alter
bone properties.
Bone tissue possesses a unique ability for repair,
frequently restoring the original load-bearing
capacity in weeks to months. However, this repair
process is influenced by the mechanical
environment to which the healing bone is subjected
and bone healing will fail under adverse conditions.
The rate at which the load-bearing capacity is
restored is affected by the stability of the fracture
site.
Successful fracture treatment requires control of
both the biological and mechanical aspects of
fracture healing. Different approaches to fracture
treatment will control the mechanical environment
in different ways and can influence the rate at which
load-bearing capacity is restored.
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
Basic Concepts
A force causes an object to either accelerate or
decelerate. It has magnitude (strength) and acts in a
specific direction, therefore it is termed a vector.
However complex the system of forces acting on a
bone, each force may be separated into its vector
components (which form a 90-degree triangle with
the force). Any of several components, acting in the
same direction, can be summed to yield the net or
resultant force. As a simple example, consider the
resultant force acting at the shoe/floor interface
during ambulation. It can be separated into a
vertical force because of body weight and a
horizontal frictional force that produces the
forward thrust.
In the static case, i.e., when no accelerated
movements occur, force and counteracting force
add up to zero. Both effects of a force, acceleration
and deformation, can be observed in the course of
the gait cycle when the heel strikes the floor. After a
heel strike, the velocity of the body decreases; in
addition, the heel deforms. Deceleration (negative
acceleration) of the body and deformation of the
heel are caused by a force exerted from the floor on
to the foot. There is an equal, opposite force from
the foot on the floor. This force deforms the floor.
The deformation of a concrete floor is small, but still
measurable. The deformation of an elastic floor in a
gymnasium can be seen with the naked eye.
In the dynamic case, i.e. when accelerated
movements are encountered, inertial forces come
into play. If the acceleration of a mass m equals a,
the inertial force amounts to
F=m.(-a)
The inertial force has the magnitude m.a and its
direction is opposite to the direction of the
acceleration.
Inertial forces become apparent when the human
body is decelerated (i.e. negatively accelerated), for
example, when hitting the floor after jumping from
a wall or gymnastic apparatus. The magnitude of the
force between the body and the floor depends on
the acceleration a. The acceleration can be
calculated approximately by dividing the change in
velocity Δv by the time interval Δt required to
decelerate the body. With a given change in velocity,
a short time interval for deceleration will result in a
larger inertial force; a longer time interval will
result in a smaller inertial force. When hitting the
floor with a straight leg, the time interval required
to decelerate the body will be short and the force
between floor and foot will be accordingly high. If
the time interval for decelerating the body is
prolonged, either by bending the knees or by a
deformable (compliant) gym floor, the magnitude of
the inertial force will be smaller. Decreasing an
inertial force by prolongation of the time interval
available for acceleration (or deceleration) is known
as 'damping'.
In many biomechanical problems gravitational
forces play an important role. The gravitational
93
force is always directed perpendicularly
downwards.
A three-dimensional, solid body of mass m can be
thought to be composed of ‘n’ small volume
elements with masses mi (i = 1,2,3, ...n). Gravity
exerts a force on each of these masses. To arrive at a
simple description of the effect of gravity on the
whole body, a special point, the 'center of gravity', is
defined where the mass of the whole body is
imagined to be concentrated. Gravity then acts at
this point of mass m. The center of gravity need not
coincide with a material point of the body. For
example, the center of gravity of a torus (circular
ring) lies in the center of the torus, i.e. at a location
where there is no mass.
Muscle forces can be separated in the same
manner-one force along the axis of the long bone
and one perpendicular. The components of the
different forces that act in the same direction can be
added, and the resultant force acting on the bone
can then be found. This concept is important when
designing fracture fixation systems because it
allows the designer to size the implants so that they
can withstand the mechanical loads applied without
failure.
The basic forces are:
1. Compression
2. Transverse Loading
3. Torsion
Forces in specified directions with respect to a
given surface bear additional designations. A force
directed perpendicularly on to a surface is
designated as compressive force. A force directed
perpendicularly away from the surface is
designated as tensile force. A force acting in or
parallel to the plane of the surface is designated as
shear force. A compressive force results in
shortening the length of the bone, while tension
elongates it. Torsion causes twisting of a bone about
its long axis, while bending causes it to bow at the
center. The forces and moments that act on a long
bone during functional use produce three basic
stresses on the healing fracture region: tension,
compression, and shear (as shown previously, all
forces can be reduced to their basic components).
(Fig 3.1-1)
MOMENT
The moment effected by a force can be defined in
different ways, as a number or as a vector. The
moment can be given as a product of the distance L1
of the point of force exertion from the fulcrum, the
sine of the angle Ф between the direction of the
force and the line connecting the point of force
exertion and the fulcrum and the magnitude of the
force M=±ΙL1Ι.sinФ.ΙFΙ In this equation, Ф is the
smaller of the two angles between the direction of
the force and the distance line.
94 Plate Fixation in Orthopaedics
Figure 3.1-1: Basic force types and their effect on the
subject
If the moment is defined as a product of the
magnitudes of distance and force (and not as a
product of vectors), a further rule for obtaining the
positive or negative sign of the moment has to be
followed. If the force effects a rotation in a
clockwise direction, the moment is counted as
positive; if the force effects a counterclockwise
rotation, the moment is given a negative sign.
As with forces, moments cannot be observed or
measured directly; only their effects can be
observed. These effects are the acceleration of a
rotational motion or the deformation of a body in
torsion or bending.
The two major loads acting on a long bone are
those that cause it to displace in a linear direction
(translation) and those that cause it to rotate
around a joint center. Muscles typically cause a
bone to rotate (e.g., the biceps causes the forearm to
rotate, the anterior tibialis causes the foot to
dorsiflex). When a force causes rotation, it is termed
a moment and has a moment arm. The moment arm
is the lever arm against which the force acts to
cause rotation. It is the perpendicular distance of
the muscle force from the center of rotation of the
joint. The moment or rotary force is affected not
only by the magnitude of the force applied, but also
by its distance from the center of rotation.
When dealing with objects whose length is large
compared with the dimensions of their cross
sections (for example, beams or long bones),
moments that load the objects in certain directions
bear specific designations. A moment which twists a
beam about its long axis is called 'torsional moment'
or 'torque'. A moment that bends the beam is called
'bending moment'. According to the definition of the
moment, the bending moment increases in part a
with increasing distance from the point where the
force is exerted. Depending on the point of
application, forces may affect linear and torsional
deformation as well as linear and rotational
acceleration at the same time.
PRESSURE
Pressure describes in detail how force is
transmitted from one object to another via an
interface. Pressure is defined as 'force
perpendicular to an interface divided by the area of
the interface: P=F/A
In this equation force F is inserted in newtons [N]
and the area A in square meters [m2]. The unit of
pressure [N/m2] bears the name pascal [Pa].
In simple cases the pressure on an interface can
be calculated directly from the definition. If a rigid
body lies with a plane side on a plane surface the
pressure may be assumed to be uniform over the
whole area A of the interface. When loaded by a
force F directed perpendicular to the surface, the
pressure is calculated as P = F/A. If the force
remains constant and the area A is increased, the
pressure decreases in proportion to the increase in
area. Plane areas of contact are rarely encountered
between the human body and its environment or
between articulating bones. And even if the
interface is planar, as between the bare foot and the
floor, experience tells us that the pressure does not
assume identical values at different points of the
contact area. If the pressure is not uniform over the
interface area, the term 'pressure distribution' is
used.
The term 'mean pressure' denotes the mean value
of the pressure, averaged over the pressure
distribution on the interface. The mean pressure
Pmean can be calculated by dividing the force F by the
projected area Aproj.
The projected area is the area that is seen when
looking along the direction of the force on to the
interface area.
When a force acts on a body, a deformation in the
direction of the force is observed. Compressive or
tensile forces shorten or stretch the body; shear
forces effect an angular deformation. The
deformation changes the relative locations of atoms
or molecules within the material. This gives rise to
internal forces (rejection and attraction) of
electrical origin, which balance the external forces.
In static mechanical equilibrium, stresses on
opposite sides of a cube-shaped volume element are
equal in magnitude but opposite. Different values of
compressive, tensile, and shear stress may exist on
the three pairs of opposing surfaces of the cube. The
state of mechanical stress of a cube-shaped volume
element is thus uniquely described by six numbers
(three compressive or tensile stresses, three shear
stresses). It has to be pointed out that the stress on
the surface of a volume element imagined to be cut
from a body depends on the spatial orientation of
the element with respect to the body.
The pressure on surfaces and the stresses within
a material depend a) on the magnitude of the load,
b) on the loading mode (i.e., the way forces and
moments are applied), c) on the geometrical shape
of the organs, and d) on the material properties of
the tissues. It follows that pressure or mechanical
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
stress is altered by changing the external loading, by
changing the shape and architecture of organs, or by
changing the material properties of the tissues. In
the human body, however, the last two of these
procedures are only rarely applicable. The easiest
way is to try to influence the external loading and
the mode of load transmission to the human body.
Obviously, it makes a big difference whether a
needle is pressed (with equal force) with its pointed
or blunt end against a fingertip.
MECHANICAL WORK, ENERGY AND
POWER
Mechanical work E is defined as 'force times
distance'; the distance L is to be measured in the
direction of the force F: E=F.L
Mechanical work has the dimension 'newton
times meter' [Nm]. This unit bears the name joule
[J]. If a person lifts a mass m by a distance L, the
human body performs mechanical work F.L=m .g . L
[Nm] on the mass. The energy to produce this work
stems from chemical processes in the muscles. The
muscles, however, also consume chemical energy in
situations involving no mechanical work, for
example, in isometric contraction when holding a
weight. For this reason, the energy consumption of
muscles is usually not equal to the mechanical work
performed by the muscles. The kinetic energy of a
body moving in linear direction amounts to:
E=1/2 m.v2
Energy and work are mechanically the same
entity; the kinetic energy of a body can be regarded
as the sum of the mechanical work performed in
order to reach its velocity. Potential mechanical
energy is stored energy that can be converted into
other forms of energy.
Mechanical power P is defined as mechanical
work per unit time. Thus, power is measured in
units of [Nm/s]. This unit bears the name watt [W].
The product of moment and angular velocity
characterizes, for example, the power generated or
absorbed by the muscles moving a joint. The
product of power and time, or in case of a temporal
variation of the power, the integral
extended over the time interval of interest, equals
the energy. For a joint this quantifies the energy
generated or absorbed by the muscles within the
observation time.
Translation and Rotation in a
Plane
Describing body movements is a frequently
occurring problem in orthopedic biomechanics. An
example of such a movement is the forward bending
of the trunk in order to grasp an object from the
floor. At the beginning, the trunk is erect (initial
state); at the end it is bent forward (final state).In
the field of mechanics, the analysis of motions has
95
physical and geometrical aspects. The physical
aspects deal with the forces and moments required
to generate a specified motion. The description of
spatial location and orientation is a geometrical
problem.
Translation
A motion that moves all points of a body on straight
lines over identical distances is termed 'linear
movement' or 'translation'.
Rotation
A rotation is characterized by the fact that all points
of a body move on concentric circles with the
identical angle of rotation around a center of
rotation.
Combined Translation and Rotation
In general, a motion may be combined from
translation and rotation. For plane motions the
following noteworthy theorem holds. Any motion
resulting from a combination of translation and
rotation can be described by a single rotation. This
'substitute' rotation occurs around a center of
rotation differing from the original center of
rotation but with the identical angle of rotation.
The fact that an identical change of location of a
body may be described either by a pure rotation or
by a combination of translation and rotation
emphasizes that the description of a motion
provides no information on the actual course of the
motion between the initial and the final state.
When the center of rotation is located at the
contact area, pure joint surface rolling occurs.
Rolling is characterized by the fact that the point of
contact moves during the course of rolling (e.g., the
rolling of a wheel on a rail: the center of rotation is
the point of contact between wheel and rail; this
point moves as the wheel rolls). If the center of
rotation is located far away from the point of
contact, a lesser amount of surface rolling relative to
gliding will occur. We thus infer from the location of
the center of rotation of the knee joint that the
relative motion of femur and tibia is a combination
of rolling and gliding.
STRESS/STRAIN
Stress is simply the force divided by the area on
an object over which it acts. This is a convenient
way to express how the force affects a material
locally . For example, comparing two bones, one
with half the cross-sectional area of the other, if the
smaller bone is subjected to half the force of the
larger bone, the stress experienced by each bone
would be the same. Therefore, a smaller woman
with less weight has proportionally smaller bones
to keep the stresses on the bone tissue similar to
that of a larger and heavier man. Just as stress is
normalized force (force per unit area), so can length
changes be normalized. Strain is simply the change
in height or length that a bone undergoes during
96 Plate Fixation in Orthopaedics
loading divided by its original height or length.
Under the same force and for bones of similar
composition, a bone twice as long will experience
twice the length change. Nevertheless, the strain
will be the same in both cases because the strain (in
the longer bone) will be twice the change in length
divided by twice the original length.(Fig 3.1-2)
Material properties relate to the properties of the
substances that make up each component (bone,
stainless steel, titanium). As load is applied to the
construct in a testing machine, the construct
deforms. This deformation is termed elastic because
when the load is removed, the construct will return
to its original shape (an important consideration in
preventing malalignment of the bone fracture
components). At some load, however, the construct
becomes overloaded, entering the plastic range. If
the load is released after loading in the plastic range
but before failure, some permanent deformation
remains in the construct. Practically, this represents
a bent plate, fixator, or rod and a malaligned
fracture. The point at which elastic behavior
changes to plastic is termed the yield point. The
elastic range represents the working range for the
fixation construct. Its two most important
properties are its yield point, which defines its safe
maximum functional load, and its stiffness, or the
amount it deforms under load in the elastic range.
(A third very important property is fatigue which
will be discussed later.)
Note that a fixation construct may have different
yield points and stiffnesses for loads acting in
different directions. An example is a half-pin
external fixator construct applied to a tibia, with the
pins oriented anterior-posteriorly. The stiffness is
much greater in anterior-posterior bending than
medial-lateral bending for this construct. Another
property to consider is the work done in deforming
a fixation construct. The product of the force
applied and the distance the construct bends is
defined as the work done, and is represented by the
area under the force-displacement graph.
The ultimate stress of a material is the force
required to make it fail or break. Elasticity is the
material's ability to restore its original shape after a
deforming force lower than the yield point is
removed. This is quantified by the modulus of
elasticity, which is the slope of the elastic region of
the stress-strain curve. Stiffness is proportional to
the modulus of elasticity.
Plastic deformation is a permanent change in
structure of a material after the stress is relieved.
Ductility and brittleness are relative characteristics
and not numerically quantified. Ductility is the
ability of a material to further deform beyond the
yield point before fracture. A brittle material has
minimal deformation before failure. These
characteristics are explained by the shape of the
plastic (permanent deformation) curve past the
yield point; a longer curve implies a more ductile
substance. (Fig 3.1-3)
Toughness is the total energy required to stress a
material to the point of fracture. It is defined as the
area under both the elastic and the plastic parts of
the stress-strain curve or as the energy to failure. A
material may be flexible and tough (e.g., rubber, or a
child's bone that deforms but is difficult to break) or
stiff but brittle (e.g., glass, elderly bone), if it cannot
absorb much deformation without fracturing.
Hardness is the ability to resist plastic
deformation at the material surface only. For many
materials, the mechanical properties at the surface
differ from those found in the bulk of the
material.(Fig 3.1-4)
Metal has a variety of mechanical properties.
Some are a function of its chemical composition and
do not change with further processing; others are
strongly affected by the relative orientation of the
crystals and therefore are altered by processing.
The elastic moduli in tension and compression do
not change with processing, but yield strength,
ultimate strength, and fatigue strength can be
altered significantly by small changes in chemical
composition and processing.
Fatigue is caused by cyclical (repetitive) stressing
of a material. In cyclical loading, the maximal force
required to produce failure decreases as the cycle
number increases until the endurance limit is
reached. The resulting fatigue curve shows the force
necessary to cause failure of a material at each
specific cycle number. The higher the overall stress,
the fewer the cycles required to produce failure
(loading to the ultimate stress produces failure in
one cycle). The endurance limit is the lowest point
on the fatigue curve and represents a cyclical
applied force below which the material will not
have failed after 10 million (1 × 107) cycles. If the
material has not failed at this point, in theory, it
never will. By choosing different materials and
altering implant geometry, manufacturers attempt
to design implants that will tolerate cyclical loads
without failure.
The fatigue strength (point of fatigue failure) of a
material is defined as a single stress value on the
fatigue curve for a specific number of cycles. In
practice, certain points on a metal implant reach the
fatigue failure level before others because of
localized concentrations of stress (stress risers).
Fatigue failure at these points results in the
initiation of a crack that can propagate, causing the
entire implant to fracture. On the basis of anatomic
location, implants are subject to varying loads and
varying frequency of stress cycles. The usual design
estimate of cyclical load for orthopaedic implants is
2 × 106 stress cycles per year.
Fatigue fractures of implants result from a high
number of cycles of relatively low stress. Single-
cycle and low-cycle failures are caused by high
stress. Implants that have failed as a result of fatigue
can be distinguished from single-cycle failures
because they display a series of concentric fatigue
striations over the fracture surface.
 Biomechanics of Bone Tissue & Orthopaedic Hardwares 97

Figure 3.1-2: Schematic presentation of Stress and Strain

Figure 3.1-3: Stress-strain curve: The red line is an example of a ductile material, it can be stressed beyond the yield point. If a
stress lower than the yield point is applied and released, the object the object will return to its original shape. The plastic or
permanent deformation area is the portion of the curve between the amount of stress needed to reach the yield point and the amount
of stress needed to reach the ultimate failure point.

Figure 3.1-4: Toughness is defined as the area underneath the stress-strain curve. The two materials illustrated in this diagram
have vastly different characteristics, however, they both have the same toughness because of equivalent areas under their respective
curves.
 Biomechanics of Bone Tissue & Orthopaedic Hardwares 98

These striations appear to radiate from certain viscoelasticbehavior is loading rate dependence. In
initiation points, which represent areas in which the simple terms, stretching a soft tissue can be thought
overall peak tensile stress combined with the of as stretching two components, an elastic one and
presence of stress risers (e.g., cracks, scratches, a viscous one, which make up that tissue. The
holes) exceeds the material's local resistance to stiffness of the tissue increases at higher loading
failure. If the average peak stresses are large, then rates. That is, the stiffness of the tissue depends
the striations have more distance between them. upon the rate at which the load is applied.(Fig 3.1-5)
When these striations have propagated a sufficient A well-known example of loading rate
distance to decreasethe cross-sectional area of the dependence relates to failure of ligament and bone.
implant, ultimate strength is reduced, leading to At low loading rates, ligament is weaker than bone
complete failure. This area of final failure is called and the ligament fails generally in midsubstance. At
the tear zone, and it can provide clues to the type of higher loading rates, the ligament becomes stiffer,
failure. High-stress, low-cycle failure produces a and failure may occur by avulsion of the bony
larger tear zone than low-stress, high-cycle failure. attachment of the ligament. Stress-relaxation occurs
Implants must be designed to withstand these if the applied force, instead of increasing, is held
anticipated loads and cycles. If failure of an implant constant.
occurs, it should be examined to determine the
failure pattern.
The factors that govern stiffness and yield point
are the material from which the fixation device is
made and its shape (considering an ununited
fracture in which the fracture callus contributes
little to structural properties). A construct made of
higher elastic modulus materials will be stiffer (for
example, stainless steel as compared to titanium).
The elastic modulus of titanium alloy is about one
half that of stainless steel, so given two plates of the
same size and shape, the titanium plate has about
one half the stiffness of the stainless steel plate. This
can be important to consider when using new
devices made of different materials. The shape of
the implant is important in determining the loads
that it can support. The moment of inertia provides
a measure of how the material is distributed in the
cross section of the object relative to the load
applied to it. The farther away the material is from
the center of the beam, the greater its stiffness.
Another basic property is viscoelasticity. Biologic
materials do not act as pure springs when load is
applied to them. (A spring deforms under load, then
returns to its original shape when the load is
released.) For example, if a load is applied to a Figure 3.1-5: Viscoelastic response in a biological tissue
tendon, and the load is maintained for a period of can be explained by considering and combining the
time, the tissue will continue to deform or creep. properties of two devices, a simple spring and a fluid-filled
This is the basic principle behind stretching syringe. The elastic or spring component instantly
compresses when the load is applied to it. When the load is
exercises. Under a constant load, a metal fixation
released, the spring returns to its original shape. When the
plate will deform and remain at that deformation load is applied to the syringe, fluid is forced out of the
until the load is removed (elastic behavior). In needle. If the load is released, the plunger does not return, but
contrast the tendon both deforms elastically and remains in its final position, representing the creeping
creeps, exhibiting both viscous and elastic behavior. properties of the tissue. Further, if the force is applied to the
This property has important implications for certain plunger more rapidly, there is greater resistance to motion,
types of fixation, especially those that rely on explaining the increased stiffness of tissue to increased rates
loading of soft tissues, such as in certain types of of loading.
spinal fixation.A second characteristic of
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
CHAPTER
BIOMECHANICS OF BONE
TISSUE
CHAPTER OUTLINE
Bone properties
Stress and strain of inhomogeneous
anisotropic materials
Bone as a hierarchical composite material
Cortical bone
Trabecular bone
Cortical and trabecular bone
Biomechanical properties of whole bones
Biomechanical behavior of bone
Bone behavior under various loading modes
Influence of bone geometry on biomechanical
behavior
Influence of muscle activity on stress
distribution in bone
Strain rate dependency in bone
Adaptation of bones to mechanical demands
Fatigue of bone under repetitive loading
BONE PROPERTIES
Both the material properties of bone as a tissue and
the structural properties of bone as an organ
determine the fracture resistance of bone and
influence fracture healing.
Stress and strain of inhomogeneous
anisotropic materials
Bone material is inhomogeneous because it is
composed of a crystallized mineral and a fibrous
99
3.2
Biomechanics of bone fracture
Biomechanics of healing bone
Fracture treatment concepts
Bone remodeling
Degenerative changes in bone associated
with aging
Fracture risk
Fracture risk with metastatic and benign
defects in bone
organic component. Biomechanically, bone tissue
may be regarded as a two-phase (biphasic)
composite material, with the mineral as one phase
and the collagen and ground substance as the other.
In such materials (a nonbiological example is
fiberglass) in which a strong, brittle material is
embedded in a weaker, more flexible one, the
combined substances are stronger for their weight
than is either substance alone. Functionally, the
most important mechanical properties of bone are
its strength and stiffness.
100 Plate Fixation in Orthopaedics

Three parameters for determining the strength of

a structure are reflected on the load-deformation
curve:
1. The load that the structure can sustain before
failing
2. The deformation that it can sustain before
failing
3. The energy that it can store before failing
The strength in terms of load and deformation, or
ultimate strength, is indicated on the curve by the
ultimate failure point. The strength in terms of
energy storage is indicated by the size of the area
under the entire curve. The larger the area, the
greater the energy that builds up in the structure as
the load is applied. The stiffness of the structure is
indicated by the slope of the curve in the elastic
region. The steeper the slope, the stiffer the
material is.
Due to the spatial alignment of the organic fibers
in lamellar bone, to the architecture of the layered
lamellae in cortical bone, and to the spatial
configuration of the trabeculae in trabecular bone,
the mechanical properties of bone (moduli of
elasticity and shear etc.) depend on the orientation
in which they have been measured. Materials whose
mechanical properties depend on the orientation of
measurement are described as 'anisotropic'. Unlike
isotropic materials, the strain occurring in
anisotropic materials is not necessarily in the same
direction as the applied stress. The deformation of
inhomogeneous, anisotropic materials under the
influence of external forces cannot be characterized Figure 3.2-1: The effect of collagen fiber direction on
the resistance to loads applied in different directions, A)
by the three material constants (modulus of
under tensile loading, the strongest arrangement is having the
elasticity E, shear modulus G and Poisson's ratio µ) collagen fibers parallel to the load, B) under compressive
as is the case with homogeneous, isotropic loading, the strongest arrangement is having the collagen
materials. fibers perpendicular to the load, C) in bone that must
There is a preferred orientation in the accommodate different loading directions, the arrangement of
microstructure of bone. In cortical bone, the the Haversian system produces one strongest direction along
preferred orientation is determined by the the axis, with proximately equal strengths in other directions
generally parallel assembly of the osteons, whereas
in trabecular bone it is determined by a Bone as a Hierarchical Composite
predominant alignment of the plates and rods. As Material
result of this orientation, bone is an anisotropic Bone tissue is a hierarchical composite at many
material. Like most biological materials-for levels. At the lowest level (≈0.1 micron scale), it is a
example, wood-the preferred orientation is called composite of mineralized collagen fibrils. At the
the grain. (Fig 3.2-1) next level (≈10 micron scale), these fibrils are
In the technical domain the generalized Hooke's arranged in two forms, either as stacked thin sheets
law forms the basis for a description of the called lamellae (about 7 microns thick) that contain
mechanical properties of fiber-reinforced materials. unidirectional fibrils in alternate angles between
But even in such applications, it proves difficult to layers or as a block of randomly oriented "woven"
determine the complete set of 21 material constants fibrils. Lamellar bone is the most common type of
experimentally. When dealing with bone material, bone found in an adult, but woven bone can only be
additional difficulties arise. found in situations of rapid growth in children and
Due to changes in bone density and architecture, also during the initial stages of bone fracture
the mechanical properties of bone change from one healing. Laminar or "plexiform" bone consists of
volume element to the next. In addition, bone is smaller sandwich-type constructions layered
non-linearly elastic, i.e. the material properties lamellae, arranged around openings for blood
depend on the magnitude of the applied strain and vessels. This type of bone is often interspersed with
on the deformation velocity. In technical materials woven bone and is common in large animals, such
there is no equivalent to the repair and adaptation as cows, that grow rapidly.
processes in vivo, as encountered in bone. Lamellar bone can take various forms at the next
hierarchical level (0.5-1.0 mm scale). Primary
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
lamellar bone is new bone that consists of the large
concentric rings of lamellae that circle the outer 2-3
mm of the diaphysis, similar to growth rings on a
tree. The most common type of cortical bone in
adult humans is called osteonal or haversian bone,
where about 10-15 lamellae are arranged in
concentric cylinders about a central Haversian canal
(a canal about 50 microns in diameter), which
contains blood vessel capillaries, nerves, and a
variety of bone cells. The substructure of concentric
lamellae, including the Haversian canal, is termed
an osteon, which has a diameter of about 200
microns and lengths of 1-3 mm. Other channels,
called Volkmann's canals, about the same diameter
as Haversian canals, run perpendicular to the
Haversian canals, providing radial paths for blood
vessels.
Osteons represent the primary discrete unit of
human adult cortical bone, and are continually
being torn down and replaced by the various types
of bone cells in a biological process called bone
remodeling. Over time, the osteon can be
completely removed, leaving behind a hole
(resorption cavity, about 200 microns in diameter),
which is then filled in by a new osteon. Typically,
there are about 10-15 Haversian canals per mm2
cross section of adult human cortical bone. A
cement line, which is a thin, low-mineral-content
layer of calcified mucopolysaccharides with very
little collagen, surrounds each newly formed osteon.
The cement line is a weak interface between the
osteon and the surrounding interstitial bone. This
may actually improve the fatigue properties of
cortical bone by providing avenues for dissipating
energy during crack propagation. Since
mineralization of a new osteon is a slow process
that can take months, the distribution of the degree
of mineralization can be large at any time in a
particular whole bone cross section. The
remodeling process occurs in part to repair the
fatigue damage that can occur in bone during
strenuous repetitive activities. Within this structure,
there is an underlying level of porosity at the scale
of 5-10 microns or less that is associated with the
bone cells. Osteocytes, the most common type of
bone cell, reside alone, surrounded by a thin layer of
extra cellular fluid, in small ellipsoidal holes (about
5 microns minor diameter; 7-8 microns major
diameter) called lacunae, of which there are about
25,000 per mm3 in bone tissue. The lacunae are
generally arranged along the interfaces between
lamellae. Each osteocyte has arms or processes that
extend from the cell through tiny (≈0.5 micron
diameter, 3-7 microns long) channels called
canaliculi and meet with the processes of
surrounding cells at cellular gap junctions. Gap
junctions are arrays of small pores in the cell
membrane that make connections between the
interiors of neighboring cells, allowing direct
passage of small molecules such as ions from one
cell to another. There are about 50-100 canaliculi
per single lacuna and about one million per mm3 of
101
bone. The resulting intercommunication between
osteocytes provides an important mechanism by
which bone cells are thought to sense mechanical
loading or deformation and transmit signals
elsewhere to the osteoclast bone cells that remove
bone tissue. In this way, the remodeling sequence is
thought to be initiated when loading becomes too
different from some physiological set point or if the
bone becomes damaged. At the highest hierarchical
level (1-2 mm), there are two types of bone: (1)
cortical bone: which comes as tightly packed
lamellar, Haversian, laminar, or woven bone and,
(2) trabecular bone, which is a highly porous
cellular solid. In the latter, the lamellae are arranged
in less well-organized "packets" to form a series of
rods and plates, about 200-300 microns thick,
interspersed with large marrow spaces. Sometimes,
when the rods and plates in trabecular bone are
very thick, osteons can be found, but this is rare in
human bone.
Cortical Bone
To provide material property data that can be
applied to any specimen geometry, the force and
displacement data are converted to stress and
strain. This is a normalization process that
eliminates the influence of specimen geometry.
Bone is loaded cyclically during many activities of
daily living, and the load that causes bone to fail can
be dramatically lower if the load is applied
repeatedly. The number of cycles of stress that bone
can tolerate decreases as the stress level increases.
This property of bone is measured using stress
versus number of cycles to failure curves. These
curves depend on the type of loading (axial,
bending, or torsion), the loading rate, and the
physical composition of the bone.
Material Properties of Cortical Bone
As a consequence of its composite, osteonal
microstructure, the material properties of cortical
bone are anisotropic and inhomogeneous (vary with
spatial location). These properties depend on
loading rate, and when loaded past the yield point,
cortical bone shows behavior characteristic of
plasticity, damage accumulation, creep, and fatigue.
Thus, under typical loading, its behavior is
viscoelastic or viscoplastic and can be further
modified if damage occurs.
Human cortical bone is generally assumed to be
transversely isotropic, meaning that it has one
primary material axis (the longitudinal direction)
and is isotropic in the plane perpendicular to this
axis (the transverse plane. The longitudinal axis is
generally aligned with the diaphyseal axis of long
bones. Cortical bone is both stronger and stiffer
when loaded in the longitudinal direction,
compared with the radial or circumferential
directions. This structure efficiently resists the
largely uniaxial stresses that develop along the
diaphyseal axis during habitual activities such as
walking and running.
102 Plate Fixation in Orthopaedics
Cortical bone also has asymmetric strengths; it is
stronger in compression than tension for each
principal material direction. The longitudinal
compressive strength of 170-210 MPa far exceeds
that of engineering construction materials such as
concrete. The strength to modulus ratio for cortical
bone is about 1.12 percent and 0.78 percent for
longitudinal compression and tension, respectively.
Compared with high-performance engineering
metal alloys such as Aluminum 6061- T6 and
Titanium 6Al 4V, with corresponding ratios of about
0.45 percent and 0.73 percent, respectively, it seen
that cortical bone has a relatively large strength to
modulus ratio. In that sense, it is a high-
performance material, particularly in compression.
When loaded to failure in a monotonic test,
human cortical bone exhibits an initial linear elastic
behavior, a marked yield point, and failure at a
relatively low strain level. Unlike the ultimate
stresses, which are higher in compression, ultimate
strains are higher in tension for longitudinal
loading. These strains can be up to 5 percent in
young adults and fall to less than 1 percent in the
very elderly, cortical bone becomes more brittle
with aging. In contrast to its longitudinal tensile
behavior, cortical bone is relatively brittle in tension
for transverse loading and brittle in compression
for all loading directions. Cortical bone is weakest
when loaded transversely in tension and is also
weak in shear.
The asymmetry and anisotropy of strength have
practical clinical relevance. For example, transverse
tension can be generated when large intramedullary
implants such as tapered uncemented hip stems are
driven too far during surgery into the femoral
diaphysis and produce circumferential or hoop
stresses. If these stresses become too great, then the
bone cracks longitudinally. When this occurs, it is
treated by supporting the bone externally with
circumferential tensioned wires, and weight bearing
is limited until the crack is healed. Development of
large transverse tensile stress rarely, if ever, occurs
during normal physiological behavior.(Table 3.2-1)
In comparison, moduli for common isotropic
materials used in orthopedic implants are stainless
steel, 207 GPa; titanium alloys, 127 GPa; bone
cement, 2.8 GPa; ultra-high molecular weight
polyethylene, 1.4 GPa. (Table3.2-2)
Table3.2-1: Anisotropic Material Properties for Human
Cortical Bone
Loading Direction Modulus (GPa)
Longitudinal 17.0
Transverse 11.5
Shear 3.3
Table3.2-2: Ultimate Strength Values for Human
Femoral Cortical Bone
Ultimate Loading Mode Strength (MPa)
Longitudinal
Tension 135 (15.6)
Compression 205 (17.3)
Shear 71 (2.6)
Transverse
Tension 53 (10.7)
Compression 131 (20.7)
Heterogeneity
While it is often appropriate to assume average
properties for cortical bone, it may be necessary in
some cases to account for the heterogeneity that can
arise from variations in microstructural parameters
such as porosity. For example, for stem stress
analysis in bone-implant systems using composite
beam theory, since the modulus of the metal is
much greater than that of the cortical bone, ±20
percent variations in the modulus of the cortical
bone will not affect substantially the calculated
stem stresses. However, if there is no implant and
the focus is on bone stress-for example, in a study of
bone fracture mechanics- errors in the assumed
material properties of the bone become more
important.
Cortical porosity, which is due primarily to the
variations in the number, length, and diameter of
Haversian and Volkmann's canals, can vary from
less than 5 percent to almost 30 percent and is
positively correlated with age because the bone
becomes more porous with aging. Both modulus
and ultimate stress can be reduced by 50 percent
when porosity is increased from 5 percent to 30
percent. Thus, cortical bone properties for specific
individuals depend upon porosity.
Fatigue, Creep, and Viscoelasticity
Cortical bone also exhibits fatigue and creep and has
a greater resistance to failure in these modes in
compression than tension. Fatigue properties are
normally expressed on a traditional S-N curve
(stress vs. number of cycles to failure), just as with
metals, but stress is usually divided by Young's
modulus to minimize interspecimen scatter of the
data. Interestingly, for cortical bone, when the
fatigue and creep behaviors are expressed as
functions of stress/modulus vs. time-to-failure,
experimental scatter is reduced, fatigue life is
independent of frequency (0.2 - 2.0 Hz range), and
substantial similarities appear between the fatigue
and creep behaviors. This suggests that levels of
strain (=stress/modulus) determine these failure
properties and that the underlying fatigue and creep
mechanisms are related.
 Biomechanics of Bone Tissue & Orthopaedic Hardwares 103

It is unlikely that high cycle (low stress) fatigue and ultimate strength of bone approximately
failure occurs in vivo, since the resulting fatigue proportional to the strain rate raised to the 0.06
damage would be healed biologically before large power.
enough cracks could develop that would cause overt
fracture of the bone. Low cycle fatigue (stress Trabecular Bone
fractures), however, can occur when higher levels of The major physical difference between trabecular
repetitive stress are applied over shorter time bone and cortical bone is the increased porosity
intervals, such as in marching military recruits and exhibited by trabecular bone. The bone tissue that
marathon runners. makes up the individual trabeculae is just slightly
When cortical bone is loaded to its monotonic less stiff and strong than the bone tissue within
yield point, but not fractured, and is then unloaded, cortical bone.
permanent residual strains develop similar to
ductile metal behavior. When cortical bone is loaded Material Properties of Trabecular Bone
beyond its yield point, unloaded, and reloaded, its
Trabecular bone is a highly heterogeneous material,
modulus is reduced. This is evidence of damage,
and its material properties vary accordingly. From a
something that does not occur in metals where the
biomechanical perspective, the most important
modulus after plastic yielding is the same as the
microstructural parameter for trabecular bone is its
initial modulus. This complex viscoplastic, damaged
apparent density, in contrast to the tissue density of
material behavior is difficult to account for in stress
the individual trabeculae. Similarly, we distinguish
analyses, but it probably has significant biological
between apparent (continuum) and tissue
consequences. As the surrounding bone matrix
properties of trabecular bone. The continuum
permanently deforms and sustains damage, cells
properties of trabecular bone primarily depend
may be altered and a biological response may be
upon the architecture and, to a lesser extent, on the
induced, which prompts the bone cells to repair the
tissue properties. To treat trabecular bone as a
damage done to the bone matrix.
continuum, its dimensions must be on the order of
Cortical bone is a viscoelastic material. Its
5-10 mm or greater. Smaller specimens of
modulus and strength increase as the rate of loading
trabecular bone may have to be treated as
is increased. Over a six-order-of-magnitude increase
structures for which concepts of material properties
in strain rate, modulus only changes by a factor of
such as Young's modulus do not apply, since they
two, and strength by a factor of three. Thus, for the
depend upon the size of the specimen. This concept
majority of physiological activities, which tend to
of scale and continuum vs. microstructural behavior
occur in a relatively narrow range of strain rates
is critical when analyzing the mechanical behavior
(0.01-1.0 percent strain per second), cortical bone
of trabecular bone and most other biological tissues.
can reasonably be assumed to behave elastically.
However, the increased stiffness and strength
properties and the tendency toward more brittle Architecture of trabecular bone
behavior are important in high strain-rate Trabecular bone is composed of a three-
situations such as high-speed trauma and perhaps dimensional mesh of interconnected bone beams
during falls. and plates, arranged similarly to that of open-pore
technical foam materials. With the exception of
woven bone, the beams and plates are oriented in
Aging and Disease preferred directions that are readily discernible to
Aging and disease also affect the mechanical
the naked eye on bone sections. Below the
properties of cortical bone. Modulus varies little, if
cartilaginous layer of joints, for example, the
at all, with age, but tensile ultimate stress decreases
trabeculae are preferentially oriented
at a rate of approximately 5 percent per decade.
perpendicular to the joint surface. There appears to
Perhaps most importantly, tensile ultimate strain
be a second preferred direction, oriented at
decreases by about 10 percent per decade, from a
approximately 90° to the first, where the beams and
high of almost 5 percent strain at age 20-30 years to
plates are interconnected, thus reinforcing the
a low of less than 1 percent strain beyond about 80
mesh. It is understandable from these observations
years. Old bone is more brittle than young bone.
that the elastic properties and the strength of
Thus, the energy to fracture, given by the total area
trabecular bone are determined by the density, the
under the stress-strain curve before fracture, is
distance, and the relative orientation and
much less for old bone than for younger bone.
interconnection of the beams and plates. It follows
Fracture toughness also decreases with aging.
furthermore that measured material properties of
Several factors influence the material properties
trabecular bone depend on the direction of testing.
of cortical bone. For instance, the properties are
Trabecular bone is an anisotropic material. If the
dependent on the rate at which the bone tissue is
material properties of cortical bone, and those of
loaded. Materials such as bone whose stress-strain
the beams and plates of trabecular bone, are
characteristics are dependent on the applied strain
assumed to be approximately equal, the material
rate are termed viscoelastic or time-dependent
properties of samples of cortical and trabecular
materials. However, the strain rate dependency of
bone (save for anisotropic effects) can be expected
bone is relatively modest, with the elastic modulus
to vary in relation to the degree of porosity.
104 Plate Fixation in Orthopaedics
The term 'porosity' designates that fraction of the
volume of a sample that is not filled by bone
material. The porosity of a sample of cortical bone
with no voids would be zero; the porosity of
trabecular bone can approach (though not reach)
the value 1 (100%). This increased porosity is
quantified by measurements of the apparent
density. The physical difference between the two
bone tissues is quantified in terms of the apparent
density of bone, which is defined as the mass of
bone tissue present in a unit of bone volume (gram
per cubic centimeter [g/cc]). [i.e., the mass of bone
tissue divided by the bulk volume of the test
specimen, including mineralized bone and marrow
spaces]. The compressive stress-strain behavior of
trabecular bone is typical is of a class of porous
materials called cellular solids. It displays an
approximately linearly elastic region followed by a
local peak, and then a strain-softening or plateau
region of near constant stress with increasing
strain. Tensile behavior is much more brittle, with
fracture occurring at relatively low strains. Most
importantly, for trabecular bone, the stiffness and
strength depend on its apparent density and can
vary by two orders of magnitude within the same
metaphyseal region. Because of the large variation
in apparent density for trabecular bone, its
mechanical properties cannot generally be
described by average values. In the human skeleton,
the apparent density of trabecular bone ranges from
approximately 0.1 g/cm3 to 1.0 g/cm3, while the
apparent density of cortical bone is about 1.8 g/cm3.
A trabecular bone specimen with an apparent
density of 0.2 g/cm3 has a porosity of about 90
percent.
The modulus of elasticity of trabecular bone with
porosity p can be approximated by:
E=15 . (1 - p)3 [GPa]
This formula tells us that, with increasing
porosity p (with increasing void space in the
sample), the modulus of elasticity E exhibits a
marked decrease. Depending on the trabecular
architecture (the general arrangement, shape, and
dimensions of the individual trabeculae for a
particular specimen), modulus or strength vary
with apparent density by a linear relationship or a
power law relationship with an exponent of 1-3.
Quantitatively, the modulus of elasticity of
trabecular bone ranges between 1.4 and 9800 MPa.
In general, average modulus values per anatomic
site for trabecular bone vary from as low as about
3000 MPa in the elderly spine to over 3000 MPa in
the loadbearing portions of the femoral head.
Ultimate strength values for individual specimens
vary from 0.1-40 MPa, typically being a factor 100
less than modulus. By contrast, the yield strains are
relatively uniform. For higher density trabecular
bone, compressive and tensile values are about 0.8
percent and 0.6 percent, respectively. For lower
density bone, such as in the vertebral body,
compressive yield strains are lower at about 0.7
percent, due presumably to underlying large
deformation bending or buckling-type failure
mechanisms of the individual trabeculae that can
occur when the density is low. In this situation, the
individual trabecular tend to be longer and thinner
than for high-density bone, and according to
engineering buckling theory, this may promote
buckling as a failure mode, compared with material
yielding. Buckling or excessive bending do not
appear to occur much for high-density bone
(volume fraction> 0.25) and do not occur for tensile
loading. It is most interesting, however, that the
variation in yield strain within sites is very small
and is even small across sites.
The ultimate stress is decreased substantially
with increasing porosity. With increasing porosity
(or decreasing apparent density) trabecular bone
becomes 'softer' and ·weaker'. The maximum strain
of trabecular bone is about 4 %. The ultimate strain
is independent of the porosity and the apparent
density. Samples of trabecular bone are usually not
irreparably damaged by one single overload
episode, but subsequently still exhibit some
strength, though at a reduced level. The residual
strength of mechanically damaged bones, e.g. of
fractured osteoporotic vertebrae, constitutes a vital
safety factor for the functioning of the locomotor
system. When a sample of trabecular bone is viewed
with the naked eye, the alignment of the trabeculae
in preferred directions is obvious beyond any
doubt.
The compressive stress-strain properties of
trabecular bone are markedly different from those
of cortical bone and are similar to the compressive
behavior of many porous engineering materials that
absorb energy on impact. Stress-strain curves for
trabecular bone in compression exhibit an initial
elastic region followed by yield. The slope of the
initial elastic region ranges from one to two orders
of magnitude less than cortical bone. Yield is
followed by a long plateau region created as more
trabeculae fracture. The fractured trabeculae begin
to fill the marrow spaces at approximately 50
percent strain. Further loading of the specimen after
the pores are filled is associated with a marked
increase in specimen modulus.
Both the compressive strength and compressive
modulus of trabecular bone are markedly
influenced by the apparent density of the tissue.
Many studies have shown a highly significant
relationship between bone density and mechanical
properties. However, it has also been shown by
many investigators that density alone cannot
predict all of the variation in the mechanical
properties and that the way the bone is organized
and the variations in the internal structure of tissue
within the bone are also important determinants of
the strength and stiffness of bone.
These relationships between mechanical
properties and the apparent density of bone tissue
are important. They suggest that bone tissue can
generate large changes in modulus and strength
through small changes in bone density. Conversely,
 Biomechanics of Bone Tissue & Orthopaedic Hardwares 105

subtle changes in bone density result in large
differences in strength and modulus. This is an
important consideration when we note that bone
density changes are usually not radiographically
evident until the bone density has been reduced by
30 to 50 percent.
As well as contributing to the tensile, compressive
and shearing strengths of bone, the small degree of
elasticity shown by collagen imparts a measure of
resilience to the tissue, and helps to resist fracture
when bone is mechanically loaded.
Anisotropy
Like cortical bone, trabecular bone is an anisotropic
material. Modulus and strength can vary by as much
as eight times, depending on the direction of loading
compared with the principal material direction,
which coincides with the main trabecular
orientation. For some sites, such as the vertebral
body of the spine, the general anatomic directions
(e.g., the inferior-superior axis) coincide with the
main trabecular orientation. However, for most
sites this is not the case, and the main trabecular
orientation is oblique to the anatomic axes (e.g.,
proximal femur). In these cases, a local coordinate
system can be used to describe the principal
material directions.
Failure, Fatigue, and Creep
The multiaxial failure behavior of trabecular bone is
an important aspect of its in vivo failure behavior,
because failure usually occurs during some type of
trauma where loads will be multiaxial or oblique to
the principal material direction. A criterion based
on maximum strains will explain the trabecular
failure behavior. The criterion works as follows:
Strains for any state of loading are converted into
principal strains. When either the maximum or
minimum principal strain exceeds the maximum
allowable on-axis uniaxial strains, then failure is
assumed to occur .
Like cortical bone, trabecular bone exhibits the
phenomena of creep and fatigue. Trabecular bone
also undergoes modulus and strength reductions if
it is loaded beyond its yield point, unloaded, and
reloaded..
the difference is subtle. This difference in
mineralization and the different arrangements of
the lamellar bone are thought to produce slightly
lower material properties of the tissue that makes
up the struts of trabecular bone compared with the
tissue that makes up cortical bone. It is difficult to
measure these properties directly due to the small
size and irregular shapes of individual trabeculae.
The resulting uncertainties in the trabecular tissue-
level properties complicate micromechanical
analysis of trabecular bone. Both cortical and
trabecular tissues are porous. Cortical bone has a
porosity P less than about 30 percent, or
equivalently, a volume fraction Vf greater than
about 0.70 (Vf = 1 - P/100). Volume fraction is the
ratio of the volume of actual bone tissue to the bulk
volume of the specimen, which includes the volume
associated with the vascular pore spaces, but
ignores the presence of lacunae and canaliculi.
Trabecular bone has a volume fraction rarely
greater than about 0.60, so the difference between
cortical and trabecular bone is fairly distinct.
Porosity of adult human femoral cortical bone, for
example, can vary from as low as 5 percent at age
20 up to almost 30 percent at age 80. Porosity of
trabecular bone varies from about 50 percent in the
young adult femoral head up to about 95 percent in
the elderly vertebra. Mechanical properties differ in
the two bone types. Cortical bone is stiffer than
cancellous bone, withstanding greater stress but
less strain before failure. Cancellous bone in vitro
may sustain up to 50% of strains before yielding,
while cortical bone yields and fractures when the
strain exceeds 1.5 to 2.0%. Because of its porous
structure, cancellous bone has a large capacity for
energy storage. (Fig 3.2-2)

Cortical and trabecular bone

The main difference, therefore, between cortical and
trabecular bone is the open cellular structure of the
latter. The actual bone tissue at the underlying
hierarchical level is very similar, being made of
lamellar bone arranged as previously described for
cortical bone or in the more irregularly shaped
packets for trabecular bone. However, one
difference does exist. There is more bone
remodeling on the free surfaces of the rods and
plates within trabecular bone than on the internal
surfaces of Haversian canals within the cortical
bone, and newly formed bone is less mineralized Figure 3.2-3: Cortical bone tolerates greater loads at the
than older bone. Therefore, trabecular bone tends price of less flexibility, while trabecular bone is able to
deform more but sacrifices peak loading ability
to be less mineralized than cortical bone, although
106 Plate Fixation in Orthopaedics
BIOMECHANICAL PROPERTIES OF
WHOLE BONES
Materials are classified as brittle or ductile
depending on the extent of deformation before
failure. Glass is a typical brittle material, and soft
metal is a typical ductile material. The difference in
the amount of deformation is reflected in the
fracture surfaces of the two materials. When pieced
together after fracture, the ductile material will not
conform to its original shape whereas the brittle
material will. Bone exhibits more brittle or more
ductile behavior depending on its age (younger
bone being more ductile) and the rate at which it is
loaded (bone being more brittle at higher loading
speeds). After the yield point is reached, glass
deforms very little before failing, as indicated by the
absence of a plastic region on the stress-strain
curve. By contrast, metal exhibits extensive
deformation before failing, as indicated by a long
plastic region on the curve. Bone also deforms
before failing but to a much lesser extent than
metal. The difference in the plastic behavior of
metal and bone is the result of differences in
micromechanical events at yield. Yielding in metal
(tested in tension, or pulled) is caused by plastic
flow and the formation of plastic slip lines; slip lines
are formed when the molecules of the lattice
structure of metal dislocate. Yielding in bone (tested
in tension) is caused by debonding of the osteons at
the cement lines and microfracture, while yielding
in bone as a result of compression is indicated by
cracking of the osteons.
Because the structure of bone is dissimilar in the
transverse and longitudinal directions, it exhibits
different mechanical properties when loaded along
different axes, a characteristic known as anisotropy.
When the skeleton is exposed to trauma, some
regions are subjected to extreme loads. Fracture
occurs when the local stresses or strains exceed the
ultimate strength or strain of bone in that region.
Bone fracture can therefore be viewed as an event
that is initiated at the material level and then affects
the load-bearing capacity of bone at the structural
level. The major difference between behavior at the
material level and at the structural level relates to
inclusion of geometric features at the structural
level and their exclusion at the material level. Thus,
the structural behavior includes the effects of both
bone geometry and material properties, whereas
material behavior occurs without the effects of
complex bone geometries. Any attempt to predict
the structural behavior of a skeletal region must
therefore reflect both the material properties of
different types of bone in that region and the
geometric arrangement of the bone.
There are several aspects of bone cross-sectional
geometry, such as cross-sectional area and moment
of inertia, that can be used to predict the structural
properties. The cross-sectional area is
straightforward. Subjected to axial loads and
assuming similar bone material properties, a large,
thick-walled bone is more resistant to fracture
simply because it distributes the internal forces
over a larger surface area, resulting in lower
stresses. The moment of inertia expresses the shape
of the cross-section and the particular distribution
of tissue or material with respect to applied bending
loads. The moment of inertia must be expressed in
relation to a particular axis, since bending can occur
in many different planes. From these equations, it is
apparent that the moment of inertia is highly
sensitive to the distribution of area with respect to
an axis. Material that is at a greater distance from
the axis is more efficient at resisting bending with
respect to that axis.
Long bones are loaded by axial loads, bending in
several planes, and torsion. Under these conditions,
a semitubular structure is most efficient. Diaphyseal
bone cross-sectional geometries are roughly tubular
in some regions but highly irregular elsewhere. The
moment of inertia for an irregular bone cross-
section can be determined from traces of the
periosteal and endosteal surfaces by means of
simple numerical techniques. The moment of inertia
partially determines the risk of fracture. For
example, small cross-sectional areas and moments
of inertia of the femoral and tibial diaphysis
predispose military trainees to stress fractures.
Although bones are typically subjected to a
variety of complex loads, it is instructive to evaluate
the strength of a bone or fracture treatment method
for simple, well-defined loads. Three types of
loading are typically considered in laboratory
experiments: axial, bending, and torsion. For each
load case, the behavior of the structure is described
by a rigidity term that is a combination of both
material stiffness (represented by a modulus) and a
geometric factor (area or moment of inertia).
Structures with high rigidity deform little under a
load. For axial loads, the important parameters that
govern the mechanical behavior of a structure are
the cross-sectional area and the modulus of
elasticity. The product of area and modulus is the
axial rigidity. For bending, the applied loads are
expressed as a moment with dimensions of force
times distance. The important structural
parameters in a bending test are the moment of
inertia and the elastic modulus, and their product is
the bending (or flexural) rigidity. Torsional loads
are also expressed as a force times a distance. The
cross-sectional distribution of bone and the shear
modulus of bone determine the torsional
properties. Just as the moment of inertia describes
the distribution of material about the bending axis,
for a cylindrical bone, the polar moment of inertia
describes the distribution of material about the long
axis of the structure being tested. The product of
shear modulus and polar moment of inertia gives
the torsional rigidity. For noncircular cross-
sections, and structures with cross-sections that
vary along the length, a simple polar moment of
inertia can be inaccurate.
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
Figure 3.2-3: Some simple geometric cross-sections and
the corresponding formulas for calculating the moment of
inertia with respect to the x-axis.
For these structures, various formulae and simple
analytical models can be used to calculate the
structural properties under torsional loads.(Fig 3.2-
3)
BONE BEHAVIOR UNDER VARIOUS
LOADING MODES
Forces and moments can be applied to a structure in
various directions, producing tension, compresion,
bending, shear, torsion, and combined loading. Bone
in vivo is subjected to all of these loading modes.
Tension
During tensile loading, equal and opposite loads are
applied outward from the surface of the structure,
and tensile stress and strain result inside the
structure. Tensile stress can be thought of as many
small forces directed away from the surface of the
structure. Maximal tensile stress occurs on a plane
perpendicular to the applied load. Under tensile
loading, the structure lengthens and narrows.
Clinically, fractures produced by tensile loading are
usually seen in bones with a large proportion of
cancellous bone.
Compression
During compressive loading, equal and opposite
loads are applied toward the surface of the
structure and compressive stress and strain result
inside the structure. Compressive stress can be
thought of as many small forces directed into the
surface of the structure. Maximal compressive
stress occurs on a plane perpendicular to the
applied load. Under compressive loading, the
structure shortens and widens.
Shear
During shear loading, a load is applied parallel to
the surface of the structure, and shear stress and
strain result inside the structure. Shear stress can
be thought of as many small forces acting on the
surface of the structure on a plane parallel to the
applied load. A structure subjected to a shear load
deforms internally in an angular manner; right
angles on a plane surface within the structure
107
become obtuse or acute. Whenever a structure is
subjected to tensile or compressive loading, shear
stress is produced. Clinically, shear fractures are
most often seen in cancellous bone.
Human adult cortical bone exhibits different
values for ultimate stress under compressive,
tensile, and shear loading. Cortical bone can
withstand greater stress in compression
(approximately 190 Mpa) than in tension
(approximately 130Mpa) and greater stress in
tension than in shear (70Mpa). The elasticity
(Young's modulus) is approximately 17 GPa in
longitudinal or axial loading and approximately 11
GPa in transverse loading. Human trabecular bone
values for testing in compression are approximately
50 Mpa and are reduced to approximately 8 Mpa if
loaded in tension. The modulus of elasticity is low
(0.0-0.4 GPa) and dependent on the apparent
density of the trabecular bone and direction of
loading. The clinical biomechanical consequence is
that the direction of compression failure results in
general in a stable fracture, while a fracture
initiated by tension or shear may have catastrophic
consequences.
Bending
In bending, loads are applied to a structure in a
manner that causes it to bend about an axis. When a
bone is loaded in bending, it is subjected to a
combination of tension and compression. Tensile
stresses and strains act on one side of the neutral
axis, and compressive stresses and strains act on
the other side; there are no stresses and strains
along the neutral axis. The magnitude of the
stresses is proportional to their distance from the
neutral axis of the bone. The farther the stresses are
from the neutral axis, the higher their magnitude.
Because a bone structure is asymmetrical, the
stresses may not be equally distributed. Bending
may be produced by three forces (threepoint
bending) or four forces (four-point bending).
Fractures produced by both types of bending are
commonly observed clinically, particularly in the
long bones. Three-point bending takes place when
three forces acting on a structure produce two equal
moments, each being the product of one of the two
peripheral forces and its perpendicular distance
from the axis of rotation (the point at which the
middle force is applied). If loading continues to the
yield point, the structure, if homogeneous,
symmetrical, and with no structural or tissue defect,
will break at the point of application of the middle
force. Four-point bending takes place when two
force couples acting on a structure produce two
equal moments. A force couple is formed when two
parallel forces of equal magnitude but opposite
direction are applied to a structure. Because the
magnitude of the bending moment is the same
throughout the area between the two force couples,
the structure breaks at its weakest point.
108 Plate Fixation in Orthopaedics
Torsion
In torsion, a load is applied to a structure in a
manner that causes it to twist about an axis, and a
torque (or moment) is produced within the
structure. When a structure is loaded in torsion,
shear stresses are distributed over the entire
structure. As in bending, the magnitude of these
stresses is proportional to their distance from the
neutral axis. The farther the stresses are from the
neutral axis, the higher their magnitude. Under
torsional loading, maximal shear stresses act on
planes parallel and perpendicular to the neutral axis
of the structure. In addition, maximal tensile and
compressive stresses act on a plane diagonal to the
neutral axis of the structure. The fracture pattern
for bone loaded in torsion suggests that the bone
fails first in shear, with the formation of an initial
crack parallel to the neutral axis of the bone. A
second crack usually forms along the plane of
maximal tensile stress.
Combined Loading
Although each loading mode has been considered
separately, living bone is seldom loaded in one
mode only. Loading of bone in vivo is complex for
two principal reasons: bones are constantly
subjected to multiple indeterminate loads and their
geometric structure is irregular. In vivo
measurement of the strains on the anteromedial
surface of a human adult tibia during walking and
jogging demonstrates the complexity of the loading
patterns during these common physiological
activities. Studies showed that during normal
walking, the stresses were compressive during heel
strike, tensile during the stance phase, and again
compressive during push-off. Values for shear stress
were relatively high in the later portion of the gait
cycle, denoting significant torsional loading. This
torsional loading was associated with external
rotation of the tibia during stance and push-off.
During jogging, the stress pattern was quite
different. The compressive stress predominating at
toe strike was followed by high tensile stress during
push-off. The shear stress was low throughout the
stride, denoting minimal torsional loading produced
by slight external and internal rotation of the tibia
in an alternating pattern. The increase in speed
from slow walking to jogging increased both the
stress and the strain on the tibia.
Influence of bone geometry on
biomechanical behavior
The geometry of a bone greatly influences its
mechanical behavior. In tension and compression,
the load to failure and the stiffness are proportional
to the cross-sectional area of the bone. The larger
the area, the stronger and stiffer the bone. In
bending, both the cross-sectional area and the
distribution of bone tissue around a neutral axis
affect the bone's mechanical behavior. The quantity
that takes into account these two factors in bending
is called the area moment of inertia. A larger
moment of inertia results in a stronger and stiffer
bone.
A third factor, the length of the bone, influences
the strength and stiffness in bending. The longer the
bone, the greater the magnitude of the bending
moment caused by the application of a force. In a
rectangular structure, the magnitude of the stresses
produced at the point of application of the bending
moment is proportional to the length of the
structure.
Because of their length, the long bones of the
skeleton are subjected to high bending moments
and, therefore, to high tensile and compressive
stresses. Their tubular shape gives them the ability
to resist bending moments in all directions. These
bones have a large area moment of inertia because
much of the bone tissue is distributed at a distance
from the neutral axis.
The factors that affect bone strength and stiffness
in torsion are the same that operate in bending: the
cross-sectional area and the distribution of bone
tissue around a neutral axis. The quantity that takes
into account these two factors in torsional loading is
the polar moment of inertia. The larger the polar
moment of inertia, the stronger and stiffer the bone.
When bone begins to heal after fracture, blood
vessels and connective tissue from the periosteum
migrate into the region of the fracture, forming a
cuff of dense fibrous tissue, or callus (woven bone),
around the fracture site, stabilizing that area.(Fig
3.2-4) The callus significantly increases the area and
polar moments of inertia, thereby increasing the
strength and stiffness of the bone in bending and
torsion during the healing period. As the fracture
heals and the bone gradually regains its normal
strength, the callus cuff is progressively resorbed
and the bone returns to as near its normal size and
shape as possible.
Certain surgical procedures produce defects that
greatly weaken the bone, particularly in torsion.
These defects fall into two categories: those whose
length is less than the diameter of the bone (stress
raisers) and those whose length exceeds the bone
diameter (open section defects). A stress raiser is
produced surgically when a small piece of bone is
removed or a screw is inserted. Bone strength is
reduced because the stresses imposed during
loading are prevented from being distributed evenly
throughout the bone and instead become
concentrated around the defect.
This defect is analogous to a rock in a stream,
which diverts the water, producing high water
turbulence around it. The weakening effect of a
stress raiser is particularly marked under torsional
loading; the total decrease in bone strength in this
loading mode can reach 60%.
 Biomechanics of Bone Tissue & Orthopaedic Hardwares 109

A. Rel strength/mm2 ½
Rel rigidity/mm2 1/4

B. Rel strength/mm2 1
Rel rigidity/mm2 1

C.Rel strength/mm2 5/3

Rel rigidity/mm2 2

Figure 3.2-4: A comparison of the moments of inertia and resulting strengths when fracture callus is located: A) on the outer
surface, B) on bone surfaces, C) in the medullary canal. The strength and rigidity are significantly increased when callus is located
over the periosteal surface, compared to within the medullary canal.

Burstein and associates showed the effect of deformation to failure was diminished by
stress raisers produced by screws and by empty approximately 70%. Clinically, the surgical removal
screw holes on the energy storage capacity of rabbit of a piece of bone can greatly weaken the bone,
bones tested in torsion at a high loading rate. The particularly in torsion.
immediate effect of drilling a hole and inserting a
screw in a rabbit femur was a 74% decrease in
energy storage capacity. After 8 weeks, the stress
raiser effect produced by the screws and by the
holes without screws had disappeared completely
because the bone had remodeled: bone had been
laid down around the screws to stabilize them, and
the empty screw holes had been filled in with
bone.(Fig 3.2-5) In femora from which the screws
had been removed immediately before testing,
however, the energy storage capacity of the bone
decreased by 50%, mainly because the bone tissue
around the screw sustained microdamage during
screw removal.
An open section defect is a discontinuity in the
bone caused by the surgical removal of a piece of
bone longer than the bone's diameter (e.g., by the
cutting of a slot during a bone biopsy). Because the
outer surface of the bone's cross-section is no
longer continuous, its ability to resist loads is
altered, particularly in torsion. In a normal bone
subjected to torsion, the shear stress is distributed
throughout the bone and acts to resist the torque.
In torsion tests in vitro of human adult tibiae, an Figure 3.2-5: Stress is concentrated at the equator of the
open section defect reduced the load to failure and hole and at the bottom of the notch. A sharp notch will
energy storage to failure by as much as 90%. The concentrate the stress further.
110 Plate Fixation in Orthopaedics
Influence of muscle activity on stress
distribution in bone
When bone is loaded in vivo, the contraction of the
muscles attached to the bone alters the stress
distribution in the bone. This muscle contraction
decreases or eliminates tensile stress on the bone
by producing compressive stress that neutralizes it
either partially or totally. During locomotion,
bending moments are applied to the femoral neck
and tensile stress is produced on the superior
cortex. Contraction of the gluteus medius muscle
produces compressive stress that neutralizes this
tensile stress, with the net result that neither
compressive nor tensile stress acts on the superior
cortex. Thus, the muscle contraction allows the
femoral neck to sustain higher loads than would
otherwise be possible.
Strain rate dependency in bone
Because bone is a viscoelastic material, its
biomechanical behavior varies with the rate at
which the bone is loaded (i.e., the rate at which the
load is applied and removed). Bone is stiffer and
sustains a higher load to failure when loads are
applied at higher rates. Bone also stores more
energy before failure at higher loading rates,
provided that these rates are within the
physiological range. The in vivo daily strain can vary
considerably. The calculated strain rate for slow
walking is 0.001 per second, while slow running
displays a strain rate of 0.03 per second. In general,
when activities become more strenuous, the strain
rate increases. The bone is approximately 30%
stronger for brisk walking than for slow walking. At
very high strain rates (> 1 per second) representing
impact trauma, the bone becomes more brittle. In a
full range of experimental testing for ultimate
tensile strength and elasticity of cortial bone, the
strength increases by a factor of three and the
modulus by a factor of two.
The loading rate is clinically significant because it
influences both the fracture pattern and the amount
of soft tissue damage at fracture. When a bone
fractures, the stored energy is released. At a low
loading rate, the energy can dissipate through the
formation of a single crack; the bone and soft tissues
remain relatively intact, with little or no
displacement of the bone fragments. At a high
loading rate, however, the greater energy stored
cannot dissipate rapidly enough through a single
crack, and comminution of bone and extensive soft
tissue damage result.
Clinically, bone fractures fall into three general
categories based on the amount of energy released
at fracture: low-energy, high-energy, and very high-
energy. A low-energy fracture is exemplified by the
simple torsional ski fracture; a high-energy fracture
is often sustained during automobile accidents; and
a very high-energy fracture is produced by very
high-muzzle velocity gunshot.
Adaptation of bones to mechanical
demands
Long before the cellular basis for bone adaptation
and remodeling had been discovered, it was
conjectured that bones are not unchangeable
structures, but can adapt to their mechanical
demands in the human locomotor system. Meyer
(1867) demonstrated surprising similarities
between the alignment of trabeculae in the vicinity
of joints and the latticework of iron bridges. Wolff
(1892) hypothesized that trabecular bone
represented a latticework reaching maximum
strength while employing a minimum of bone
material. In the interim, the work of Meyer and of
Wolff has proved to be extremely stimulating and
inspiring to researchers.
When discussing the adaptation of bones to their
mechanical demands, 'Wolff’s law of the
transformation of bones' is frequently cited. No
specific conclusions can be drawn from Wolff’s law.
The frequent reference to 'Wolff’s law' in the
scientific literature is a somewhat meaningless
phrase. What is really meant is the hypothesis that a
change in mechanical demands induces changes in
bone structure or, conversely, that an observed
change in bone structure permits conclusions to be
drawn on changed mechanical demands.
Incidentally, with respect to adaptation to
mechanical demands, bones are not an exception.
Muscles, tendons, skin, and all other tissues of the
body exhibit such adaptation as well. Specific
conclusions derived from Wolff’s law by some
authors, e. g. 'the architecture of bones can be
deduced exclusively from basic mechanical
principles', or 'the trabeculae of trabecular bone are
aligned in the direction of the principal stresses
(directions where only compressive or tensile
stresses exist)', have proved to be incorrect. In
addition, our present knowledge suggests that
adaptation and remodeling processes of bone are
often masked by other processes. If, for example,
the adaptation of proximal femur and vertebral
body to their mechanical demands at increasing age
were the number one priority, it might be concluded
from Wolffs law (naively viewed) that more new
bone is deposited than old bone removed. This is,
unfortunately, not the case in reality. However, the
fact that some aspects of bone mechanics are
nowadays, more than one hundred years after the
pioneering conjectures of Meyer and Wolff, viewed
differently should not diminish our admiration for
the remarkable powers of observation displayed by
these ingenious researchers.
While it is agreed that the functional adaptation of
bones is triggered and controlled by mechanical
stimuli, there is disagreement on which specific
mechanical signal, or combination of signals,
actually induces the cell system of osteoclasts,
osteoblasts, and osteocytes to either resorb or
produce bone at specific sites in cortical or
trabecular bone.
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
This is an intricate problem, because the complex
mechanical properties of bone material make it very
difficult to determine the local stress and strain
even under simple loading conditions. Mechanical
stimuli that might control the adaptation of bones
are magnitude of the deformation, frequency of the
deformation, difference in deformation in adjacent
volumina (deformation gradients), deformation
rate, sum of the deformations encountered in the
past (deformation history) and density of the
deformation energy. Processes accompanying
deformation of bones are pressure changes and flux
of the water contained in the bone material or
piezoelectric voltages originating from the
deformation of the crystalline component of bone.
Furthermore, the role of micro-fractures of the
trabecular bone in the adaptation process is
debated controversially. Such micro-fractures are
frequently seen in the trabecular bone in the region
of the hip joint and in vertebral bodies. Such
fractures can be regarded as pathologic because
they indicate insufficient strength in relation to the
mechanical loading. On the other hand it is quite
feasible that these fractures occur in the course of a
physiologic process in which old, brittle bone is
removed and replaced with newly formed, better
adapted bone. It is hypothesized that the fracture
callus in the trabecular mesh might also enable
growth of new trabeculae, bridging between
formerly separated trabeculae.
Bone constantly experiences the processes of
growth, reinforcement, and resorption. It adapts to
the mechanical demands placed on it by daily
activities (or lack thereof). If one considers the way
the heart and other muscles adapt to exercise or
atrophy with disuse, it is not hard to imagine that
bone goes through a similar process. The adaptation
of cortical bone requires both changes in its internal
structure as well as its shape, especially its cross-
sectional area. The idea that bone adapts to its
mechanical environment or damage is not new. As
far back as the late 1800s, it was postulated that
bone architecture is related to the mechanical loads
it experiences, a notion now referred to as Wolff's
Law, after its chief postulator. But it is not clear
what the bone cells are trying to accomplish.
Adaptation of Haversian Bone
Secondary osteons are formed by the coordinated
actions of BMUs (basic multicellular units). Within
each BMU, the osteoclasts resorb bone and are
followed by osteoblasts, which deposit new bone.
The BSU (basic structural unit) is the amount of
bone that is laid down by each BMD. It includes the
bone between the cement lines and the opening of
the Haversian canal. Each BMU goes through the
process of activation, resorption and reversal, and
formation (the A-R-F sequence) .
Activation: The entire process takes about three
days. Differentiated, dedicated cells must be
recruited. The osteoclasts that do the tunneling may
111
survive for weeks, and it is postulated that the
osteocytes play a central role.
Resorption and reversal: Approximately 30 days
are required for the resorption and reversal process
to pass through a given cross section in human
bone. The osteoclasts occupy a half-eggshell region
(200 µm in diameter and 300 µm long) that can
move 40-50 µm/day. The reversal region is
generally quiescent, because the osteoblasts remain
a short distance behind the osteoclasts.
Formation: Osteoblasts lay down osteoid, which is
a collagenous matrix material that will later calcify
and become bone. The average radial closure rate is
less 1 µm/day, taking approximately 90 days to
reach completion. As osteoblasts lay down osteoid,
some of them become trapped and differentiate into
osteocytes. The osteocytes then extend their
processes toward the formation front to contact and
trap other osteoblasts, and the process continues.
Eventually, there will be a network of living cells
inhabiting the lamellae of the Haversian canal. Once
this is finished, it takes about 10 days before
calcium and phosphorus diffuse or convect into the
region in sufficient quantities to begin the
mineralization process. Once they do, however, 60
percent of the mineralization occurs within 24
hours. The remainder mineralizes over the next six
months.
Trabecular Bone Adaptation
Remodeling in trabecular bone is not as organized
as it is within Haversian bone. Typically, osteoclasts
attach themselves to the surfaces of trabeculae and
eat away a small region of bone known as a
Howship's lacunae, ordinarily 40-60 microns deep.
As long as the osteoclast does not penetrate
completely through the trabeculae, osteoblasts will
eventually follow and lay down new bone. While
trabecular bone does not have the extensive
osteocyte array that cortical bone has to act as
mechano-sensors, it is still adaptive. It is generally
accepted that the architecture represents an
optimized state. It is thought that the osteoclasts
respond to trabecular damage, as well as to the
body's demand for calcium. It may also be that the
osteoblasts target areas that are experiencing large
deformations.
Modulus Changes and Bone Adaptation
In strain-driven bone remodeling theory, a
fundamental assumption is made that the bone
adaptation process is error driven; that is, the
magnitude of the response is based on the
difference between the local strain state due to the
applied mechanical load and a biological set point
(sometimes called an attractor state). Loads well
below the set point stimulate bone removal and
subsequent reductions in local bone stiffness.
Reduced local stiffness leads in turn to increases in
local strains until the set point is reached (or
approximated) and the bone is adapted to the
loading stimulus.
112 Plate Fixation in Orthopaedics

Fatigue of bone under repetitive loading BIOMECHANICS OF BONE

Bone fractures can be produced by a single load that
exceeds the ultimate strength of the bone or by
FRACTURE
repeated applications of a load of lower magnitude.
To appreciate why bone fractures in certain
A fracture caused by a repeated load application is
patterns, one must understand that, bone is weakest
called a fatigue fracture and is typically produced
in tension and strongest in compression. Therefore,
either by few repetitions of a high load or by many
when a force creates tensile stresses in a particular
repetitions of a relatively normal load.
region of a loaded bone, failure will generally occur
For some materials (some metals, for example),
first in that region. When loaded in tension,
the fatigue curve is asymptotic, indicating that if the
diaphyseal bone normally fractures along a plane
load is kept below a certain level, theoretically the
that is approximately perpendicular to the direction
material will remain intact no matter how many
of loading. The simplest example is the transverse
repetitions. For bone tested in vitro, the curve is not
fracture created in a long bone subjected to pure
asymptotic. When bone is subjected to repetitive
bending. Because in this example the upper, convex
low loads, it may sustain micro-fractures. Testing of
surface undergoes the greatest elongation, it is
bone in vitro also reveals that bone fatigues rapidly
subjected to the largest tensile stresses, and failure,
when the load or deformation approaches its yield
indicated by a crack, initiates here. The crack then
strength; that is, the number of repetitions needed
progresses transversely through the material, and
to produce a fracture diminishes rapidly.
layers just below the outer layer become subjected
In repetitive loading of living bone, the fatigue
to high tensile stress until they crack as well. In this
process is affected not only by the amount of load
manner, the crack progresses through the bone
and the number of repetitions but also by the
transversely until it fails. The concave surface is
number of applications of the load within a given
subjected to compression so the crack does not
time (frequency of loading). Because living bone is
initiate there. (Fig 3.2-6 A)
self-repairing, a fatigue fracture results only when
A compressive load results in failure of cortical
the remodeling process is outpaced by the fatigue
bone by shear, indicated by slippage along the
process-that is, when loading is so frequent that it
diagonal, because bone is weaker in shear than in
precludes the remodeling necessary to prevent
compression. These maximum shear stresses are
failure.
approximately one half the applied compressive
Fatigue fractures are usually sustained during
stress. In this case, compressive loading causes an
continuous strenuous physical activity, which
interface within the bone at 45 degrees to the
causes the muscles to become fatigued and reduces
applied load to slide along another at an oblique
their ability to contract. As a result, they are less
angle. Thus, compressive failures of bone occur
able to store energy and thus to neutralize the
along planes of maximum shear stress while tensile
stresses imposed on the bone. The resulting
fractures occur along planes of maximum tensile
alteration of the stress distribution in the bone
stress. (Fig3.2-6 B)
causes abnormally high loads to be imposed, and a
When a bone is subjected to bending, high tensile
fatigue damage accumulation occurs that may lead
stresses develop on the convex side, while high
to a fracture. Bone may fail on the tensile side, on
compressive stresses develop on the concave side.
the compressive side, or on both sides. Failure on
The resulting fracture pattern is consistent with
the tensile side results in a transverse crack, and the
that observed during axial compressive and tensile
bone proceeds rapidly to complete fracture. Fatigue
loading of whole bones. A transverse fracture
fractures on the compressive side appear to be
surface occurs on the tensile side, while an oblique
produced more slowly;the remodeling is less easily
fracture surface is found on the compressive side.
outpaced by the fatigue process and the bone may
Two fracture surfaces commonly occur on the
not proceed to complete fracture.
compressive side, creating a loose wedge of bone
Resistance to fatigue behavior is greater in
that is sometimes referred to as a “butterfly”
compression than in tension. On average,
fragment. (Fig3.2-6 C)
approximately 5,000 cycles of experimental loading
The fracture pattern is more complex when a
correspond to the number of steps in 10 miles of
bone is subject to torsion. Consider a rectangular
running. One million cycles corresponds to
area on the surface of a long bone that is loaded in
approximately 1,000 miles. A total distance of less
torsion. The rectangle distorts as the bone twists,
than 1,000 miles could cause a fracture of the
with one diagonal of the rectangle elongating and
cortical bone tissue. This is consistent with stress
the other shortening, depending on the direction of
fractures reported among military recruits
twist. A crack will form perpendicular to the
undergoing strenuous training of up to 1,000 miles
diagonal that is elongating, and progresses around
of running over a short period of time (6 weeks).
the perimeter of the bone resulting in a spiral
Fractures of individual trabeculae in cancellous
fracture. The region of bone with the smallest
bone have been observed in postmortem human
diameter is usually the least stiff region, resulting in
specimens and may be caused by fatigue
the greatest distortion of the surface and is
accumulation.
generally the location of the fracture. This explains
why torsional fractures of the tibia often occur in
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
the narrow distal third. Fractures usually begin at a
small defect at the bone surface and then the crack
follows a spiral pattern through the bone along
planes of high tensile stress. The final fracture
surface appears as an oblique spiral that
characterizes it as a torsion fracture. (Fig3.2-6 D)
The fracture patterns discussed for idealized
loading conditions are consistent with some
fractures seen clinically. However, with many
traumatic loading conditions, bone is subject to a
combination of axial, bending, and torsional loading,
and the resulting fracture patterns can be complex
combinations of the above patterns. Additionally,
high loading rates often result in additional
comminution of the fracture caused by the
branching and propagation of numerous fracture
planes. Bone may tolerate higher loads if the loads
are applied rapidly, although the ability of bone to
absorb energy may not change with loading rate. In
addition, fractures can occur owing to a single load
that is greater than the load-bearing capacity of the
bone, and these loads are commonly called the
ultimate failure load. Repeated application of loads
smaller than the ultimate failure load can fatigue the
bone, resulting in the accumulation of microcracks
in the bone, and can eventually lead to failure.
Fatigue failures of bone are common in military
training and in athletes. If the loading is stopped or
sufficiently reduced before gross failure of the bone,
then each microcrack will be repaired through
direct cortical remodeling.
At very high loads, such as during impact
fractures, crushing or comminution of bone also
occurs, especially at the weaker metaphyseal ends
of a long bone. The trabecular bone at the
metaphyseal ends is weaker in compression than
the diaphyseal cortical bone is in shear. Because of
this, it is unlikely that shearing failure will occur in
the diaphysis caused by pure compressive forces.
A. B.
C. D.
Figure 3.2-6: Characteristic fractures typically found for
bones loaded to failure with pure loading modes.
113
The butterfly fracture results from combined
bending and compression. Bending load causes the
fracture to start to fail in tension producing a
transverse crack, but as the crack progresses and
the remaining intact bone weakens, it starts to fail
in compression, causing an oblique (shear) fracture
line. As the ends of the failing bone are driven
together, a third fragment-the butterfly-may result
as the oblique fragment splits off. The production of
a butterfly fragment probably depends on the
timing and magnitude of the two basic applied
loads: compression and bending.
Auto crashes account for many fractures. Some
particular mechanisms have been observed.
Fracture of the calcaneus or the malleoli of the foot
and ankle can occur through a combination of the
foot being forced against the brake pedal by the
weight of the occupant during a high speed frontal
collision. Drivers who were braking during a crash
were shown to be much more likely to injure their
right foot compared with their left foot. If the
Achilles tendon applies load to resist the forced
dorsiflexion of the foot on the brake pedal, the
combination of these two loads make cause three
point bending loading of the calcaneus, with the
posterior facet of the talus as the fulcrum. A crack
initiates on the plantar or tensile side of the
calcaneus and a tongue type calcaneus fracture can
occur. Inversion or eversion, in which the foot is not
securely planted on the brake pedal and rotates
with compression, is likely to result in a malleolar
fracture, although the combinations of forces
causing these high energy fractures are not entirely
predictable.
A major mechanism of midshaft femur fractures is
impact with the dashboard of the vehicle in a frontal
collision, especially for unrestrained drivers who
submarine or slide forward in the seat. Tensing the
quadriceps and hamstrings muscles during a crash
applies significant additional compression along the
femur. The anterior bow of the femur causes the
external compressive force from contact of the knee
with the dashboard, and internal muscle forces to
bend the femur, resulting in bending and transverse
or oblique fractures. If the femur of the occupant
hits the dashboard in an adducted orientation, the
femur can be displaced from the acetabulum,
causing a fracture of the acetabular roof and
dislocation of the hip joint. Pelvic fractures result
from loading in side impact crashes, in which the
door punches inward against the hip and pelvis. The
actual fracture pattern (symphysis, sacroiliac joint,
or both) is probably the result of the specific
alignment of the pelvis with the applied loads at
impact. Pelvic fracture classifications are based on
the presumed mechanism of injury and specific
forces applied. Bilateral hip fractures have been
found to occur in crashes in which the vehicle has a
large center console that tends to trap the pelvis as
force is also applied on the hip opposite that which
contacts the door. Auto crashes also create, in
occupants with lap but not shoulder belts, the
114 Plate Fixation in Orthopaedics
classic "Chance fracture," which is combined
compression and flexion failure of a lumbar
vertebra, usually at the level in which the lap belt
forms a fulcrum. Upper extremity injuries in auto
crashes have been found to be related to airbag
deployment and entrapment of the arm in the
steering wheel.
BIOMECHANICS OF HEALING BONE
As a fracture heals, its strength is affected by
changes in its mineral content, callus diameter, and
fiber organization. The initial callus forms from the
periosteal surface outward, which is beneficial
mechanically, because as the outer diameter of the
healing area enlarges, its moment of inertia and
therefore its initial stiffness both increase. The
cross-sectional area increases progressively, as does
the mineral content of the callus. From torsional
tests of healing rabbit long bones, progressive
increases were observed in stiffness and peak
torque to failure with time. Interestingly, in that
experiment, the stiffness appeared to gain normal
values before the peak torque to failure.
Bone has a hierarchical structure. The lowest
level of the structure consists of single collagen
fibrils with embedded apatite crystals. At this level
of structure, changing the collagen to mineral ratio
has a significant effect on the elastic modulus of
bone, because it decreases with loss of mineral. This
is important from a fracture healing perspective
because mineralizing healing callus goes through
phases of increasing mineral density and
corresponding increased modulus as healing occurs.
At the next level of structural organization, the
orientation of the collagen fibrils is important. The
orientation of its fibers affects the ability of bone to
support loads in specific directions. During fracture
healing, the callus initially starts as a disorganized
random array of fibers, which progressively
reorganize to become stiffest along the directions of
the major applied loads (body weight and muscle
forces) to which the bone is exposed. At the next
level, the density of the haversian systems affects
bone strength. It has been repeatedly demonstrated
that a power law relationship exists between bone
density and strength at this level of structure. This
means that as bone density decreases, its strength
decreases as the square of its density (as density
decreases by half, strength decreases by a factor of
4). Similarly, the modulus changes with bone
density by a power of between 2 and 3.
The mechanical environment created by the
fixation system along with the available blood
supply affects the type of tissue formed in a healing
fracture. The theory of interfragmentary strain
attempts to relate the types of tissues formed to the
amount of strain experienced by the tissue between
the healing bone fragments. This theory is a simple
representation and cannot describe the complex
stresses that the tissue is exposed to during actual
healing. Nonetheless, within the limitations of the
theory, when large strains occur in the tissues
between healing bone surfaces, granulation tissue is
formed. Intermediate level strains produce cartilage
and small strains result in primary bone healing, or
direct deposition of bone tissue with limited callus
formation.
Among the limitations of this theory, one should
recognize that it doesn't follow that zero strain will
result in maximum bone formation. Load and some
resulting strain are necessary within the healing
fracture to stimulate bone formation. In a study in
which controlled daily displacements in
compression were applied to healing long bones
using an external fixator, and the bone mineral
within the healing fracture was measured with time,
there was an optimal displacement above or below
which less mineral was created in the fracture
callus. Further, compression rather than tension is
the preferred direction of loading. Fracture fixation
constructs of different stiffnesses within a certain
range produce healed fractures with similar
mechanical properties, however, they may reach
this endpoint by different routes. In a study of
femoral fixation using intramedullary rods of either
5% or 50% of the torsional stiffness of the intact
femur, the femurs fixed with the lower stiffness
rods produced an abundance of stabilizing callus, as
opposed to the femurs with more rigid fixation. This
is because with more rigid fixation there was less
necessity for biological fracture stabilization. In
both cases, however, the mechanical properties of
the healed fractures were ultimately similar. These
studies demonstrate that some strain as a result of
loading the fracture stimulates healing, and that
bone will adapt and heal within a relatively wide
range of mechanical stability environments.
Fracture Treatment Concepts
A primary goal of fracture treatment is to provide
the initial mechanical stability required to achieve
successful and rapid fracture healing. The
traditional approach has been to stabilize the
fracture sufficiently so that the normal healing
process can occur with the use of splints and casts.
This is still the option of choice in simple fractures.
One school of thought in modern fracture
treatment, called functional bracing is based upon
the idea that the introduction of function (weight
bearing and motion) results in stimulation of
vascularity and proliferation of periosteal (on the
external bone surface, literally around the bone)
callus. The idea is to enhance the natural healing
process so that it occurs rapidly and successfully.
While this approach has the advantage that it is
noninvasive, it has been mostly limited to femoral
and tibial fractures. Furthermore, it is difficult to
predict the amount of bracing (stability) that
represents a proper compromise between adequate
callus stimulation and excessive fragment motion
leading to nonunion.
It is also possible to essentially bypass the process
of callus formation. A second school of thought uses
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
the concept of "rigid" fixation and "primary
healing," healing via direct bony bridging without
any significant external callus formation. This can
be accomplished by fixation, usually employing
internal fracture plates. In its most successful form,
this healing process is essentially reduced to the
process of normal bone remodeling. In this case, the
biological process responsible for the normal
turnover of healthy bone provides a direct bony
connection across the fracture site, and the healing
process can be very rapid. This has been a popular
treatment technique for long-bone fractures.
It, too, however, has potential problems. First,
there are the obvious problems of morbidity and
risk of infection due to the surgery involved. Second,
very precise fragment positioning may be required
to allow primary healing. Also, at the latter stages of
healing, there is actually a loss of bone tissue under
the plate. This may come in part from the stress-
shielding effect, whereby the presence of the bone
plate reduces the normal loads in the bone. The
bone then responds by reducing its mass. It is also
possible that a major amount of this bone
resorption occurs because the plate rides directly
on the bone and prevents the normal
revascularization of the bone. In either event, it is
often true that the bone fails to return to normal
biological and mechanical function, unless the plate
is removed.
The concepts of functional cast bracing and rigid
internal fixation represent the extremes of a
spectrum of possible treatment techniques for
fractures.
Biomechanical Stages of Repair
The biomechanical behavior of a healing long bone
parallels the biological process. Based on torsional
tests of animal bones, four stages have been
identified:
Stage 1, during which the torsional stiffness and
strength of the healing bone are low, corresponds to
the early callus formation stage. When bony callus
bridges the fracture gap, then the structural
stiffness increases substantially (Stage 2). If a very
large volume of callus is formed, it is possible for the
stiffness to be fairly high without significant bony
bridging, but normally there is a significant increase
in stiffness when bony bridging occurs. As healing
progresses, the maturation of the bone at the
fracture site results in a substantial increase in
strength, and the fracture site begins to approach
the strength of the parent bone (Stage 3). Often, in
long-bone fracture in animals that are healing, the
stiffness and strength exceed the parent bone, and
failure in torsional testing will occur in the parent
bone adjacent to the fracture site (Stage 4).
Bone Remodeling
Bone has the ability to remodel, by altering its size,
shape, and structure, to meet the mechanical
demands placed on it. This phenomenon, in which
bone gains or loses cancellous and/or cortical bone
115
in response to the level of stress sustained, is
summarized as Wolff's law, which states that the
remodeling of bone is influenced and modulated by
mechanical stresses.
Load on the skeleton can be accomplished by
either muscle activity or gravity. A positive
correlation exists between bone mass and body
weight. A greater body weight has been associated
with a larger bone mass. Conversely, a prolonged
condition of weightlessness, such as that
experienced during space travel, has been found to
result in decreased bone mass in weight-bearing
bones. Astronauts experience a fast loss of calcium
and consequent bone loss. These changes are not
completely reversible.
Disuse or inactivity has deleterious effects on the
skeleton. Bed rest induces a bone mass decrease of
approximately 1% per week. In partial or total
immobilization, bone is not subjected to the usual
mechanical stresses, which leads to resorption of
the periosteal and subperiosteal bone and a
decrease in the mechanical properties of bone (i.e.,
strength and stiffness).
An implant that remains firmly attached to a bone
after a fracture has healed may also diminish the
strength and stiffness of the bone. In the case of a
plate fixed to the bone with screws, the plate and
the bone share the load in proportions determined
by the geometry and material properties of each
structure. A large plate, carrying high loads, unloads
the bone to a great extent; the bone then atrophies
in response to this diminished load. (The bone may
hypertrophy at the bone-screw interface in an
attempt to reduce the micromotion of the screws.)
A reduction in the size of the bone diameter
greatly decreases bone strength, particularly in
bending and torsion, as it reduces the area and
polar moments of inertia. A 20% decrease in bone
diameter may reduce the strength in torsion by
60%. This phenomenon suggests that rigid plates
should be removed shortly after a fracture has
healed and before the bone has markedly
diminished in size. Such a decrease in bone size is
usually acompanied by secondary osteoporosis,
which further weakens the bone.
Degenerative Changes in Bone
Associated With Aging
A progressive loss of bone density has been
observed as part of the normal aging process. The
longitudinal trabeculae become thinner, and some
of the transverse trabeculae are resorbed. The
result is a marked reduction in the amount of
cancellous bone and a thinning of cortical bone.
The decrease in bone tissue and the slight
decrease in the size of the bone reduce bone
strength and stiffness. The trabecular bone stiffness
varies with the cube (3rd power) of its density and
strength approximately with the square of its
density. Bone mass normally peaks around age 25
to 30 years and decreases up to 1% annually
thereafter. If the density of trabecular bone is
116 Plate Fixation in Orthopaedics
decreased by 30% in a 60- to 70-year-old as a result
of osteoporosis, the bone compressive strength is
about half of that of a 30-year-old.
The ultimate stress is approximately the same for
the young and the old bone. The old bone specimen
can withstand only half the strain that the young
bone can, indicating greater brittleness and a
reduction in energy storage capacity. The reduction
in bone density, strength, and stiffness results in
increased bone fragility. Age-related bone loss
depends on a number of factors, including gender,
age, postmenopause, endocrine abnormality,
inactivity, disuse, and calcium deficiency.
Age-related changes occur in both cortical and
trabecular bone, and changes in both regions can
result in increased fracture risk.
At the tissue level, several age-related changes in
the material properties of cortical bone have been
demonstrated. A small decrease in elastic modulus
occurs with age (2.3% per decade), but the most
significant change occurs in the ease with which a
fracture progresses through bone. With aging, the
ultimate strength decreases at approximately 4
percent per decade. The energy required to fracture
a bone is reflected in the area under the stress-
strain curve. Since the elastic modulus does not
decrease as much, the energy to failure is
predominantly reduced by age-related decreases in
ultimate strain. Thus, with aging, the bone behaves
more like a brittle material, and the capacity of bone
to absorb the energy and resist fracture propagation
from a traumatic event decreases.
The cortical bone density is not the only
important parameter in causing bone fragility, but a
change in bone geometry is a major concern. With
aging, bone expands in periosteal diameter, but the
cortical thickness decreases by increasing the
endosteal diameter. If cortical outer diameter
increased and cortical thickness decreased at the
same rate, the moment of inertia of the bone cross
section would be larger. That is why large-diameter
thin tubing can be substituted for smaller diameter
thicker tubing in structures (for example, sailboat
masts), saving weight while not sacrificing strength.
However, in the human bone, the inner surface of
the cortex also becomes more irregular and porous,
decreasing its material strength. When density and
geometry are factored together into a parameter
called the section modulus, it is shown that males
tend to maintain overall structural properties past
the fifth decade of life, but losses are recorded in
women after the fifth decade.
Trabecular bone plays an important structural
role in many bones, and the age-related changes in
trabecular bone clearly contribute to the increased
fracture risk in the elderly. Even in young people,
there are wide variations in trabecular bone
between individuals and between anatomic sites
within an individual. The important variables
include the thickness of trabeculae, the orientation
of trabeculae with respect to the primary loading
direction(s), the morphology of the trabeculae (rods
vs. plates) and how the trabeculae are connected
together. Quantitative studies of trabecular bone
morphology document that the thickness of
trabeculae decreases while the spacing between
trabeculae increases. There are surprisingly few
fundamental differences in trabecular bone
between the sexes other than that bone is lost faster
in females between the ages of 50 and 85. These
age-related morphological changes significantly
reduce the strength of vertebrae, the proximal
femur, and other bones, contributing to the
observed increased fracture incidence in the
elderly.
There is a progressive net loss of bone mass with
aging, becoming of clinical importance in the fifth
decade and proceeding at a faster rate among
women. Over several decades, the skeletal mass
may be reduced to 50% of original trabecular and
25% of cortical mass. In the fourth decade, women
lose approximately 1.5 to 2% a year while men lose
only approximately half that rate (0.5 to 0.75%)
yearly. Regular physical activity and exercise,
calcium, and possibly estrogen intake may decrease
the rate of bone mineral loss during aging.
Concurrent with this general loss of bone mass,
bone tissue becomes more brittle and less able to
absorb energy. The major clinical consequence of
these skeletal changes is an age-related increase in
fracture incidence. Typically, fractures as a result of
osteoporosis occur in the vertebrae, the distal
radius, and the femoral neck.
FRACTURE RISK
A bone will fail when the applied loads exceed the
load-bearing capacity, so both the applied loads and
the load-bearing capacity must be known to
calculate fracture risk. Most structures, such as a
bridge or a building, are designed to withstand
loads several times greater than expected. Similarly,
the normal human skeleton can support loads much
higher than expected during activities of daily living.
The ratio of load-bearing capacity over load-bearing
requirement is frequently termed the safety factor.
The inverse of this ratio has been termed the factor
of risk for fracture. For loads approximating the
midstance phase of gait, the average load-bearing
capacity of mature and osteoporotic human femurs
averages around 9000 N (2000 lb) with a standard
deviation of around 3000 N.[19] Peak loads at the hip
joint have been recorded to be as high as 3 to 5
times body weight during high-demand activities
such as stair-climbing. Therefore, a 600 N (140 lb)
individual who applies 5 times body weight to his or
her femur has a femoral load-bearing capacity from
less than 1 to 5 times as strong as needed,
depending on the properties of the femur. For the
tibia, axial loads while walking are estimated to be 3
to 6 times body weight, and the greatest bending
moment applied during restricted weight-bearing is
estimated to be about 79 newton-meters in men.
Intact human tibiae loaded in three-point bending
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
failed at from 57.9 to 294 newton-meters, so the
bending strength of the tibia is also 1 to 4 times the
maximum applied bending loads. The maximum
torque that the tibia can tolerate was estimated to
be about 29 newton-meters. Under torsional loads,
tibiae failed at from 27.5 to 89.2 newton-meters,
and this is 1 to 3 times the maximum applied
torques. These calculations are only valid for
particular types of loading. Nevertheless, these
estimated factors of risk may help determine when
a healing femoral fracture can tolerate moderate
weight-bearing, or when a femur with a bone defect
requires prophylactic stabilization.
There are several groups in whom fractures are
prevalent and for whom prevention may be possible
if fracture mechanisms and the patients at greatest
risk can be identified. One group is the growing
aged population in which age-related fractures are
prevalent. Another group is cancer patients with
metastatic bone disease in which prophylactic
stabilization of impending fractures may increase
the patients' quality of life. The next few sections
will discuss the fracture risk and methods for
predicting fracture risk due to aging and metastatic
bone lesions.
Fracture risk with metastatic and
benign defects in bone
Metastatic lesions frequently occur in the axial and
appendicular skeleton of breast, prostate, and other
cancer patients. Benign bone tumors occur in as
many as 33 percent of asymptomatic children
evaluated by random radiographs of long bones.
These lesions can represent a significant fracture
risk. Approximately 5 percent of patients receiving
radiation therapy for painful bone metastases suffer
a pathological fracture. Prophylactic fixation of an
impending fracture has several advantages over
treating a pathological fracture, including relief of
pain, decreased hospital stay, reduced operative
difficulty, reduced risk of nonunion, and reduced
morbidity. On the other hand, operations that do
not reduce the overall morbidity must be avoided.
Clinicians are thus faced with the task of
determining whether or not a defect requires
prophylactic stabilization. Commonly used clinical
guidelines can provide contradictory indications for
prophylactic stabilization, and the specificity of
these guidelines is poor. These guidelines likely
overestimate the risk of pathological fracture. There
are many aspects of metastatic and benign defect
geometry and material properties that determine
the structural consequences of the lesion. In
common sites of osseous metastases such as the
proximal femur, even experienced orthopaedic
oncologists cannot predict the strength reduction
due to the defect from radiographs or from
qualitative observation of CT examinations.
Existing guidelines for determining when to
prophylactically stabilize long bones with
metastatic lesions can overestimate the actual risk
of fracture in some cases but can place a bone at
117
significant risk of fracture in others. Based on our
data, the strength of bones with simulated endosteal
metastatic defects is proportional to defect size but
is highly dependent on the type of loading. For
example, a 65 percent reduction in bending strength
was determined for transcortical lesions destroying
50 percent of the cortex, whereas the same lesion
reduces torsional load-bearing capacity by 85
percent. The finite element models show that the
material properties of bone along the border of a
defect can significantly increase the structural
consequences of a metastatic defect. Many
metastatic lesions are associated with bone
resorption along the border of the lesion that
extends beyond the radiographically evident lysis.
Thus, for osteolytic metastatic lesions, the structural
consequences may be significantly greater than
predicted from plain radiographs. The finite
element models also demonstrated that for
endosteal defects, a critical geometric parameter is
the minimum cortical wall thickness. For example,
an asymmetric defect that compromises 80 percent
of the cortical wall at one point but only 20 percent
of the wall on the opposite side will be only 2
percent stronger in torsion than a bone with a
defect that compromises 80 percent of the cortical
wall around the entire circumference. Even biplanar
radiographs will fail to detect critical geometric
parameters if the critical defect geometry is not
aligned with respect to the radiographic planes. In a
retrospective study of 516 metastatic breast lesions
using anteroposterior radiographs, Keene et al.
could not establish a geometric criterion for lesions
at risk of fracture, perhaps because critical
geometric parameters were missed using plain
radiographs. Results of ex vivo experiments with
simulated defects suggest that CT scans at small
consecutive scan intervals could facilitate
evaluation of the fracture risk due to metastatic or
benign lesions.
Strength reductions due to long bone or vertebral
defects can be determined from CT data using
relatively simple engineering models. These CT-
based measurements require placing a phantom
under the patient during the examination so that CT
attenuation data can be converted to bone density.
Known relations between bone density and bone
modulus are then used to convert the bone density
data to modulus. For each cross-section through the
bone, the product of area and modulus is summed
over the entire cross-section, excluding posterior
elements. The lowest axial rigidity of all cross-
sections was linearly related to the measured failure
load, and predicted almost 90 percent of the
variability in the measured failure loads in a
laboratory study. In a similar study using the same
CT-based technique, a one-to-one correspondence
between measured and predicted failure load was
found, although this study looked at a wider range
of defect locations and was able to predict only 74
percent of the variation in measured failure loads.
118 Plate Fixation in Orthopaedics
In a clinical study, the CT-based rigidity of a bone
with a benign defect has been shown to be
significantly more sensitive and specific to
pathological fracture than criteria based on defect
size. In this study, the rigidity of a bone with a
benign lesion was normalized to corresponding
sections through the contralateral bone. A
combination of the minimum bending and torsional
rigidities calculated from the CT data provided was
100 percent sensitive and 94 percent specific in
distinguishing between the 18 patients who
sustained a pathological fracture and the 18
nonfracture patients. In contrast, x-ray based
criteria were 28 to 83 percent sensitive and 6 to 78
percent specific.
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
CHAPTER
MECHANOBIOLOGY
CHAPTER OUTLINE
Mechanical influence on the fracture repair
phases
Biomechanical stages of fracture healing
Stages of bone healing in different strain
conditions
Optimal mechanical environment for
fracture healing
Delayed healing and nonhealing under
unstable fixation
Current thinking in fracture fixation is moving
toward a symbiotic link between biology and
mechanics, rather than regarding them as separate
entities in the healing process of fractured bones.
Mechanobiology is the embodiment of Julius
Wolff's Law, which states: "The form of a bone being
given, the bone elements place or displace
themselves in the direction of the functional
pressure and increase or decrease their mass to
reflect the amount of pressure." The surgeon needs
to understand how to influence the process of bone
healing in any given fracture. It is clearly
understood that careful soft-tissue handling is very
important in preserving blood supply to injured
bone. In addition, the outcome of reliable and
predictable fracture healing can be influenced by
mechanical devices sharing load in unstable
fracture patterns. Hence it is important that
osteosynthesis is directed at producing a
119
3.3
Main factors influencing the biomechanics of
fracture healing
Mechanical stimulation of fracture callus
cells
Mechanoregulation of fracture healing
Monitoring of fracture healing
Biomechanical monitoring of fracture
healing
mechanically friendly environment for optimal
fracture healing.
MECHANICAL INFLUENCE ON THE
FRACTURE REPAIR PHASES
As with all tissue-repair mechanisms, the
inflammatory phase is mandatory, so that
chemotactic factors and cytokines will induce host
defense cells as well as highly vascularized repair
granulation tissue to form around the damaged and
necrotic bone ends. With high local tissue oxygen,
fibrogenic tissue will proliferate to provide an initial
scaffold between the fracture ends. This phase lasts
from the first 24-48 hours of injury into the first
week. Granulation tissue can tolerate 100% strain
and mechanics do not seem to play a major role
during this phase, but surgery should not
120 Plate Fixation in Orthopaedics
devascularize this repair tissue. Here lies the main
reason for minimally invasive procedures.
Medullary blood supply to the diaphysis is
important for bone healing, and intramedullary
nailing disrupts this source. Periosteal blood flow
alone cannot reach the endosteum and endosteal
callus may be inhibited. Plate fixation preserves the
medullary and metaphyseal vessels as well as
periosteal vessels on the opposite side of the
"footprint" caused by the plate. The internal fixator
aims to preserve blood flow under the plate by
reduced contact with the bone.
Under conditions of low oxygen as the
inflammatory phase passes, hyaline and
fibrocartilage differentiation will occur. This
process begins within 48 hours after injury and may
peak at 9-14 days, depending on the tissue
condition. It also follows the peak fracture blood
flow at 2 weeks. Osteogenic factors then cause
further differentiation of chondroid tissue into
bone. much in the way as an ossification center
forms during normal growth. Intramembranous
ossification occurs as hard fracture callus further
from the fracture site, while endochondral
ossification occurs as soft callus around the fracture
ends. Mechanical stability allows metaplasia of
cartilage to bone. If excessive motion is applied to
the bone ends there will be increased vascularity
and fibrogenic tissue will persist, resulting in
nonunion. Goodship and Kenwright, however,
demonstrated that bony enhancement with
interfragmentary motion in the order of 500 pm and
artificial micromovement during the first month of
treatment resulted in significantly shorter healing
time. Flexible fixation promotes micromotion,
which produces exuberant callus clearly visible on
x-rays, while rigid fixation diminishes this.
BIOMECHANICAL STAGES OF
FRACTURE HEALING
The fracture healing occurs in biomechanically
unique stages that was first described by White et
al. Based on animal studies, they identified four
biomechanical stages of fracture healing. The first
indication of increasing stiffness occurred after 21
to 24 days. At this stage the fracture exhibited a
rubbery type of behavior characterized by large
angular deflections for low torques. The bone fails
through the fracture site at low loads. This stage
corresponds to bridging of the fracture gap by soft
tissues. At approximately 27 days, a sharp increase
in stiffness identified the second stage, where
failures occurred through the fracture site at low
loads. Stiffness approached that of intact cortical
bone. The third biomechanical stage is
characterized by failure occurring only partially
through the fracture site, with a stiffness similar to
cortical bone but below normal strength. The final
stage is achieved when the site of failure is not
related to the original experimental fracture, and
the stiffness and strength are similar to those of
intact bone.
Panjabi et al. compared radiographic evaluation of
fracture healing with the failure strength of healing
osteotomies. They applied nine different
radiographic measures of fracture healing. The best
radiographic measure was cortical continuity,
where the correlation coefficient between the
radiographic measure and bone strength was 0.8.
The lowest correlation between radiographic and
physical measurements was found for callus area.
The general conclusion of this study was that even
under laboratory conditions, radiographic
information is not sufficient to accurately decide the
biomechanical condition of a healing fracture. This
is an important result, since radiographic diagnosis
is commonly applied to assessing fracture healing,
though few studies have objectively tested the
predictive capability of this practice. Using a canine
model, Davy and Connolly experimentally produced
fractures in weight-bearing (radii) and presumed
non-weight-bearing bones (ribs). Healing bones
were tested using four-point bend tests at 2 to 12
weeks. Both weight-bearing and non-weight-
bearing bones healed with formation of periosteal
callus. For non-weight-bearing bones, bending
strength increased more rapidly than stiffness,
whereas stiffness increased more rapidly than
strength with the weight-bearing bones. The bone
and periosteal callus geometry can theoretically
account for observed changes in fracture properties.
However, radiographic criteria have not been
shown to predict the strength or stiffness of a
healing fracture. Under bending loads, the failure
mechanism appears to be delamination of repair
tissue from the bone fragments, suggesting that the
adhesive bond between repair tissue and bone
fragments determines the structural properties.
Stages of bone healing in different strain
conditions
Fracture of a bone leads to a healing response
among four major tissue types: cortical bone,
periosteum, bone marrow, and external soft tissues.
When tissue strain is below 2%, all calcified
cartilage will become bone provided there are
adequate osteogenic factors. This process is easily
monitored by x-rays, in which the fracture gap or
lucency will slowly disappear with more
mineralization. There is also a reduction in
osteopenia (porosity) concomitant with the
reduction of hypervascularity at 12 weeks.
Consolidation begins as early as 6 weeks and may
last up to 6 months.
Strain of between 5% and 20% will result in
limited ossification and persistence of fibrous
tissue, leading to fibrous nonunion. Mechanically
speaking, an implant should hold the fracture at
least until the consolidation phase is complete.
Primary cortical healing involves anatomic
reduction of the fracture fragments, optimization of
the strain environment, and a biological response in
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
which the cortex directly attempts to reestablish its
own continuity with the aid of so-called “cutting
cones.” These are remodeling units consisting of
osteoclasts that resorb cortical bone, thereby
permitting angiogenesis and stem cell deposition
into the fracture site, and progenitor cells
differentiate into osteoblasts that secrete matrix
and bridge the fracture gap. This process enlists
minimal participation from the periosteum, external
soft tissues, and the bone marrow.
If rigid internal fixation is not provided and
micromotion exists at the fracture site, secondary
bone healing or “natural healing” occurs. The
response of the periosteum and neighboring soft
tissues to bony injury forms the basis of secondary
fracture healing through which the majority of
fractures heal. It involves both intramembranous
and endochondral ossification that proceed
concurrently. Intramembranous bone formation
occurs on either side of the fracture, and the cells
that drive this process are derived from periosteum.
The endochondral response is also dependent on
the periosteum, but the cells in the neighboring soft
tissues additionally contribute to this process.
Within the first 7 days after fracture, an
inflammatory response takes place at the fracture
site as demonstrated by the invasion of
macrophages, polymorphonuclear leukocytes, and
lymphocytic cells. These cells secrete
proinflammatory cytokines including interleukin-1,
interleukin-6, and tumor necrosis factor-α (TNF-α).
At the same time, peptide signaling molecules such
as members of the transforming growth factor-beta
(TGF-β) super gene family, including all of the bone
morphogenetic proteins (BMPs), as well as platelet-
derived growth factor, are triggered. The
relationship between the proinflammatory
cytokines and the triggering of these peptide
signaling, growth-promoting molecules is unknown
at this time.
Once the fracture healing events are initiated, the
first 7 to 10 days of healing involve a process of
chondrogenesis in which two major biochemical
constituents are secreted: type II collagen and a
variety of proteoglycans. Type II collagen provides
the initial structure of the fracture callus while the
proteoglycans mediate hydration of the newly
formed tissue and control the rate and physical
chemistry of the mineralization process. Although
the inflammation caused by a fracture follows the
same sequence for almost every fracture, the
amount and composition of repair tissue and the
rate of repair may differ depending on (i) whether
the fracture occurs through primarily cancellous
bone or through primarily cortical bone, (ii) the
extent of the soft tissue disruption surrounding the
fracture, (iii) the mechanical stability of the fracture
and (iv) other factors influencing the fracture
healing. By 14 days, protein synthesis is complete
and hypertrophic chondrocytes release calcium into
the extracellular matrix in order to precipitate with
phosphate ions. High-energy phosphate bonds
121
contained in phosphate esters in the extracellular
matrix (e.g., ATP) are hydrolyzed by protein-
degrading enzymes released from chondrocyte
membranes. As proteoglycans inhibit
mineralization, their degradation by these enzymes
is a way by which chondrocytes control the rate and
physical chemistry of this mineralization process. In
simple terms, preliminary fracture callus is
composed largely of cartilage; that cartilage must
develop a critical mass before it is ready to calcify;
that goal is achieved by the presence of
proteoglycans, which prevent mineralization; and
once enough cartilaginous callus is formed,
mineralization takes place by the removal of the
proteoglycan inhibitors.
By 3 to 4 weeks after fracture, the callus is
composed mostly of calcified cartilage, also known
as primary spongiosa. This tissue becomes a target
for chondroclasts, multinucleated cells specialized
in the resorption of calcified tissues. The removal of
calcified cartilage includes not only resorption of
the mineralized matrix but also removal of the
chondrocytes themselves. Lee et al. have shown that
chondrocytes undergo programmed cell death
(apoptosis) during endochondral fracture healing
and this process is identical to that which occurs in
the lower hypertrophic zone of the growth plate.
Thus, the transition from cartilage to bone involves
a highly programmed series of events involving
cellular removal and matrix modification.
As chondroclasts remove the calcified cartilage,
blood vessels penetrate the tissue and bring
perivascular mesenchymal stem cells that
differentiate into osteoprogenitor cells and then
bone-forming osteoblasts. This remodeling of the
primary spongiosa to secondary spongiosa, or
woven bone, results in fracture union by
approximately 28 to 35 days. At this time,
osteoclasts populate the tissue and remodel the
callus, converting it to lamellar bone.
Fracture healing can be divided into two types:
primary or direct healing by internal remodeling;
secondary or indirect healing by callus formation.
The former occurs only with absolute stability
and is a biological process of osteonal bone
remodeling. The latter occurs with relative stability
(flexible fixation methods). It is very similar to the
process of embryological bone development and
includes both intramembraneous and endochondral
bone formation.
Optimal Mechanical Environment for
Fracture Healing
One primary goal of fracture treatment is to
continually control the mechanical environment so
that it is optimal for each stage of fracture healing.
While it is known that the mechanical environment
can alter the bone healing process, the conflicting
results for studies that investigate the effect of
fixation rigidity on fracture healing leave the
question of optimum fixation rigidity unsolved.
Perren and co-workers describe a hypothesis and
122 Plate Fixation in Orthopaedics
supporting evidence that help explain how fracture
healing is controlled by the local mechanical
environment. They postulated that a tissue can be
formed only in the interfragmentary region of a
healing fracture if the involved tissues can tolerate
the local mechanical strain. The tissues that formed
will, in turn, contribute to the fracture rigidity,
making possible the next step in tissue
differentiation. For example, formation of
granulation tissue may reduce the strain to a level
where fibrocartilage formation is possible. They
further hypothesized that the fracture gap is
widened by resorption of the bone ends until the
local tissue strain falls below a certain limiting
value. Resorption of fragment ends may reduce the
strain sufficiently to permit completion of a bridging
callus. Interfragmentary strain may influence
fracture healing in several ways. Local deformations
may disrupt vascularization and interrupt blood
supply to developing osteons. Deformation of cells
may alter their permeability to macromolecules and
increase biological activity. Strains may also induce
changes in the electrical signals within the healing
fracture site or elicit a direct cellular response. In all
likelihood, there exists a multifactorial relationship
at various stages of the healing process.
The interfragmentary strain hypothesis is
complicated by the complexity of stresses and
strains at a fracture site. Cheal et al. used computer
models to show that complex three-dimensional
strain fields exist, even within a relatively simple
fracture gap, and that the simple longitudinal
strains considered by Perren et al. underestimate
the true strains experienced by
interfragmentary tissues. The analytical models
show that the strain in tissue is greatest at the
endosteal and periosteal surfaces of the bone
fragments. These are also the areas of early bone
resorption observed in the experimental animals.
Although the strains within a healing fracture may
be complex, these strains currently must be
considered in more simple terms during the clinical
management of fracture healing in patients. One
strategy is to consider the apparent axial and shear
components of the strain across a fracture gap.
Fracture fixation methods that result in shear
motion within a fracture gap can significantly
degrade fracture healing. Shear can result in less
bone bridging across a fracture gap. Shear can
additionally reduce the amount of callus and
therefore the rigidity of the healing fracture.
However, it is important to note that even in the
presence of shear strains and shear forces, some
fractures will heal, although slower than they would
under ideal conditions. The clinicians must estimate
conditions to the best of their ability and adjust
fixation if deemed necessary. The optimal
mechanical environment that a fracture fixation
system should facilitate has not been determined.
Some motion has been shown by multiple authors
to facilitate fracture healing, but others authors
have demonstrated ranges of motions and loads
that degrade fracture healing when applied across a
fracture gap.
It is also important to note that along with the
evidence of central nervous system control of bone
formation and resorption, there is evidence that
innervation of the fracture site is a requirement for
timely and competent fracture repair. In general, it
is assumed that reinnervation of a healing fracture
will follow a parallel course with revascularization,
but this hypothesis is not yet well supported by
scientific evidence.
Delayed Healing and Nonhealing under
Unstable Fixation
When the interfragmentary movement is too large,
the bony bridging of the fragments is delayed or
even prevented. Callus formation begins with
normal intramembranous bone formation remote
from the fracture in areas of low mechanical strain
and the callus grows in volume and diameter, but
the bridging of the fracture line is delayed or even
prevented. Large interfragmentary movements
cause large tissue strains and hydrostatic pressures
in the fracture that prevent the vascularization of
the fracture zone. Without this vascularization, bone
cells cannot survive, bone cannot be built, and only
fibrocartilage can be formed.
MAIN FACTORS INFLUENCING THE
BIOMECHANICS OF FRACTURE
HEALING
the
Small interfragmentary movements (IFMs)
stimulate callus formation in animal experimental
models. With small fracture gaps, the stimulated
callus volume seems to correlate with the amplitude
of the cyclic axial movement. When the fracture gap
is too large, the callus formation seems to be limited
and bridging of the fracture gap is delayed. For large
gaps, a more stable fixation with small
interfragmentary movements seems to be
advantageous. Very stiff fixation of a fracture
suppress the callus formation and delay healing. In
such cases, an externally applied interfragmentary
movement can be used to stimulate callus healing.
However, when the fracture fixation itself allows
axial movements to a sufficient extent to stimulate
callus formation, an additional external application
of interfragmentary movement leads to the shear
movement. There is an ongoing controversial
discussion whether a shear movement delays the
fracture healing when compared with an axial
movement of similar amplitude. It is assumed that
shear movements impede vascularization and
promote fibrous tissue differentiation. However,
oblique tibial fractures treated with functional
bracing show rapid natural healing even though this
type of fixation allows shear movements of up to 4
mm.
The effects of shear compared with axial
interfragmentary motion appears to be sensitive to
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
timing, magnitude, and/or gap size. There are
various types of fractures that can be associated
with various degrees of injuries: simple oblique,
transverse, and spiral fractures or more severe
fractures with one or more fragments. From a
purely mechanical point of view, a fracture with
several fragments and several fracture gaps might
be less critical with regard to an unstable fixation
than a simple oblique fracture. The overall
deformation of fracture fixation, which takes place
in one fracture gap of a simple fracture, will be
distributed and shared by several fracture gaps in a
complex fracture. This can reduce large overall
deformations of fixation to individual
interfragmentary movements that are small enough
for uncritical bone healing. Besides this mechanical
view, however, we should take into consideration
that complex fractures with several fragments are
mainly caused by high-energy injuries and are
associated with severe damage to the blood supply
and the surrounding periosteum and soft tissue.
Therefore, fast revascularization is more important
than stable fixation, and less invasive surgical
intervention for stabilization of the fracture is the
preferred technique. Fracture healing has two major
prerequisites: mechanical stability and sufficient
blood supply.
Blood supply is necessary for the nutrition of the
healing zone, and an insufficient blood supply is
likely to result in a delayed union or even an
atrophic nonunion. In addition to other reasons for
a diminished blood supply such as trauma or
smoking, there is a different pattern of
vascularization under stable and unstable fixation
conditions. It is speculated that under unstable
fixation, capillaries required for osseous repair are
constantly ruptured and delay the fracture healing
process, resulting in the development of
fibrocartilaginous tissue. Large interfragmentary
movement causes considerable tissue strains and
hydrostatic pressure in the non-ossified callus
tissue. Whereas large tissue strains may prevent
revascularization, large hydrostatic pressures may
cause a collapse of the blood vessels.
MECHANICAL STIMULATION OF
FRACTURE CALLUS CELLS
Throughout the healing process, the various cells
found in the callus are modulated by the local
mechanical environment of the tissue in which they
are embedded. Cyclic hydrostatic pressure applied
to in vitro cell cultures of bone-marrow-derived
mesenchymal stem cells were found to enhance
differentiation into chondrocyres and stimulated
cartilaginous matrix production. When intermittent
hydrostatic pressure was applied to embryonic
bone organ cultures, hypertrophy of chondrocyres
and mineralization were accelerated. Osteoblasts
have also been demonstrated to be sensitive to
mechanical stimuli. Cyclic tensile strain has been
found to increase their proliferation and osteoid
123
production. In contrast, biaxial stretch was found to
regulate apoptosis and proliferation of osteoblasts
in a differential fashion dependent on their state of
differentiation. Hence, the mechanoregulation of
callus cells is a feedback loop where the signals are
created by the applied load and modulated by the
callus tissue. Mechanical loading applied to the
callus tissue produces local biophysical stimuli
sensed by the cells. This may regulate cell
phenorype, proliferation/apoptosis, and anabolic
and catabolic synthesis activities. With alteration of
the extracellular matrix and the associated changes
in material properties of the tissue, the biophysical
stimuli produced by mechanical loading is
modulated, producing different biophysical signals
with even the same loads. In normal fracture
healing this feedback process reaches steady state
when the callus has ossified and the original cortex
has regenerated. However, this feedback process
may also explain some complications of fracture
healing such as delayed or nonunions where the
tissue properties combined with loading may
promote the persistence of soft tissues. Thus, the
mechanobiology of callus cells is integral to
understanding the biomechanics of fracture healing.
Mechanoregulation of Fracture Healing
The concept that biological processes at the cellular
level can be regulated by mechanical loading dates
back to the late 1800s when Roux introduced his
theory of functional adaptation. He proposed that
the mechanical environment or "irritations" actually
stimulated the formation of particular types of
connective tissue. He postulated that compression
stimulated the formation of bone, tension for
connective tissue, and relative displacement, i.e.,
tissues moving relative to each other, in
combination with compression or tension for
cartilage. In modern times, Roux's basic premise of
functional adaptation as it relates to tissue
differentiation is widely accepted, but the
identification of the mechanical parameters of
importance and their mechanisms of actions, from
multi-potential progenitor cells to bone, are
unresolved and continue to be investigated. Almost
a century later, Pauwels proposed a more rigorous
mechanoregulation theory based on continuum
mechanics. He analyzed the mechanical
environment with a healing fracture callus and
hypothesized that the invariants of the strain and
stress tensors guided the differentiation pathway,
whereby hydrostatic pressure resulted in cartilage,
distortional strain, or elongation favored fibrous
tissue, and with low magnitudes of strain and
hydrostatic stress, the natural course was followed
resulting in bone. About the same time, a much
simpler idea, strain modulation, was postulated by
Perren and Cordey. They believed that tissue
differentiation was a result of tissue disruption. If
stresses exceeded the tissue strength or tissue
elongation resulted in rupturing, the tissue would
change its phenotype such that tissue failure would
124 Plate Fixation in Orthopaedics
not occur. Using finite element analysis (FEA) to
calculate the complex tissue strain in the callus at
the beginning of healing, Cheal et al. compared
histology of the fracture callus with magnitudes of
strain. Although they did not demonstrate tissue
damage, they found an association of high strain
levels with soft tissues and bone resorption and low
strain levels with bone formation. Based on the
framework of Pauwels, Carter et al. proposed local
stress or strain history as a method to allow a range
of cyclically applied loads to influence tissue
differentiation over time. They postulated that
compressive hydrostatic stress history guides
formation of cartilage, whereas tensile strain
history guides synthesis of fibrous connective tissue
and bone is formed in regions without significant
levels of both. However, unlike Pauwels, they also
recognized the influence of vascular perfusion and
proposed that low oxygen tension diverts cells
down the cartilaginous pathway. Using FE models,
Carter and his co-workers showed that normal
differentiation patterns in fracture healing at
various stages of healing were consistent with
patterns of pressure and strain in the fracture
callus. More recently, Loboa et al. demonstrated that
this was also the case for a general oblique
pseudarthrosis. Interestingly, the
mechanoregulation concept of Carter et al. has been
much discussed, but it has never been presented in
quantitative terms. In contrast, the
mechanoregulation theory of Claes and Heigele was
initially presented in quantitative terms, and
although the resulting concept is similar to that of
Carter et al, they based their mechanoregulation
theory on the observation that bone formation
occurs mainly near calcified surfaces and that both
Intramembranous and endochondral ossification
exist in fracture healing. Depending on the amount
of tissue strain and hydrostatic pressure, different
cellular reactions and tissue differentiatior
processes were predicted to occur. Very small tissue
strains (less than approximately 5%) and
hydrostatic pressures (below about -0.15 MPa)
would allow direct Intramembranous bone
formation by bone cells (osteoblasts), larger values
(less than about 15%, greater than -0.15 MPa)
would allow endochondral ossecation, and tissue
strains above approximately 15% would lead to
fibrocartilage and connective tissue preventing
bone healing. Comparing FEA of fracture healing in
the ovine tibia with histological findings from in vivo
experiments, they were able demonstrate that the
quantitative formula did indeed properly predict
tissue differentiation events in the callus at three
states of healing. Finally, Prendergast, Huiskes, and
colleagues have developed a different
mechanoregulation concept taking into
consideration that connective tissues are
poroelastic and comprise both fluid and solid. They
proposed a mechanoregulatory pathway composed
of two biophysical stimuli, octahedral strain of the
solid and interstitial fluid velocity relative to the
solid. In the more recent models, the two
mechanical tissue parameters of importance are
measures of volumetric (pressure or fluid flow) and
deviatoric load or deformation (octahedral, shear,
or principal strain). With low magnitudes of
deviatoric strain, higher levels of volumetric
parameters stimulate cartilage formation and lower
levels, that of bone. Hence, it should not be too
surprising that all of these proposed mechanisms
are consistent with the temporal sequence and
spatial distribution of resulting callus tissues in
healing fractures.
In addition to the callus tissue itself, other factors
may also have significant influences on
mechanoregulation of fracture healing. The most
obvious of these is the vascularity, without which
the chondroeytes would not mineralize and
osteoblasts could not receive enough nutrition to
produce bone.
MONITORING OF FRACTURE
HEALING
Because bones are structural members whose
functions are to support the body and permit
skeletal motions necessary for survival, it seems
natural that fracture healing should be evaluated by
the return of prefracture stiffness and strength.
Instead, however, clinical assessments of fracture
healing are typically made by radiographic criteria
that are known to be imprecise, by subjective
assessments of pain, and by reference to previous
clinical experience. As a result, little is known about
the return of stiffness and strength to healing bones.
Noninvasive imaging techniques may also allow
objective assessment of fracture healing, but the
sensitivity and specificity of these techniques are
largely unknown in clinical practice.
Several research groups have proposed or
implemented noninvasive physical tests for
monitoring the biomechanical progression of
fracture healing.
Biomechanical monitoring of fracture
healing
The interfragmentary movement can be used for the
monitoring of the bone healing process for patients
with fracture treatment by external fixation.
External loads applied to the operated extremity by
the activity of the patient are shared by the external
fixator and the repair tissue. Directly after surgery,
there is only hematoma in the fracture, and the
external fixator has to carry the entire load. As the
healing process progresses, the callus increases in
size and rigidity and shares more and more of the
external load. The load at the external fixator
decreases, which leads to decreasing deformation of
the fixator frame. Therefore, the measurement of
fixator deformation allows an indirect
determination of the interfragmentary movement
and stiffness of the callus. By measuring the fixator
 Biomechanics of Bone Tissue & Orthopaedic Hardwares 125

deformation under constant loading conditions corrective action can be taken earlier than would be
(scale), e.g., every 3 weeks, the course of the allowed using radiographic information alone.
fracture healing process can be seen and used as a Second, the biomechanics of the fracture treatment
criterion for the speed of healing. can be “fine tuned” to provide the optimal
As the fracture heals, the slope of the load versus mechanical environment for fracture healing.
displacement curve increases, representing a return
to the original stiffness of the bone. The goal is to
monitor the load versus displacement curve to
determine whether the union is proceeding
normally. There are two advantages to this
information. First, in the case of delayed union,
126 Plate Fixation in Orthopaedics
 Biomechanics of Bone Tissue & Orthopaedic Hardwares 127

CHAPTER 3.4
BIOMECHANICS OF HARDWARES
FOR FRACTURE TREATMENT

CHAPTER OUTLINE

Basic concepts of internal fixation Bone-plate fixation rigidity

Interfragmentary compression Geometry and material of plate
Splintage Placement of plate relative to loading forces
Bridging Quality of bone
Comparative studies of healing with different Bone-plate interface
types of fixation Number of screws in a plate
Fixation of osteopenic bone Influence of screw placement relative to the
Hardware fracture site
Cerclage wire Combined behavior of bone and plate
Screws Specific plate designs
Basic structure of screw DC plate
Screw types LC-DC plate (limited contact)
Drills Point contact fixators
Taps Semi-tubular, one-third tubular and quarter-
tubular plates
Plates
Reconstruction plate
Biomechanical functions of plates
Angled plates
Neutralization
Sliding screw and compression plates
Buttressing
Helical plating
Compression
Bridging
Tension band
Prevention of glide
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
Many techniques are currently available for
treatment of skeletal fractures, and many factors are
important in choosing the best fixation. Each
method of fixation imparts specific levels of stability
to a fracture, thus directly influencing fracture-
healing biology. When a fracture treatment method
is evaluated, the healing bone and fracture
treatment device should be considered as a
mechanical system, with both tissue and device
contributing to the biomechanical behavior. The
biomechanical behavior of the system can thus be
altered by changes in tissue properties (such as
resorption at fracture surfaces, osteopenia under
plates), changes to the fracture treatment device
(such as dynamization of external fixation), or
changes to the mechanical connection between
device and tissue (such as pin or bone screw
loosening). Additionally, bones are subject to
diverse loads that can be a combination of axial,
bending, and torsional loads. Thus, the axial,
bending, and torsional stability of a fracture
treatment method should be considered.
From a biomechanical point of view, fracture
fixation must have sufficient stability, which means
it has to reduce the interfragmentary movement that
occurs under external loading and muscle activity to
such a degree that bone healing may take place.
The key factor that guides bone healing is the
interfragmentary movement, which determines the
tissue strain and the cellular reaction in the fracture
healing zone. Therefore, the methods of fracture
fixation will be assessed with regard to their
capability to reduce the interfragmentary
movement.
The optimal fixation technique must allow
transfer of forces between bone and implant without
causing gross failure of either the bone or the
implant. For example, failure of bone has been
observed with many rigid nail-plate devices used for
fractures of the proximal femur. Sliding screws that
allow load transmission between bone fragments as
well as load transmission between bone and implant
reduce, but do not eliminate, penetration of the
implant into the femoral head. This penetration is
associated with improper placement of the sliding
screw in the proximal femur, and with osteoporotic
bone. Quantitative measurements of bone density in
the femoral head can help determine the load-
bearing capacity of fractured proximal femurs
following fixation with a sliding hip screw or with
standard pins and screws and may also help identify
when augmentation is required for distal
interlocking in osteoporotic bone. The load required
to cause penetration of the sliding hip screw
superiorly into the femoral head may be insufficient
to support activities of daily living in osteoporotic
patients. For example, hip screw penetration loads
as low as 750 N have been recorded in osteoporotic
femurs. Allowing for contact forces of 3.3 times body
weight during gait, load-bearing capacities greater
than 1300 N would be required in a very light
weight person.
128
BASIC CONCEPTS OF INTERNAL
FIXATION(Table 3.4-1)
Internal fixation has three basic modes:
interfragmentary compression, splintage, and
bridging. Mechanical characteristics of the bone
implant fixation construct vary depending on the
consistency of bone, the fracture pattern and
location, the specific implant, and the mode of
application. The advantages of mechanical stability
of the final construct must be balanced against the
detrimental surgical trauma associated with fracture
reduction and implant insertion. Maintenance of
sufficient blood flow to injured soft tissue and bone
is essential to avoid infection and facilitate the
healing process. Internal fixation also must be
applied in a way that provides the desired anatomic
reconstruction with adequate mobilization to reduce
pain and permit full activity while facilitating
fracture union and soft tissue healing. The
relationship between these two major
considerations can be expressed in the statement of
Tscherne and Gotzen: “Stability is the mechanical
basis and vascularity the biologic basis of
uncomplicated fracture healing.”
The amount of motion at the fracture site in any
fixation construct varies according to the mechanical
characteristics of the construct and the direction and
magnitude of the forces applied. The term stability
has many definitions and is therefore a source of
confusion. ASIF/AO considers stable fixation as that
achieved in a fixation construct and subjected to
loads of functional muscle activity and joint motion
without any movement at the fracture site. This
method is often termed rigid fixation. An alternative
definition would hold that a fracture construct is
stable when it allows pain-free functional activity
even though a small amount of motion is present at
the fracture site.
Additional clarity is given to the consideration of
stability when the level of functional activity (e.g.,
active motion exercises versus weight-bearing) is
specified. Under conditions of loading, there is a
range of micromotion at the fracture site within
which bony union will progress but above which
nonunion will occur. Within this safe zone, the
histologic pathway to fracture healing varies
depending on the relative motion between fracture
fragments. If there is motion, the body supplements
the immobilization provided by the implant through
the development of callus. This small amount of
skeletal material laid down at a distance from the
central axis of the bone provides an effective method
of bridging and immobilizing the main fracture
fragments. The amount of callus is roughly
proportional to the amount of motion. If there is
complete elimination of motion between fracture
fragments, callus formation is not necessary, and
healing occurs more directly through intracortical
osteogenesis. Small gaps between fragments are
filled by woven bone. Where fracture fragments are
in direct contact, new intracortical haversian
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
systems drill across the fracture site, producing
direct union. This has been termed primary union,
which suggests that it is inherently superior to the
fracture union that occurs with the production of
callus. Although intracortical union does progress
more directly to an advanced stage of fracture
remodeling, the mechanical strength and therefore
the functional capability of this type of bone union
are not superior to that of fracture healing through
callus formation.
Both types of fracture union are functional, and
the selection of an internal fixation method should
pursue the fixation construct most appropriate for
the specific fracture pattern. This decision must
include consideration of the patient's general state
of health, associated injuries, grade of the soft tissue
injury, consistency of the bone, location and pattern
of the displacement of the fracture, the technical
expertise of the surgeon, and the physical and
human resources available.
Interfragmentary compression
In order to achieve absolute stability, the
compression over the whole cross-section of a
fracture must be sufficiently high to neutralize all
forces and moments acting on the fracture site.
When this requirement is met, no interfragmentary
movement occurs.
In interfragmentary compression, the fracture
fragments are restored to their anatomic position
and held together under compression by a metal
implant. This compression improves the
interference fit and increases friction at the fracture
interface, enabling the final bone-implant construct
to resist the deforming forces produced by
functional activity. The compression of the bone
fragments achieved by application of tension to the
implant results in a completed construct that is said
to have been prestressed. This term means that the
stress that has been applied to the construct during
application precedes the stress to which it is
exposed when the fixation construct is loaded
during functional activity. One result of prestressing
is that the bone component of the construct is better
able to share a functional load with the implant and
thereby partially protect the metal from cyclical
deformation and fatigue failure. Also, load sharing
exposes the bone to a mechanical stimulus for
fracture healing and maintenance of mineralization.
The compression force or prestress on implants
must be sufficient to resist the deforming forces to
which the fixation construct is exposed during
functional activity. If compression is applied
incorrectly, excessive micromotion of the fracture
fragments occurs, resulting in resorption of the bone
ends and formation of small amounts of callus. Even
though this occurrence is a protective physiologic
response, in this circumstance, it is a warning sign of
loosening and fatigue of the implant system. If steps
are not taken to reverse this condition, the
continued loading will lead to implant failure and
nonunion. Such an interfragmentary compression
129
can be achieved by lag screws, compression plates,
and tension band systems.
The compression applied across the fracture
surfaces can be static, dynamic, or both. Static
compression results from pretensioning of the
implants. Dynamic compression is achieved by
harnessing forces that act on the skeleton during
normal physiologic loading. In addition, implants
can be applied in such a way as to combine static
and dynamic compression.
Static compression
Interfragmentary compression leads to increased
stability through friction. Theoretically, the security
against dislocation of two fragments that are fixed
together by a lag screw depends on the screw force
that is normally created on the fracture surface and
the coefficient of friction. As long as the frictional
force is greater than the resultant force in the
fracture plane, the construct is stable. The amount of
force created by a lag screw mainly depends on the
type of screw, the thread geometry, the length in the
bony thread, and the mechanical quality of the bone.
In the cortex of large long bones such as the tibia
and femur, forces of up to 2500 N per screw can be
created. These originally applied forces are reduced
by the viscoelastic properties of the bone and
biological bone remodeling processes. However, the
bone can keep about 50% of these forces in a
diaphyseal area over a period of 6 weeks. Fractures
in metaphyseal and epiphyseal areas with lower
bone density (spongy bone) can be stabilized with
lag screws but need screws of larger diameter and a
different thread design. To achieve sufficient holding
power of the screws in the mechanically weaker
bone, larger thread depths are necessary. The
interfragmentary compression that can be achieved
by lag screw fixation in these areas is limited,
especially for elderly patients with mechanically
weak osteoporotic bones. Therefore, an internal
fixation of a fracture with lag screws alone is rarely
stable enough to allow load bearing of the operated
extremity. In most cases, a lag screw is used in
combination with a plate.
The lag screw is a classic example of applied static
compression. The screw is tensioned across the
fracture line, and the fracture is compressed.(Fig
3.4-1) The screw has a small length of thread at its
tip and a smooth shank between the head and the
tip. Tension results when the screw threads bite into
the cortex on one side of the fracture and the screw
head blocks its progression into the bone on the
other. This method is called a lag screw by design.
These screws are usually employed to achieve
interfragmentary compression between two
fragments of cancellous bone (as in a metaphysis or
epiphysis).
Interfragmentary compression can also be applied
with simple, fully threaded screws. This technique is
usually used in cortical bone. The cortex near the
screw head is over-drilled so that the screw thread
gains purchase only in the far cortex. This is called a
130 Plate Fixation in Orthopaedics

lag screw by application. The over-drilled hole in the

cortex near the screw head is called the glide hole,
and the hole in the far cortex is called the thread
hole. Optimal fixation with a cortical lag screw is
achieved by correctly following the steps for screw
insertion. The best compression is obtained by
aiming the screw into the center of the opposite
fragment.
Comparing the compressive forces across the
fracture site using fully and partly threaded lag
screws demonstrated that the average compressive
force at the opposite cortex (i.e., the force in the
screw itself) was about 50% greater when a partly
threaded screw was used. When applying a plate
onto a bone, interfragmentary compression can be
accomplished with lag screws placed
independently(Fig 3.4-2) or through a plate(Fig 3.4-
3).
In addition to applying compression across the
fracture surface, a screw fixing a simple fracture in a
long bone must prevent the shear that would occur
in oblique fractures under axial loading. Insertion of
the screw perpendicular to the long axis of the bone
best prevents shearing and fracture
displacement.(Fig 3.4-4)
Figure 3.4-1: The lag screw results in static compression
across the fracture site
A.
B.
Figure 3.4-4: A) Insertion of the screw at a right angle to
the fracture plane results in the best interfragmentary
compression but offers inadequate resistance to axial loading,
B) Insertion of the screw perpendicular to the long axis of the
bone best prevents shearing and fracture displacement.
In transverse or short oblique fractures of the
diaphysis, the placement of a lag screw is not always
possible. In such cases, a stabilization can be
performed with a compression plate. Compression
may be accomplished using an external tension
device(Fig 3.4-5) or plates with specially designed
screw holes that cause tensioning of the implant.
(Fig 3.4-6) With an external tensioning device,
compression forces of more than 1,000 N can be
achieved. When a single plate is used, the
application of tension to the plate tends to cause
eccentric compression, with close apposition of the
bone under the plate and slight gapping at the side
of the bone away from the plate. This complication
can be prevented by over-bending the plate before
application. The optimal construct utilizes an
interfragmentary lag screw placed through the plate
to achieve greater fracture compression.
Interfragmentary compression created by the screw
fixation of the cortex opposite the plate reduces the
shearing of this fracture surface that could
otherwise occur with torsional forces.

Figure 3.4-2: Lag screw osteosynthesis with a protection

plate. Lag screw is inserted independent of the plate.

Figure 3.4-3: Lag screw osteosynthesis in addition to a Figure 3.4-5: Interfragmentary compression by an
compression plate. Lag screw is inserted through the plate. external tensioning device
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
Figure 3.4-6: Interfragmentary compression by Dynamic
Compression Plate (DCP)
This combination of lag screw and plate should be
used for most simple, oblique diaphyseal fractures.
A pretensioned plate can be applied as the primary
mode of compression in a transverse fracture in
which lag screws are impractical. If the fracture
includes at least one major butterfly fragment, the
fracture planes between the butterfly fragment and
the major diaphyseal fragments are best fixed with
individual interfragmentary screws placed outside
of the plate. The strength of this fixation is not great
enough to resist all torsional bending and axial
loading forces, and it must be supplemented with a
plate that spans the fracture site to neutralize the
other forces that would disrupt the unprotected
compression lag screw fixation.
Dynamic compression
Stated simply, dynamic compression (DC) is a
phenomenon by which an implant can transform or
modify functional physiologic forces into
compression of a fracture site. There is little or no
prestress on the bone when the limb is at rest. Four
typical examples of DC constructs are the tension
band, the antiglide plate, splintage by
noninterlocked intramedullary nails, and the
telescoping hip screw.(Fig 3.4-7)
Combined static-dynamic compression
Plates can be applied as tension bands if applied to
the tension side of a fracture or nonunion. In
addition to the anatomic situations noted
previously, definite tension and compression sides
can be identified at locations where anatomic or
pathologic curvature or angulation of the bone or
fracture results in loading that is eccentric to the
central axis of the bone with weight-bearing and
muscle activity. Because of its normal curvature, the
femur is under tension anterolaterally and
compression posteromedially. When a plate is
placed on the lateral surface of the bone, it functions
131
as a tension band. Subsequent weight-bearing and
muscle activity result in dynamic compression at the
fracture site. In a varus nonunion of the tibia, the
abnormal angulation results in a significant bending
moment. By placement of a tensioned plate in the
lateral aspect of this bone, it is possible to capitalize
on the abnormal eccentric loading to produce
dynamic compression with weight-bearing and
muscle activity.(Fig 3.4-8)
In some situations, fractures and nonunions
present conditions that allow their fixation with a
combination of static and dynamic compression.
This approach is usually accomplished through the
use of plates that are pretensioned to provide static
compression. In these situations, conditions permit
the identification of a clear tension and compression
side of the fracture. When placed on the tension
surface, the plate also acts as a tension band. When
functional activity is commenced, weight-bearing
and muscle forces cause dynamic compression that
supplements the static compression produced by
pretensioning the implants.
SPLINTAGE
In contrast to the relatively rigid fixation achieved
with interfragmentary compression, standard
nonlocking intramedullary nails provide fixation
through splintage. Splintage may be defined as a
construct in which sliding can occur between the
bone and the implant. Nails extend from entry
portals in the bone through the medullary canal over
most of its length and allow axial loads to be
transmitted to the apposed ends of the fracture
fragments. Intramedullary fixation is much less rigid
than interfragmentary compression but is no less
effective when properly applied. Because a greater
amount of motion occurs at the fracture site with
functional activity, callus formation is regularly
observed.
Figure 3.4-7: Dynamic compression obtained by the
application of a plate as a “Tension Band”.
132 Plate Fixation in Orthopaedics
Static Compression Dynamic Compression
Figure 3.4-8: Combined static-dynamic compression
Bridging
Bridging is a subtype of splintage mode of fracture
fixation. Both interfragmentary compression and
splinting through intramedullary nailing require
contact between the fracture fragments to achieve
stability. They are best applied to simple fractures
and with minimal comminution. Achieving
apposition of all fragments in a markedly
comminuted fracture is impractical and potentially
harmful. These fractures most often result from the
rapid dissipation of large amounts of energy into the
trauma patient. The fracture occurs like an
explosion, with great fragmentation of the bone and
wide radial displacement of the individual fragments
into the surrounding soft tissue. Elastic recoil of the
remaining soft tissue envelope causes a reduction in
the displacement that occurred at the moment of
impact. The injury is considered more severe if it
results in an open wound that breaches the soft
tissue envelope and communicates directly with the
fracture site. If this pattern has not occurred, the
presence of a great degree of comminution and
marked fragment displacement indicates that there
has been significant injury to the soft tissue
surrounding the bone.
Because the bone fragments are of variable size
and are often rotated and impaled in the
surrounding muscle, reduction requires direct
surgical exposure and manipulation. Dissection and
retraction of the injured soft tissue further
compromise its damaged circulation. The use of
clamps and reduction forceps to reposition and hold
the bone fragments disrupts the tenuous muscle
attachments that carry the remaining blood supply
to these individual islands of bone. Further
devascularization of soft tissue and bone increases
the risk of infection and impairs fracture healing.
When fracture healing is prevented or delayed,
extended cyclical loading of the implants may
exceed their fatigue limit and lead to failure.
To avoid these consequences, it is necessary to
choose a fixation method that achieves the goals of
internal fixation without causing severe damage to
the vascularity of bone and surrounding soft tissue.
This fixation can be provided by the technique of
bridging. Bridging is accomplished by the insertion
of implants that extend across the zone of soft tissue
injury and fracture but are fixed to the major bone
fragments proximal and distal to the fracture site.
Bridging fixation can be accomplished with locked
intramedullary nails inserted with a closed
technique or with plates using indirect
reduction.(Fig 3.4-9)
Although fractures often appear to be held in
distraction by bridging fixation with a locking
intramedullary rod or plate, healing through
periosteal callus is the usual outcome. These
methods protect the viability of bone fragments by
sparing their vascular supply and provide a
favorable mechanical environment for bone
formation. The metals from which most rods and
plates are manufactured are somewhat elastic. This
material property, combined with the structural
geometry of the implants, results in a range of
fracture motion consistent with callus formation.
The implants allow restoration and preservation of
alignment and permit functional activity. Because
these tissues remain viable and a limited amount of
motion is permitted at the fracture site during
functional activity, a favorable environment for
callus formation is present.
Comparative Studies of Healing with
Different Types of Fixation
Micromovement between bone fragments facilitates
fracture healing, but the acceptable range of
micromotion and the optimal range of micromotion
have not been determined.
Although nonmechanical clinical aspects of a
fracture may dictate the best fracture treatment
approach, there are cases for which several options
exist, and mechanical considerations are important
in selecting a fixation method. Several animal
studies have been reported that compare fracture
healing with different types of fixation (plates vs.
rods, internal vs. external fixation, etc.). Rand et al.
compared compression plates and reamed, fluted
intramedullary rods using the canine transverse
tibial osteotomy model.
Figure 3.4-9: Fracture fixation by “Bridging
Mechanism”
 Biomechanics of Bone Tissue & Orthopaedic Hardwares 133

Table 3.4-1: Concepts of fracture fixation

Mechanical stability High= absolute stability Low=relative stability

Compression Splinting
Static Dynamic Locked Unlocked
External splinting
Lag screw Tension band External splinting (casting)
(external fixator)
Intramedullary
Lag screw and
Tension band plate splinting Intramedullary splinting
protection plate
(DCP, LC-DCP, LCP) (intramedullary (elastic nails)
(DCP, LC-DCP, LCP)
nailing)
Internal
Compression plate
extramedullary
(DCP, LC-DCP, LCP)
splinting
Technique and
Implants Bridging with
conventional
Buttress plate plating (DCP, LC-
(DCP, LC-DCP, LCP) DCP, LCP with
conventional
screws)
Bridging with
locked internal
fixators (LISS, LCP
with LHS)
Reduction Direct Indirect
Bone healing Primary Secondary

They evaluated blood flow, fracture site

morphology, and bone strength at various times up
to 120 days postfracture. Clinical union was evident
in all dogs after 42 days. Blood flow to the fracture
site reached higher levels and it remained high
longer in osteotomies treated with reaming and
intramedullary rods. There was significantly more
new bone formation with intramedullary fixation,
with most of the new bone formed in periosteal
callus. With compression plating, most of the new
bone formed was endosteal. Plated bones were
significantly stronger and stiffer than rod fixed
bones at 42 and 90 days but not at 120 days. The
study demonstrated different healing mechanisms
with the two treatments studied, but the time
required to establish normal strength and stiffness
was not different.
Sarmiento et al. compared rigid compression
plating to functional braces for closed, nondisplaced
fractures and found that the fractures treated with
functional braces produced abundant callus and had
greater torsional strength than the rigidly fixed
fractures. However, Lewallen et al. radiographically,
histologically, and biomechanically compared
osteotomies fixed by compression plating to those
stabilized by external fixators using the canine tibia
model. Initially, the less rigid externally fixed
osteotomies were significantly less stiff than those
fixed by the more rigid compression plating. Dogs
applied more load sooner to the compression-plated
leg than to the contralateral externally fixed limb.
After 120 days, bone union occurred in most
animals independently of fixation method. However,
compression-plated bones were significantly
stronger and stiffer in torsion than those that were
externally fixed. Histologically, the total amount of
new bone was similar for the two fixation methods,
but there was significantly more resorbed bone and
intracortical porosity with externally fixed bones
and more intracortical new bone on the
compression-plated side. In addition, there was
greater blood flow to externally fixed osteotomy
sites, consistent with other results suggesting
increased bone remodeling with the less stable
fixation.
Terjesen and Svenningsen utilized transverse
tibial osteotomies in rabbits to compare fracture
healing with metal plates to that with plaster casts
and to examine the role of limb loading in fracture
healing with the different treatments.[86] Four
experimental groups were studied: (1) plate
fixation, (2) plate fixation with a long plaster cast,
(3) long plaster cast, and (4) short plaster cast. The
long plaster casts were intended to restrict loads on
the healing bone. Callus area, bending strength, and
bending stiffness were evaluated after 6 weeks.
Fractures that were treated with the long plaster
cast, both with and without plating, were
significantly weaker and less stiff. More periosteal
callus developed with both long and short cast
treatments than with plated fractures. The authors
134 Plate Fixation in Orthopaedics

made the very important and clinically relevant improve the bending stiffness of pedicle screws by
observation that weight-bearing and muscular up to 125%.
activity are more effective at promoting bony union
than fixation stiffness. HARDWARE
FIXATION OF OSTEOPENIC BONE Internal fixation is based on the implantation of
various appliances to assist with the body's natural
The treatment of fractures involving osteopenic healing process. The following sections describe the
bone will become more prevalent as the aging basic biomechanics and types of hardware, including
population increases. Because the attachment screws, drills, taps and plates.
strength of a fixation device to bone is directly
related to the local bone density, and because a
dominant mechanical characteristic of osteoporotic
Cerclage Wire
bone is low density, several strategies can be used
The tensile strength of surgical wire has been shown
when osteoporotic bone is encountered. Routine
to increase directly with its diameter, and when
internal fixation techniques may not be adequate to
twisted, the optimal number of turns is between
obtain stability.
four and eight. However, solid wire is very sensitive
1. Avoid iatrogenic comminution of the fracture.
to notches or scratches. Testing shows that notches
Fracture reduction and fixation should proceed
as small as 1 % of the diameter of the wire can
with caution to avoid increased comminution
reduce its fatigue life by 63%. For this reason, cable
of the fragile, fragmented osteopenic bone.
has been introduced for cerclage applications. Cable
2. Bone-to-implant stability and strength should
has significantly better fatigue performance
be enhanced in three ways.
compared to wire. Because cables consist of multiple
3. Cortical buttressing by impaction
strands of single thin wires, damage to any
4. Use longer implants (plate or rod) to avoid
particular strand does not result in failure of the
failure at the junction of implant and
whole cable. Single loops of suture such as Ethibond
osteopenic bone.
are about 30% as strong as 18-gage stainless steel
5. Use additional screws when plating, increase
wire in tension, and Merseline tape is about 50% as
the number of locking screws when using
strong. Four loops of Ethibond were shown to have
intramedullary rods, and use increased pins
tensile strength equivalent to stainless steel wire.
when applying external fixators to distribute
the force over a greater area, thus unloading
the osteopenic bone slightly. Screws
6. Use fixed angled devices, which prevent pull-
out. Bone implant stability can be increased by A screw is a powerful element that converts
using fixed angled devices such as locking rotation into linear motion. Any discussion about
plates, blade plates, and Schuhli washers. different types of screws and their applications
Prevention of implant to bone failure can be should be based on an understanding of basic screw
accomplished by attaching a screw to the plate design.(Fig 3.4-10) Most screws are characterized
with a threaded hole or by attaching the screw by some common design features(Fig 3.4-11):
to the plate with a specialized nut. 1. A central core that provides strength
7. Augment weakened bone with various 2. A thread that engages the bone and is
substances. The osteopenic bone itself can be responsible for the function and purchase
augmented at certain areas with the use of 3. A tip that may be blunt or sharp, self-cutting
polymethylmethacrylate (PMMA) or or self-drilling and –cutting
biodegradable calcium phosphate bone 4. A head that engages in bone or a plate
substitutes. 5. A recess in the head to attach the screwdriver
Screw stability or holding strength is directly
related to the cross-sectional area of the screw
thread in the material and the density of material.
PMMA and calcium phosphate bone substitutes both
increase the density for greater screw holding
strength and can also improve fracture stability by
acting as an intramedullary strut. Biomechanical
studies have shown significantly improved strength
of the fixation of femoral neck fractures, up to 170%,
and similar findings, including decreased shortening
and greater stability were noted when
hydroxyapatite cement was applied to unstable
three-part intertrochanteric fractures fixed with a
dynamic hip screw. Calcium phosphate cement
injection into the pedicle has been shown to Figure 3.4-10: Force conversion in a screw.
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
One and the same screw can have different
functions, depending on the screw design and
way of application. The two basic principles of a
conventional screw are to compress a fracture
plane (lag screw) and to fix a plate to the bone
(plate screw). The more recent designed locking
head screws provide angular stability between
the implant and the bone.
Basic structure of screw
The outer diameter is defined as the outermost
diameter of the threads. Pitch is defined as the
longitudinal distance between the threads. The
bending strength and shear strength of a screw
depend on its root, or core, diameter. This
dimension is the solid section of the screw from
which the threads protrude. The core diameter
also determines the size of the drill bit used for
the pilot hole. Many screws have a common core
diameter. For example, the 4.5-mm cortical, 6.5-
mm cancellous, and 4.5-mm malleolar screws all
have the same core diameter (3.0 mm). The core
diameter of a screw determines its strength in
bending because strength is a function of the
cross-sectional moment of inertia, which is
proportional to the third power of the radius. If
the thickness of the core is increased, a
significant increase in bending strength is
obtained. The core or root diameter is often
confused with the shaft diameter, which is the
unthreaded portion of the screw between the
head and the screw threads.
Although bending strength and shear strength
are important mechanical features, the pullout
strength of a screw is of even greater significance
in internal fixation. The ability of a screw to
achieve interfragmentary fixation or stable
attachment of a plate relates to its ability to hold
firmly in bone and resist pullout. The pullout
strength of a screw is proportional to the surface
area of thread that is in contact with bone. Other
factors that can increase the pullout strength are
larger screw diameter, a longer embedded length
of screw shaft, and greater density of the bone it
is placed in.
Recess
Head
Thread
Core
Tip
Figure 3.4-11: Basic Components of a screw
135
There are two methods to increase this surface
contact. The first is to increase the difference
between the core and the external diameters;
this maximizes the amount of screw thread
surface that is in contact with bone, resulting in
stronger fixation.
The second method is to increase the number of
threads per unit length—that is, to decrease the
point-to-point distance between successive threads
(pitch). The smaller the pitch, the greater the
number of threads that can engage in the bone, and
the more secure the fixation.
Particularly in cancellous bone, the maximum
force that a screw can withstand along its axis, the
pullout force, depends upon the size of the screw
and the density of the bone it is placed into. When
the force acting on the screw exceeds its pullout
strength, the screw will pull or shear out of the hole,
carrying the sheared bone within its threads,
because it is usually the bone that fails and not the
screw. The diameter and length of the embedded
screw can be thought of as defining the outer surface
of a cylinder along which the screw shears. Given the
maximum stress that bone of a particular density
can withstand, increasing the surface area of the
screw cylinder increases the pullout force. To
enhance screw purchase, consider embedding the
largest diameter screw possible into bone of the
greatest density over as long a purchase length as
possible. Pullout strength also increases significantly
if the screw is placed through both bone cortices.
In cancellous bone, hole preparation, specifically
drilling but not tapping, improves the pullout
strength of screws. The reason that tapping reduces
strength in cancellous bone is that running the tap in
and out of the hole removes bone, effectively
increasing the diameter of the hole and reducing the
amount of bone material that interacts with the
screw threads. Tapping has more effect as bone
density decreases and can reduce the pullout
strength from 10% to as much as 30%. It should also
be noted that the findings of studies related to
pullout strength relate to the time immediately after
insertion. As the bone heals, it also remodels around
the screw, possibly doubling its initial pullout
strength.
The cortical screw torque and compression
profiles for insertion to failure have a consistent
shape, with values linearly increasing on screw head
contact, followed by a nonlinear region prior to
reaching maximum load and stripping failure.
Clinical torque levels for screw tightening (86%
Tmax) are usually reached beyond the linear region of
the curve, after a loss in stiffness by an average of
51% as estimated by decreasing slope of torque
curves. It is this yielding of the material that
surgeons detect by proprioception, signaling them to
cease tightening before stripping occurs.
There is no significant difference between
normalized pullout strength with screws tightened
to 50% Tmax or 70% Tmax, but there was decreased
pullout strength at 90% Tmax (significantly lower
136 Plate Fixation in Orthopaedics
compared to 70% Tmax values). Screws tightened to
90% Tmax have pullout strength values decreased by
7–13% compared to 50% Tmax and 70% Tmax,
respectively.
The damage caused during screw insertion and
tightening may have consequences further along the
healing process. Once stabilization is achieved,
cellular activity begins at the fracture site, resorbing
injured bone tissue and laying down new woven
bone. Some remodeling is desirable for encouraging
bony ingrowth and stability. However, if there is
extensive microdamage to bone around the screw
threads from overtightening, this will also be
targeted for repair, at worst resulting in loosening
and ultimately failure of the fixation construct.
A screw can break in two ways (Fig 3.4-12):
The first is through the application of a torque that
exceeds the shear strength of the screw. This can
occur especially when using smaller (less than 4 mm
diameter) screws in dense bone, especially without
tapping. The stiffness and strength of a screw are
related to the 4th power of its diameter (the effect of
moment of inertia; for screws of the same material).
A 6-mm diameter screw is approximately 5 times as
stiff as a 3-mm diameter screw and 16 times as
resistant to shear failure by over-torquing the screw
during insertion. Von Arx determined the range of
torque applied by surgeons during insertion to be
2.94 to 5.98 N-m. This force can break a screw with
a root diameter of 2.92 mm or less if it becomes
incarcerated.
The second way is through application of bending
forces when a load is applied perpendicularly to the
long axis of the screw. If the screws fixing the plate
to the bone are not secure enough, the plate will
slide between the bone and the screw head. This
sliding permits application of an excessive bending
force perpendicular to the axis of the screw which,
along with possible stress corrosion and fretting
corrosion, ultimately can result in fatigue failure of
the screw. In the clinical setting, the screw must be
tight enough to avoid plate sliding but not so tight as
to exceed the maximal shear strength of the screw
itself. Several factors affect how tight the screw-
plate-bone interface can be made, including the
maximal torque applied during insertion, thread
design (Fig 3.4-13), bone quality, screw diameter,
the embedded length of screw shaft. The screws
tightened against a plate with only 10% to 15% less
force than the maximum possible failed in less than
1000 loading cycles, by bending fatigue, compared
with fully tightened screws that were able to sustain
over 2.5 million loading cycles. Small fragment
screws, around 4 mm outside diameter, can fatigue
because their core diameters are small. Screws that
lock into the plate reduce this problem.
Because of the variation in bone quality among
individuals and among anatomic locations, it is not
possible to determine the insertional torque
necessary to optimally tighten all screws. For this
reason, a torque screwdriver cannot be used, and
screw purchase is best assessed empirically.
Figure 3.4-12: Screw failure mechanisms: A) Bending
failure, B) Excessive torque
Figure 3.4-13: Effect of thread design on screw failure:
A sharp intersection between the screw and the thread acts as
an area of stress concentration
Purchase is defined as the perception that the
screw is meeting resistance and becoming tight
rather than slipping and spinning. The trade-off in
use of these devices is choosing a screw with a
larger core diameter and shallower thread to reduce
the possibility of fatigue, or a smaller core diameter
and deeper thread to increase purchase strength in
bone.
The design of the threads can also influence the
strength of the screw and its resistance to breakage.
Stress on the core can be increased if the surfaces of
adjoining threads intersect with the core at a sharp
angle. This sharp notch acts as a stress concentrator,
increasing the possibility of screw failure. To
minimize this problem, bone screws are designed so
that the intersection of the thread surfaces with the
core contains curves without a sharp angle.
Cannulated screws are commonly used for
fixation, having the significant advantage that they
can be precisely guided into position over a guide
wire, which itself may aid in reduction of a fracture
fragment. Nevertheless, drilling precision for the
screw or guide wire is decreased with increasing
density of bone, and with the use of longer and
smaller diameter drill bits.
The same size cannulated screws usually have less
thread depth compared with solid screws due to an
increase in minor diameter. The result is less pullout
strength. For 4-mm diameter screws, cannulated
screws of the same outside diameter had about 16%
less pullout strength. Alternatively, to keep the same
thread depth, the outer diameter of the screw may
be increased.
 Biomechanics of Bone Tissue & Orthopaedic Hardwares 137

Screw Types diamond-shaped tip as well as flutes. This design is

In practice, screws are most commonly referred to
by the outer diameter of the threads (1.5, 2.0, 2.7,
3.5, 4.5, 6.5, and 7.3 mm). Screws are also described
as self-tapping or non-self-tapping, solid or
cannulated, cortical or cancellous, and fully or
partially threaded. The final variables are the
overall length of the screw and the thread length of
a partially threaded screw.
Non-self-tapping screws
Non-self-tapping screws (Fig 3.4-14 A) do not have
flutes and are designed with a blunt tip. These
screws require a predrilled pilot hole and threads
cut with a tap. The most important advantage of
non-self-tapping screws is that less axial load and
torque are applied during tapping and screw
insertion than with self-tapping screws. This
difference allows the screws to be used more
effectively for interfragmentary compression,
lessening the chance of fracture displacement. In
addition, unlike self-tapping screws, these screws
can be replaced accurately because they cannot cut
their own channel.
Baumgart and colleagues evaluated the insertion
torque, pullout force, and temperature on insertion
of a self-tapping screw and compared the results
with those of non-self-tapping screws with or
without the process of proper tapping. They found
that 1 to 1.5 N-m of insertion torque was required
to insert a 4.5-mm self-tapping screw into human
cortical bone. This value is slightly more than the
torque required to insert a non-self-tapping screw
into a pretapped hole. Placement of a non-self-
tapping screw into an untapped pilot hole required
twice the torque. The pullout force of a self-tapping
screw is 450 to 500 N per millimeter of cortex,
which is less than but not significantly different
from the pullout force of a tapped screw in cortical
bone. The heat generated during introduction of the
self-tapping screw causes an increase in
temperature at the screw tip, but little heat is
transferred to the surrounding bone. The increase
in temperature does not depend on the rate of
insertion as long as the insertion is not hindered.
(Fig 3.4-15)
most commonly used in cannulated screw systems.
Although not designated as self-tapping screws,
cancellous screws are commonly inserted without
tapping of the cancellous bone. The thread tip of
these screws has a corkscrew pattern with a
gradually increasing thread diameter. The
corkscrew shape impacts the bone around the sides
of the pilot hole rather than cutting and removing
debris. The purchase of the cancellous screw is
enhanced by this impaction. Tapping of the entire
length of the cancellous threads removes essential
bone, reducing the pullout strength.
An advantage of self-tapping screws is that the
number of steps necessary for the operation is
reduced, decreasing the operative time. An intimate
fit of the screw thread in the bone occurs because
the screw cuts its own thread and bone is impacted
in the thread path. A disadvantage of self-tapping
screws is the increased torque required for screw
insertion. Ansell and Scales found that three flutes
extended over three threads required the least
torque for insertion. However, these flutes weaken
the pullout strength of this portion of the screw
because the fluted threads have 17% to 30% less
thread surface than threads farther up the screw.
Therefore, the screw should be advanced so that
the cutting flutes protrude beyond the far
cortex.(Fig 3.4-16) Because additional axial load
and torque are necessary for insertion of self-
tapping screws, fracture displacement may occur.
This is one reason why self-tapping screws are not
recommended for interfragmentary lag screw
fixation.

Self-tapping screws A.
Self-tapping screws (Fig 3.4-14 B) are designed to
cut their own thread path during insertion without
prior use of a tap. The feature that differentiates
these screws from others is the tip shape and
design. Most commonly, the tip has cutting flutes
that allow the leading threads to cut a path. Because
the flutes are only at the tip and do not extend the
full length of the screw, debris cannot be removed
completely and is instead impacted into the thread
path. These fluted-tipped, self-tapping screws are
designed primarily for use in cortical bone. Some B.
screws are designed to drill the pilot hole and tap Figure 3.4-14: A) A non-self-tapping screw, B) A
the threads. These screws usually have a trochar, self-tapping screw
138 Plate Fixation in Orthopaedics

Figure 3.4-15: A comparison between compression

generated by non-self-tapping and self-tapping screws

Figure 3.4-17: A cortical (left) and a shaft (right)

screw

Figure 3.4-16: To maximize screw thread purchase in
cortical bone, self-tapping screws should be inserted so that
the cutting threads extend beyond the far cortex
Cortical screws
Cortical screws are made with a shallow thread,
small pitch, and relatively large core diameter. The
large core diameter increases the strength of the
screw, which is important for attachment of plates
to bone and for resistance to the deforming loads
experienced by interfragmentary compression.
These screws are fully threaded throughout their
length and are commonly non-self-tapping.(Fig 3.4-
17) The thread and the polished surface allow easy
removal and replacement if incorrect insertion has
been performed.
Shaft screws
The shaft screw is a partially threaded cortical
screw in which the shaft diameter equals the
external diameter of the thread.(Fig 3.4-17) This
screw is used for interfragmentary compression,
either in bone alone or positioned through a plate.
The nonthreaded shaft presents a smooth surface
to sit in the glide hole, eliminating binding. Klaue
and associates reported that almost 40% of the
compressive effect of a fully threaded cortical lag
screw through a plate may be lost because of
binding of the screw on the side of the glide hole in
the proximal cortex. They termed this binding
phenomenon parasitic force. The absence of
binding removes the parasitic force, resulting in a
60% improvement in lag screw compression.
Cancellous screws
Cancellous screws are characterized by a thin core
diameter and wide, deep threads. The higher ratio
of outer to core diameter increases the holding
power, which is especially important for cancellous
trabeculae commonly found at the epiphysis and
metaphysis. Cancellous screws are available in
either fully or partially threaded forms with
variable thread lengths and in different outer
diameters (4.0- to 8.0-mm).(Fig 3.4-18) The choice
of the specific thread length depends on fracture
configuration and bone anatomy. When a
cancellous screw is used as a lag screw, the entire
length of thread must be contained within the
fracture fragment. Allowing the thread to cross the
fracture site inhibits compression and may cause
distraction. Choosing the correct thread length is
critical to ensure maximal purchase while avoiding
displacement. Compression of cancellous bone by
screw threads does not cause resorption but
actually causes hypertrophy and realigns the
trabeculae with the force on the side exposed to
pressure. The design of a cancellous screw takes
into account the fact that cancellous bone is softer
than the denser cortical bone. The root diameter is
decreased, allowing for increased thread depth.
This configuration results in greater holding
capacity at the expense of loss of bending and shear
strength.
Cannulated screws
A cannulated screw has a hollow center that allows
it to be passed over a guide wire. The root diameter
is increased to account for placement of the screw
over the wire.(Fig 3.4-19) The increased size of the
screw is necessary to account for the cannulation
wire, which must be of adequate strength to hold
steady in bone without bending. The screw cannot
be too large or it would remove too much bone and
decrease the strength of the construct. Guide pins
are used to determine the optimal screw position
and aid in the fracture reduction. The guide pin
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
makes a relatively small defect in the bone,
allowing modification with little effect on the
ability of the screw to compress and hold bone. It is
threaded to aid in its fixation and to prevent
migration when the screw is inserted. The guide
pin also makes the pilot hole for the cannulated
screw. When combined with fluoroscopic imaging,
cannulation improves the precision of cancellous
screw placement significantly. This method is
important in areas where errant placement could
result in catastrophic complications. Once the guide
pin is in position, the screw is advanced through
the soft tissues in a counterclockwise fashion to
avoid tissue damage. At the proximal cortex, the
screw is turned clockwise and self-tapped to the
desired level of insertion. Cannulated screw
systems are commonly used in areas with
abundant cancellous bone; tapping of this type of
bone decreases the pullout strength.
The mechanics of a cannulated screw are
different from those of solid screws. Pullout
strength depends on two basic parameters: screw
fixation and screw design. The patient's variable
bone density is the primary factor affecting screw
fixation. There are many variables to screw design.
The larger the outer diameter, the greater the
pullout strength. A 6.4-mm screw has significantly
greater holding power than a 4.5-mm screw in
bone of comparable density. A smaller pitch also
increases holding power. This variable is limited
because as the number of threads per inch
increases, they become tight and remove too much
bone. The most important factor in maximizing the
overall pullout strength of a cannulated screw is
the host material density, followed by outer
diameter, pitch, and root diameter.
Comparison of cortical, cancellous, and
cannulated screws
A cortical screw can handle four times the stress of
a cancellous screw of similar size and 1.7 times the
stress of a cannulated screw. The thread design and
larger root diameter enable it to handle 6.2 and 1.7
times the maximal bending stress of a solid
cancellous or cannulated screw, respectively.
Figure 3.4-18: A fully threaded (left) and partially
threaded (right) cancellous screw
139
The increase in strength caused by increased root
diameter comes with the disadvantage of
decreased thread depth. However, this decrease in
thread depth does not decrease holding power in
cortical bone. The resistance of a screw to bending
stresses does increase with the root diameter.
For screws to have cannulation, the root
diameter must be increased. In relation to solid
screws of the same external diameter, the thread
depth of a cannulated screw is decreased and the
root diameter is increased, resulting in the
decreased pullout strength of cannulated screws.
Leggon and coworkers found a 20% decrease in
holding power between cannulated and solid
screws of similar diameter. To compensate for this
difference, larger diameter cannulated screws are
recommended. Hearn and colleagues found no
significant difference in pullout strength between
solid 6.5-mm cancellous screws and 7.0-mm
cannulated cancellous screws.
Malleolar screws
Malleolar screws were originally designed for
the fixation of the medial malleolus. They are
partially threaded cortical screws with a
trephine tip that allows them to cut their own
path in cancellous bone. To achieve stable
fixation of the malleolar fragment, two points of
fixation are necessary. Medial malleolar
fractures often have distal fragments that are too
small to permit fixation with two of these
screws; the large size of the screw often shatters
these small fragments. The prominence of the
large screw head at the tip of the medial
malleolus also causes excessive patient
discomfort.
Figure 3.4-19: Cannulated screw; inner, outer and
core hole diameters
140 Plate Fixation in Orthopaedics
DRILL BITS
Fundamental to screw placement is proper
preparation of the bone with drilling. The most
important aspect of this process is the design of the
drill bit. The configuration of a drill bit is relatively
simple. The central tip is the first area to bite into
the bone. The sharper the tip, the better the bite and
the less skive or shift in the proposed drill site. The
cutting edge, located at the tip of the drill bit,
performs the actual cutting and is crucial to efficient
penetration. Flutes are helical grooves along the
sides of the bit that direct the bone chips away from
the hole. Failure to remove bone debris could cause
the drill bit to deviate from its intended path,
decreasing drilling accuracy. The land is the surface
of the bit between adjacent flutes. The reaming edge
is the sharp edge of the helical flutes that runs along
the entire surface, clearing the drill hole of bone
debris while performing no cutting function.
Disruption of these edges diminishes reaming
performance. The rake or helical angle is the angle
made by the leading edge of the land and the center
axis of the drill bit. A larger rake angle reduces the
cutting forces regardless of the direction in which
the bone is cut. This angle can be positive, negative,
or neutral. Positive rake angles cut only when
rotated clockwise.(Fig 3.4-20)
Most drill bits are constructed with two flutes; they
are used with rotary-powered drills and are
provided in standard fracture fixation sets. To limit
drilling damage to the soft tissues adjacent to bone,
an attachment has been developed that converts a
drill's action from rotary to oscillating drive. With
the oscillating drive, there is less tendency for the
drill bit to damage neighboring soft tissue. An
oscillating drill bit can be placed on skin and will
not cut it because of the skin's elasticity. A three-
fluted drill bit has been developed for use with
oscillating drill attachments. To work effectively, a
two-fluted drill bit must rotate beyond 180°.
Figure 3.4-20: Configuration of the drill bit
Because the excursion of the oscillating device is
less than 180°, a three-fluted drill bit must be used
to achieve cutting. This drill bit also provides an
added advantage when drilling on an oblique angle.
Although the oscillating three-fluted drill bit may
be safer for soft tissue, the two-fluted rotary drill
bit cuts through bone more efficiently and is used
more commonly.
Drilling into bone is different from drilling into
wood because bone is a living tissue. The process of
drilling in bone must minimize physiologic damage.
Jacob and Berry determined the optimal drill bit
design and method for bone drilling. They found
that the cutting forces are higher at lower
rotational speeds and suggested a physiologic bone
drilling method that includes the following: (1)
bone drill bits with positive rake angles between
20° and 35°; (2) a point on the drill to avoid
walking (skiving); (3) high torque and relatively
low drill speeds (750 to 1250 rpm) to take
advantage of a decrease in flow stress of the
material; (4) continuous, copious irrigation to
reduce friction-induced thermal bone necrosis; (5)
reflection of the periosteum to prevent bone chips
from being forced under the tissue, clogging the
drill flutes; (6) drill flutes that are steep enough to
remove chips at any rake angle; (7) sharp and
axially true drill bits to decrease the amount of
retained bone dust; and (8) drilling of the thread
hole exactly in the direction in which the screw is
to be inserted for accuracy and strength. These
techniques reduce local bone damage significantly.
Most drill bits are constructed with high-carbon
stainless steel and are heat-processed for increased
hardness. Damaged or dull bits decrease drilling
efficiency significantly and may cause local trauma
to bone. A damaged drill bit can increase drilling
time by a factor of 35. Damage is frequently caused
by contact with other metal (plate or drill sleeve).
AO/ASIF recommends certain procedures to
decrease drill bit damage. The first is to drill only
bone. Pohler found that drilling of 110 bone
cortices had a negligible effect on the bit itself. The
second is to always use the drill guide. This
minimizes bending, which is the leading cause of
drill failure. The drill guide or sleeve should be of
correct size; an excessively large guide results in a
larger hole because of wobbling of the drill. The
third recommendation is to start the drill only after
the drill bit has been inserted into the drill guide.
This technique limits contact with the drill guide
and consequent damage to the cutting and reaming
edges. These recommendations combined with the
defined physiologic bone drilling method limit local
damage to bone and result in optimal holes for
screw fixation.
Most standard fracture fixation sets provide
specific drill bits that are used to drill tap and glide
holes appropriate for all screws contained in the
set. Drill bits are named by their diameter and,
because they should always be used with soft tissue
protective sleeves, they have both a total and an
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
effective length, the latter being the portion of the
bit that extends past the drill sleeve and is
responsible for cutting. The diameters of drill bits
correspond to specific screws in the fracture
fixation set. Generally, the size of the drill bit used
to make the pilot hole for the screw threads is 0.1
to 0.2 mm larger than the core diameter of the
corresponding screw. The size of the drill bit used
to make glide holes is the same size as the diameter
of the shaft of a shaft screw or the outer diameter
of a fully threaded cortical screw. The cutting edge
of the bit is at its tip; it should always be protected
and should frequently be examined for flaws.
TAPS
Taps are designed to cut threads in bone that
resemble exactly the profile of the corresponding
screw thread. The process of tapping facilitates
insertion and enables the screw to bite deeper into
the bone. This allows the torque applied to the
screw to be used for generating compressive force
instead of being dissipated by friction and cutting of
threads. Tapping also removes additional material
from the hole, thereby enlarging it. The screw
pullout strength depends on the material density.
The larger hole created by the tap does not
decrease pullout strength in cortical bone because
of its density; in less dense trabecular or osteopenic
bone, the larger hole has a progressively larger
effect and can decrease pullout strength by as much
as 30%.
Taps are threaded throughout their length and
increase gradually in height up to the desired
thread depth. A flute extends from the tip through
the first 10 threads to facilitate clearing of bone
debris, which can collect and jam the tap. Proper
technique calls for two clockwise and one
counterclockwise turn to facilitate bone chip
removal. The entire far cortex should always be
tapped, because screw pullout strength increases
substantially with full cortical purchase. The tap
size, which corresponds to its outer diameter,
should be the same as the outer diameter of the
screw. For example, a 4.5-mm cortical screw has an
outside diameter of 4.5 mm and uses a 4.5-mm tap;
a 6.5-mm cancellous screw with an outside
diameter of 6.5 mm uses a 6.5-mm tap.
PLATES
Plates are a fundamental element of internal
fixation. Several basic biomechanical principals are
important to fracture fixation using bone plates.
They are principally differentiated by the
biomechanical function they perform. Examples of
these functions are neutralization, buttressing,
compression, bridging, formation of a tension band,
and anti-glide. Additionally, plates can be
categorized by their specific designs: dynamic
compression (DC), limited contact-dynamic
compression (LCDC), tubular, reconstruction,
141
angled, and sliding screw plates. Certain specially
designed plates can be modified to perform
different biomechanical functions according to
anatomic need. In addition, some plates have
evolved with specific names based on their location
(e.g., lateral tibial head plate). Various plates can be
used or adapted on the basis of function, design, or
anatomic location. This section discusses the basic
biomechanical functions of plates and some specific
plate designs. The application of particular plates to
certain injuries is discussed in other parts of this
book.
BIOMECHANICAL FUNCTIONS OF
PLATES
Neutralization
A neutralization plate is used to protect lag screw
fixations from various external forces. Torsional
and bending forces on long bone fractures are too
great to be overcome by lag screw stabilization
alone. A plate can protect the interfragmentary
compression achieved with the lag screw from
torsional, bending, and shear forces exerted on the
fracture.(Fig 3.4-21) This technique achieves
fracture fixation that is sufficiently stable to allow
early motion. When comparing two plates of the
same design, a longer plate provides greater
neutralization capability.
Buttressing
The buttress plate is used to counteract bending,
compressive, and shearing forces at the fracture
site when an axial load is applied. Buttress plates
are used commonly to stabilize intra-articular
and periarticular fractures at the ends of long
bones. Without fixation or with lag screw
fixation alone, epiphyseal and metaphyseal
fragments can displace when they are subjected
to axial compression or bending forces. The
buttress plate supports the underlying cortex
and effectively resists displacement and the
resulting angular deformity of the joint. In this
manner, the plate acts as a buttress or retaining
wall.
Figure 3.4-21: A plate applied with a neutralization
mechanism
142 Plate Fixation in Orthopaedics

To minimize the potential for angular deformity,

the screws attaching the plate to the bone must be
inserted in such a manner that when a load is
applied there will be no shift in the position of the
plate in relation to the bone. A screw inserted
through an oval hole closest to the fracture is said to A.
be in buttress mode. This mode minimizes axial
movement at the fracture site. To avoid the
possibility of displacing the fracture fragment
during application of the plate, the plate should be
accurately contoured to match the anatomy of the B.
underlying cortex. Screw placement in a buttress
mode does not always imply that the plate is
functioning as a buttress plate. A buttress plate
applies force to the bone in a direction normal
(perpendicular) to the flat surface of the plate, in
contrast to a compression plate application, in which
the direction of stress is parallel to the plate.(Fig 3.4-
22) Buttress plates are designed to fit specific
anatomic locations. If the fracture extends from the
metaphysis into the diaphysis, a long plate with a
condylar end can be used to combine buttressing
with other plate functions. A spring plate is a
specialized form of buttress in which the plate is
affixed with screws to only one of the two fracture
fragments. C.
Plates designed to provide compression (DC or
LCDC plates) can be used as buttress plates with
proper contouring. Other plates are designed Figure 3.4-23: Interfragmentary compression by an
specifically to function as buttress plates in external tensioning device (A) or Dynamic Compression
particular locations. Some examples of buttress Plate (B) or Overbending (C)
plates by design are the T-buttress plate for lateral
tibial plateau fractures, the spoon plate for
treatment of anterior metaphyseal fractures of the Bridging
distal tibia, the cloverleaf plate for the medial distal A bridge plate is intended to maintain length and
tibia, and the distal femoral condylar buttress plate. alignment of severely comminuted and segmental
fractures. It is called a bridge plate because its
Compression fixation is out of the main zone of injury at the ends
Compression plates can be used to reduce and of the plate to avoid additional injury in the
stabilize transverse or short oblique fractures when comminuted zone. During fracture fixation, the
lag screw fixation alone is inadequate. The plate can bridge plate can be used as a reduction device to
produce static compression in the direction of the limit the dissection in the zone of injury. This
long axis of bone in three ways: by over-bending of fixation method limits devitalization of bone
the plate, by application of a tension device, and by fragments and thereby allows for a better healing
a special plate design that generates axial environment.
compression by combining screw hole geometry The wave plate is similar to a bridge plate; it is
with screw insertion.(Fig 3.4-23) primarily used in areas of delayed healing. The
wave plate is contoured away from the comminuted
area or pseudarthrosis to be bridged. This contour
leaves some distance between the cortex of bone
and the plate, where autologous bone graft can be
placed. In the treatment of nonunions, this space
allows for better ingrowth of vessels into the graft
beneath the plate. The bending of the plate
distributes force over a greater area, decreasing
local stress at the fracture site. The plate also can
act as a tension band, creating compression on the
opposite cortex. These factors make the wave plate
an efficient tool in the treatment of nonunions.(Fig
Fig 3.4-22: A plate applied with a buttressing mechanism 3.4-24)
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
Figure 3.4-24: Bridging mechanism: intended to
maintain length and alignment of severely comminuted and
segmental fractures without approaching directly to the
comminution area, A) A “Bridge Plate”. B) A “Wave Plate”.
Tension Band
Pauwels adopted the tension band principle from
classical mechanics. It is best understood by
examining the forces that occur at discontinuity in
an I-beam. The stretching and compressing of
springs can be used to demonstrate the different
forces. As shown in this analogy, forces applied in
line with the central axis of the I-beam produce
uniform compression in both springs on either side
of the neutral axis and uniform closure of the
discontinuity in the beam. In contrast, when the
force is applied eccentrically at a distance from the
central axis to the beam, a bending moment is
created. This bending moment produces tension on
the opposite side of the beam. This change is
demonstrated by opening of the discontinuity and
spring distraction. On the same side of the beam on
which the weight is applied, the moment creates
compression, as evidenced by closing of the
discontinuity with spring compression. In
anticipation of this eccentrically applied weight, an
unyielding band can be applied to the side on which
tension will be created by the bending moment. This
band is used to create a small amount of
compression, which results in partial closure of the
discontinuity and compression of the spring on the
same side as the band. Under these conditions, the
application of an asymmetric force to the opposite
side of the beam leads to uniform compression on
both sides of the discontinuity, further closing of the
space and compression of the springs. This
technique, which is placed before the functional
application of the eccentric load, is called the tension
band.
Wires, cables, nonabsorbable sutures, and plates
can be used to perform the function of the tension
band.(Fig 3.4-25) Practically speaking, tension band
implants can be used to fix fractures in only certain
limited locations in the body. Some examples are
the greater trochanter of the femur, the olecranon,
and the patella. In these situations, the eccentric
pull of the muscles forces the joint surface of the
fractured bone against the corresponding joint
surface of another bone, which acts as a fulcrum.
The extensor muscle usually provides the major
143
deforming force causing the bending moment at the
discontinuity. A wire or cable is frequently used as a
tension band in these situations. It is applied to the
surface of the bone, which is subjected to tensile
loads during active motion. The wire is tensioned to
apply slight compression to the site of the fractures.
This creates a small gap on the opposite side. When
dynamic forces are applied during subsequent
contractions of these antagonistic deforming
muscles, the tension band resists the tendency for
distraction of the opposite side of the bone,
producing uniform compression at the fracture site.
Parallel longitudinal Kirschner wires, Steinmann
pins, or cancellous lag screws are used as adjunctive
fixation to prevent displacement of the fracture site
through shearing, translation, or rotation. Because
they are placed in parallel orientation, the smooth
pins or screw shafts act as rails along which the
bone fragment can slide during dynamic
compression.
In fractures of the patella and olecranon, dynamic
compression is achieved through antagonistic
muscle function during active flexion of the knee
and elbow. The intercondylar grooves of the distal
femur and humeral trochlea act as a fulcrum over
which the antagonistic muscle groups apply
bending forces to the patella and olecranon.
Fractures or osteotomies of the greater trochanter
of the femur and greater tuberosity of the humerus
can also be fixed in a similar fashion using the
tension band principle. The antagonistic pull of the
gluteal and abductor musculature, using the hip
joint as a fulcrum, causes a bending moment at the
site of discontinuity between the greater trochanter
and the remaining femur. In a similar fashion, the
antagonistic pull of the supraspinatus and pectoralis
major, using the glenohumeral joint as a fulcrum,
causes a bending moment at the site of
discontinuity between the greater tuberosity and
the remaining humerus. Optimal compression is
achieved with this method only during functional
activity that results in eccentric loading and the
production of bending moments.
Figure 3.4-25: Application of a plate to the anterolateral
aspect of the femur act by the “Tension Band” mechanism
144 Plate Fixation in Orthopaedics
Prevention of Glide
The anti-glide plate is another example of the
dynamic compression principle. Although there are
many potential applications, the construct is most
commonly used for oblique, Weber type B fractures
of the distal fibula. A plate applied to the posterior
surface of the proximal fragment forms an axilla
into which the spike of the distal fragment fits. The
axial loads of walking are converted into
compression of the surfaces of the two fracture
fragments. The plate acts as a buttress to prevent
external rotation of the distal fragment.(Fig 3.4-26)
The size, shape, and quality of bone and the
physiologic stress on the fracture site determine the
number of screws required for adequate fixation.
The AO/ASIF group has performed retrospective
clinical reviews of large numbers of fracture
fixations. These studies have empirically
determined the number of screws that should be
used to attach a plate to each long bone. Because the
diaphysis of long bones is tubular, it is possible to
achieve thread purchase in the cortex on one or
both sides of the intramedullary canal. The
recommended number of cortices on each side of
the fracture is seven in the femur, six in the tibia or
humerus, and five in the radius or ulna.
Circumstances may dictate the use of a longer plate
that has more holes than required. The question
arises whether all of the holes should be filled.
Placement of a screw limits micromotion and
reduces stress by increasing the area of surface
contact between the plate and the bone. On the
other hand, every drill hole in bone represents a site
of stress concentration and a point of potential
fracture. Brooks and colleagues found that a single
hole can reduce overall bone strength by 30%.
However, leaving screw holes empty may cause
concern about plate failure. Plates can fail because
of stress concentration caused by the fracture type
or by the screw hole itself. A short defect has an
increased stress concentration because the forces
are distributed over a smaller area than with a
longer, more oblique defect.
Figure 3.4-26: A typical antiglide plate which acts as a
“Dynamic Compressor” at the fracture site, as well
In addition, the screw hole is the plate's weakest
portion because it has the highest stress
concentration. Stress equals force divided by area;
the presence of a screw hole reduces the area of the
plate, so the stress on the plate is greater at the
screw hole.
Although each hole in the plate acts as a stress
concentrator, the load experienced at each hole
relates to its location in terms of the fracture site
and the shape and stability of the fracture. Empty
holes at the ends of the plate experience less stress
than those closer to the fracture. Pawlik and
associates reported bending strains for screws
proximal to the fracture at 240 με and for those
distal to the fracture at 87 με under bone-to-bone
contact conditions. Filling of these holes is of limited
value because the screw does not reinforce the plate
and may needlessly increase the risk of fracture at
the screw site. When a long plate is used, it is
desirable to intersperse screws and open holes at
the ends of the plate while concentrating screw
placement close to the fracture site.
Empty screw holes in bone, both those drilled but
not filled and those left after screw removal, weaken
the bone. Burstein and co-workers reported 1.6
times greater stresses around empty holes than in
the surrounding bone when in torsion. Within
approximately 4 weeks, these holes are filled with
woven bone, which eliminates the stress-
concentrating effect. This point is important for
postoperative management after implant removal.
BONE-PLATE FIXATION RIGIDITY
It is crucial to realize that the plate and the bone
together form a mechanical construct with some
load supported by the plate and some load passing
between bone fragments. In general, the in vivo
loading on a bone-plate system is complex and
includes axial, bending, torsional, and shear loads.
The structural characteristics of the bone and the
plate are also complex. For example, the cross-
sectional shape of long bones and the material
properties of the bone tissue vary along the length.
Additionally, the plate cross section is generally not
rectangular, because the long edges of the cross
section are slightly curved to conform
approximately to the circumferential shape of the
bone. Also, the plate is often deformed plastically
(twisted and bent) in the operating room to better
conform to the bone along its length. Finally, the
plate is not bonded to the bone, but is attached at
discrete points with screws. Therefore, changes in
the plate, the bone, or the interface between plate
and bone can dramatically influence the mechanical
environment of a fracture. The interaction between
plate and bone is also load dependent; the plate may
improve stability for one type of loading much more
than for other types of loads.
The purpose of the plate in the near term is to
hold the fragments in apposition as the bone heals,
while providing the load-carrying capabilities lost
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
because of the fracture. During this time, the
behavior of the construct is further complicated by
any small gaps that exist between the fragments. As
the bone-plate system is loaded, these gaps can
close (or open), which adds further complexity to
the structural analysis problem.
In the short term and in the long term, there may
be situations where the plate carries the lion's share
of the load. This occurs in the short term if the
fracture is so severe that the load in the bone cannot
be transferred across the fragments of the fracture.
In the long term, stress shielding may cause the
structural rigidity of the bone to decrease with
respect to the plate, which can further decrease the
stresses in the bone and further decrease the
structural rigidity of the bone. The potential exists
for the process to enter a vicious cycle until,
eventually, the plate itself is taking the load. The
concern then is that the plate may be at risk of
failure.
Several factors are effective on bone-plate fixation
rigidity. These are:
1. Geometry and material of plate
2. Placement of plate relative to loading forces
3. Bone-screw interface
4. Induction of compressive stress between bone
fragments
5. Quality of bone
6. Surface area of bone-plate interface
7. Type, number, direction, and location of
screws
Based on these factors, a surgeon can decide
whether to achieve rigid fixation or flexible fixation.
Geometry and material of plate
The plate can be approximated by a rectangular
cross section; the area moments of inertia about the
two axes are the well-known expressions:
Izz=wh3/12 Iyy= wh3/12
where the h is the smaller dimension and w is the
larger dimension of the cross section of the plate
shown in Figure 8.6. The expression for the
torsional constant of a rectangular cross section is
more complicated, but can be approximated by the
expression
J= k. wh3/16
where the parameter k is a shape factor that gives
good approximation to the exact value, which is
determined from a series solution for the torsion
problem. Similarly, the maximum shear stress for a
rectangular cross section is given approximately by
Tmax= k1. T(h/2)/J
Where T is the applied torque, J is as previously
defined. We can express the torsional strength
(maximum allowable torque) as
Tmax= [J/k1(h/2)](SD)T
where (SD)T is the maximum allowable shear
stress. Recall that the maximum shear stress occurs
at the midpoint of the longer side, which is the
shortest distance from the plate centroid to the
surface. This rather counterintuitive fact seems
contrary to the result for the circular section, but is
145
an important feature of torsion of noncircular
sections.
The bending stiffness of a bone plate with a
rectangular cross-section is related to the third
power of the plate thickness, whereas the bending
stiffness is directly proportional to the width or
elastic modulus of the plate. Therefore, plate
stiffness can be changed more by plate thickness
than plate width or modulus, with the limitation
that thick plates may not be possible in regions with
limited overlying soft-tissue thickness.
Placement of plate relative to loading
forces
The location of the plate (tension vs. compressive
side of the bone) is an important factor in the
biomechanics of bone plates. This is because
application of a bone plate will change the moment
of inertia of the plate-bone system compared with
an intact bone. With uniform axial loads, the stress
throughout a cross-section of intact bone will be
relatively constant. With application of a bone plate,
a combination of bending and axial stresses will be
realized in the same cross-section of bone.
Subjected to bending loads, a plated bone can be in
a bending open or bending closed configuration.
The placement of the plate relative to the loading
direction will determine the proportion of the loads
supported by the plate. Although experimental
efforts have shown that preloading a fracture gap
through compression plating can increase fracture
stability, a static preload does not necessarily affect
the pattern of bone remodeling, with the main
difference being prevention of motion-induced
resorption at the fracture gap that can occur if the
fracture gap opens and closes with loading. When
placing the plate on the "opening" side of the
fracture under normal loads, the bone fragments
are allowed to close on each other, and the effective
stiffness and strength across the fracture site can be
as great as or greater than the parent bone. Also, it
is obvious that for most properties, except possibly
torsion, the combined behavior of the bone and
plate is in fact much stiffer and stronger than the
original parent bone by itself. As we have already
noted, this actually causes reduced stresses in the
bone when the bone and plate work together. This
is the so-called stress-shielding problem, which
results in bone loss because the stresses in the bone
fall below their normal values. It also may be
responsible for slowed maturation of the new bone
at the fracture site. The size of the callus formed has
been shown to be related to the proportion of the
loads that are supported by the plate.
The local mechanics within an oblique or
comminuted fracture are significantly more
complicated than with a transverse osteotomy.
Insufficient bone to support ideal compression plate
fixation can compromise bone healing. If contact
between bone fragments cannot be achieved, there
are situations in which the risk of plate failure will
146 Plate Fixation in Orthopaedics
be reduced if the plate is applied to the compression
side of the bone.
Several studies have concluded that early porosis
noted beneath bone plates during the first 6 months
is due to the plate shielding bone from functional
stresses, although it is also attributed to the effect of
the plate on the blood supply. Early in fracture
healing, the porosis noted beneath bone plates is
likely due to disruption of the blood supply to the
bone caused by the contact between bone and plate.
Plate-bone contact has been shown to result in
porosis by 1 month after surgery. There are four
arguments in support of vascular disruption as the
cause of porosis beneath bone plates. First, the
porosis beneath plates appears to be a temporary,
intermediate stage in bone remodeling in response
to surgery. Second, the bone-remodeling pattern is
better explained by the pattern of vascular
disruption than by the stress distribution beneath
the plate. Third, in a comparative study of plastic
plates and steel plates, more porosis was noted
beneath the plastic plate, even though the steel
plate should provide substantially more stress
shielding. The fourth supporting argument is that
porosis beneath bone plates can be substantially
reduced by use of plates that provide improved
circulation.
Quality of bone
The mechanical properties of bone will also affect
the behavior of the plate-bone system. For example,
less stiff bone will increase the load sharing
contribution of the plate. In addition, osteoporosis,
osteopetrosis, or other bone diseases may affect
bone remodeling at the plate-bone or screw-bone
interfaces and thus affect the mechanical
performance of the plated bone. However, the role
of bone properties in fracture fixation with bone
plates has yet to be investigated. Most in vivo
animal studies and ex vivo studies of plate fixation
examined the biomechanics of plates applied to
osteotomized bones in which reduction and
compression of bone fragments could be achieved.
In cases of highly comminuted fractures or when
bone defects need to be stabilized, adequate
reduction and stability are more difficult to achieve.
In these cases, the mechanical demands on the plate
will be increased, since load transmission between
bone fragments may not be possible and all loads
must pass through the plate.
Bone-plate interface
Loads can be transmitted between plate and bone
through the bone screws and through mechanical
interlocking or frictional forces between the plate
surface and bone.
Stability in plate fixation of fractures relates to the
motionless fastening between plate and bone. When
the plate is affixed to the bone, high shear force may
appear between plate and bone, particularly near
the end screws, which can lead to motion under
weight-bearing. Two mechanisms might be involved
in the prevention of motion: the bending stiffness of
the screws or the friction between the screw and
the plate.
High frictional compressive forces will develop
between conventional plates and the bone by
tightening of screws. This frictional force prevents
the sliding motion between plate and bone during
loading and helps to reduce shear forces on screws
at the bone-plate interface.(Fig 3.4-27) The factors
affecting the amount of friction are the surface
roughness of the plate and compressive force
applied during tightening of the screws.
Experiments performed in vivo and in vitro show
that friction depends upon the axial force of the
screw, pressing the plate onto the bone. The torque
applied to the screws is crucial. The contribution of
surface roughness of the plate stabilization is
controversial, but recent studies show that this
roughness contributes to high stabilization in
conventional nonlocking plates. Motion appears
under smooth plates under relatively low
physiological loads. The major disadvantage of this
friction mechanism in conventional plates is that the
compressive forces will damage the blood supply in
the bone underneath the plate. The bone
underneath the plate may become weakened due to
temporary porosity resulting from internal
remodeling. The solution to this problem while
preventing the slippage of plate is the internal
fixator, whereby the screws no longer press the
plate onto the bone, but act as firmly oriented bolts.
With these newly developed internal fixators, the
motion is prevented by the structural stiffness of
the plate-screw system.
Number of screws in a plate
In plate fixation using the tension band technique,
the screw farthest from the fracture site is loaded
more than the screws near the fracture site during
bending. Keeping the length of the plate constant,
with the increase in number of screws, there is a
decrease in the magnitude of load on each screw.
With more screws, the fixation is more rigid and
there is less tendency of failure due to screw pull-
out. However. more screws weaken the bone. Hence
we need to strike a balance with the appropriate
number of screws.
Figure 3.4-27: In standard plate and screws, the friction
between plate and bone acts as the mechanism of construct
stability
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
Influence of screw placement relative to
the fracture site
The screws enable the plate to conform to the bone
surface. Minimizing the distance between the
nearest screws on either side of the bone fragments
(also called working length) increases stiffness at
the fracture (ie, reducing gap motion). The plate
stress within this short working length is also
higher. When the innermost screws are further
away from the fracture site, the working length of
the plate is greater, allowing bone deformation and
gap opening, but there is better stress distribution
in the plate.(Fig 3.4-28) The farthest screws
determine the effective usage of plate length and
contribute to fracture gap stability. Long plates not
only help in overall fracture stability, but also
reduce internal plate stress with less likelihood of
fatigue failure.(Fig 3.4-29) Analysis of the influence
of the distance between the screws and the location
of the nearest screws from the fracture site on the
forces in the screws and the fracture gap have
confirmed this. It is also important to balance the
spacing between the screws with respect to overall
plate length on either side of the fracture.
Differential stiffness may lead to one-sided fixation
failure, especially in the softer metaphyseal bone.
For plates extending from diaphysis to epiphysis,
fewer screws are required in the former and more
Figure 3.4-28: Influence of “Working Length” of a plate on gap strain. When the innermost screws are further away from the
fracture site, the working length of the plate is greater, allowing bone deformation and gap opening, but there is better stress
distribution in the plate. C) Basic concept of “working length”.
147
screws needed in the latter to achieve stiffness-
balanced fixation.
COMBINED BEHAVIOR OF BONE
AND PLATE
In the long term, after healing has occurred, the
plate may become something of a liability. The bone
becomes capable of carrying the entire load itself,
but must share the load with the attached plate. Our
goal is to understand the fundamental behavior of
bone-plate systems after healing has occurred. As
mentioned earlier, if the plate carries a substantial
part of the in vivo load, less bone tissue is needed
than when it carried the entire load, and it may
change both its density and geometry due to the
stress shielding of the device.
The concept of working length introduced with
intramedullary devices is also applicable to bone
plates. The working length of the plate, especially in
the bending open configuration, is greater when the
inner screws are not placed. Maximum plate
deflection is approximately proportional to the
square of the working length, so large decreases in
bending rigidity occur when the inner screws are
not used. (Fig 3.4-28)
C.
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
Figure 3.4-29: Long plates help in overall fracture
stability; increased plate length, both increases the working
leverage of the screws, leading to decreased pull-out force on
the screws, and reduces internal plate stress with less
likelihood of fatigue failure
It should also be noted that when a plate is used,
the stress is not very sensitive to the relative
bending stiffness of the plate with respect to the
bone. The stress is very sensitive, however, to the
relative axial stiffness of the plate with respect to
the bone, because this ratio determines the location
of the neutral axis. When the plate is applied to the
bone, the neutral axis moves from the centroid of
the bone to a location close to the plate; and the
load, which was axial with respect to the bone alone,
now produce a bending moment with respect to the
neutral axis of the bone-plate system. When the
intramedullary rod is used, the neutral axis of the
bone-rod system remains at the centroid of the
bone. As a result, the stress in the bone is much less
sensitive to the normalized axial stiffness of the rod
with respect to the bone than when a plate is used.
SPECIFIC PLATE DESIGNS
An important concept is that different plates can be
used for various biomechanical problems. Some
plates are specifically designed for function; others
can be functionally modified for the same
application. The idea of design versus function
versus anatomic location is important for the
general understanding of plates. For example, the
LCDC plate is designed primarily as a self-
compression plate, but it can also be used as a
bridging plate or tension band plate or further
modified as a medial femoral condylar buttress
plate. Therefore, depending on anatomic location
and bending modification, it can function in most
other biomechanical applications.
To understand the decisions orthopaedic
surgeons make in using different plates for different
applications, it is important to have a general
understanding of the different types of plates
manufactured and the mechanics of their designs.
This section includes the basic designs such as DC
plates, LCDC plates, point contact (Schuhli) plates,
semi-tubular and one-third tubular plates,
148
reconstruction plates, angled plates, and sliding
screw plates. Locking plates are addressed
separately.
DC Plate
The special geometry of the DC plate hole allows for
two basic functions: independent axial compression
and the ability to place screws at different angles of
inclination. Perren and colleagues designed a screw
housing in which an inclined and a horizontal
cylinder meet at an obtuse angle, permitting a
downward and horizontal movement of the screw
head for axial compression in one direction.
Sideways movement of the screw head is
impossible. There are three areas in which to place
a screw in an oval hole: one at each end
(eccentrically) and one in the middle
(concentrically).
The plate can be placed for neutralization,
compression, or buttressing, depending on the
insertion of the screw. In the neutral mode, the
screw is placed in a relatively central position. In
actuality, this neutral position is 0.1 mm eccentric,
causing horizontal displacement of the plate that
results in minimal axial compression.
In the compressive mode, the screw is inserted
1.0 mm eccentrically to its final position in the hole
on the side away from the fracture site. When the
screw is tightened, its head slides down along the
inclined plane, merging the eccentric circles and
causing horizontal movement of the plate (1.0 mm).
This results in fracture compression, assuming that
a plate screw has previously been inserted to affix
the plate into the other fracture fragment.(Fig 3.4-
30 A) This procedure can produce a maximum of
600 N of axial compression if anatomic reduction of
the fragments is accomplished. One screw in
compression produces 1 mm of displacement, and
the horizontal track in the hole still permits a
further 1.8 mm of gliding. A second load screw can
therefore be inserted into the next hole without
being blocked by the first screw, producing another
1.0 mm of horizontal movement. This is sometimes
referred to as double loading.(Fig 3.4-30 B,C)
In buttress mode, the screw is placed eccentrically
in the horizontal tract closest to the fracture. This
position results in no horizontal movement of the
plate when an axial load is placed. Under certain
circumstances, the screw position may not be
perpendicular to the plate. The design of the DC
plate allows for inclined insertion of the screw head
up to angles of 25° longitudinally and 7° laterally.
The DC plate can be modified for use in most
biomechanical applications of fracture fixation, and
its use is based on fracture pattern and location.(Fig
3.4-31)
Certain shortcomings of the DC plate have been
discovered through the years. These include a large
area of undersurface contact, which can lead to an
interference with the periosteal blood supply. This
effect is thought to be a reason for plate-induced
osteoporosis and the possible danger that a
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
sequestrum could form underneath the plate. Also, a
soft spot in fracture healing can occur where the
periosteal surface of the bone is in contact with the
plate. This defect may act as a stress riser because it
increases the mechanical stress locally; therefore,
the possibility of refracture after plate removal is
increased.(Fig 3.4-32)
Another shortcoming is that the design of the
plate limits static compression to one site. This
occurs because the orientation of the inclined
planes within the screw holes points in one
direction on either side of the plate center. The plate
center is defined as a small area of the plate with no
screw hole. These inclines oppose each other, so
compression can occur only at a single site.(Fig 3.4-
30)
Because the plate is of uniform width, the holes
produce areas of increased stress and decreased
stiffness, causing uneven stiffness in the entire
plate. With contouring, the plate bends
preferentially through the holes rather than with
even distribution, further increasing stress at the
screw holes and the risk of implant failure. (Fig 3.4-
33)
A
Figure 3.4-30: A) Single compression, B and C) Double
compression
Figure 3.4-31: Application of a DCP in Buttress
function
149
LC-DC Plate (Limited Contact)
The LCDC plate is a modification that attempts to
correct some of the design shortcomings of the DC
plate. Based on work by Klaue and Perren, there are
three main differences in design. First, the sides of
the plate are inclined to form a trapezoidal cross
section interrupted by undercuts that form arcs.(Fig
3.4-34) This design reduces the area of contact
between the plate and the periosteal surface of the
bone, decreasing the disturbance of the blood
supply and allowing for periosteal callus formation
under the plate- decreasing stress concentration at
an unhealed fracture gap.(Fig 3.4-35) However, the
extent of the contact also depends upon the
relationship of the radii of curvature of the plate
and the bone. When the radius of curvature of the
undersurface of the plate is larger than that of the
bone, plate contact may be in a single line, and this
reduces the advantages of the LC-DCP when
compared to the flat undersurface of the DCP. If the
situation is reversed and the plate has a smaller
radius of curvature than the bone, there will be
contact at both edges (two-line contact), and the
lateral undercuts of the LC-DCP will significantly
reduce the area of contact. (Fig 3.4-36) Second, the
screw hole is made up of two inclined and one
horizontal cylinder; they meet at the same angle,
permitting compression in both directions. As a
result, compression can be achieved at multiple
sites between screw holes, which is of value in
treating certain segmental and comminuted
fractures. (Fig 3.4-37)
Figure 3.4-32: Interference of under surface of DCP
with the periosteal blood supply
Figure 3.4-33: With contouring, DCP bends
preferentially through the holes rather than with even
distribution, increasing stress at the screw holes and the risk
of implant failure.
150 Plate Fixation in Orthopaedics
Figure 3.4-34: LC-DCP with a trapezoidal cross section
interrupted by undercuts.
Figure 3.4-35: Decreased area of contact between LC-
DCP and the periosteal surface of the bone.
A. B.
Figure 3.4-36: The decrease in the contact area between
LC-DCP and bone depends on the curvature of the bone. A)
When the radius of curvature of the undersurface of the plate
is larger than that of the bone, plate contact will be in a
single line. In this situation, the DCP and LC-DCP will have
similar areas of contact. B) If the plate has a smaller radius of
curvature than the bone, there will be contact at both edges,
so, the lateral undercuts of the LC-DCP will significantly
reduce the area of contact
Figure 3.4- 37: The screw hole of a LC-DCP is made
up of two inclined and one horizontal cylinder; they meet at
the same angle, permitting compression in both directions.
Third, because of the undercut design, the
stiffness between screw holes is relatively similar to
that across the screw holes. As a result, stress is
more equally distributed, less deformation occurs at
the screw holes when contouring, and fewer stress
risers exist within the plate. The more uniform
cross-sectional area along the plate decreases the
amount of stress concentrated at the screw holes.
The undercuts also allow for an increase to 40° of
screw horizontal tilt. The biomechanical uses and
applications of the LCDC plate are the same as those
for the DC plate.
Point Contact Fixators
Point contact fixators (PCF) are the first generation
of the locking plates. In these plates, the
undersurface is designed so that the contact
between the plate and the bone is reduced to some
points.(Fig 3.4-38) the other specification is the
conical design of the screw hole to accommodate
the screw head similar to a locking mecganism.
A Schuhli device (Fig 3.4-39), which is one of the
PCFs, consists of a three-pronged nut and a washer.
It functions to lock a cortical screw to a plate if
pullout failure due to osteopenic bone is a concern,
and to elevate the plate from the bone, decreasing
periosteal blood flow compromise. It elevates the
plate from the periosteal surface farther than the
LCDC plate does. The nut engages the screw and
locks it to the plate at a 90° angle, producing a fixed
angle construct. This device has been shown to be
effective in withstanding both axial and torsional
loads to failure.
Semi-Tubular, One-Third Tubular and
Quarter-Tubular Plates
The semi-tubular plate was the first AO self-
compression plate designed in the shape of a half-
tube. It provides compression through eccentrically
placed oval plate holes. It maintains its rotational
stability with edges that dig into the side of the
periosteum under tension. The semi-tubular plate is
1 mm thick and very malleable, so it is prone to
fatigue and fracture, especially in areas of high
stress. Its main indication is for tension resistance,
as in the treatment of open-book injury of the
pelvis. The one-third tubular plate is commonly
used as a neutralization plate in the treatment of
lateral malleolar fractures.(Fig 3.4-40) The quarter-
tubular plates have been used in small bone fixation
(e.g., in hand surgery).
Reconstruction Plate
This plate is designed with notches in its side so that
it can be contoured in any plane.(Fig 3.4-41) It is
mainly used in fractures of the pelvis, where precise
contouring is important in reduction. The plate is
not as strong as the LC-DCP and may be further
weakened by heavy contouring, so sharp bends in
any direction should be avoided. It can also be used
for fixation of distal humerus and calcaneal
 Biomechanics of Bone Tissue & Orthopaedic Hardwares 151

fractures. The plate has relatively low strength,

which is further diminished with contouring. It
offers some compression because of its oval screw
holes.

Angled Plates
Angled plates were developed in the 1950s for the
fixation of proximal and distal femur fractures. They
are a one-piece design with a U-shaped profile for
the blade portion and a 95° or 130° fixed angle
between the blade and the plate. The shaft is thicker
than the blade and can withstand higher stress. This
detail is important because the subtrochanteric
region is the most highly stressed region of the Figure 3.4-38: Reduction in plate-bone contact: Top,
skeleton, a fact that predisposes the region to DCP; Middle, LC-DCP; Bottom, PCF
fixation failure. The forces applied in this area
exceed 1200 lb/in, with the medial cortex exposed
to compression combined with greater stress and
the lateral cortex exposed to tension.

The 130° Blade Plate(Fig 3.4-42 A)

The 130° blade plate was originally designed for
fixation of proximal femur fractures and has
different lengths to accommodate different fracture
patterns. The 4- and 6-hole plates are used for
fixation of intertrochanteric fractures, while the 9-
to 12-hole plates are used for treatment of
subtrochanteric fractures. The placement of the
blade is critical; improper placement can lead to
various healing deformities. In the femoral head,
there is a zone where the tension and compression
trabeculae intersect. The plate is inserted so it is Figure 3.4-39: The Schuhli device
below this trabecular intersection (6 to 8 mm above
the calcar) and in the center of the neck, with no
anterior or posterior angulation. The use of this
device depends on the specific biomechanics and
angulation of the fracture site. It has been replaced
for the most part by the dynamic hip screw, which
allows for compression of the fragments.

The 95° Condylar Blade Plate(Fig 3.4-42 B)

The 95° condylar blade plate was designed for use
with supracondylar and bicondylar distal femur
fractures, and the length employed is also fracture
specific. It can be used for subtrochanteric fractures
where more purchase on the fracture fragment can
be gained with a sharper angled plate. With the
130° blade plate, the blade enters the proximal
femoral fragment close to the subtrochanteric
fracture site, precluding insertion of plate screws
into the proximal fragment. In contrast, the blade of
the 95° blade plate can be introduced into the
proximal fragment just below the tip of the greater
trochanter, allowing placement of screws proximal
to the fracture site into the calcar for added
stability. Although the device is strong and provides
stable fixation, its insertion is technically Figure 3.4-40: One-third tubular plates: with addition of
demanding. The need for precise alignment in all the “collar” (black arrow), plate-screw-bone coupling is
three planes demands careful preoperative planning improved, since the screw head does not protrude through the
and intraoperative radiographic control. plate anymore.
152 Plate Fixation in Orthopaedics

do not cross the fracture site. In these

circumstances, the lag screw acts only as a fixation
device and does not contribute to fracture
compression by sliding.
The second principle is that the lag screw must
slide far enough through the barrel to allow the
fracture gap to close sufficiently for the proximal
and distal fragments to impact completely. Sliding
does not occur as desired if the bending forces
(from weight-bearing and muscle contraction) on
the lag screw cause it to impinge and bind(Fig 3.4-
44). The lag screw slides more predictably through
a longer barrel because it provides more support.
Some sliding hip screw systems include two side
Figure 3.4-41: Reconstruction plate and its versatility to plates, with one long and one short barrel. Usually,
be bent in any direction the long barrel is chosen to ensure adequate
support and unimpeded lag screw sliding. Lag
screws are available in varying lengths (60 to 120
mm) to accommodate patient anatomy and fracture
configuration. If a lag screw of 80 mm or smaller is
used, there may not be enough space between the
base of the threads on the screw and the tip of the
long barrel to allow full impaction of the fracture. In
this small proportion of cases, the short-barrel side
plate should be used. Some of these systems are
slotted and provide rotational control as a result.
However, the fragment still may rotate around the
screw itself despite implant geometry. Various
A. B. manufacturers produce systems containing a range
of side plate-lag screw angles; the angle used
Figure 3.4-42: Angled plates, A) 135o blade plate, B) depends on the fracture configuration and the
patient's anatomy. The basic principle of these
o
95 condylar blade plate
devices is that they collapse and shorten to
accommodate comminution, osteopenia, and bone
lysis at the fracture site.
Sliding screw and compression plates

Compression/Telescoping hip screw

The compression/telescoping or sliding hip screw
system is designed for internal fixation of
basicervical, intertrochanteric, and selected
subtrochanteric fractures. It uses the principle of
dynamic compression, which modifies functional
physiologic forces into compression at the fracture
site. The implant consists of two major parts: a
wide-diameter cannulated lag screw that is inserted
into the femoral head and a side plate with a barrel
at a set angle that is attached to the femoral shaft.
Weight-bearing and abductor muscle activity cause
the screw shaft to slide through the barrel, resulting
in impaction of the fracture surfaces and, optimally,
a stable load-sharing construct.
Two basic principles must be recognized when
using a sliding hip screw. The first is that fracture
compression can occur only if the lag screw and
barrel are inserted across the fracture site. This
occurs when a sliding hip screw is used to fix a
fracture at the base of the femoral neck or in the
intertrochanteric area(Fig 3.4-43). In contrast,
when a sliding hip screw is used to fix a high Figure 3.4-43: Dynamic compression mechanism can
subtrochanteric fracture, the lag screw and barrel work only if the lag screw and barrel are inserted across the
are located exclusively in the proximal fragment and fracture site
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
Figure 3.4-44: The greater the length of the sliding
screw within the barrel, the lower its resistance to sliding.
A Helical plating(Fig 3.4-46)
B providing good stability at the fracture site.
Figure 3.4-45: A) Dynamic Condylar Screw, B) 95o
Side-Plate
Dynamic Condylar Screw
The condylar compression screw system has
basically the same design as the 95° condylar blade
plate except that the blade is replaced by a
cannulated screw. The angle between screw and
plate is fixed at 95°, in contrast to the sliding hip
screw, which allows different angles to be selected.
The compression generated by the large cannulated
screw placed across the femoral condyles permits
greater compression of the fracture fragments than
can be achieved with a blade plate. The plate is
contoured to fit the distal end of the femur. It is a
two-piece device that can allow for some correction
in the lateral and coronal planes after the lag screw
is inserted, unlike a blade plate. This system is used
for fixation of low, supracondylar, and intercondylar
T- and Y-fractures.
153
Figure 3.4-46: Helical Plating technique for Humerus
Precise positioning of the implants is critical for
fixation and proper alignment. If the screw is
inserted in a valgus position (angled away from the
midline), a varus deformity will develop on healing.
Conversely, if the plate is angled in varus (toward
the midline), a valgus deformity will develop. The
screw systems allow for some correction of
alignment, whereas blade plates do not, and,
correspondingly, are technically more forgiving.
The concept of a helical plate was first introduced
by Fernandez. This plate offers distinct clinical
advantage; for instance helical contouring takes into
account the anatomy of the humerus with respect to
the radial nerve. In the Finite Element Method
(FEM) analysis, the helical plate was more effective
in bearing the tensile force (diagonal to the bone
axis) generated during torsional loading thus
During torsion, the bone is weakest in tension and
a helical plate protects the bone in the same
direction. In bending, the helical plate protects the
fracture by not allowing the callus to be under
tension, while away from the fracture site the
helical plate allows the bone to bear both tensile
and compressive stress generated due to bending.
Thus, the bone away from fracture is not shielded
from stress due to the helical shape of the plate.
Under axial loading, the fracture gap closure is quite
uniform, unlike that with the conventional straight
plate.
However, in all loading conditions the helical
plate is highly stressed at the screw holes near the
fracture site. The screws nearest to the fracture site
are concomitantly high loaded compared with the
other screws in compression and torsion, while in
the case of bending, stress is distributed more
toward the farther screws. Hence, in general helical
plates will provide good fracture stability in torsion
and reasonable stability in bending, while reducing
stress shielding of the bone.
154 Plate Fixation in Orthopaedics
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
CHAPTER
BIOMECHANICAL ASPECTS
OF FRACTURE FIXATION
IN SPECIFIC LOCATIONS
CHAPTER OUTLINE
Fixation in the Proximal Femur
Fixation around the Metaphyseal
Region of the Knee
Fixation of the Humerus
In this section, the focus is placed on specific
challenging problems in fixation, including the
femoral neck, tibial plateau, pelvis, and spine.
FIXATION IN THE PROXIMAL
FEMUR
Fixation of fractures of the proximal femur is
particularly challenging because the compressive
force acting through the femoral head can range
from 4 to 8 times body weight during normal
activities. This force acts through a significant
moment arm (the length of the femoral neck), which
causes large bending loads on the fixation
hardware. In addition, many of these fractures
occur in the elderly, who are likely to have
155
3.5
trabecular bone of low density and poor mechanical
quality. Also, it is generally not possible to gain
screw purchase in the cortical bone of the femoral
head. The major force acting in, for example, a
basicervical fracture of the femoral neck, fixed with
a sliding hip screw is the joint reaction force
through the femoral head, which derives from body
weight and forces generated by muscle action
during ambulation. The joint reaction force can be
divided into two components.
One is perpendicular to the axis of the sliding
screw and causes shearing of the fracture surfaces
along the fracture line, which results in inferior
displacement and varus angulation of the femoral
head, and increases the resistance of the screw to
sliding. The other is parallel to the screw, driving
the surfaces together and enhancing stability by
156 Plate Fixation in Orthopaedics
frictional and mechanical interlocking of the
fracture. Therefore, the aim of femoral neck fixation
systems is to utilize the component of the joint force
parallel to the femoral neck to encourage the
fracture surfaces to slide together. This is the basic
principle behind selection of a higher angle hip
screw when possible.
When using the compression (or sliding) hip
screw, or a nail with a sliding lag screw, it is
important to ensure that the screw can slide freely
in the barrel of the side plate or the hole in the nail.
The following comments related to sliding hip
screw devices apply as well to nail lag screw
constructs. When screw sliding occurs, the screw is
supported by the barrel against inferior bending of
the femoral head because the construct is
buttressed by fracture interdigitation. Adherence to
two basic mechanical principles will enhance the
ability of the screw to slide in the bore of the side
plate or nail. As mentioned above, the higher angle
hip screw is more effective at accommodating
sliding. Also, the screw should be engaged as deeply
as possible within the barrel. For the same force
acting at the femoral end of the screw, the internal
force where the screw contacts the barrel is
increased if less of the screw shaft remains in the
barrel. This occurs because the moment (bending
load) caused by the force transverse to the axis of
the screw (at the femoral head) acts over a longer
moment arm or perpendicular distance. The
balancing moment arm is shorter because less of the
screw remains in the barrel. The internal force
where the screw contacts the barrel causes a
greater frictional resistance force, which requires
more force to overcome to permit sliding. Sliding
hip screws with either two- or four-hole side plates
appear to provide equivalent resistance to
physiologic compressive loading.
Several factors affect the strength of femoral neck
fixation using multiple screws, but the number of
screws used (three or four) is not a significant
factor. Factors that do increase the strength of this
type of fixation include a more horizontal fracture
line with respect to the long axes of the screws,
placement of the screws in areas of greater femoral
head bone density, fractures with less comminution
and a shorter moment arm for the joint load
(shorter distance from the center of the femoral
head to the fracture line). However, the most
important factor has been found to be the quality of
the reduction because of the importance of cortical
buttressing in reducing fracture displacement.
Under physiological load, several mechanisms of
failure of fixation have been observed. In some
cases the screws bend inferiorly, especially if
buttressing of the fracture surfaces inferior to the
screws is not possible because of comminution of
the fracture. The fixation screw heads, if no washers
are used to distribute the screw load against bone,
have been found to pull through cortex near the
greater trochanter when the cortex is thin. Finally, if
the screws are not well supported inferiorly where
they cross the fracture, they may rotate inferiorly
carrying the femoral head into a varus orientation.
Supporting at least one screw against the inferior
cortex may help prevent this from occurring. With
respect to the biomechanical performance of
different devices, the actual stiffness provided by
the sliding hip screw, the reconstruction nail, and
multiple pin constructs are quite similar, except that
the reconstruction nail offers significantly greater
torsional stiffness than the other forms of fixation
because of its tubular shape. New techniques
applied to proximal fracture fixation include the
femoral locking plate and percutaneous
compression plating. In fixation of the challenging
vertical shear fracture of the proximal femur, the
proximal femoral locking plate was found to
produce considerably stiffer constructs than
cannulated screws, a dynamic hip screw, or a
dynamic condylar screw. Percutaneous
compression plating has been found to provide
adequate bending and torsional stability and was
equivalent to the trochanteric antegrade nail in
fracture site stability, though it failed at about
3000N (about 3 times body weight) compared to
the ante grade nail at 3200N.
FIXATION AROUND THE
METAPHYSEAL REGION OF THE
KNEE
Both supracondylar femur and tibial plateau
fractures are challenging to stabilize because they
may involve fixation of multiple small fragments of
primarily cancellous bone. Supracondylar fixation
alternatives that have been compared mechanically
include condylar plates, plates with lag screws
across the fracture site, and blade plates. All devices
tested appeared to provide similar construct
stiffnesses. The most important factor identified for
plate fixation was maintaining contact at the cortex
opposite that to which the fixation device was
applied. Fixation constructs without cortical contact
were only about 20% as stiff as those with cortical
buttressing. Using a retrograde intramedullary
supracondylar nail was found to produce constructs
that were 14% less stiff in axial compression and
17% less stiff in torsion, compared with a fixed
angle side plate. However, longer nails (36 cm)
enhanced fixation stability compared to shorter
nails (20 cm). Several newer fixation systems have
been described for femoral supracondylar fracture
stabilization. The less invasive stabilization system
(LISS) uses a low-profile plate with mono cortical
screws distally which also lock to the plate. LISS
plates produced constructs with more elastic
deformation and less subsidence than those with a
condylar screw or buttress plate.
Tibial plateau fractures are challenging to
stabilize. Considering patient outcomes, the loss of
reduction was related to patients being more than
60 years old, premature weight bearing, fracture
 Biomechanics of Bone Tissue & Orthopaedic Hardwares
fragmentation, and severe osteoporosis. Different
methods of fixation include using wires or screws
alone, or screws placed through an L- or T-shaped
plate, which buttresses the cortex. Various
configurations of wires have been tested and show
that the stiffness of the construct increases with the
number of wires, regardless of their specific
orientations. Fixation with screws alone requires
that the screw resist bending forces as the tibial
fragment is loaded distally in compression through
the joint. With the addition of a plate, not only is the
load distributed to the plate, but additional screws
can be placed in the stronger cortical bone distal to
the metaphyseal region of the tibia. One
disadvantage of a buttress plate is the additional
invasiveness that it requires for installation with
potential compromise of blood supply. Fixation with
T plates and screws showed the greatest resistance
to an axial compressive load, regardless of the
specific configuration of the screws. Investigations
of different plate configurations found that for
bicondylar tibial plateau fractures, dual (lateral and
medial) side plating reduced subsidence under axial
loading by about 50% compared with single-sided
lateral locking plating. For medial plateau fractures,
the medial buttress plate, which supports the load
directly, is superior mechanically to a lateral locked
References:
Augat P., Burger J., Schorlemmer S., et al: Shear movement
at the fracture site delays healing in a diaphyseal fracture
model. J Orthop Res 2003; 21(6):1011-1017.
Bartel DL, et al. Orthopaedic biomechanics. First edit.
Pearson Prentice Hall. 2006.pp: 235-287
Claes L.: The effect of mechanical stability on local
vascularization and tissue differentiation in callus healing. J
Orthop Res 2002; 20(5):1099-1105.
Claes LA, Ito K. biomechanics of fracture fixation and
fracture healing. In Mow VC: basic orthopaedic
biomechanics and Mechanobiology, third edit. LWW. 2005.
pp: 563-584
Cordey J., Borgeaud M., Perren S.M.: Force transfer between
the plate and the bone: Relative importance of the bending
stiffness of the screws and the friction between plate and
bone. Injury 2000; 31:21-28.
Cornell C.N.: Internal fracture fixation in patients with
osteoporosis. J Am Acad Orthop Surg 2003; 11(2):109-119.
157
plate. A new alternative is the short proximal tibial
nail with multiple interlocking screws. In combined
axial loading, bending and rotation, the nail
provided stability equivalent to that of double
plating and was greater than constructs with a
locking plate, external fixator, or conventional
unreamed tibial nail.
FIXATION OF THE HUMERUS
Proximal humerus fractures fixed with locking
plates provided greater stability against torsional
loading but were similar to blade plate constructs in
bending, because both fixation devices are loaded as
tension bands in bending. In comparing different
types of blade plate constructs, the stiffest construct
employed an eight-hole, low-contact dynamic
compression plate, contoured into a blade
configuration, and fixed with a diagonal screw that
triangulates with the end of the blade. This
arrangement was considerably stiffer than other
blade plates or T plate and screw constructs. One
potential problem is penetration of the screws
through the subchondral bone in osteoporotic
patients.
Egol KA, et al. Early Complications in Proximal Humerus
Fractures (OTA Types 11) Treated With Locked Plates. J
Orthop Trauma 2008;22:159–164
Dong X.N., Guo X.E.: The dependence of transversely
isotropic elasticity of human femoral cortical bone on
porosity. J Biomech 2004; 37(8):1281-1287.
Floyd JC, et al. Biomechanical Comparison of Proximal
Locking Plates and Blade Plates for the Treatment of
Comminuted Subtrochanteric Femoral Fractures. J Orthop
Trauma 2009;23:628–633
Frankel VH, Nordin M, Biomechanics pf bone. In: Noredin,
Basic biomechanics of musculoskeletal system. Third edit.
LWW. 2001.pp:26-60
Frankle M., Cordey J., Sanders R.W., et al: A biomechanical
comparison of the antegrade inserted universal femoral nail
with the retrograde inserted universal tibial nail for use in
femoral shaft fractures. Injury 1999; 30(suppl 1):A40-A43.
Frigg R. Development of the Locking Compression Plate.
Injury. 2003;34: B6–10.
Gardner MJ, Brophy RH, Campbell D, et al. The mechanical
behavior of locking compression plates compared with
158 Plate Fixation in Orthopaedics

dynamic compression plates in a cadaver radius model. J
Orthop Trauma. 2005;19:597–603.
Goesling T, Frenk A, Appenzeller A, et al. LISS PLT:
design, mechanical and biomechanical characteristics. Injury.
2003;34:A11–15.
Goldstein C, et al. Electrical Stimulation for Fracture
Healing: Current Evidence. J Orthop Trauma 2010;24:S62–
S65
Goodship A.E., Kenwright J.: The influence of induced
micromovement upon the healing of experimental tibial
fractures. J Bone Joint Surg Br 1985; 67(4):650-655.
Perren S.M.: Evolution of the internal fixation of long bone
fractures: The scientific basis of biological internal fixation:
Choosing a new balance between stability and biology. J
Bone Joint Surg Br 2002; 84(8):1093-1110.
Roderer G, et al. Minimally Invasive Application of the Non-
Contact-Bridging (NCB) Plate to the Proximal Humerus: An
Anatomical Study.J Orthop Trauma 2007;21:621–627
Stoffel K, Lorenz KU, Kuster MS. Biomechanical
Considerations in Plate Osteosynthesis: The Effect of Plate-
to-Bone Compression With and Without Angular Screw
Stability.J Orthop Trauma 2007;21:362–368

Hipp JA, Hayes WC. Biomechanics of fractures. In Browner: Terjesen T., Apalset K.: The influence of different degrees of
skeletal trauma. 4th edit. 2008. Saunders company. Chapter 3 stiffness of fixation plates on experimental bone healing. J
Orthop Res 1988; 62:293-299.
Huiskes R., Chao E.Y.S.: Guidelines for external fixation
frame rigidity and stresses. J Orthop Res 1986; 41:68-75. Yeni Y.N., Fyhrie D.P.: A rate-dependent microcrack-
Huiskes R, van Rietbergen B. biomechanics of bone. In Mow bridging model that can explain the strain rate dependency of
VC: basic orthopaedic biomechanics and Mechanobiology, cortical bone apparent yield strength. J
third edit. LWW. 2005.pp: 123-180 Biomech 2003; 36(9):1343-1353.

Kenwright J., Richardson J.B., Cunningham J.L., et al: Axial Zioupos P., Currey J.D.: Changes in the stiffness, strength,
movement and tibial fractures: A controlled randomised trial and toughness of human cortical bone with age.
of treatment. J Bone Joint Surg Br 1991; 73(4):654-659. Bone 1998; 22(1):57-66.

Kummer FJ. Introduction to the biomechanics of fracture

fixation. In: Noredin, Basic biomechanics of musculoskeletal
system. Third edit. LWW. 2001.pp: 390-399

Leung F, Chow SP. A prospective, randomized trial

comparing the limited contact dynamic compression plate
with the point contact fixator for forearm fractures. J Bone
Joint Surg Am. 2003;85A:2343–2348.

Levangie PK. Biomechanical applications to joint structure

and function. In Levangie PK: joint structure and function.
Fourth edit. F A Davis. 2005.pp: 5-136

Lewallen D.G., Chao E.Y., Kasman R.A., et al: Comparison

of the effects of compression plates and external fixators on
arly bone-healing. J Bone Joint Surg Am 1984; 66:1084-
1091.
 Metallurgy 159

SECTION 4
METALLURGY
SECTION OUTLINE

CHAPTER 4.1 CHAPTER 4.6

Basic concepts 161 Corrosion resistant
orthopaedic alloys 197
CHAPTER 4.2
Structure of metals 165 CHAPTER 4.7
Role of kidney in handling
CHAPTER 4.3
metal ions 213
Metal processing 171
CHAPTER 4.8
CHAPTER 4.4
Surface coating of metals for
Corrosion 175
orthopaedics 221
CHAPTER 4.5
Stress-Strain relationship 189
160 Plate Fixation in Orthopaedics

CHAPTER
BASIC CONCEPTS OF
METALLURGY
CHAPTER OUTLINE
Metals
Definition
Properties
Chemical
Physical
Mechanical
Alloys
Metal implants are successful in fracture
stabilization because they reproduce the supportive
and protective functions of bone without impairing
bone healing, remodeling, or growth.
However, because there is no perfect material for
use in internal fixation, a variety of issues must be
examined when specific metals are considered as
surgical implants:
1) Biocompatibility—the material must be
systemically nontoxic, nonimmunogenic, and
noncarcinogenic
2) Strength parameters—tensile, compressive,
and torsional strength; stiffness; fatigue
resistance; and malleability are all important
aspects
3) Resistance to degradation and erosion
4) Ease of integration when appropriate
5) Minimal adverse effects on imaging.
Metallurgy 161
4.1
METAL
Metal [ME, fr. OF metal, metail, fr. L metallum metal,
mine, fr. Gk metallon mine (later, metal); prob. Akin
to Gk metallan]: any of a large group of substances
(as gold, bronze, steel) that typically show a
characteristic luster, are good conductors of
electricity and heat, are opaque, can be fused, and
are usually malleable or ductile. [Webster’s Third
New International Dictionary]
A metal is a chemical element that is a good
conductor of both electricity and heat and forms
cations and ionic bonds with non-metals. In
chemistry, a metal is an element, compound, or
alloy characterized by high electrical conductivity.
In a metal, atoms readily lose electrons to form
positive ions (cations). Those ions are surrounded
by delocalized electrons, which are responsible for
the conductivity. The solid thus produced is held by
162 Plate Fixation in Orthopaedics
electrostatic interactions between the ions and the
electron cloud, which are called metallic bonds.
Definition
Hence as describe above, metals are sometimes
described as an arrangement of positive ions
surrounded by a cloud of delocalized electrons.(Fig
4.1-1) They are one of the three groups of elements
as distinguished by their ionization and bonding
properties, along with the metalloids and non-
metals.
An alternative definition of metal refers to the
band theory. If one fills the energy bands of a
material with available electrons and ends up with
a top band partly filled then the material is a metal.
This definition opens up the category for metallic
polymers and other organic metals, which have
been made by researchers and employed in high-
tech devices.
Properties
Chemical
Metals are usually inclined to form cations through
electron loss, reacting with oxygen in the air to
form oxides over changing timescales (iron rusts
over years, while potassium burns in seconds).
Examples:
4 Na + O2 → 2 Na2O (sodium oxide)
2 Ca + O2 → 2 CaO (calcium oxide)
4 Al + 3 O2 → 2 Al2O3 (aluminium oxide)
Figure 4.1-1: Schematic presentation of Covalent,
Metallic and Ionic bonds
Physical
In materials science and engineering, typically
researchers categorize the materials behaviors into
their physical and mechanical properties. Physical
properties of metals in general cover the topics like
electrical, thermal, optical and magnetic properties.
From physical points of view, metals have high
electrical and thermal conductivity. Metals also
have high density and do not let the lightwaves
readily to transmit through their lattice. Hence,
metals are opaque. Along with their opacity, due to
the cloud of electron within the atomic structure of
metals, they have shiny and lustrous apparent.
The electrical and thermal conductivity of metals
originate from the fact that in the metallic bond, the
outer electrons of the metal atoms form a gas of
nearly free electrons, moving as an electron gas in a
background of positive charge formed by the ion
cores. Good mathematical predictions for electrical
conductivity, as well as the electrons' contribution
to the heat capacity and heat conductivity of metals
can be calculated from the free electron model,
which does not take the detailed structure of the
ion lattice into account.
Mechanical
In engineering, vast varieties of topics are covered
by the title of mechanical properties. Mechanical
properties consider ductility, elasticity, strength,
toughness and etc of materials.
Ductility is largely due to the metal’s inherent
capacity for plastic deformation. Reversible
elasticity in metals can be described by Hooke's
Law for restoring forces, where the stress is linearly
proportional to the strain. Forces larger than the
elastic limit, or heat, may cause a permanent
(irreversible) deformation of the object, known as
plastic deformation or plasticity. This irreversible
change in atomic arrangement may occur as a result
of:
The action of an applied force (or work). An
applied force may be tensile (pulling) force,
compressive (pushing) force, shear, bending or
torsion (twisting) forces.
A change in temperature (or heat). A temperature
change may affect the mobility of the structural
defects such as grain boundaries, point vacancies,
line and screw dislocations, stacking faults and
twins in both crystalline and non-crystalline solids.
The movement or displacement of such mobile
defects is thermally activated, and thus limited by
the rate of atomic diffusion.
Viscous flow near grain boundaries can give rise
to internal slip, creep and fatigue in metals. It can
also contribute to significant changes in the
microstructure like grain growth and localized
densification due to the elimination of intergranular
porosity.
In addition, the nondirectional nature of metallic
bonding is also thought to contribute significantly
to the ductility of most metallic solids. When the
planes of an ionic bond slide past one another, the

resultant change in location shifts ions of the same
charge into close proximity, resulting in the
cleavage of the crystal; such shift is not observed in
covalently bonded crystals where fracture and
crystal fragmentation occurs.
ALLOYS
An alloy is a mixture of two or more elements in
solid solution in which the major component is a
metal. Most pure metals are either too soft, brittle
or chemically reactive for practical use. Combining
different ratios of metals as alloys modifies the
properties of pure metals to produce desirable
characteristics. The aim of making alloys is
generally to make them less brittle, harder,
resistant to corrosion, or have a more desirable
color and luster. Of all the metallic alloys in use
Metallurgy 163
today, the alloys of iron (steel, stainless steel, cast
iron, tool steel and alloy steel) make up the largest
proportion both by quantity and commercial value.
Iron alloyed with various proportions of carbon
gives low, mid and high carbon steels, with
increasing carbon levels reducing ductility and
toughness. The addition of silicon will produce cast
irons, while the addition of chromium, nickel and
molybdenum to carbon steels (more than 10%)
results in stainless steels.
Other significant metallic alloys are those of
aluminium, titanium, copper and magnesium. The
alloys of aluminium, titanium and magnesium are
valued for their high strength-to-weight ratios;
magnesium can also provide electromagnetic
shielding. These materials are ideal for situations
where high strength-to-weight ratio is more
important than material cost.
164 Plate Fixation in Orthopaedics

CHAPTER
STRUCTURE OF METALS
CHAPTER OUTLINE
Crystal structure of metals
Unit cells
Cubic crystal system
Simple cubic structure
Body-centered cubic structure
Face-centered cubic lattice
Close-packed hexagonal structure
Grain boundaries
Anisotropy
Textures or preferred orientations
Metal atoms are held together in a crystal lattice
by the interaction of the valence electrons
(outermost electrons) with the positive metallic
ions. These nonlocalized electrons are free to move
throughout the solid because the valence electrons
are not tightly bound to the metal ions. Such an
arrangement is called the metallic bond. This
distinguishes it from the covalent and ionic bonds
present in polymers and ceramics, respectively. In
these other configurations, electrons are not free to
roam. The independent electrons in the metallic
bonds can quickly transfer electric charge and
thermal energy. As a result of the different binding
states of the electrons, there is a difference in
thermal expansion coefficient between metals and
ceramics. Because it is often desirable to coat
metallic implants with a bioactive ceramic film in
Metallurgy 165
4.2
order to improve implant fixation, the difference in
thermal properties between metals and ceramics is
an important issue, as this difference may be the
basis of destabilization of the coating.
As the electrons can move easily in metals,
neighboring atoms are weakly bonded, making
metals easily deformable. This facilitates wear,
except if special processing techniques are
employed with the intent to enhance bonding in the
metallic structure. As the number of valence
electrons increases down the periodic table, they
become more localized and the metallic bonds
become more directional, resulting in more brittle
metals. As the mechanical, chemical and physical
properties of metals can be improved by alloying,
most metals used in orthopaedic surgery are
alloyed.
166 Plate Fixation in Orthopaedics
As mentioned above, metals are crystalline when
in the solid form. The normal metallic object
consists of an aggregate of many very small crystals,
therefore, metals are polycrystalline. The crystals in
these materials are normally referred to as its
grains. Because of their very small sizes, an optical
microscope, operating at magnifications between
about 100 and 1000 times, is usually required in
order to examine the structural features associated
with the grains in a metal. Structures requiring this
range of magnification for their examination fall into
the class known as microstructure. Occasionally,
metallic objects, such as castings, may have very
large crystals that are discernible to the naked eye
or are easily resolved under a low-power
microscope. Structure in this category is called
macrostructure. Finally, there is the basic structure
inside the grains themselves: that is, the atomic
arrangements inside the crystals. This form of
structure to logically called the crystal structure.
THE CRYSTAL STRUCTURE OF
METALS
Analyzing the atomic arrangements within a solid
considerably facilitates studying the effect of bond
type on resulting material properties. Metal atoms
form unit cell configurations based on their inherent
atomic properties. These unit cells associate as a
latticework or crystalline formation. As molten
metal cools and solidifies, the crystals line up next to
each other and interdigitate to determine the
mechanical and chemical properties of the metal.
Microscopic defects or impurities alter the
crystalline structure and can change the mechanical
properties. The differences in the mechanical
behavior of metals are explained by their different
atomic structures; for example, crystals of stainless
steel are face-centered cubic, and titanium crystals
are hexagonal close-packed.
The word crystal is derived from the Ancient
Greek word κρύσταλλος (krustallos), meaning "rock-
crystal”.
A crystal is defined as an orderly array of atoms in
space. A crystalline material is a solid material,
characterized by long-range order and an infinitely
repeating unit cell of atoms/ions. A crystal structure
is composed of a pattern, a set of atoms arranged in
a particular way, and a lattice exhibiting long-range
order and symmetry. Patterns are located upon the
points of a lattice, which is an array of points
repeating periodically in three dimensions. The
points can be thought of as forming identical tiny
boxes, called unit cells, that fill the space of the
lattice. The lengths of the edges of a unit cell and the
angles between them are called the lattice
parameters. A crystal's structure and symmetry play
a role in determining many of its physical
properties, such as cleavage, electronic band
structure, and optical transparency. There are many
different types of crystal structures, some of which
are quite complicated. Fortunately, most metals
crystallize in one of three relatively simple
structures: the face-centered cubic, the body-
centered cubic, and the close-packed hexagonal.
Almost all metal exists in a polycrystalline state;
amorphous or single-crystal metals must be
produced synthetically, often with great difficulty.
Polymorphism refers to the ability of a solid to
exist in more than one crystalline form or structure.
According to Gibbs' rules of phase equilibria, these
unique crystalline phases will be dependent on
intensive variables such as pressure and
temperature. Polymorphism can potentially be
found in many crystalline materials including
polymers, minerals, and metals, and is related to
allotropy, which refers to elemental solids.
Polymorphs have different stabilities and may
spontaneously convert from a metastable form (or
thermodynamically unstable form) to the stable
form at a particular temperature.
Unit Cells
The unit cell of a crystal structure is the smallest
group of atoms possessing the symmetry of the
crystal which, when repeated in all directions, will
develop the crystal lattice. The unit cell is given by
its lattice parameters, the length of the cell edges
and the angles between them, while the positions of
the atoms inside the unit cell are described by the
set of atomic positions (xi, yi, zi) measured from a
lattice point. Even a small crystal will contain
billions of unit cells, and the cells in the interior of
the crystal must greatly exceed in number those
lying on the surface. In the interior of a crystal, each
corner atom of a unit cell contributes one-eighth of
an atom to a unit cell. In addition, each cell also
possesses an atom located at its center that is not
shared with other unit cells. It is frequently
convenient to consider metal crystals as structures
formed by stacking together hard spheres. This
leads to the so-called hard-ball model of a crystalline
lattice, where the radius of the spheres is taken as
half the distance between the centers of the most
closely spaced atoms.
The crystallographic directions are fictitious lines
linking nodes (atoms, ions or molecules) of a crystal.
Similarly, the crystallographic planes are fictitious
planes linking nodes. Some directions and planes
have a higher density of nodes. These high density
planes have an influence on the behavior of the
crystal as follows:
Optical properties: Refractive index is directly
related to density (or periodic density fluctuations).
Adsorption and reactivity: Physical adsorption
and chemical reactions occur at or near surface
atoms or molecules. These phenomena are thus
sensitive to the density of nodes.
Surface tension: The condensation of a material
means that the atoms, ions or molecules are more
stable if they are surrounded by other similar
species. The surface tension of an interface thus
varies according to the density on the surface.
 Metallurgy 167

Microstructural defects: Pores and crystallites

tend to have straight grain boundaries following
higher density planes.
Cleavage: This typically occurs preferentially
parallel to higher density planes.
Plastic deformation: Dislocation glide occurs
preferentially parallel to higher density planes. The
perturbation carried by the dislocation (Burgers
vector) is along a dense direction. The shift of one
node in a more dense direction requires a lesser
distortion of the crystal lattice. Figure 4.2-1: A body-centered cubic crystals lattice

Cubic crystal system

The cubic (or isometric) crystal system is a crystal
system where the unit cell is in the shape of a cube.
This simplest and most symmetric unit cell has the
symmetry of a cube, that is, it exhibits four threefold
rotational axes oriented at 109.5° (the tetrahedral
angle) with respect to each other. These threefold
axes lie along the body diagonals of the cube. The
other six lattice systems, are hexagonal, tetragonal,
rhombohedral (often confused with the trigonal
crystal system), orthorhombic, monoclinic and
triclinic.
Figure 4.2-2: A face-centered cubic lattice
For the special case of simple cubic crystals, the
lattice vectors are orthogonal and of equal length
(usually denoted a); similarly for the reciprocal The Face-Centered Cubic lattice
lattice.
The face-centered cubic has lattice points on the
Because of the symmetry of cubic crystals, it is
faces of the cube of which each unit cube gets
possible to change the place and sign of the integers
exactly one half contribution, in addition to the
and have equivalent directions and planes:
corner lattice points, giving a total of 4 atoms per
There are three main varieties of these crystals,
unit cell ((1⁄8 for each corner) × 8 corners + (1⁄2 for
called "simple cubic", "body-centered cubic" (BCC),
each face) × 6 faces). (Fig 4.2-2)
and "face-centered cubic" (FCC). Note that although
The face-centered cubic lattice is one of the most
the unit cell in these crystals is conventionally taken
common types of crystal lattices. In addition to the
to be a cube, the primitive unit cell often is not. This
eight atoms located at the corners of the cube, the
is related to the fact that in most cubic crystal
face-centered cell contains an additional atom on
systems, there is more than one atom per cubic unit
each face of the cube.
cell.
The number of atoms per unit cell in the face-
centered cubic lattice can be computed in the same
The simple cubic structure manner as in the body-centered cubic lattice. The
The simple cubic system consists of one lattice point eight corner atoms again contribute one atom to the
on each corner of the cube. Each atom at the lattice cell. There are also six face-centered atoms to be
points is then shared equally between eight adjacent considered, each a part of two unit cells. These
cubes, and the unit cell therefore contains in total contribute six times one-half an atom, or three
one atom (1⁄8 × 8). atoms. The face-centered cubic lattice has a total of
four atoms per unit cell, or twice as many as the
The Body-Centered Cubic Structure body-centered cubic lattice.
A cubic crystal with atoms located at corners and in It should be pointed out that the face-centered
the center of the cube is called a body-centered cubic structure has four close-packed or octahedral
cubic crystals lattice (BCC). The body-centered cubic planes. The face-centered cubic lattice, however, is
lattice has two atoms per unit cell; one contributed unique in that it contains as many as four planes of
by the corner atoms, and one located at the center of closest packing, each containing three close-packed
the cell. All atoms in the body-centered cubic lattice directions. No other lattice possesses such a large
are equivalent. Thus, the atom at the center of the number of close-packed planes and closed-packed
cube has no special significance over those directions. This fact is important, since it gives face-
occupying corner positions. Each of the latter could centered cubic metals physical properties different
have been chosen as the center of a unit cell, making from those of other metals, among which is the
all corner atoms centers of cells, and all centers of ability to undergo severe plastic deformation.
cells corners. (Fig 4.2-1) One important characteristic of a crystalline
structure is its atomic packing factor. This is
calculated by assuming that all the atoms are
168 Plate Fixation in Orthopaedics
identical spheres, with a radius large enough that
each sphere abuts the next. The atomic packing
factor is the proportion of space filled by these
spheres.
Assuming one atom per lattice point, in a simple
cubic lattice with cube side length a, the sphere size
would be a⁄2 and the atomic packing factor turns out
to be about 0.524 (which is quite low). Similarly, in a
BCC lattice, the atomic packing factor is 0.680, and in
FCC it is 0.740. The FCC value is the highest
theoretically possible value for any lattice, although
there are other lattices which also achieve the same
value, such as hexagonal close packed.
The close-packed hexagonal structure
Close-packed crystal structure is characterized by
the regular alternation of two layers; the atoms in
each layer lie at the vertices of a series of equilateral
triangles, and the atoms in one layer lie directly
above the centers of the triangles in neighboring
layers. (Fig 4.2-3)
Many structures are based upon the close-packing of
atoms or ions into hexagonal layers. In a close-
packed structure, each atom or ion is surrounded by
six others, resulting in very efficient packing. These
hexagonal layers, in turn, may be packed in two
different ways, giving rise either to a hexagonal
close-packed structure, or a cubic close packed
structure. In one type of structure layers are stacked
in an ABC fashion, so that the fourth layers lies
immediately over the first, the fifth layer lies
immediately over the second, and so forth. This is
emphasized by the vertical lines, which connect the
first and fourth layers.
Figure 4.2-3: A close-packed hexagonal structure
The ABC stacking of hexagonal layers gives rise to
the face-centered cubic structure. Hexagonal layers
may also stack in an ABAB fashion. Whereas the
stacking of layers in an ABC gives rise to a face-
centered cubic structure, the stacking of layers in an
AB fashion gives rise to a hexagonal structure. The
hexagonal-close packed structure arises when close-
packed layers are stacked in an AB fashion so that
the third layer lies over the first, the fourth layers
lies over the second, and so forth.
Closest-packed planes of the HCP lattice are
parallel with the base of the hexagonal prism. It is
apparent that there is considerable configurational
symmetry in these structures. This allows
deformation of the structure in a great variety of
ways. Thus, because the cubic and hexagonal lattices
are very common metal lattices, it further
substantiates the easy deformability of metals.
As mentioned before, there are two simple regular
lattices that achieve this highest average density.
They are called face-centered cubic (FCC) (also
called cubic close packed) and hexagonal close-
packed (HCP), based on their symmetry. Both are
based upon sheets of spheres arranged at the
vertices of a triangular tiling; they differ in how the
sheets are stacked upon one another.
In both arrangements each sphere has twelve
neighbors. For every sphere there is one gap
surrounded by six spheres (octahedral) and two
smaller gaps surrounded by four spheres
(tetrahedral). Relative to a reference layer with
positioning A, two more positionings B and C are
possible. Every sequence of A, B, and C without
immediate repetition of the same one is possible and
gives an equally dense packing for spheres of a given
radius.
The most regular ones are:
FCC = ABCABCA (every third layer is the same)
HCP = ABABABA (every other layer is the same)
The coordination number of a crystal structure
equals the number of nearest neighbors that an
atom possesses in the lattice. In the body-centered
cubic unit cell, the center atom has eight neighbors
touching it. We have already seen that all atoms in
this lattice are equivalent. Therefore, every atom of
the body-centered cubic structure not lying at the
exterior surface possesses eight nearest neighbors,
and the coordination number of the lattice is eight.
The coordination number of HCP and FCC is 12.
GRAIN BOUNDARIES
Grain boundaries are interfaces where crystals of
different orientations meet. A grain boundary is a
single-phase interface, with crystals on each side of
the boundary being identical except in orientation.
Grain boundary areas contain those atoms that have
been perturbed from their original lattice sites,
dislocations, and impurities that have migrated to
the lower energy grain boundary.
Grain boundaries disrupt the motion of
dislocations through a material, so reducing

crystallite size is a common way to improve
strength. Since grain boundaries are defects in the
crystal structure they tend to decrease the electrical
and thermal conductivity of the material. The high
interfacial energy and relatively weak bonding in
most grain boundaries often makes them preferred
sites for the onset of corrosion and for the
precipitation of new phases from the solid. They are
also important to many of the mechanisms of creep.
Grain boundaries are generally only a few
nanometers wide. In common materials, crystallites
are large enough that grain boundaries account for a
small fraction of the material. However, very small
grain sizes are achievable. In nanocrystalline solids,
grain boundaries become a significant volume
fraction of the material, with profound effects on
such properties as diffusion and plasticity. In the
limit of small crystallites, as the volume fraction of
grain boundaries approaches 100%, the material
ceases to have any crystalline character, and thus
becomes an amorphous solid.
ANISOTROPY
When the properties of a substance are independent
of direction, the material is said to be isotropic.
Thus, in an ideal isotropic material, one should
expect to find that it has the same strength in all
directions. The physical properties of crystals
normally depend strongly on the direction along
which they are measured. This means that, basically,
crystals are not isotropic, but anisotropic.
Ideally, a polycrystalline specimen might be
expected to be isotropic if its crystals were
randomly oriented, for then, from a macroscopic
point of view, the anisotropy of the crystals should
be averaged out. However, a truly random
arrangement of the crystals is seldom achieved,
because manufacturing processes tend to align the
grains in a metal so that their orientations are not
Metallurgy 169
uniformly distributed. The result is what is known
as a texture or a preferred orientation. Because most
polycrystalline metals have a preferred orientation,
they tend to be anisotropic, and the degree of this
anisotropy depends on the degree of crystal
alignment.
TEXTURES OR PREFERRED
ORIENTATIONS
Wires are formed by pulling rods through
successively smaller and smaller dies. In the case of
iron, this kind of deformation tends to align the
direction of each crystal parallel to the wire axis.
About this direction the crystals are normally
considered to be randomly arranged. This type of
preferred arrangement of the crystals in an iron or
steel wire is quite persistent. Even if the metal is
given a heat treatment that completely reforms the
crystal structure, the crystals tend to keep the
direction parallel to the wire axis. Not only does one
tend to find a direction parallel to the rolling
direction or length of the plate, but there is also a
strong tendency for a cube plane, or face of the unit
cell, to be aligned parallel to the rolling plane or
surface of the sheet or plate.
A number of metals are polymorphic, that is, they
crystallize in more than one structure. The most
important of these is iron, which crystallizes as
either body-centered cubic or face-centered cubic,
with each structure stable in separate temperature
ranges. Thus, at all temperatures below 910°C and
above 1400°C to the melting point, the preferred
crystal structure is body-centered cubic, whereas
between 910°C and 1400°C the metal is stable in the
face-centered cubic structure.
170 Plate Fixation in Orthopaedics

CHAPTER
METAL PROCESSING
CHAPTER OUTLINE
Cold working, Work hardening
Stored energy of cold work
Annealing
Recovery
Recrystallization
Grain growth
Processing metals with chemical, thermal, or
physical means changes the structure of the metal
and affects its physical and mechanical properties.
Grain size or crystal size of metal is broadly
indicative of its quality; in general larger grain, less
the tensile strength of metal; conversely, smaller or
finer the grain, greater toughness or strength.
Heating metal to approximately its melting point
increases grain size, while forging decreases the
grain size. Deforming stainless steel stem increases
the grain size primarily on outer segment.
Iron-based alloys are either cast or wrought.
Casting is the process of pouring liquid metal into a
mold of a specific shape. With this technique,
problems arise when impurities migrate into the
grain boundaries, resulting in areas of mechanical
weakness. Wrought iron is made by mechanical
processing of cast metal via rolling, extruding, or
heat force. The word "wrought" is an archaic past
tense form of the verb "to work". "Wrought iron"
literally means "worked iron". Wrought iron is an
iron alloy with a very low carbon content. It is
Metallurgy 171
4.3
tough, malleable, ductile and easily welded. Forging
is a process by which a piece of metal is heated and
has a force applied through an open or closed die
that represents the inverse geometry of the product
being manufactured. This process refines the grain
structures, increases strength and hardness, and
decreases ductility. Vacuum re-melting and
electroslag re-melting are processes that remove
impurities and produce a purer grade of metal,
which is desirable for surgical implants.
COLD WORKING, WORK HARDENING
Work hardening, also known as strain hardening, is
the strengthening of a metal by plastic deformation.
This technique requires repetitive application of a
stress greater than the elastic limit of the metal.
These load cycles increase the hardness and elastic
limit of the material through elongation of the
grains in the direction of the stress. The increased
grain boundary area results in a stronger material.
172 Plate Fixation in Orthopaedics
This strengthening occurs because of dislocation
movements within the crystal structure of the
material. This is characterized by shaping the
workpiece at a temperature below its
recrystallization temperature, usually at the
ambient temperature. Cold forming techniques are
usually classified into four major groups: squeezing,
bending, drawing, and shearing. Any material with a
reasonably high melting point such as metals and
alloys can be strengthened in this fashion. Alloys not
amenable to heat treatment, including low-carbon
steel, are often work-hardened.
Before work hardening, the lattice of the material
exhibits a regular with low defects (fewer
dislocations) pattern. The lattice with low defects
can be created or restored at any time by annealing.
As the material is worked hardened it becomes
increasingly saturated with new dislocations, and
more dislocations are prevented from nucleating (a
resistance to dislocation-formation develops). This
resistance to dislocation-formation manifests itself
as a resistance to plastic deformation; hence, the
observed strengthening.
In metallic crystals, irreversible deformation is
usually carried out on a microscopic scale by defects
called dislocations, which are created by
fluctuations in local stress fields within the material
culminating in a lattice rearrangement as the
dislocations propagate through the lattice. At
normal temperatures the dislocations are not
annihilated by annealing. Instead, the dislocations
accumulate, interact with one another (Fig 4.3-1),
and serve as pinning points or obstacles that
significantly impede their motion. This leads to an
increase in the yield strength of the material and a
subsequent decrease in ductility.
Such deformation increases the concentration of
dislocations which may subsequently form low-
angle grain boundaries surrounding sub-grains.
Cold working generally results in higher yield
strength as a result of the increased number of
Dislocation
line
Figure 4.3-1: Transition Electron Microscope (TEM) image of dislocations in a metal.
dislocations and the Hall-Petch effect of the sub-
grains, and a decrease in ductility. The effects of
cold working may be reversed by annealing the
material at high temperatures where recovery and
recrystallization reduce the dislocation density.
Work hardening occurs most notably for ductile
materials such as metals. Ductility is the ability of a
material to undergo large plastic deformations
before fracture. Cold working produces an increase
in dislocation density (ρ); for most metals ρ
increases from the value of 1010−1012 lines m−2
typical of the annealed state, to 1012–1013 after a
few percent deformations, and up to 1015–1016 lines
m−2 in the heavily deformed state. Such an array of
dislocations gives rise to a substantial strain energy
stored in the lattice, so that the cold-worked
condition is thermodynamically unstable relative to
the undeformed one. Consequently, the deformed
metal will try to return to a state of lower free
energy, i.e. a more perfect state. In general, this
return to a more equilibrium structure cannot
occur spontaneously but only at elevated
temperatures, where thermally activated processes
such as diffusion, cross-slip and climb take place. A
material generally deforms elastically if it is under
the influence of small forces, allowing the material
to readily return to its original shape when the
deforming force is removed. This phenomenon is
called elastic deformation. This behavior in
materials is described by Hooke's Law. Materials
behave elastically until the deforming force
increases beyond the elastic limit, also known as
the yield stress. At this point, the material is
rendered permanently deformed and fails to return
to its original shape when the force is removed.
This phenomenon is called plastic deformation. For
example, if one stretches a coil spring up to a
certain point, it will return to its original shape, but
once it is stretched beyond the elastic limit, it will
remain deformed and won't return to its original
state.
The dislocations’
accumulation. This
is the tangle of
dislocations which
cannot easily move.
173 Plate Fixation in Orhtopaedics
Elastic deformation stretches atomic bonds in the
material away from their equilibrium radius of
separation of a bond, without applying enough
energy to break the inter-atomic bonds. Plastic
deformation, on the other hand, breaks inter-atomic
bonds, and involves the rearrangement of atoms in
a solid material.
Yield strength is increased in a cold-worked
material. Using lattice strain fields, it can be shown
that an environment filled with dislocations will
hinder the movement of any one dislocation.
Because dislocation motion is hindered, plastic
deformation cannot occur at normal stresses. Upon
application of stresses just beyond the yield
strength of the non-cold-worked material, a cold-
worked material will continue to deform using the
only mechanism available: elastic deformation.
However, ductility of a work-hardened material is
decreased. Ductility is the extent to which a
material can undergo plastic deformation, that is, it
is how far a material can be plastically deformed
before fracture. A cold-worked material is, in effect,
a normal material that has already been extended
through part of its allowed plastic deformation. If
dislocation motion and plastic deformation have
been hindered enough by dislocation accumulation,
and stretching of electronic bonds and elastic
deformation have reached their limit, a third mode
of deformation occurs: fracture.
Techniques have been designed to maintain the
general shape of the workpiece during work
hardening, including shot peening and equal
channel angular extrusion.
During cold working the part undergoes work
hardening and the microstructure deforms to
follow the contours of the part surface. Unlike hot
working, the inclusions and grains distort to follow
the contour of the surface, resulting in anisotropic
engineering properties.
Intermediate annealings may be required to
reach the required ductility to continue cold
working a workpiece; otherwise it may fracture if
the ultimate tensile strength is exceeded.
Cold worked items suffer from a phenomenon
known as springback, or elastic springback. After
the deforming force is removed from the
workpiece, the workpiece springs back slightly. The
amount a material springs back is equal to Young's
modulus for the material from the final stress.
Stored Energy of Cold Work
When a metal it plastically deformed at
temperatures that are low relative to its melting
point, it is said to be cold worked. The temperature
defining the upper limit of the cold working range
cannot be expressed exactly, for it varies with
composition as well as the rate and the amount of
deformation. Most of the energy expended in cold
work appears in the form of heat, but a finite
fraction is stored in the metal as strain energy
associated with various lattice defects created by
the deformation. The amount of energy retained
depends on the deformation process and a number
of other variables, for example, composition of the
metal as well as the rate and temperature of
deformation. A number of investigators have
indicated that the fraction of the energy which
remains in the metal varies from a low percentage
to somewhat over 10 percent.
ANNEALING
Annealing, in metallurgy and materials science, is a
heat treatment wherein a material is altered,
causing changes in its properties such as strength
and hardness. It is a process that produces
conditions by heating to above the recrystallization
temperature and maintaining a suitable
temperature, and then cooling. Annealing is used to
induce ductility, soften material, relieve internal
stresses, refine the structure by making it
homogeneous, and improve cold working
properties.
Annealing occurs by the diffusion of atoms within
a solid material, so that the material progresses
towards its equilibrium state. Heat is needed to
increase the rate of diffusion by providing the
energy needed to break bonds. The movement of
atoms has the effect of redistributing and
destroying the dislocations in metals and (to a
lesser extent) in ceramics. This alteration in
dislocations allows metals to deform more easily, so
increases their ductility.
The relief of internal stresses is a
thermodynamically spontaneous process; however,
at room temperatures, it is a very slow process. The
high temperatures at which the annealing process
occurs serve to accelerate this process.
The removal of the cold-worked condition occurs
by a combination of three processes, namely: (1)
recovery, (2) recrystallization and (3) grain growth.
During the recovery stage the decrease in stored
energy and electrical resistivity is accompanied by
only a slight lowering of hardness, and the greatest
simultaneous change in properties occurs during
the primary recrystallization stage.
Recovery
This process describes the changes in the
distribution and density of defects with associated
changes in physical and mechanical properties
which take place in worked crystals before
recrystallization or alteration of orientation occurs.
In the recovery stage of annealing the physical
and mechanical properties that suffered changes as
a result of cold working tend to recover their
original values.
Recrystallization
The most significant changes in the structure-
sensitive properties occur during the primary
recrystallization stage. In this stage the deformed
lattice is completely replaced by a new unstrained
one by means of a nucleation and growth process,
174 Plate Fixation in Orthopaedics

in which practically stress-free grains grow from which usually begin on the surface and can cause
nuclei formed in the deformed matrix. The fracture of the metal.
orientation of the new grains differs considerably
from that of the crystals they consume. During the
growth of grains, atoms get transferred from one
grain to another across the boundary. Such a
process is thermally activated. It is well known that
the rate of recrystallization depends on several
important factors, namely: (1) the amount of prior
deformation (the greater the degree of cold work,
the lower the recrystallization temperature and the
smaller the grain size), (2) the temperature of the
anneal and (3) the purity of the sample.

Grain growth A
When primary recrystallization is complete (i.e.
when the growing crystals have consumed all the
strained material), the material can lower its
energy further by reducing its total area of grain
surface. With extensive annealing it is often found
that grain boundaries straighten, small grains
shrink and larger ones grow (Fig 4.3-2). The
general phenomenon is known as grain growth, and
the most important factor governing the process is
B
the surface tension of the grain boundaries.
The cold-forging process uses substantially more
cold-working to achieve a higher degree of
deformation. This step is coupled with a stress-
relieving process to make a cold-forged steel of
exceptionally high strength softer.
Two practical examples of cold-working are shot-
peening of the surface of intramedullary nails and
cold-forging of dynamic hip screw plates. The shot-
peening process involves bombardment of the C
outer surfaces of the metal with a high-velocity
stainless steel cut wire. The impact causes residual
Figure 4.3-2: Schematic model of growth; from A to C,
compressive stress, which reduces surface tensile time is increasing.
stress. Shot-peening thus minimizes fatigue cracks,
 Metallurgy 175

CHAPTER 4.4
CORROSION

CHAPTER OUTLINE
Basic concepts Methods of protection from corrosion
Electrochemistry of corrosion Passivation
How and why metals corrode? Surface treatments
Electronegativity Cathodic protection
Corrosion rections Combinable metals
Consequences of corrosion Corrosion inhibitors
Types of corrosion Stainless steel properties and corrosion
Galvanic corrosion Primary mechanisms of implant corrosion
Pitting corrosion Kinetic barriers to corrosionThe solution–
Fretting corrosion metal interface
Crevice corrosion Metallic biomaterials
Stress corrosion cracking Metal ion/soluble metal levels
Intergranular corrosion Soluble corrosion debris
Dealloying corrosion Particulate debris corrosion
Uniform corrosion
Erosion

BASIC CONCEPTS
Corrosion is the disintegration of an engineered
material into its constituent atoms due to chemical
reactions with its surroundings. Corrosion is the
unwanted chemical reaction of a metal with its
environment, resulting in its continued degradation
to oxides, hydroxides, or other compounds.
Biological fluids in the human body contains water,
salt, dissolved oxygen, bacteria, proteins, and
various ions such as chloride and hydroxide. As a
result, the human body is a very aggressive
environment for metals.
In the most common use of the word, this means
electrochemical oxidation of metals in reaction with
an oxidant such as oxygen. Formation of an oxide of
iron due to oxidation of the iron atoms in solid
solution is a well-known example of electrochemical
corrosion, commonly known as rusting. This type of
damage typically produces oxide(s) and/or salt(s)
of the original metal. In other words, corrosion is
the wearing away of metals due to a chemical
reaction.
Corrosion can be concentrated locally to form a
pit or crack, or it can extend across a wide area
more or less uniformly corroding the surface.
176 Plate Fixation in Orthopaedics
Because corrosion is a diffusion controlled process,
it occurs on exposed surfaces. As a result, methods
to reduce the activity of the exposed surface, such as
passivation and chromate-conversion, can increase
a material's corrosion resistance. However, some
corrosion mechanisms are less visible and less
predictable.
Electrochemistry of corrosion
Metallic implant degradation results from both
electrochemical dissolution and wear, but most
frequently occurs through a synergistic combination
of the two. Corrosion is release of ions and
compounds as result of chemical action; in contrast
wear is loss of solid fragments from surfaces due to
mechanical action.
As in all chemical reactions, corrosion reactions
occur through an exchange of electrons. In
electrochemical reactions, the electrons are
produced by a chemical reaction in one area, the
anode, travel through a metallic path and are
consumed through a different chemical reaction in
another area, the cathode.
Electrochemical corrosion processes include both
generalized dissolution uniformly affecting an entire
surface and localized areas of a component.
Metal implant corrosion is controlled by (1) the
extent of the thermodynamic driving forces which
cause corrosion (oxidation/reduction reactions)
and (2) physical barriers which limit the kinetics of
corrosion. In practice these two parameters that
mediate the corrosion of orthopedic biomaterials
can be broken down into a number of variables:
geometric variables (e.g., taper geometry in modular
component hip prostheses), metallurgical variables
(e.g., surface microstructure, oxide structure, and
composition), mechanical variables (e.g., stress
and/or relative motion), and solution variables (e.g.,
pH, solution proteins, enzymes).
All metals used for surgical implantation undergo
corrosion. The driving force for corrosion is also the
basis of the electrical storage battery, which
employs materials with two different levels of
reactivity. Electrical energy is produced when ions
of a more reactive material are released and partial
consumption of the material occurs. This
electrochemical consumption is termed corrosion.
Corrosion or galvanic attack can occur if metals of
different electrochemical potentials are placed in
contact with each other (e.g., the inappropriate use
of a titanium plate with stainless steel screws).
Corrosion can occur within a single type of metal
or between implants made of the same metal when
the reactivity differs from one area to another
within the same implant. Differences in local
reactivity are seen in areas of higher stress, lower
oxygen, and crevices. The natural tendency of the
base metal to corrode is decreased by the surface
oxide coating from the passivation process.
Scratches on the surface of the plate can disrupt the
protective surface oxide coating and substantially
increase corrosion. Crevices can develop from a
scratch on the surface or develop macroscopically
between a screw and a plate. The metal in this area
is subjected to compressive forces, leading to high
stress concentration. Oxygenated extracellular fluid
cannot circulate in this area, resulting in a local
decrease in oxygen tension. All these factors can
cause differences in local reactivity and subsequent
corrosion.
How and Why Metals Corrode?
The basic reaction that occurs during corrosion is
the increase of the valence state (i.e., loss of
electrons) of the metal atom.
M→Mz++ze− (oxidation)
This oxidation event (loss of electrons and
increase in valence) may result in the release of free
ions from the metal surface into solution (which can
then migrate away from the metal surface), or may
result in many other reactions such as the formation
of metal oxides, metal chlorides, organometallic
compounds, or other species. These ‘‘end’’ products
may also be soluble in solution or may precipitate to
form solid phases. Solid oxidation products may be
subdivided into those that form adherent compact
oxide films, or those that form nonadherent oxide
(or other) particles that can migrate away from the
metal surface. For corrosion to occur there must be
a thermodynamic driving force for the oxidation of
metal atoms.
There are two interrelated sources of energy to be
considered in electrochemical corrosion processes:
chemical and electrical (charge separation). The
chemical driving force determines whether or not
corrosion will take place under the conditions of
interest. When the free energy for oxidation is less
than zero, oxidation is energetically favorable and
will take place spontaneously. The second energy
force relates to how the positive and negative
charges (metal ions and electrons, respectively) are
separated from one another during corrosion. This
charge separation contributes to what is known as
the electrical double layer and creates an electrical
potential across the metal–solution interface
(similar to that of a capacitor).
Electronegativity
Electronegativity, χ (the Greek letter chi), is a
chemical property that describes the ability of an
atom (or, more rarely, a functional group) to attract
electrons (or electron density) towards itself.
This potential is also a measure of the reactivity of
the metals, or the driving force for metal oxidation.
The more negative the potential of a metal in
solution, the more reactive it will tend to be. At
equilibrium, the chemical energy balances with the
electrical energy, this can be quantified using the
Nernst equation, which defines the electrical
potential across an idealized metal–solution
interface when in a solution.
ΔE = ΔE o+ (RT/ zF) In ([M ] Z+/ [M])

Where E is the potential of the metal, Eo is the
standard electrode potential of the metal, R is the gas
constant (8.314 J/mol), T is temperature in Kelvin (25
°C is 298 K), z is the valency and F is the Faraday
constant (96,490 coulombs/mol). From this equation,
a theoretical scale of metal reactivity can be
established, known as the electrochemical series,
which is a ranking of the equilibrium potential from
most positive (i.e., least reactive or most noble) to
most negative (most reactive or most base). Be
aware that this ranking is based only on
thermodynamic equilibrium. That is, it is only true if
we assume that there are no barriers (i.e., no surface
oxide formation) to the oxidation (loss of
electrons/corrosion) of the metal; then these
potentials would be the ones that would exist across
the metal–solution interface. Certain metals owe
their corrosion resistance to the fact that their
equilibrium potentials are very positive. Gold and
platinum are examples of metals that have little or
no driving force for oxidation in aqueous solutions,
and thus they tend to corrode very little in the
human body. However, most orthopedic metals
have very negative potentials, indicating that from a
chemical driving force perspective they are much
more likely to corrode, indicating that there is a
large chemical driving force for corrosion
(oxidation). If surface oxide formation (or
passivation) did not intervene, pure titanium would
react with its surroundings (typically oxygen, water,
or other oxidizing species) and corrode vigorously.
But it doesn’t, thanks to the formation of metal
oxides.
Corrosion rections
A typical anodic oxidation that produces dissolved
ionic product, for example for iron metal is:
[1] Fe →Fe2+ + 2e-
Examples of cathodic reductions involved in
corrosion process are:
[2] O2 + 2H2O + 4e- →4OH-
[3] O2 + 4H+ + 4e- →2H2O
[4] 2H+ + 2e- →H2
The cathodic reaction represented by Equation
[2] exemplifies corrosion in natural environments
where corrosion occurs at nearly neutral pH values.
Equations [3] and [4] represent corrosion processes
taking place in the acidic environments encountered
in industrial processes or for the confined volumes
(pits, crevices) where the pH can reach acidic values
because of hydrolysis reactions such as:
[5] Fe2+ + 2H2O →Fe(OH)2 + 2H+
This reaction produces H+ ions, the concentration
of which can, under certain conditions, become
Metallurgy 177
large if the H+ ions cannot readily move out from a
confined volume. The overall corrosion reaction is,
of course, the sum of the cathodic and anodic partial
reactions. For example, for a reaction producing
dissolved ions (sum of reactions [1] and [4]):
[6] Fe + 2H+ →Fe2+ + H2 (Fig 4.4-1)
or, for a reaction producing insoluble hydroxide
(sum of reactions [1] and [2]):
[7] 2Fe + O2 + 2H2O →2Fe(OH)2
Consequences of corrosion
All metallic implants electrochemically corrode to
some extent. This is disadvantageous for two main
reasons: (1) the process of degradation reduces the
structural integrity and (2) degradation products
may react unfavorably with the host. Recent years
have seen an increasing use of metal prosthetic
devices in the body, such as pins, plates, hip joints,
pacemakers, and other implants.
Figure 4.4-1: The electrochemical cell set up between
anodic and cathodic sites on an iron surface undergoing
corrosion
New alloys and better techniques of implantation
have been developed, but corrosion continues to
create problems. Examples include failures through
broken connections in pacemakers, inflammation
caused by corrosion products in the tissue around
implants, and fracture of weight-bearing prosthetic
devices. An example of the latter is the use of
metallic hip joints, which can alleviate some of the
problems of arthritic hips. The situation has
improved in recent years, so that hip joints which
were at first limited to persons over 60 are now
being used in younger persons, because they will
last longer.
Types of corrosion
Galvanic (and thermogalvanic)
corrosion(Fig 4.4-2)
Galvanic corrosion occurs when two different
metals electrically contact each other and are
178 Plate Fixation in Orthopaedics
immersed in an electrolyte (Galvanic Cell). A
galvanic cell describes a local environment where
electrons flow from the more negative to the more
positive material when immersed in a liquid
conductor. In order for galvanic corrosion to occur,
an electrically conductive path and an ionically
conductive path are necessary. This affects a
galvanic couple where the more active metal
corrodes at an accelerated rate and the more noble
metal corrodes at a retarded rate. Factors such as
relative size of anode (smaller is generally less
desirable), types of metal, and operating conditions
(temperature, humidity, salinity, etc.) will affect
galvanic corrosion. The surface area ratio of the
anode and cathode will directly affect the corrosion
rates of the materials. In a fixed fracture, the
dissimilar materials are the surface of the plate, for
example, stainless steel, which has an oxide surface
coating and the same material within the just-
opening crack that has not yet developed the oxide
film. The conductive fluid is the blood and saline
found in the surrounding tissues. Galvanic corrosion
can accelerate the failure of an implant, even when
the implant is loaded well below its yield point, by
increasing the rate at which the crack grows,
because along with yielding at the site of the crack,
material at the crack is being removed by the
corrosion process
Pitting corrosion
The initiation of a pit occurs when electrochemical
or chemical break-down exposes a small local sight
on a metal surface to damaging species such as
chloride ions. The sites where pits initiate are not
completely understood, but some possibilities are at
scratches, surface compositional heterogeneities
(inclusions), or places where environmental
variations exist. The pit grows if the high current
density – the area of breakdown initiation is
exceedingly small – involved in the repassivation
process does not prevent the formation of a large
local concentration of metal ions produced by
dissolution at the point of initiation. If the rate of
repassivation is not sufficient to choke off the pit
growth, two new conditions develop. First, the
metal ions produced by the breakdown process are
precipitated as solid corrosion products which
usually cover the mouth of the pit. This covering
traps the solution in the pit and allows the buildup
of positive hydrogen ions through a hydrolysis
reaction. Then, chloride or another damaging
negative ion diffuses into the pit to maintain charge
neutrality. Consequently, the repassivation becomes
considerably difficult because the solution in the pit
is highly acidic, contains a large concentration of
damaging ions and metallic ions, and contains a low
oxygen concentration. Thereby the rate of pit
growth accelerates.
The pit is the anode of an electrochemical
corrosion cell, and the cathode of the cell is the non-
pitted surface. Since the surface area of the pit is a
very small fraction of the cathodic surface area, all
of the anodic corrosion current flows to the
extremely small surface area of the breakdown
initiation site. Thus, the anodic current density
becomes very high, and penetration of a metal
structure bearing only a few pits can be rapid. In the
passive condition, the current density is of the order
of nA cm-2; in the pit, however, it may exceed 1 A cm-2.
The reason why the current density is so large in the
pit is that the anodic region is very small in area
when compared with the cathodic part (the unpitted
steel).
For a given corrosion current, this greatly
exaggerates the corrosion rate at the pits. Similarly,
the concentration of chloride ions in the vicinity of a
pit can be thousands of times greater than that in
the solution as a whole. While the propagation
phenomenon is well understood, the mechanism of
pit initiation is not. Initiation has long been
associated with MnS inclusions which are difficult to
avoid in the steel-making process. It appears that
the inclusions are surrounded by a Cr depleted
region which is believed to cause the initiation.
Increasing the Cr content or adding Mo or N
enhances the pitting resistance.
Fretting (erosion) corrosion (Fig 4.4-3)
Another mechanism of corrosion, termed fretting,
results when the surfaces of two implants rub
together, which often occurs between the head of a
screw and the surface of the plate through which it
passes. In this type of corrosion, abrasive wear,
which removes the protective oxide layer on metal,
begins the corrosion. Although in some metals, the
passivation layer forms again, this new passivation
layer is neither as durable nor as chemically inert as
original layer, so, the metal is more susceptible to
corrosion. Among the orthopaedics implant metals,
stainless steel & cobalt-chromium alloys are most
susceptible to fretting corrosion.
Figure 4.4-2: Galvanic corrosion around a scratch or pit
in the plate.

Crevice corrosion (Fig 4.4-4)
Crevice corrosion is a corrosion occurring in spaces
to which the access of the working fluid from the
environment is limited. These spaces are generally
called crevices. Examples of crevices are gaps and
contact areas between parts, under gaskets or seals,
inside cracks. Crevice corrosion, not common in
modem orthopaedic materials, results from small
galvanic cells formed by impurities in the surface of
the implant, causing crevices as the material
corrodes.
Mechanism
To function as a corrosion site, a crevice has to be of
sufficient width to permit entry of the corrodent,
but sufficiently narrow to ensure that the corrodent
remains stagnant.
Accordingly crevice corrosion usually occurs in gaps
a few micrometres wide, and is not found in grooves
or slots in which circulation of the corrodent is
possible. This problem can often be overcome by
paying attention to the design of the component, in
particular to avoiding formation of crevices or at
least keeping them as open as possible. Crevice
corrosion is a very similar mechanism to pitting
corrosion; alloys resistant to one are generally
resistant to both. Crevice corrosion can be viewed
as a more severe form of pitting corrosion as it will
occur at significantly lower temperatures than does
pitting.
Figure 4.4-3: Fretting corrosion caused by the loss of
the oxide layer on the surface of a plate caused by rubbing of
the base of the screw against the plate
Metallurgy 179
Figure 4.4-4: Crevice corrosion, with a local galvanic
cell caused by an impurity in the surface of a plate and ions,
M+, being released, resulting in loss of material and
formation of a crevice
Two factors are important in the initiation of
active crevice corrosion: the chemical composition
of the electrolyte in the crevice and the potential
drop into the crevice.
Some of the phenomena occurring within the
crevice may be somewhat reminiscent of galvanic
corrosion.
Galvanic Corrosion: two connected metals +
single environment
Crevice Corrosion: one metal part + two
connected environments
Stress corrosion cracking (Fig 4.4-5)
Stress corrosion cracking (SCC) is the unexpected
sudden failure of normally ductile metals subjected
to a tensile stress in a corrosive environment. It is a
form of localized corrosion which produces cracks
in metals by the simultaneous action of a corrodent
and tensile stress. The electrochemical cell between
the exterior and the interior environments of a
crack is similar to that described above for a crevice.
Because of the necessity for the application of
stress, the breakdown of the passive layer on a
metal surface in SCC is generally ascribed to
mechanical causes but many suggest that
electrochemistry is a significant factor because it
controls the rate of repair of the passive layer
ruptured by mechanical stress. SCC is highly
chemically specific in that certain alloys are likely to
undergo SCC only when exposed to a small number
of chemical environments. The chemical
environment that causes SCC for a given alloy is
often one which is only mildly corrosive to the metal
otherwise. The specific environment is of crucial
importance, and only very small concentrations of
certain highly active chemicals are needed to
180 Plate Fixation in Orthopaedics
produce catastrophic cracking, often leading to
devastating and unexpected failure.
The stresses can be the result of the crevice loads
due to stress concentration, or can be caused by the
type of assembly or residual stresses from
fabrication (e.g. cold working).
Crack growth
The subcritical nature of propagation may be
attributed to the chemical energy released as the
crack propagates. That is,
elastic energy released + chemical energy =
surface energy + deformation energy
Intergranular corrosion
With the exception of metallic glasses, the metals
used in practical devices are made up of small
crystals (grains) whose surfaces join the surfaces of
other grains to form grain boundaries.
Such boundaries or the small regions adjacent to
these boundaries can under certain conditions be
considerably more reactive (by being more anodic)
than the interior of the grains. The resulting
corrosion is called intergranular corrosion. It can
result in a loss of strength of metal part or the
production of debris (grains that have fallen out).
Dealloying Corrosion
Dealloying is the selective corrosive attack of one or
more constituent of a metallic alloy.
Figure 4.4-5: Stress corrosion occurs by a local galvanic
cell setup between the material at the tip of the crack, which
just opened and has not oxidized, and the remaining oxidized
surface of the plate. The released ions enhance crack growth
occurring from loading.
Mechanism
As can be seen from the galvanic series, constituents
of many common alloys have widely separated
positions on the galvanic series. In the case of brass,
the main constituents are zinc and copper. In the
case of cast iron, the main constituents are iron and
graphite. When the surface of such alloys is exposed
to an electrolyte, galvanic action proceeds with the
more anodic material being selectively attacked. In
many cases, the cathodic material remains behind
and is bound into its original shape by a residue of
remaining anodic material and corrosion products.
The strength of the remaining material is, however,
greatly reduced and will often fail during normal
handling. Single phase material, where the alloy
constituents are well mixed, are often less
susceptible to this form of attack than alloys where
phases of largely different composition are present.
In many alloys, heat treatments have been
developed specifically to make the alloy more
homogeneous and less susceptible to dealloying.
Uniform corrosion
Uniform corrosion results from the sites, not
necessarily fixed in location, that are distributed
over a metal surface where the anodic and cathodic
reactions take place. Uniform corrosion damage,
sometimes called wastage, is usually manifested in
the progressive thinning of a metal part until it
virtually dissolves away or becomes a delicate lace-
like structure.
Erosion
Erosion is a physical process that results in
structural degradation of the implant surface, with
the release of material debris that ranges in size
down to a few nm. In orthopedic medicine, the
major form of erosion is fretting encountered in
modular implant systems (such as when a screw
head moves in relation to the plate hole). Fretting
occurs with micromotion between two adjacent
implant surfaces. This results in the release of
submicron sized particles into nearby tissue.
Fretting particles cause a number of clinical
complications. Experimentally produced debris
from steel, commercially pure titanium (CPTi),
and an alloy Ti-15Mo, when examined in vitro,
showed phagocytosis of particles of all three
materials by macrophages in a dose dependent
response. Steel particles also inhibited cell
proliferation, even when the particles were not in
direct contact with the cells, and caused cell
membrane damage. When two implants made of
CPTi are moved against each other under load,
metal debris from abrasion may be observed in the
local surrounding area (with particle sizes often
larger than 10 pm), giving a harmless discoloration
in the tissues. Steel wear debris has been observed
in organs remote from the site of the implant,
showing that it can disseminate around the body.
When steel fretting occurs, the particles produced
are less than 0.5 pm in size and can be easily

transported away from the implant site. If
submicron titanium particles are transported away
from the implant site, they should not elicit a tissue
reaction due to their high biocompatibility. Up until
now, no publications have shown tissue reactions in
organs remote from the site of a CPTi implant. For
flexible internal fixation where motion and thus
fretting is to be expected, titanium or its alloys are
the materials of choice.
Methods of protection from corrosion
Some metals are more intrinsically resistant to
corrosion than others, either due to the
fundamental nature of the electrochemical
processes involved or due to the details of how
reaction products form.
Passivation
Passivation is a process that allows spontaneous
oxidation on the surface of the metal or treats the
metal with acid or electrolysis to increase the
thickness or energy level of the oxidation layer.
Commonly, the process involves immersion of the
implant in a strong nitric acid solution, which
dissolves embedded iron particles and generates a
dense oxide film on the surface. This step generally
improves the biocompatibility of the implant.
Passivation also enhances the corrosion resistance
of the finished implant device. Oxide layer inhibits
metal egress and thus inhibits corrosion. This layer
serves to protect the metal by insulating it from
electrolyte solution.
Chromium oxide passivation layer forms on
stainless steel and cobalt-chromium alloy. Titanium
oxide layer forms on titanium and titanium alloys.
Chloride ions interfere with oxidation and
formation of passivation layer in stainless steel
implants. Practice of steam sterilization of implants
with saline in environment gives rise to surface
corrosion in both instruments and implants and
should be prohibited. Rough usage of implants and
scratches will break the oxide film on surface of an
implant and be the nidus where
corrosion, especially stress corrosion, may start.
Implants should never be thrown around in basins
or shaken together in basket, nor immersed in
saline.
Given the right conditions, a thin film of corrosion
products can form on a metal's surface
spontaneously, acting as a barrier to further
oxidation. When this layer stops growing at less
than a micrometre thick under the conditions that a
material will be used in, the phenomenon is known
as passivation (rust, for example, usually grows to
be much thicker, and so is not considered
passivation, because this mixed oxidized layer is not
protective).
Surface treatments
Cathodic protection
Cathodic protection (CP) is a technique to control
the corrosion of a metal surface by making it work
Metallurgy 181
as a cathode of an electrochemical cell. This is
achieved by placing in contact with the metal to be
protected another more easily corroded metal to act
as the anode of the electrochemical cell. Cathodic
protection systems are most commonly used to
protect steel. Cathodic protection can be, in some
cases, an effective method of preventing stress
corrosion cracking.
Combinable metals
In order for cathodic protection to work, the anode
must possess a lower (that is, more negative)
potential than that of the cathode (the structure to
be protected).
Corrosion inhibitor
A corrosion inhibitor is a chemical compound that,
when added to a liquid or gas, decreases the
corrosion rate of a metal or an alloy.
Some of the mechanisms of its effect are
formation of a passivation layer, that is a thin film
on the surface of the material that stops access of
the corrosive substance to the metal, inhibiting
either the oxidation or reduction part of the redox
corrosion system (anodic and cathodic inhibitors),
or scavenging the dissolved oxygen.
STAINLESS STEEL PROPERTIES
AND CORROSION
The stainless steels exhibit two potential states:
 Active
 Passive
The passive state is substantially cathodic to the
active state. It is this potential difference that drives
non-uniform attack, such as pitting and crevice
corrosion on these alloys. For purposes of
evaluating possible galvanic corrosion between the
stainless steels and other alloys, the potential of the
passive state should be used.
300 Series Stainless Steels
This group of alloys are non-magnetic and have an
austenitic structure. The basic alloy contains 18%
chromium and 8% nickel. These alloys are subject to
crevice corrosion and pitting. They have been
widely used in facilities with mixed results. If used
in an application where chloride levels are low, they
are likely to perform well. When chloride levels are
high, the performance of these alloys is often poor.
PRIMARY MECHANISMS OF
IMPLANT CORROSION
There are significant clinical problems relating to
the corrosion of implant alloys in the current state-
of-the-art implants which will likely continue to be a
potential hazard for the near future, one of which is
corrosion observed in the taper connections of
182 Plate Fixation in Orthopaedics
retrieved modular joint replacement components.
With the large and growing number of total joint
designs that use modular connections (i.e., metal-to-
metal press-fit conical tapered connections), the
effects of crevices, stress, and motion take on
increasing importance. Retrieval studies have
shown that severe corrosion attack can take place in
the crevices formed by these tapers in vivo. It has
been postulated that this corrosion process is the
result of a combination of stress and motion at the
taper connection and the crevice geometry of the
taper. The stresses resulting from use cause
fracturing and abrasion of the oxide film covering
these passive metal surfaces. This, in turn, causes
significant changes in the metal surface potential
and in the crevice solution chemistry as the oxides is
continuously fractured and repassivate. These
changes may result in deaeration (loss of O2) of the
crevice solution and a lowering of the pH in the
crevice as is expected in crevice corrosion attack.
The ultimate result of this process is a loss of the
oxide film and its kinetic barrier effect and an
increase in the rate of corrosive attack in the taper
region.
Severe corrosion attack has been associated with
Co–Cr alloy modular taper connections. While less
common, corrosion attack of titanium alloy stems
can also occur. In general, Co–Cr alloys undergo
intergranular corrosion, etching, selective
dissolution of cobalt, and the formation of Cr-rich
particles that are most likely oxides or oxychlorides.
The corrosion products generated at the taper
connections can migrate into periprosthetic tissues
and in between articulating polymeric surfaces. In
the past there have been instances where retrieved
implants have corroded to such an extent that
intergranular corrosion resulted in fatigue failure in
the neck of Co–Cr stems. It is to be emphasized that
it is the mechanical integrity of the oxide films that
form on these alloys that determines long-term
stability and performance of metallic components.
Relatively little is known about the mechanical
stability of oxide films and the electrochemical
reactions which occur when an oxide film is
fractured. What is known is that when the oxide
films of these orthopedic alloys are abraded or
removed from the surface by fretting the open
circuit potential can decrease to values as low as
500 mV. These potential excursions may be
significant enough and prolonged enough to cause
changes in the oxide structure and stability by
bringing the interface potential into the active range
of the alloy, thereby dramatically accelerating the
corrosion rate.
Combinations of metals: Dissimilar metal alloys
are used in combination in total joint implants.
Clinically, mixing of plates and screws made of more
inert metals such as vitallium and titanium does not
give rise to significant corrosion. Titanium based
alloys and cobalt based alloys can be combined with
themselves and with each other, but stainless steel
alloys also can be combined with each other, but not
with either titanium or cobalt. It was shown that
combining stainless steel with titanium in
oerthopaedic implants did not cause higher metal
release than the single-material constructions,
indicating comparable clinical safety. This study
showed that the titanium screws and plates
corroded more extensively in serum than in saline,
while the opposite was true for stainless steel. The
experiments with human serum can be regarded as
being closest to the clinical setting, which is in
favour of stainless steel. The weight loss of titanium
(equal to the metal ion released from the implant) is
most likely to be due to release of metal debris from
abrasion (galling), while for stainless steel
electrochemical corrosion is the predominant cause
of metal ion release. The combination of Ti and steel
implants gave approximately the same weight loss
and metal release as the combinations of similar
materials.
Surgeons are generally hesitant to mix
components made of different metals due to
potential galvanic corrosion. Nevertheless, back in
1975, Ruedi and Perren suggested combining
titanium plates with stainless steel screws, making a
less stiff plate available without the risk of screw
fractures. An additional advantage was that they
found less titanium wear debris in surrounding
tissues for stainless screws with commercially pure
titanium (CPTi) plates when compared with CPTi
plates and screws. This combined construct is
clinically acceptable, since the cathode is the screw
and the anode is the plate, which mean that cathode
is small and anode is large and as mentioned in the
previous paragraph, in this condition, the corrosion
is not significant, but the reverse construct is not
clinically sound, because the anode become small
and cathode become large, so corrosion will be
significant.
Kinetic Barriers to Corrosion:
Oxide Film Formation
The second primary factor that governs the
corrosion process of metallic biomaterials is the
formation of stable surface barriers or limitations to
the kinetics of corrosion. These barriers prevent
corrosion by physically limiting the rate at which
oxidation or reduction processes can take place. The
formation of a metal–oxide passive film on a metal
surface is one example of a kinetic limitation to
corrosion.
In general, kinetic barriers to corrosion prevent
either the migration of metallic ions from the metal
to the solution, the migration of anions from
solution to metal, or the migration of electrons
across the metal–solution interface. Passive oxide
films are the most well known forms of kinetic
barriers in corrosion, but other kinetic barriers exist
including manufactured polymeric coatings
Orthopedic alloys rely almost entirely on the
formation of passive films to prevent significant
 Metallurgy 183

oxidation (corrosion) from taking place. These films formation, are central to the performance of oxide
consist of metal oxides (ceramic films) which form films in orthopedic applications.
spontaneously on the surface of the metal in such a
way that they prevent further transport of metallic THE SOLUTION–METAL
ions and/or electrons across the film. To be effective
barriers, the films must be compact and fully cover INTERFACE:
the metal surface; they must have an atomic METAL, OXIDE LAYER, BIOFILM,
structure that limits the migration of ions and/or
electrons across the metal oxide–solution interface;
AND SOLUTION
and they must be able to remain on the surface of
The interface between a passivating metal and body
these alloys even with mechanical stressing or
fluid can then be summed up with the following
abrasion, expected with orthopedic devices.
description. Prior to implantation, the metal surface
Passivating oxide films spontaneously grow on
spontaneously reacts with its surroundings to form
the surface of metals. These oxide films are very thin
a passive metal oxide film which may be
(on the order of 5 to 70 A˚) and may be amorphous
nonuniform in cross-section (domed or needle
or crystalline, which depends on the potential
shaped) and, at least initially, amorphous. An oxide
across the interface as well as solution variables like
film nucleates and grows on the metal surface and
pH. Since the potential across the metal solution
contains within it defects which allow for electronic
interface for these reactive metals is typically 1 to 2
and ionic transport of charged species across the
V and the distances are so small, the electric field
film. There are species such as oxygen, phosphates,
across the oxide is very high, on the order of 106–
hydroxides, or proteins adsorbed from solution onto
107 V/cm. One of the more widely accepted models,
the surface of the oxide film which may change the
by Mott and Cabrera, states that oxide film growth
properties of the film. There also exists a large
depends on the electric field across the oxide. If the
electric field that is the driving force for the
potential across the metal oxide–solution interface
movement of these ions across the film. Also,
is decreased, then the film thickness will decrease
depending on conditions, the oxide film will change
by reductive dissolution processes at the oxide to
crystal structure, size, and thickness. Several
keep the electric field strength constant. Increasing
treatments have been investigated to see if
the voltage will correspondingly increase the
improvements in the barrier effect of the oxide films
thickness of the film. In fact, oxide thickness is often
can be achieved. These treatments include a hot,
determined by an anodization rate which is given as
concentrated nitric acid bath treatment, boiling in
oxide thickness per volt. The film will change its
distilled water, and anodization. However,
thickness by growth or dissolution until the rates of
optimizing changes in oxide film structure with
both are equal, giving rise to a film thickness that is
these treatments remains incomplete. Oxidation and
dependent on metal oxide–solution potential. If the
reduction reactions upon metal surfaces are
interfacial potential is made sufficiently negative or
typically separated spatially from each other (i.e.,
the pH of the solution is made low enough, then
the rate of oxidation of a species may be
these oxide films will no longer be
heterogeneously distributed about a metal surface).
thermodynamically stable and will undergo
That is, regions where oxidation is occurring may be
reductive dissolution, or there will be no driving
well separated spatially from where the
force for the formation of the oxide, and the metal
corresponding reduction process is operating.
surface will become unprotected.
These variations can be due to local microstructural
Oxide films are not flat, smooth, continuous sheets
heterogeneities or differences between grain
of adherent oxide covering the metal. Transmission
boundaries and grain interiors in the alloy,
electron microscopy (TEM) and atomic force
differences in strain energy, or geometry (as occurs
microscopy (AFM) techniques have shown that
in crevice corrosion or pitting corrosion). During
oxides of titanium, for instance, consist of needle or
crevice corrosion the region inside a crevice
dome shapes. Also, mechanical factors such as
develops into a deaerated environment and may
fretting, micromotion, or applied stresses may be
have a lower pH than the bulk solution. This tends
such that the oxide films are abraded or fractured.
to accelerate the release of metal ions in the crevice
When an oxide film is detached from the metal
(oxidation), while away from the crevice the
substrate, unoxidized metal is exposed to solution.
reduction reactions involving oxygen can take place.
These films tend to reform or repassivate, and the
In this case oxidation is localized inside the crevice
magnitude of the repassivation currents may be
and reduction takes place outside of the crevice.
large. This is due to the normally large driving
forces that are present for the oxidation process
which, when the kinetic barrier is removed, can METALLIC BIOMATERIALS:
operate to cause oxidation. However, the extent and CORROSION RESISTANCE AND
duration of the oxidation currents will depend on
the repassivation kinetics for oxide film formation. RELATED PROPERTIES
Hence, the mechanical stability of the oxide films, as
well as the driving force associated with their Corrosion resistance of a metallic implant material
is an important aspect of its biocompatibility.
184 Plate Fixation in Orthopaedics
Metallic biomaterials are normally considered to be
highly corrosion resistant because of the presence
of an extremely thin passive oxide film that
spontaneously forms on their surfaces. These films
serve as a barrier to corrosion processes in alloy
systems that would otherwise experience very high
corrosion rates. That is, in the absence of passive
films, the driving force for corrosion for typical
implant alloys [e.g., titanium-based, cobalt-
chromium (Co-Cr)-based, and stainless-steel alloys]
is very high, and corrosion rates would also be high.
The properties of these passive oxide films depend
to a large extent on their structure and chemistry,
which are themselves dependent on the substrate's
prior thermal, mechanical, and electrochemical
history.
There are two Co-Cr alloys extensively used in
implant fabrications such as artificial joints, or
stems of prostheses for heavily loaded joints such as
knees and hips: the castable Co-Cr-Mo alloy and the
Co-Ni-Cr-Mo alloy, which is usually wrought by
(hot) forging. The chromium is a reactive element
and is added to produce a stable firmly adherent
protective chromium oxide surface layer. Chromium
also enhances the solid solution strengthening of
the alloy. The molybdenum is added to produce
finer grains, which results in higher strengths after
casting or forging.
As with stainless steel, molybdenum also
enhances the corrosion resistance of Co-Cr alloys.
The inhomogeneous microstructure of the cast Co-
Cr-Mo alloy renders it more susceptible to corrosion
than the forged alloy, presumably due to the
presence of chromium-depleted dendritic regions
acting as the more anodic sites in a galvanic
reaction. Wrought Co-Cr-Mo has lower carbon
content than cast Co-Cr-Mo and, as a result, a lower
corrosion resistance when tested in physiologic
solution.
The metallic products released from the
prosthesis because of wear, corrosion, and fretting
may impair organs and local tissues, and moreover,
some alloys with certain amount of Co can be toxic
in the body. Low wear has been recognized as an
advantage of metal-on-metal hip articulations
because of their hardness and toughness.
Both CPTi and Ti-6Al-4V possess excellent
corrosion resistance for a full range of titanium
oxide states and pH levels. Titanium is a base metal
in the context of the electrochemical series;
however, it derives its resistance to corrosion by the
formation of a solid oxide layer to a depth of 10 nm.
Under in vivo conditions the oxide, TiO2, is a very
stable reaction product.
Corrosion currents in normal saline are very low
(10-8 Acm-2). The low dissolution rate and near
chemical inertness of titanium dissolution products
allow bone to thrive and therefore osteointegrate
with titanium.
Titanium implants remain virtually unchanged in
appearance; however, even in their passive
condition, metals, including titanium, are not inert.
It is established beyond doubt, by both in vitro and
in vivo experiments, that there is a passive
dissolution from the metal. Thus, linked to the issue
of electrochemical behavior are several questions:
1. What material is released?
2. How much material is released under static
conditions?
3. How is the release modified by wear
conditions?
4. What subsequent reactions do the release
products get involved in?
5. What percentage of the release products is
excreted and what percentage is retained?
6. Of the percentage that is retained, where does
it accumulate?
7. What biological response(s) will result from
the retained fraction?
Stainless steel contains enough chromium to
confer corrosion resistance by passivity. The
passive layer (chromium oxide) is not as robust as
in the case of titanium or the Co-Cr alloys. The
relatively resistant varieties of stainless steel are the
austinitic types 316, 316L, and 317, which contain
molybdenum (2.5% to 3.5%). Even these types of
stainless steels are vulnerable to pitting and to
crevice corrosion around screws, under certain
circumstances such as in a highly stressed and
oxygen-depleted region.
The corrosion resistance can be enhanced by
increasing the thickness of the protective oxide
using concentrated nitric acid ("passivation"), by
boiling in distilled water, or by electrochemical
means (anodization). The reduction of carbon to
less than 0.03% has virtually eliminated the risk of
intercrystalline corrosion, which can occur when
there is precipitation of chromium carbide at the
grain boundary in stainless steel with the carbon
content above this value. Unfortunately, lowering
the carbon content results in lowering the ultimate
tensile strength of stainless steel.
Corrosion of an implant in the clinical setting can
result in symptoms such as local pain and swelling
in the region of the implant, with no evidence of
infection; only cracking or flaking of the implant
(seen on roentgenograms), and excretion of excess
metal ions. At surgery, gray or black discoloration of
the surrounding tissues may be seen and flakes of
metals may be found in the tissue. Corrosion also
plays a role in the mechanical failures of
orthopaedic implants. Most of these failures are due
to fatigue, and the presence of a saline environment
certainly exacerbates fatigue. The extent to which
corrosion influences fatigue in the body is no
precisely known, although once an initial crack has
formed, crack propagation will be faster than in air
or vacuum. Other mechanisms of corrosion such as
fretting may also be involved at point of contact
such as in the countersink of hip nails.
Different parts of the body undergo different
types and rates of corrosion. Wounds and infections
can significantly change pH. In vivo the equilibrium
state between a metal and its reaction products

(oxide, hydroxide, etc.), which causes passivation,
may not occur if the reaction products are removed
by the tissue fluid turnover. The replenishment of
ions accumulated at the implant-tissue interface
may cause an adverse increase in the rate of ion
release that may cause damage on the cellular level.
Focusing on the major alloying elements in cobalt
based materials (Co, Cr, and Ni), Co and Ni ions bind
to serum albumin, and Cr6+ binds to red blood cells.
Chemical analyses of urine from animals subjected
to metal salts indicated that most Co and Ni is
rapidly excreted, while less than 50% of the Cr is
excreted, and this occasionally at a slower rate than
Co or Ni. Furthermore, organ levels of Co and Ni are
not significantly elevated, whereas they are for Cr.
Serum and urine analyses of patients with total joint
placements have also indicated a dose-response
relationship. Koegel and Black using a cast Co-Cr-Mo
microsphere model found dose-related elevations in
serum Co and Cr, with peak concentrations achieved
3 days after implantation. In a related study, it was
determined that the form of the released chromium
was Cr6+, a more biologically active form of Cr than
Cr3+. Black et al. found that when a pyrolytic carbon
coating was applied to cast Co-Cr-Mo, the carbon-
coated implants released more Co and Cr than the
uncoated implants.
Relative motion between the implant and tissue
may have caused the release of additional debris,
possibly in the form of metal carbides. Ducheyne
and Healy determined that hydroxyapatite coatings
reduce the Ti and Al passive dissolution rate from
porous coated Ti-6Al-4Y. Hydroxyapatite, however,
did not produce a change in the release kinetics of
Co and Cr from Co-Cr alloys.
Other studies on Ti and Ti-6Al-4V have shown
that titanium is preferentially accumulated locally,
with elevated levels of Ti detected in adjacent soft
tissue and bone. Healy and Ducheyne further
determined that serum proteins increase the release
rate kinetics of titanium compared with solutions
containing only serum electrolytes.
METAL ION/SOLUBLE METAL
LEVELS
Normal human serum levels of prominent implant
metals are approximately as follows: 1–10 ng/mL
aluminum, 0.15 ng/mL chromium, 0.01 ng/mL
vanadium, 0.1–0.2 ng/mL cobalt, and 4.1 ng/mL
titanium. Metal ions released in vivo and in vitro are
bound by specific serum proteins. Two molecular
weight ranges of human serum proteins were
determined to be associated with the binding of Cr
from Co–Cr–Mo (ASTM F-75) implant alloy
degradation (at approximately 68 and 180 kD); only
one range of serum protein(s) (at approximately 68
kD) is associated with the binding of Ti released
from Ti-6Al-4V implant alloy. The role of serum or
tissue proteins in the mediation of metal-induced
effects remains largely unknown. The toxicological
importance of these findings is not known.
Metallurgy 185
Ultimately, toxicological experiments using relevant
chemical species identified by bioavailability studies
will be used in animal models and cell cultures to
define specific toxicities of the degradation
products. However, at the present time this
information is not available. Homogenates of organs
and tissues obtained postmortem from subjects
with cobalt base alloy total joint replacement
components have indicated that significant
increases in cobalt and chromium concentrations
occur in the heart, liver, kidney, spleen, and
lymphatic tissue. Similarly, patients with titanium
base alloy implants demonstrated elevated titanium,
aluminum, and vanadium levels around their metal
implants (with up to 200 ppm of titanium, six orders
of magnitude greater than that of controls; 880 ppb
of aluminum; and 250 ppb of vanadium). Spleen
aluminum levels and liver titanium concentrations
can also be markedly elevated in patients with failed
titanium alloy implants. It has been found that even
in the absence of significant elevations in serum
metal concentrations, deposition of metal can occur
locally and in remote organ stores in association
with a well-functioning device.
Metallic particulate species are present in variable
amounts and may have important sequelae. When
present in sufficient amounts, particulates
generated by wear, corrosion, or a combination of
processes can induce the formation of an
inflammatory, foreign body granulation tissue with
the ability to invade the bone–implant interface.
This can result in progressive, peri-implant bone
loss that threatens the fixation of implant. The
response to metallic debris in lymph nodes includes
immune activation of macrophages and associated
production of inflammatory cytokines.
Soluble Corrosion Debris
The tissues surrounding modern implants may
include areas of bone ingrowth (osseointegration),
fibrous encapsulation, and a variable presence of
the foreign body responses. There are no
generalizable types of metal release that are known
to occur with all metallic implants. However,
accelerated corrosion and a tissue response that can
be directly related to identifiable corrosion products
have been demonstrated in the tissues surrounding
multipart devices. In vitro investigations indicate
that specific metals in ionic form can affect the
functionality of a variety of peri-implant cells such
as fibroblasts, osteoblasts, macrophages, and
lymphocytes within the ranges of metal
concentrations reported to exist in periprosthetic
tissue. Generally, the most toxic metal ions have
been found to be Ni, Fe, Cu, Mn, and V, while others
such as Na, Cr, Mg, Mo, Al, Ta, and Co demonstrate
relatively less cellular reactivity in vitro. Different
metals act through different cellular mechanisms to
induce distinct responses. There is mounting
evidence that adverse local and remote tissue
responses, which in the past have been entirely
associated with metal particles, to some extent may
186 Plate Fixation in Orthopaedics
be due to soluble forms of specific metal
degradation products. However, the effect of soluble
metals on periprosthetic cells is a complex function
of cell type, composition, and concentration of
metal. In vitro investigation has determined the
stimulatory effect of some metals (e.g., Al and V) on
cells such as lymphocytes and fibroblasts, while the
same metals (and concentrations) can suppress the
viability and proliferation of other cell types (e.g.,
osteoblast-like cells). This differential impact of
metal ions on some cell types and not others
(particularly fibroblasts and osteoblasts) may
potentially explain how fibrous membranes so
readily form around implants initially placed in
intimate contact with bone (i.e., osteoblasts).
Adverse local and remote tissue responses
purportedly associated with particulate debris may
be due in part to specific soluble metals resulting
from implant degradation. High concentrations of
metals negatively impact all types of cells at some
level. For certain cell types, such as human
osteoblasts, these effects have been somewhat
characterized. One of the main functions of
osteoblasts (if not the main function) is to produce
organic bone matrix, 90% of which is type I
collagen. Type I collagen is comprised of three
helical chains. Two of the three helical protein
chains are α. The third chain, β, is similar in
structure yet genetically distinct from α. Metal
particles and ions have been found to decrease gene
expression of procollagen α before decreases could
be observed in other more osteoblast-specific
markers of bone deposition, such as gene
expression of osteocalcin, osteonectin, and alkaline
phosphatase. Other metal-induced effects on
osteoblasts have been noted, such as the production
of cytokines which recruit, prime, and activate
inflammatory cells. Interleukin-6 is secreted by
osteblasts in response to Al, Fe, Mn, Na, Ni, and V
chloride solutions (more toxic metals). The
concentrations of metal ions associated with toxic
osteoblast responses can be detected within some
ranges of metal concentrations reported to exist in
periprosthetic tissue. Comparison of the effects of
metal ions on osteoblasts to the effects of particles
previously reported demonstrates the potential of
specific metal ions released from implants or
particulate implant debris to play a clinical role in
the pathogenesis of osteolysis. This contention is
supported by past investigations where metal ions
such as Al, V, and Ti have been shown to inhibit
apatite formation in vitro by binding and blocking
potential crystal growth sites. This poisoning of
crystal growth sites by metal ions may thus act to
interfere with normal in vivo osteoid mineralization
and remodeling process of bone. Whether through
indirect osteoclast activation (i.e., IL-6 release via
osteoblasts) or direct inhibitory effects on
osteoblasts, it is apparent that metal ions released
from implants have the potential to diminish bone
formation, which previously has been largely
attributed to particulate implant debris alone.
Important to the assessment of metal-induced
osteolysis is the role of other peri-implant cells such
as fibroblasts, osteoclasts, macrophages, and
lymphocytes, which, after exposure to metal ions,
may affect osteoblast function through paracrine
mediators. Although osteoclast activity has been
reportedly impaired by exposure to metal ions at
sublethal concentrations, these effects may be
overridden by metal-induced autocrine and
paracrine induction of IL-6, which can act to directly
stimulate osteoclast activity. Thus, further study
using mixed cell populations is required to more
comprehensively assess released implant metal
effects within the peri-implant milieu.
Particulate Debris Corrosion
Histological sections of the tissues surrounding
stainless steel internal fixation devices generally
show encapsulation by a fibrous membrane with
little or no inflammation over most of the device. At
screw–plate junctions, however, the membranes
often contain macrophages, foreign-body giant cells,
and a variable number of lymphocytes in
association with two types of corrosion products:
iron containing granules and microplates of
relatively larger particles of a chromium
compound(s). Chromium microplates are of variable
morphology and are found within the tissues as
closely packed, plate-like particle aggregates
ranging in size from 0.5 to 5.0 m. They are often
found free within acellular collagen or within
frankly necrotic tissue. Several multinucleated
foreign body giant cells are usually present within
or bordering collections of these particles. In
hematoxylin and eosin preparations, the majority of
microplates are yellow or apple-green. Many
microplates, however, stain darkly with
hematoxylin and these microplates also react
strongly to staining for iron. Electron microprobe
energy dispersive x-ray analyses indicate that
microplates are a chromium compound containing
iron and a substantial amount of phosphorus. Iron
granules are often seen surrounding chromium
microplates, but the granules are found alone as
well. Iron granules are yellow-brown, mainly
spherical, and 0.1 to 3 µ in diameter. They are
predominantly intracellular, most often in
macrophages, but may also be found in fibrocytes.
X-ray diffraction indicates that the granules consist
of a mixture of two or more of the iron oxides, Fe2O3
and Fe2O3, and the hydrated iron oxides Fe2O3-H2O
and Fe2O3-H2O. Particles of the chromium–
phosphate hydrate–rich corrosion product found in
tissues range in size from submicrometer to
aggregates of particles up to 500 µ. These particles
are similar in appearance to the chromium–
containing microplates observed in association with
corroded stainless steel implants when viewed
through a light microscope. Larger particles are
often found within areas of marked fibrosis or
necrosis or associated with foreign body giant cells,
although most of these particles are less than 5 µ in

size and are found within macrophages. The
degradation products that can be observed in
histological sections of tissues adjacent to titanium
base alloys are of a different nature than the
precipitates associated with stainless steel and
cobalt base alloys that have undergone accelerated
corrosion. Titanium base alloys, although very
Metallurgy 187
corrosion resistant, typically discolor (darkly stain)
adjacent tissue due to metallic debris. Examination
has found that the ratios of titanium, aluminum, and
vanadium concentrations in the periprosthetic
tissues are similar to those of the bulk alloy.
188 Plate Fixation in Orthopaedics

CHAPTER
STRESS-STRAIN
RELATIONSHIPS
CHAPTER OUTLINE
Stress-strain relationships
Fatigue
Variation of yield stress with temperature
and strain rate
Yield points and crystal structure
A basic knowledge of mechanical terms is
fundamental to understanding comparisons
between different materials. Mechanical
characteristics are based on the ability of a material
to resist external forces, as expressed by stress-
strain curves.
Mechanical properties including elasticity and
strength are important properties to consider in
selection of a material for a specific implant design.
Many of the mechanical properties of a material
take into account how it behaves under load. If a
load, F, is applied to a material of cross-section area
A, it is subjected to a stress, α. The units of α (N/m2
=Pa) show that stress and pressure are similar
Metallurgy 189
4.5
Viscoelasticy
Superplasticity
Metallic fatigue
Nature of fatigue failure
concepts. Under this force, there also will be a
strain, ε, due to change from the original length. At
low stress and low strain, stress is proportional to
strain, i.e., E is constant for a material at low strain.
It is called Young's modulus or modulus of elasticity
of the material. E is a measure of stiffness (i.e.
resistance to strain) of a material, and is quite
distinct from strength. A small value of E means that
a small stress gives a large extension (as in rubber);
a large value of E indicates that the material is very
stiff (as in diamond). The E values are 7 MPa and 1.2
x 106 MPa for rubber and diamond, respectively.
The stress at which elongation is no longer
reversible is called the limit of elasticity. For
190 Plate Fixation in Orthopaedics
metallic and ceramic materials, the elastic region
shows a linear relationship between stress and
strain, but for polymers the relationship can be
nonlinear. The yield strength is defined as the value
of the stress when the strain is 0.2% more than the
elastic region will allow, i.e., the stress level at which
0.2% permanent deformation occurs; this value is
also referred to as the 0.2% proof stress. As it is
very difficult to determine the onset of permanent
or plastic deformation, the yield strength is a more
practical property than the limit of elasticity. Plastic
deformation (plastic strain) is permanent strain and
it occurs beyond the yield strength, as removal of
stress leaves the material deformed. The ultimate
tensile strength (UTS) is the maximum technical
stress (load divided by the original section) the
material can sustain in tension. Ductility is the
strain at failure (usually expressed as percent).
Fracture toughness is the measure of the energy
required to break a material (the area under the
stress-strain curve at failure). Fracture toughness
varies with the material: it is 0.75 MPa.m1/2 for silica
glass, 4 MPa.m1/2 for diamond, and upto 100 MPa.m
1/2 for steel. Hardness is another mechanical
property; it is the resistance of a material to the
penetration of its surface. The fatigue strength is
maximum stress a material can withstand for an
infinite or an arbitrary large number of cycles.
Usually the number of cycles selected is 10 million.
This represents about 10 years of loading a hip
prosthesis for a patient with limited activity. As any
device is subjected to cyclic loading, designing
against fatigue is essential for most orthopaedic
implants.
Strain is the change in linear dimensions of a body
resulting from the application of a force or load.
Load applied to a material produces stress within a
material and thus invariably in deformation (strain)
of the material.
Strain energy is the energy a body is capable of
absorbing by changing its shape under the
application of an external load.
As mentioned before, strain is a measure of
deformation, or potential energy, or amount of work
deformed body is capable of doing in returning to its
undeformed state. More rapidly a bone is loaded,
the greater will be the energy absorption prior to
failure; thus fractures associated with slow loading
are generally linear, whereas rapid loading infuses
enormous strain energy so that an explosion of the
bone takes place at failure.
Energy absorbed to produce fracture of the
femoral neck is approx 60 kg cm; in falls, kinetic
energy is far in excess of this amount, however, this
energy may be dissipated by muscle action, elastic
strain and plastic strain of the soft tissues.
Analysis of mechanical conditions using the
concept of strain allows one to understand why
fractures with single, narrow gap are very intolerant
of even minute amounts of displacement; such
displacement may not be detected by vision but
must be detected by intellect; Instability is better
tolerated by multifragmentary (comminuted)
fractures because overall displacement is shared
between many fracture gaps;
The yield point of a material is the force required
to induce the earliest permanent change in shape or
deformation. The yield point or limit or
proportionality, denotes end of elastic region and
beginning of the plastic region of the curve.
Metals with highest yield strength to the lowest:
1. Cast cobalt chrome
2. Titanium
3. Wrought cobalt chrome
4. Stainless steel
Elasticity is the material's ability to restore its
original shape after a deforming force lower than
the yield point is removed. This is quantified by the
modulus of elasticity, which is the slope of the elastic
region of the stress-strain curve. The steeper the
curve, the bigger the young modulus of elasticity,
the stiffer the material. If after removal of the
stretch applied to an object, it reverts to its original
resting length, the object has a linear "stress/strain"
slope.
Stiffness is defined as the resistance to
deformation; it is proportional to the modulus of
elasticity. Stiffness is measured as the relationship
between load applied and the resulting elastic
deformation. The inherent stiffness of a material is
its modulus of elasticity. The stiffness of an implant
results from the modulus of elasticity and the shape
and dimensions of the implant itself. As an example,
the modulus of elasticity of CPTi is about half that of
stainless steel, and so, under similar load conditions,
it will deform twice as much. However, the
dimension of the implant is important as well:
Increasing the thickness of a standard CPTi plate by
a few tenths of a millimeter will augment its
bending stiffness. Fracture of a bone can be
understood as discontinuity of bone stiffness.
The implant material of choice for internal
fixation remains metal, which offers high stiffness
and strength, good ductility, and is usually well
tolerated biologically.
Osteosynthesis restores bone stiffness
temporarily; fracture healing restores it
permanently.
When we consider an implant (nail, plate, or
external fixator) spanning a fracture, the stiffness of
the implant must prevent deformity at the fracture
site. To allow proper healing, the device must
reduce fracture mobility to below the critical level at
which healing tissue will form. Granulation tissue
and cartilaginous callus will form under conditions
of higher dynamic deformation (strain) than the
final mineralization, since the bone cannot tolerate
strain as much as the granulation tissue can
(approximately 2% cortical bone compared to
approximately 15% cartilage and 100% granulation
tissue).

In the past attempts have been made to produce
implants that have a material stiffness similar to
bone, using plastic or carbon reinforced composites.
These implants reduce the stress shielding that
occurs with stiff, metal implants that take the load
away from the bone. However, implants with very
low material stiffness do not as a rule offer an
acceptable balance between biological and
mechanical advantages. Less stiff implants reduce
but do not abolish stress shielding.
Research has shown that early temporary porosis
of bone in contact with implants does not depend
upon the degree of unloading (stress shielding) but
rather on the amount of direct vascular damage
caused by the implant.
Plastic deformation is a permanent change in
structure of a material after the stress is relieved.
The ductility of a material is the degree of
permanent (plastic) deformation it tolerates before
it breaks. In contrast, A brittle material has minimal
deformation before failure. In other word, ductility
is the ability of a material to further deform beyond
the yield point before fracture. The ductility of a
material determines the degree to which an implant,
such as a plate, can be contoured. As a general rule,
materials of high strength such as titanium alloys
and highly cold-worked CPTi offer less ductility than
steel. Ductility provides some forewarning of
impending failure, for instance during insertion of a
screw. According to international standards, a 4.5
mm cortex screw (ISO 6475) must tolerate more
than 1800 of elastic and plastic angular deformation
before breakage. However, CPTi having lower
ductility provides less prewarning, which means
that the surgeon should first acquire some bench
experience leading to a different handling
technique. The possible problems due to lower
ductility of CPTi may be overcome by the design of
the implant. In a clinical test series with more than
2,000 locked head (without thread on screw head or
plate) PC-Fix screws, failure was observed neither
at insertion nor thereafter. This demonstrates that
the choice of an implant material must be matched
with the correct design for its application.
These characteristics are explained by the shape
of the plastic (permanent deformation) curve past
the yield point; a longer curve implies a more
ductile substance. Ductility and brittleness are
relative characteristics and not numerically
quantified.
Critical Strain Levels of Repair Tissues:
(Elongation at rupture of different Sites)
Granulation Tissue: 100%
Dense Fibrous Tissue: 20%
Cartilage: 10%
Cancellous Bone: 2%
Lamellar Bone 2%
Toughness is the total energy required to stress a
material to the point of fracture. It is defined as the
area under both the elastic and the plastic parts of
Metallurgy 191
the stress-strain curve or as the energy to failure. In
other word, toughness is the ability of a material to
absorb energy by bending without breakage or the
strain energy in the material at the point of ultimate
stress. The energy a structure absorbs as it is
deformed by an applied force is equal to the work
done by that force.
It's energy of mechanical deformation per unit
volume prior to fracture. The explicit mathematical
description is:
Where ε is strain εf is the strain upon failure σ is
stress
Toughness is measured in units of joules per cubic
metre (J/m3) in the SI system.
Hardness is the ability to resist plastic
deformation at the material surface only. For many
materials, the mechanical properties at the surface
differ from those found in the bulk of the material.
Strength is the ability of a material to resist the
application of forces without deformation. Thus,
strength determines thelevel of load an implant can
resist. Before a metal breaks, it may irreversibly
deform (this is called plastic deformation). Here
again, the dimensions of the implant are often more
important then the strength of the material. The
strength of Copt is about 10% less than that of steel,
but an increase of implant cross section will
compensate for the difference in material strength.
Strength determines the limit of stress, which
results in deformation. For internal fixation, the
resistance of an implant to repeated load, which
may result in failure by fatigue, is a critical issue.
Compared to steel, Copt is somewhat less resistant
to single load, but superior when high-cycle
repeated loads are applied.
Strength and toughness are related. A material
may be strong and tough if it ruptures under high
forces, exhibiting high strains; on the other hand,
brittle materials may be strong but with limited
strain values, so that they are not tough. Generally
speaking, strength indicates how much force the
material can support, while toughness indicates
how much energy a material can absorb before
rupture.
Ultimate Tensile Strength: is the maximum load
that material can withstand in a single application
without breaking. On the stress-strain curve, the
ultimate tensile strength will be seen as the peak on
the graph, which is subsequently followed by
increasing strain with decreased stress (fracture
process). When the ultimate tensile strength is
exceeded, the material will break.
192 Plate Fixation in Orthopaedics

Materials with highest ultimate strength to important characteristic of a femoral stem because
lowest: it determines ability of device to withstand long
1. Wrought cobalt chrome term loading without fatigue fracture.
2. Titanium (alloy) Fatigue fractures of implants result from a high
3. Wrought stainless steel number of cycles of relatively low stress. Fracture or
4. Casted cobalt break in a metal caused by repetitive applications of
5. Cortical bone loads in between the fatigue limit and the Yield
Strength. Single-cycle and low-cycle failures are
Metal has a variety of mechanical properties. caused by high stress. Implants that have failed as a
Some are a function of its chemical composition and result of fatigue can be distinguished from single-
do not change with further processing; others are cycle failures because they display a series of
strongly affected by the relative orientation of the concentric fatigue striations over the fracture
crystals and therefore are altered by processing. surface (Fig 4.5-1). These striations appear to
The elastic moduli in tension and compression do radiate from certain initiation points, which
not change with processing, but yield strength, represent areas in which the overall peak tensile
ultimate strength, and fatigue strength can be stress combined with the presence of stress risers
altered significantly by small changes in chemical (e.g., cracks, scratches, holes) exceeds the material's
composition and processing. local resistance to failure. If the average peak
To analysis the mechanical properties of a definite stresses are large, then the striations have more
specimen, term of (an)isotropic is important. distance between them. When these striations have
Isotropic materials possess the same properties in propagated a sufficient distance to decrease the
all directions, whereas anisotropic materials have cross-sectional area of the implant, ultimate
mechanical properties that vary with orientation of strength is reduced, leading to complete failure. This
the loading. area of final failure is called the tear zone, and it can
provide clues to the type of failure. High-stress, low-
FATIGUE cycle failure produces a larger tear zone than low-
stress, high-cycle failure. Implants must be designed
Fatigue is caused by cyclical (repetitive) stressing of to withstand these anticipated loads and cycles. If
a material. In cyclical loading, the maximal force failure of an implant occurs, it should be examined
required to produce failure decreases as the cycle to determine the failure pattern.
number increases until the endurance limit is Fatigue Limit is the maximal load that a metal can
reached. The resulting fatigue curve shows the force endure indefinitely without bending or breaking
necessary to cause failure of a material at each when subjected to cyclic bending.
specific cycle number. The higher the overall stress,
the fewer the cycles required to produce failure
(loading to the ultimate stress produces failure in
one cycle). The endurance limit is the lowest point
on the fatigue curve and represents a cyclical
applied force below which the material will not have
failed after 10 million (1 × 107) cycles. If the
material has not failed at this point, in theory, it
never will. By choosing different materials and
altering implant geometry, manufacturers attempt
to design implants that will tolerate cyclical loads
without failure.
The fatigue strength (point of fatigue failure) of a
material is defined as a single stress value on the
fatigue curve for a specific number of cycles. In
practice, certain points on a metal implant reach the
fatigue failure level before others because of
localized concentrations of stress (stress risers).
Fatigue failure at these points results in the
initiation of a crack that can propagate, causing the
entire implant to fracture. On the basis of anatomic
location, implants are subject to varying loads and
varying frequency of stress cycles. The usual design
estimate of cyclical load for orthopaedic implants is
2 × 106 stress cycles per year.
Fatigue Strength is the maximum load that metal
can withstand without fracturing when subjected to
10 million cyclic loads. It is sometimes referred to as Figure 4.5-1: Fatigue striations on the fraction surface
the endurance limit. This is probably the most near the compression hole of a locking compression plate.

The American Society for Testing and Materials
(ASTM) and the American Iron and Steel Institute
(AISI) are two groups that test and monitor
materials. Among other functions, these groups
serve as independent sanctioning boards. Materials
purchased by implant manufacturers are certified
under their specifications. If a company wants to
use a material that has not been sanctioned, it must
go through rigorous biocompatibility and material
testing procedures and submit the results to the U.S.
Food and Drug Administration (FDA) for approval.
The load–elongation curves for both
polycrystalline mild steel and copper are shown in.
The corresponding stress (load per unit area, P/A)
versus strain (change in length per unit length, dl/l)
curves may be obtained knowing the dimensions of
the test piece. At low stresses the deformation is
elastic, reversible and obeys Hooke’s law with stress
linearly proportional to strain. The proportionality
constant connecting stress and strain is known as
the elastic modulus and may be either (a) the elastic
or Young’s modulus, E, (b) the rigidity or shear
modulus μ, or (c) the bulk modulus K, depending on
whether the strain is tensile, shear or hydrostatic
compressive, respectively. Young’s modulus, bulk
modulus, shear modulus and Poisson’s ratio ν, the
ratio of lateral contractions to longitudinal
extension in uniaxial tension, are related according
to
K = E/ 3(1 − 2ν) , μ = E/ 2(1 + ν) , E = 9Kμ/ 3K + μ
In general, the elastic limit is an ill-defined stress,
but for impure iron and low-carbon steels the onset
of plastic deformation is denoted by a sudden drop
in load, indicating both an upper and lower yield
point. This yielding behavior is characteristic of
many metals; particularly those with BCC structure
containing small amounts of solute element. For
materials not showing a sharp yield point, a
conventional definition of the beginning of plastic
flow is the 0.1% proof stress, in which a line is
drawn parallel to the elastic portion of the stress–
strain curve from the point of 0.1% strain.
The increase in stress from the initial yield up to
the tensile strength (TS) indicates that the specimen
hardens during deformation (i.e. work hardens). On
straining beyond the TS the metal still continues to
work-harden, but at a rate too small to compensate
for the reduction in cross-sectional area of the test
piece. The deformation then becomes unstable, such
that as a localized region of the gauge length strains
more than the rest, it cannot harden sufficiently to
raise the stress for further deformation in this
region above that to cause further strain elsewhere.
A neck then forms in the gauge length, and further
deformation is confined to this region until fracture.
The fatigue phenomenon is concerned with the
premature fracture of metals under repeatedly
applied low stresses, and is of importance in many
branches of engineering (e.g. aircraft structures).
Several different types of testing machines have
Metallurgy 193
been constructed in which the stress is applied by
bending, torsion, tension or compression, but all
involve the same principle of subjecting the material
to constant cycles of stress. To express the
characteristics of the stress system, three properties
are usually quoted: these include (1) the maximum
range of stress, (2) the mean stress and (3) the time
period for the stress cycle.
Creep is defined as plastic flow under constant
stress, and although the majority of tests are carried
out under constant load conditions, equipment is
available for reducing the loading during the test to
compensate for the small reduction in cross-section
of the specimen. At relatively high temperatures
creep appears to occur at all stress levels, but the
creep rate increases with increasing stress at a
given temperature.
Elastic deformation
It is well known that metals deform both elastically
and plastically. Elastic deformation takes place at
low stresses and has three main characteristics,
namely (1) it is reversible, (2) stress and strain are
linearly proportional to each other according to
Hooke’s Law, and (3) it is usually small (i.e. <1%
elastic strain).
When a body is strained, small elements in that
body are displaced. If the initial position of an
element is defined by its coordinates (x, y, z) and its
final position by (x + u, y + v, z + w), then the
displacement is (u, v,w). If this displacement is
constant for all elements in the body, no strain is
involved, only a rigid translation. For a body to be
under a condition of strain the displacements must
vary from element to element.
Plastic deformation
The limit of the elastic range cannot be defined
exactly but may be considered to be that value of
the stress below which the amount of plasticity
(irreversible deformation) is negligible, and above
which the amount of plastic deformation is far
greater than the elastic deformation. If we consider
the deformation of a metal in a tensile test, one or
other of two types of curve may be obtained. The
stress–strain curve characteristic of iron, from
which it can be seen that plastic deformation begins
abruptly and continues initially with no increase in
stress. A stress–strain curve characteristic of
copper, from which it will be noted that the
transition to the plastic range is gradual. No abrupt
yielding takes place and in this case the stress
required to start macroscopic plastic flow is known
as the flow stress.
VARIATION OF YIELD STRESS
WITH TEMPERATURE AND STRAIN
RATE
The high Peierls–Nabarro (P–N) stress, which is
associated with materials with narrow dislocations,
gives rise to a short-range barrier to dislocation
194 Plate Fixation in Orthopaedics
motion. Such barriers are effective only over an
atomic spacing or so; hence thermal activation is
able to aid the applied stress in overcoming them.
Thermal activation helps a portion of the dislocation
to cross the barrier after which glide then proceeds
by the sideways movement of kinks. Materials with
narrow dislocations therefore exhibit significant
temperature sensitivity; intrinsically hard materials
rapidly lose their strength with increasing
temperature. Materials which exhibit a strong
temperature-dependent yield stress also exhibit
high strain-rate sensitivity, i.e. the higher the
imposed strain rate, the higher the yield stress. This
arises because thermal activation is less effective at
the faster rate of deformation.
In BCC metals a high lattice friction to the
movement of a dislocation may arise from the
dissociation of a dislocation on several planes. When
a screw dislocation with Burgers vector a/2[1 1 1]
lies along a symmetry direction it can dissociate on
three crystallographically equivalent planes. If such
a dissociation occurs, it will be necessary to
constrict the dislocation before it can glide in any
one of the slip planes. This constriction will be more
difficult to make as the temperature is lowered so
that the large temperature dependence of the yield
stress in BCC metals may be due partly to this effect.
In FCC metals the dislocations lie on {1 1 1} planes,
and although a dislocation will dissociate in any
given (1 1 1) plane, there is no direction in the slip
plane along which the dislocation could also
dissociate on other planes; the temperature
dependence of the yield stress is small. In CPH
metals the dissociated dislocations moving in the
basal plane will also have a small Peierls force and
be glissile with low temperature dependence.
However, screw dislocations moving on non-basal
planes (i.e. prismatic and pyramidal planes) may
have a high Peierls force because they are able to
extend in the basal plane. Hence, constrictions will
once again have to be made before the screw
dislocations can advance on non-basal planes. This
effect contributes to the high critical shear stress
and strong temperature dependence of non-basal
glide observed in this crystal system.
A specimen of iron during tensile deformation
behaves elastically up to a certain high load A,
known as the upper yield point, and then it
suddenly yields plastically. The important feature to
note from this curve is that the stress required to
maintain plastic flow immediately after yielding has
started is lower than that required to start it, as
shown by the fall in load from A to B (the lower
yield point). A yield point elongation to C then
occurs, after which the specimen work hardens and
the curve rises steadily and smoothly.
YIELD POINTS AND CRYSTAL
STRUCTURE
The characteristic feature of discontinuous yielding
is that at the yield point the specimen goes from a
condition where the availability of mobile
dislocations is limited to one where they are in
abundance, the increase in mobile density largely
arising from dislocation multiplication at the high
stress level. A further feature is that not all the
dislocations have to be immobilized to observe a
yield drop. In the FCC metals, the P–N stress is quite
small and the stress to move a dislocation is almost
independent of velocity up to high speeds. If such
metals are to show a yield point, the density of
mobile dislocations must be reduced virtually to
zero. Yielding begins at the stress required to create
dislocations in the perfect lattice, and the upper
yield stress approaches the theoretical yield
strength. Following multiplication, the stress for
glide of these dislocations is several orders of
magnitude lower. BCC transition metals such as iron
are intermediate in their plastic behavior between
the FCC metals and diamond cubic Si and Ge.
However, in practice, the dislocation density of well-
annealed pure metals is about 1010mm−3 and too
high for any significant yield drop without an
element of dislocation locking by carbon atoms.
VISCOELASTICY
These materials exhibit stress/strain behavior that
is time-rate dependent, and varies with the material,
that is a function of the material's internal friction,
viscoelastic materials are stiffer and stronger at
high strain rates than at low strain rates, for
example in bone-ligament interface, slow rate of
loading will result in avulsion fracture of bone but a
fast rate of loading will cause ligament failure,
hence, bone has a higher modulus of elasticity at
higher strain rates; ligaments are viscoelastic, so
their stress/strain behavior is time-rate dependent,
with elongation of ligament being more likely to
occur with slower loading conditions.
Superplasticity
A number of materials have been observed to
exhibit large elongations (≈1000%) without
fracture, and such behavior has been termed
superplasticity. Several metallurgical factors have
been put forward to explain superplastic behavior
and it is now generally recognized that the effect
can be produced in materials with a particular
structural condition. The particular structural
condition is that the material has a very fine grain
size and the presence of a two-phase structure is
usually of importance in maintaining this fine grain
size during testing. In general, the superplastic
material exhibits high strain-rate sensitivity. Thus,
the plastic flow of a solid may be represented by the
relation
̇
 Metallurgy 195

where σ is the stress, ̇ the strain rate and m an good hot workability if 0.5Ti is added to produce a
exponent generally known as the strain-rate random distribution of TiC rather than Cr3Co6 at
sensitivity. When m=1 the flow stress is directly ferrite–austenite boundaries.
proportional to strain rate and the material behaves
as a Newtonian viscous fluid, such as hot glass. METALLIC FATIGUE
Superplastic materials are therefore characterized
by high m-values, since this leads to increased
Nature of fatigue failure
stability against necking in a tensile test.
The term fatigue applies to the behavior of a metal
For most metals and alloys m≈0.1–0.2 and once
which, when subjected to a cyclically variable stress
necking starts the process rapidly leads to failure.
of sufficient magnitude (often below the yield
When m=1, as a consequence, any irregularities in
stress), produces a detectable change in mechanical
specimen geometry are not accentuated during
properties. In practice, a large number of service
deformation. The resistance to necking therefore
failures are due to fatigue, and so engineers are
depends sensitively on m, and increases markedly
concerned mainly with fatigue failure, where the
when m>0.5. Superplastic materials such as Zn–Al
specimen is actually separated into two parts. Some
eutectoid, Pb–Sn eutectic, Al–Cu eutectic, etc. have m
of these failures can be attributed to poor design of
values approaching unity at elevated temperatures.
the component, but in some cases can be ascribed to
The total elongation increases as m increases and,
the condition of the material. Consequently, the
with increasing microstructural fineness of the
treatment of fatigue may be conveniently divided
material (grain size or lamella spacing), the
into three aspects: (1) engineering considerations,
tendency for superplastic behavior is increased.
(2) gross metallurgical aspects, and (3) fine-scale
Two phase structures are advantageous in
structural and atomic changes.
maintaining a fine grain size during testing, but
The amplitude of the stress cycle to which the
exceptionally high ductilities have been produced in
specimen is subjected is the most important single
several commercially pure metals (e.g. Ni, Zn and
variable in determining its life under fatigue
Mg), for which the fine grain size was maintained
conditions, but the performance of a material is also
during testing at a particular strain rate and
greatly affected by various other conditions, which
temperature. It follows that there must be several
may be summarized as follows:
possible conditions leading to superplasticity.
Surface preparation. Since fatigue cracks
Generally, it is observed metallographically that the
frequently start at or near the surface of the
grain structure remains remarkably equiaxed
component, the surface condition is an important
during extensive deformation and that grain
consideration in fatigue life. The removal of
boundary sliding is a common deformation mode in
machining marks and other surface irregularities
several superplastic alloys. While grain boundary
invariably improves the fatigue properties. Putting
sliding can contribute to the overall deformation by
the surface layers under compression by shot
relaxing the five independent mechanisms of slip, it
peening or surface treatment improves the fatigue
cannot give rise to large elongations without bulk
life.
flow of material (e.g. grain boundary migration). In
Effect of temperature. Temperature affects the
polycrystals, triple junctions obstruct the sliding
fatigue properties in much the same way as it does
process and give rise to a low m-value.
the tensile strength (TS); the fatigue strength is
The complete explanation of superplasticity is still
highest at low temperatures and decreases
being developed, but it is already clear that, during
gradually with rising temperature.
deformation, individual grains or groups of grains
Frequency of stress cycle. In most metals the
with suitably aligned boundaries will tend to slide.
frequency of the stress cycle has little effect on the
Sliding continues until obstructed by a protrusion in
fatigue life, although lowering the frequency usually
a grain boundary, when the local stress generates
results in a slightly reduced fatigue life. The effect
dislocations which slip across the blocked grain and
becomes greater if the temperature of the fatigue
pile up at the opposite boundary until the back
test is raised, when the fatigue life tends to depend
stress prevents further generation of dislocations
on the total time of testing rather than on the
and thus further sliding.
number of cycles.
The above conditions imply that any metal in
Environment. Fatigue occurring in a corrosive
which the grain size remains fine during
environment is usually referred to as corrosion
deformation could behave superplastically; this
fatigue. It is well known that corrosive attack by a
conclusion is borne out in practice. The stability of
liquid medium can produce etch pits which may act
grain size can, however, be achieved more readily
as notches, but when the corrosive attack is
with a fine microduplex structure, as observed in
simultaneous with fatigue stressing, the detrimental
some Fe–20Cr–6Ni alloys when hot-worked to
effect is far greater than just a notch effect. It is now
produce a fine dispersion of austenite and ferrite.
well established that fatigue starts at the surface of
Such stainless steels have an attractive combination
the specimen. Accordingly, any alteration in surface
of properties (strength, toughness, fatigue strength,
properties must bring about a change in the fatigue
weldability and corrosion resistance) and, unlike
properties. The best fatigue resistance occurs in
the usual range of two-phase stainless steels, have
materials with a worked surface layer produced by
196 Plate Fixation in Orthopaedics
polishing with emery, shot-peening or skin-rolling
the surface. This beneficial effect of a worked
surface layer is principally due to the fact that the
surface is put into compression. Electropolishing the
specimen by removing the surface layers usually
has a detrimental effect on the fatigue properties,
but other common surface preparations such as
nitriding and carburizing, both of which produce a
surface layer which is in compression, may be
beneficial. The alloy composition and thermal and
mechanical history of the specimen are also of
importance in the fatigue process. Any treatment
which increases the hardness or yield strength of
the material will increase the level of the stress
needed to produce slip and since the fundamental
processes of fatigue are largely associated with slip,
this leads directly to an increase in fatigue strength.
It is also clear that grain size is a relevant factor: the
smaller the grain size, the higher is the fatigue
strength at a given temperature.
The fatigue processes in stable alloys are
essentially the same as those of pure metals but
there is, of course, an increase in fatigue strength.
However, the processes in unstable alloys and in
materials exhibiting a yield point are somewhat
different. In fatigue, as in creep, structural
instability frequently leads to enhancement of the
fundamental processes. In all cases the approach to
equilibrium is more complete, so that in age-
hardening materials, solution-treated specimens
become harder and fully aged specimens become
softer. The changes which occur are local rather
than general, and are associated with the enhanced
diffusion brought about by the production of
vacancies during the fatigue test.
Accordingly, it has been suggested that the fatigue
limit occupies a similar place in the field of
alternating stresses to that filled by the yield point
in unidirectional stressing. Stresses above the
fatigue limit readily unlock the dislocations from
their solute atom atmospheres, while below the
fatigue limit most dislocations remain locked. In
support of this view, it is found that when the
carbon and nitrogen content of mild steel is
reduced, by annealing in wet hydrogen, striking
changes take place in the fatigue limit as well as in
the sharp yield point.
 Metallurgy 197

CHAPTER 4.6
CORROSION-RESISTANT
ORTHOPAEDIC ALLOYS
CHAPTER OUTLINE

Stainless steel alloys Zirconium

Iron Tantalum
Nickel New metal implant materials
Chromium High-strength alloys
Stainless steel Shape memory alloys
Surgical stainless steel Polymeric implants
New stainless steels Comparison of metals
Titanium and Titanium alloys Mechanical properties
Titanium Biocompatibility
Vanadium Surface structure
Cobalt-Chromium alloys In vivo comparison of metals
Cobalt
Molybdenum

There are three principal metal alloys used in properties such as corrosion resistance and high
orthopedics: titanium based alloys, cobalt based strength are paramount.
alloys, and stainless steel alloys. Alloy-specific STAINLESS STEEL ALLOYS
differences in strength, ductility, and hardness
generally determine which of these three alloys is Iron
used for a particular application or implant
Iron is a chemical element with the symbol Fe
component. However, it is primarily the high
(Latin: ferrum) and atomic number 26. Elemental
corrosion resistance of all metal alloys that has led
iron is reactive; it oxidizes in air to give iron oxides,
to their widespread use as implant materials.
also known as rust. Unlike many other metals which
Implant alloys were originally developed for
form passivating oxide layers, iron oxides occupy
maritime and aviation uses where mechanical
198 Plate Fixation in Orthopaedics
more volume than iron itself. Thus, iron oxides flake
off and expose fresh surfaces for corrosion.
Mechanical properties of iron crucially depend on
purity: Purest research-purpose single crystals of
iron are softer than aluminium. Addition of only
10 parts per million of carbon doubles their
strength. The hardness increases rapidly with
carbon content up to 0.2% and saturates at 0.6%.
As molten iron cools down, it crystallizes at
1538 °C into a body-centered cubic (BCC) crystal
structure. As it cools further its crystal structure
changes to face-centered cubic (FCC) at 1394 °C. At
912 °C the crystal structure again becomes BCC and
at 770 °C iron becomes magnetic. In unmagnetized
iron, all the electronic spins of the atoms within one
domain are in the same direction; the neighboring
domains point in various directions and thus cancel
out. In magnetized iron, the electronic spins of all
the domains are aligned, so that the magnetic effects
of neighboring domains reinforce each other.
Although each domain contains billions of atoms,
they are very small, about 10 microns across.
Above 912 °C and up to 1400 °C iron undergoes a
phase transition from BCC to the FCC configuration,
also called austenite. This is similarly soft and
metallic but can dissolve considerably more carbon
(as much as 2.04% by mass at 1146 °C). This form of
iron is used in the type of stainless steel used for
making hospital equipment.
Pig iron (cast iron) is not pure iron, but has 4–5%
carbon dissolved in it with small amounts of other
impurities like sulfur, magnesium, phosphorus and
manganese. As the carbon is the major impurity, the
iron (pig iron) becomes brittle and hard.
Alternatively pig iron may be made into steel
(with up to about 2% carbon) or wrought iron
(commercially pure iron). In all cases, the objective
is to oxidize some or all of the carbon, together with
other impurities. On the other hand, other metals
may be added to make alloy steels.
The hardness of the steel depends upon its carbon
content. The higher the percentage of carbon, the
greater the hardness and the lesser the malleability.
The properties of the steel can also be changed by
several methods.
Annealing involves the heating of a piece of steel
to 700–800°C for several hours and then gradual
cooling. It makes the steel softer and more
workable.
Steel may be hardened by cold working. The metal
is bent or hammered into its final shape at a
relatively cool temperature. Cold forging is the
stamping of a piece of steel into shape by a heavy
press. Cold rolling, which involves making a thinner
but harder sheet, and cold drawing, which makes a
thinner but stronger wire, are two other methods of
cold working.
Heat treatment is another way to harden steel.
The steel is heated red hot, then cooled quickly. The
iron carbide molecules are decomposed by the heat,
but do not have time to reform. Since the free
carbon atoms are stuck, it makes the steel much
harder and stronger than before.
Sometimes both toughness and hardness are
desired. A process called case hardening may be
used. Steel is heated to about 900 °C in a bed of
charcoal and/or nitrogen. They diffuse into the
steel, making the surface very hard. The surface
cools quickly, but the inside cools slowly, making an
extremely hard surface and a durable, resistant
inner layer.
Iron may be passivated by dipping it into a
concentrated nitric acid solution. This forms a
protective layer of oxide on the metal, protecting it
from further corrosion. When the metal is jarred,
however, the layer is broken, allowing the metal to
corrode again.
Commercially available iron is classified based on
purity and the abundance of additives. Pig iron has
3.5–4.5% carbon and contains varying amounts of
contaminants such as sulfur, silicon and
phosphorus. Pig iron is not a saleable product, but
rather an intermediate step in the production of cast
iron and steel from iron ore. Cast iron contains 2–
4% carbon, 1–6% silicon, and small amounts of
manganese. Contaminants present in pig iron that
negatively affect material properties, such as sulfur
and phosphorus, have been reduced to an
acceptable level.
"White" cast irons contain their carbon in the
form of cementite, or iron carbide. This hard, brittle
compound dominates the mechanical properties of
white cast irons, rendering them hard, but
unresistant to shock.
Wrought iron contains less than 0.25% carbon. It
is a tough, malleable product, but not as fusible as
pig iron. If honed to an edge, it loses it quickly.
Wrought iron is characterized by the presence of
fine fibers of slag entrapped in the metal. Wrought
iron is more corrosion resistant than steel.
Carbon steel contains 2.0% carbon or less, with
small amounts of manganese, sulfur, phosphorus,
and silicon. Alloy steels contain varying amounts of
carbon as well as other metals, such as chromium,
vanadium, molybdenum, nickel, tungsten, etc. Their
alloy content raises their cost, and so they are
usually only employed for specialist uses. One
common alloy steel, though, is stainless steel.
Nickel
Nickel is a chemical element, with the chemical
symbol Ni and atomic number 28. It is a silvery-
white lustrous metal with a slight golden tinge. (Fig
4.6-1) It is one of the four ferromagnetic elements
that exist around room temperature, the other three
being iron, cobalt and gadolinium. It is hard and
ductile.
Nickel is used in many industrial and consumer
products, including stainless steel, magnets, coinage,
rechargeable batteries, electric guitar strings and
special alloys.

Figure 4.6-1: Gross appearance of pure Nickel
Toxicity
Sensitized individuals may show an allergy to nickel
affecting their skin, also known as dermatitis.
Sensitivity to nickel may also be present in patients
with pompholyx. Nickel is an important cause of
contact allergy, partly due to its use in jewellery
intended for pierced ears. Nickel allergies affecting
pierced ears are often marked by itchy, red skin.
Many earrings are now made nickel-free due to this
problem. It was voted Allergen of the Year in 2008
by the American Contact Dermatitis Society.
Chromium
Chromium is a chemical element which has the
symbol Cr and atomic number 24. It is a steely-gray,
lustrous, hard metal that takes a high polish and has
a high melting point.(Fig 4.6-2) It is also odorless,
tasteless, and malleable. Chromium was regarded
with great interest because of its high corrosion
resistance and hardness. A major development was
the discovery that steel could be made highly
resistant to corrosion and discoloration by adding
chromium to form stainless steel.
Passivation
Chromium metal left standing in air is passivated
by oxygen, forming a thin protective oxide surface
layer. This layer is a spinel structure only a few
atoms thick. It is very dense, and prevents the
diffusion of oxygen into the underlying material.
This is in contrast to iron or plain carbon steels,
where the oxygen migrates into the underlying
material and causes rusting. Chromium is
remarkable for its magnetic properties: it is the only
elemental solid which shows antiferromagnetic
ordering at room temperature (and below). Above
38 °C, it transforms into a paramagnetic state. The
strengthening effect of forming stable metal
carbides at the grain boundaries and the strong
increase in corrosion resistance made chromium an
important alloying material for steel.
Stainless steel, the main corrosion-proof metal
alloy, is formed when chromium is added to iron in
sufficient, usually more than 12% concentration.
For its formation, ferrochromium is added to the
molten iron.
Metallurgy 199
Figure 4.6-2: Gross appearance of pure Chromium
Water insoluble chromium (III) compounds and
chromium metal are not considered a health hazard,
while the toxicity and carcinogenic properties of
chromium (VI) have been known for a long time.
Because of the specific transport mechanisms,
only limited amounts of chromium (III) enter the
cells. Several in vitro studies indicated that high
concentrations of chromium (III) in the cell can lead
to DNA damage. Acute oral toxicity ranges between
1500 and 3300 µg/kg. The proposed beneficial
effects of chromium (III) and the use as dietary
supplements yielded some controversial results, but
recent reviews suggest that moderate uptake of
chromium (III) through dietary supplements poses
no risk.
In the body, chromium (VI) is reduced by several
mechanisms to chromium (III) already in the blood
before it enters the cells. The chromium (III) is
excreted from the body, whereas the chromate ion
is transferred into the cell by a transport
mechanism, by which also sulfate and phosphate
ions enter the cell. The acute toxicity of chromium
(VI) is due to its strong oxidational properties. After
it reaches the blood stream, it damages the kidneys,
the liver and blood cells through oxidation
reactions. Hemolysis, renal and liver failure are the
results of these damages. Aggressive dialysis can
improve the situation.
Stainless steel
In metallurgy stainless steel, also known as inox
steel or inox from French "inoxydable" is defined as
a steel alloy with a minimum of 10.5 or 11%
chromium content by mass. Stainless steel does not
stain, corrode, or rust as easily as ordinary steel, but
it is not stain-proof. It is also called corrosion-
resistant steel or CRES when the alloy type and
grade are not detailed, particularly in the aviation
industry. There are different grades and surface
finishes of stainless steel to suit the environment to
which the material will be subjected in its lifetime.
Stainless steel is used where both the properties of
steel and resistance to corrosion are required.
Stainless steel differs from carbon steel by the
amount of chromium present. Carbon steel rusts
when exposed to air and moisture. This iron oxide
film (the rust) is active and accelerates corrosion by
forming more iron oxide. Stainless steels contain
200 Plate Fixation in Orthopaedics
sufficient chromium to form a passive film of
chromium oxide, which prevents further surface
corrosion and blocks corrosion from spreading into
the metal's internal structure.
Properties
Steels are said to be stainless when they resist
corrosion; the is achieved by dissolving sufficient
chromium in the iron to produce a coherent,
adherent, insulating and regenerating chromium
oxide protective film on the surface.
The stainless character occurs when the
concentration of chromium exceeds about 12 wt%.
Nickel significantly improves the general corrosion
resistance of stainless steels, by promoting
passivation.
The chromium forms a passivation layer of
chromium(III) oxide (Cr2O3) when exposed to
oxygen. The layer is too thin to be visible, and the
metal remains lustrous. The layer is impervious to
water and air, protecting the metal beneath. Also,
this layer quickly reforms when the surface is
scratched. This phenomenon is called passivation
and is seen in other metals, such as aluminium and
titanium. Corrosion-resistance can be adversely
affected if the component is used in a non-
oxygenated environment.
When stainless steel parts such as nuts and bolts
are forced together, the oxide layer can be scraped
off, causing the parts to weld together. When
disassembled, the welded material may be torn and
pitted, an effect known as galling. This destructive
galling can be best avoided by the use of dissimilar
materials for the parts forced together, e.g. bronze
and stainless steel, or even different types of
stainless steels (martensitic against austenitic, etc.),
when metal-to-metal wear is a concern.
The alloy is milled into coils, sheets, plates, bars,
wire, and tubing to be used in cookware, cutlery,
hardware, surgical instruments, major appliances.
There are different types of stainless steels. When
nickel is added the austenite structure of iron is
stabilized. This crystal structure makes such steels
non-magnetic and less brittle at low temperatures.
Significant quantities of manganese have been
used in many stainless steel compositions.
Manganese preserves an austenitic structure in the
steel as does nickel, but at a lower cost.
Pitting corrosion is the result of the local
destruction of the passive film and subsequent
corrosion of the steel below. It generally occurs in
chloride, halide or bromide solutions. It can be
initiated at a fault in the passive layer or a surface
defect. The steel underneath the break dissolves
leading to a build-up of positively charged metal
ions, which in turn causes negative charges (e.g.
chloride ions) to migrate near the defect. Even in a
neutral solution, this can cause the pH to drop
locally to 2 or 3, thereby preventing the
regeneration of the passive layer. In the passive
condition, the current density is of the order of nA
cm-2; in the pit, however, it may exceed 1A cm-2. The
reason why the current density is so large in the pit
is that the anodic region is very small in area when
compared with the cathodic part (the unpitted
steel). For a given corrosion current, this greatly
exaggerates the corrosion rate at the pits. Similarly,
the concentration of chloride ions in the vicinity of a
pit can be thousands of times greater than that in
the solution as a whole.
While the propagation phenomenon is well
understood, the mechanism of pit initiation is not.
Initiation has long been associated with MnS
inclusions which are difficult to avoid in the steel-
making process. It appears that the inclusions are
surrounded by a Cr depleted region which is
believed to cause the initiation.
Increasing the Cr content or adding Mo or N
enhances the pitting resistance.
Surgical stainless steel
Surgical stainless steel is a specific type of stainless
steel, used in medical applications, with good
biocompatibility.
Biocompatibility
To be accepted as biomaterial a new material’s
biocompatibility must be evaluated by in vivo
animal experiment. Regarding solid materials for
orthopedic implants, a small specimen is implanted
into femoral or tibial bone of small animals. After a
certain period, histological and radiological
observations are performed in terms of tissue
reaction around the implanted material. When the
implanted material is recognized as the foreign
body due to the release of chemical substances or
stimulative surface, although tiny particles or small
decomposition products in small amount can be
eliminated by phagocytic activity of foreign body
giant cells and macrophages, the implanted material
will be surrounded by interstitial fibrous tissue to
isolate from the living body, which is called
encapsulation known as one of typical foreign body
reactions in which the interstitial fibrous tissue
confines the foreign body, and minimize the harmful
influence. And the thickness of the fibrous tissue
increases depending on the degree of the
harmfulness. However, in case of the material with a
good chemical stability and nonstimulative surface,
the implanted material will exist without the
interstitial fibrous tissue, and newly formed bone
tissue can directly contact to the material surface.
Therefore, either the appearance or thicknesses of
the interstitial fibrous tissue or the bone formation
around the implanted material demonstrate the
degree of biocompatibility. According to the tissue
reaction phenomena, the biocompatibility of
orthopedic implant materials was classified into
three categories by Heimke, such as ‘‘biotolerant,’’
showing distant osteogenesis (bone formation with
indirect contact to the material); ’‘bioinert,’’
showing contact osteogenesis (bone formation with
direct contact to the material), and ‘‘bioactive,’’

showing bonding osteogenesis (bone formation
with chemical or biological bonding to the material).
The chromium gives the metal its scratch-
resistance and corrosion resistance. The nickel
provides a smooth and polished finish. The
molybdenum gives greater hardness, and helps
maintaining a cutting edge.
Although there are myriad variations in the
recipes, there are two main varieties of stainless
steel: martensitic and austenitic.
The word 'surgical' refers to the fact that these
types of steel are well-suited for making surgical
instruments: they are easy to clean and sterilize,
strong and corrosion-resistant. The
nickel/chrome/molybdenum alloys are also used
for orthopaedic implants as aids in bone repair, as a
structural part of artificial heart valves, and other
implants. Immune system reaction to nickel is a
potential complication. In some cases today
titanium is used instead in procedures that require a
metal implant which will be permanent. Titanium is
a reactive metal, the surface of which quickly
oxidizes on exposure to air, creating a
microstructured stable oxide surface. This provides
a surface into which bone can grow and adhere in
orthopaedic implants but which is incorrodible after
implant. Thus steel may be used for temporary
implants and the more expensive titanium for
permanent ones.
Stainless steel is further modified for use in
surgical implantation by the addition of a variety of
other elements to improve the alloy. The 316L
stainless steel contains nickel (13% to 15.5%),
which is added to increase corrosion resistance,
stabilize crystalline structures, and stabilize the
austenitic phase of the iron crystals at room
temperature. The terms austenitic and martensitic
describe specific crystallographic arrangements of
iron atoms. The austenitic phase is associated with
superior corrosion resistance and is favored in
biologic implants. The martensitic stainless steels
are hard and tough and are favored in the
manufacture of osteotomes and scalpel blades.
The 316L stainless steel also contains chromium
(17% to 19%), which is added to form a passive
surface oxide, thus contributing to corrosion
resistance. Molybdenum (2% to 3%) prevents
pitting and crevice corrosion in salt water.
Manganese (about 2%) improves crystalline
stability. Silicon controls crystalline formation in
manufacturing. The 316L stainless steel has a
carbon content of 0.03%, whereas 316 stainless
steel contains 0.08% carbon. Carbon is added
during the smelting process and must be taken out
in refining, because the carbon segregates from the
major elements of the alloy, taking with it a
substantial amount of chromium in the form of
chromium carbide precipitate. The corrosion
resistance of the final alloy is lessened by the
depletion of chromium. Therefore, steel with a
lower carbon content has greater corrosion
resistance. Stainless steel has good mechanical
Metallurgy 201
strength with excellent ductility, and it can be
worked by rolling, bending, or pounding to increase
its strength. Steel is available in different degrees of
strength corresponding to the proposed function of
the implant.
Most surgical equipment is made out of
martensitic steel—it is much harder than austenitic
steel, and easier to keep sharp. Depending on the
type of equipment, the alloy recipe is varied slightly
to get more sharpness, or strength.
Implants and equipment that are put under
pressure (bone fixation devices, prostheses), are
made out of austenitic steel, often 316L and
316LVM, because it is less brittle.
The 316L stainless steel as specified by ASTM F-
138 and F-139 is a standard for surgical implants.
The number 316 is part of a modern classification
system by AISI for metals and represents certain
standards that allow the metal to be used for clinical
application. The three-digit system separates the
iron into four main groups based on composition:
series 200 (chromium, nickel, and manganese),
series 300 (chromium and nickel), series 400
(chromium), and series 500 (low chromium). The
last two digits designate the particular type.
The form of stainless steel most commonly used
in orthopedic practice is designated 316LV
(American Society for Testing and Materials F138,
ASTM F138). The designation 316 classifies the
material as austenitic; the L denotes the low carbon
content, and V the vacuum under which it is formed.
The carbon content must be kept at a low level to
prevent carbide (chromium–carbon) accumulation
at the grain boundaries. This carbide formation
weakens the material by allowing a combination of
corrosion and stress to degrade the material at its
grain boundaries. In the past, elevated levels of
carbon have been associated with the fracture of
some orthopedic implants in vivo. Molybdenum is
added to enhance the corrosion resistance of the
grain boundaries, while chromium dissipated evenly
within the microstructure allows the formation of
chromium oxide (Cr2O3) on the surface of the metal.
The ionic bonds associated with this coating protect
the surface from electrochemical degradation.
Stainless steels are surface treated (e.g., in nitric
acid) to promote the growth and thickening of this
passive oxide layer.
New Stainless Steels
The relatively poor corrosion resistance and
biocompatibility of stainless steels when compared
to Ti and Co–Cr–Mo alloys provides incentive for
development of improved stainless steels. New
alloys such as BioDur attempt to solve the problem
of corrosion with an essentially nickel-free
austenitic stainless alloy. This steel contains a high
nitrogen content to maintain its austenitic structure
and boasts improved levels of tensile yield strength,
fatigue strength, and improved resistance to pitting
corrosion and crevice corrosion as compared to
202 Plate Fixation in Orthopaedics

nickel-containing alloys such as Type 316L (ASTM
F138).
For clinical use, stainless steel has best
mechanical properties, as it is strong and has good
fatigue resistance, it is easily worked and cheap to
manufacture, forged stainless steel has greater yield
strength than cast stainless steel, but has lower
fatigue strength than other alloys. Its serious
drawback is the tendency to corrode; stainless steel
corrodes more easily than other materials. Surfaces
of all metal implants in the U.S. are covered using
nitric acid to form an oxide or hydroxide on their
surfaces. From the standpoint of erosion,
biocompatibility, and fatigue life, stainless steel is
inferior to other superalloys.
TITANIUM AND TITANIUM ALLOYS
Titanium
Titanium is a chemical element with the symbol Ti
and atomic number 22. Sometimes called the "space
age metal", it has a low density and is a strong,
lustrous, corrosion-resistant transition metal with a
silver color. (Fig 4.6-3)
Titanium can be alloyed with iron, aluminium,
vanadium, molybdenum to produce strong
lightweight alloys for aerospace, military, industrial
process (chemicals and petro-chemicals,
desalination plants, pulp, and paper), automotive,
agri-food, medical prostheses, orthopedic implants,
dental and endodontic instruments and files, dental
implants, sporting goods, jewelry, mobile phones,
and other applications.
The two most useful properties of the metal form
are corrosion resistance and the highest strength-
to-weight ratio of any metal. In its unalloyed
condition, titanium is as strong as some steels, but
45% lighter. Titanium's properties are chemically
and physically similar to zirconium. It is a strong
metal with low density that is quite ductile
(especially in an oxygen-free environment),
lustrous, and metallic-white in color. The relatively
high melting point (more than 1,650 °C or 3,000 °F)
makes it useful as a refractory metal. It is
paramagnetic and has fairly low electrical and
thermal conductivity.
Commercial (99.2% pure) grades of titanium have
ultimate tensile strength of about 63,000 psi (434
MPa), equal to that of common, low-grade steel
alloys, but are 45% lighter. Like those made from
steel, titanium structures have a fatigue limit which
guarantees longevity in some applications. Titanium
alloys specific stiffnesses are also usually not as
good as other materials such as aluminium alloys
and carbon fiber, so it is used less for structures
which require high rigidity.
The most noted chemical property of titanium is
its excellent resistance to corrosion; it is almost as
resistant as platinum, capable of withstanding
attack by dilute sulfuric acid and hydrochloric acid
as well as chlorine gas, chloride solutions, and most
organic acids. However, it is slow to react with
water and air, because it forms a passive and
protective oxide coating that protects it from
further reaction. When it first forms, this protective
layer is only 1–2 nm thick but continues to slowly
grow; reaching a thickness of 25 nm in four years.
Titanium is used in steel as an alloying element
(ferro-titanium) to reduce grain size and as a
deoxidizer, and in stainless steel to reduce carbon
content. Titanium is often alloyed with aluminium
(to refine grain size), vanadium, copper (to harden),
iron, manganese, molybdenum, and with other
metals.
Medical
Because it is biocompatible (non-toxic and is not
rejected by the body), titanium is used in a gamut of
medical applications including surgical implements
and implants, such as hip joint prosthesis that can
stay in place for up to 20 years. The titanium is often
alloyed with about 4% aluminium or 6% Al and 4%
vanadium.
Titanium has the inherent property to
osseointegrate, enabling use in dental implants that
can remain in place for over 30 years. This property
is also useful for orthopedic implant applications.
These benefit from titanium's lower modulus of
elasticity (Young's modulus) to more closely match
that of the bone that such devices are intended to
repair. As a result, skeletal loads are more evenly
shared between bone and implant, leading to a
lower incidence of bone degradation due to stress
shielding and periprosthetic bone fractures which
occur at the boundaries of orthopedic implants.
However, titanium alloys' stiffness is still more than
twice that of bone, eventually leading to joint
degradation.
Since titanium is non-ferromagnetic, patients with
titanium implants can be safely examined with
magnetic resonance imaging. Preparing titanium for
implantation in the body involves subjecting it to a
high-temperature plasma arc which removes the
surface atoms, exposing fresh titanium that is
instantly oxidized.
Figure 4.6-3: Gross appearance of pure Titanium

Titanium is also used for the surgical instruments
used in image-guided surgery, as well as
wheelchairs, crutches, and any other products
where high strength and low weight are desirable.
Toxicity
Titanium is non-toxic even in large doses and does
not play any natural role inside the human body. An
estimated 0.8 milligrams of titanium is ingested by
humans each day but most passes through without
being absorbed.
Titanium is an allotropic material that exists in
both alpha and beta phases, which have a hexagonal
close-packed crystal structure and a body-centered
cubic structure, respectively. It is the least dense of
all metals used for surgical implantation. The
density of titanium is 4.5 g/cm3, whereas that of
316L stainless steel is 7.9 g/cm3 and that of cobalt-
chromium alloy is 8.3 g/cm3.
Vanadium
Vanadium is the chemical element with the symbol
V and atomic number 23. It is a soft, silvery gray,
ductile transition metal. The formation of an oxide
layer stabilizes the metal against oxidation.
Characteristics
Vanadium is a soft, ductile, silver-gray metal. It has
good resistance to corrosion and it is stable against
alkalis, sulfuric and hydrochloric acids. It is oxidized
in air at about 933 K (660 °C or 1220 °F), although
an oxide layer forms even at room temperature.
Approximately 85% of vanadium produced is
used as ferrovanadium or as a steel additive. The
considerable increase of strength in steel containing
small amounts of vanadium was discovered in the
beginning of the 20th century. Vanadium forms
stable nitrides and carbides, resulting in a
significant increase in the strength of the steel. From
that time on vanadium steel was used for
applications in axles, bicycle frames, crankshafts,
gears, and other critical components. There are two
groups of vanadium containing steel alloy groups.
Vanadium high-carbon steel alloys containing 0.15
to 0.25% vanadium and high speed tool steels (HSS)
with a vanadium content ranges from 1 % to 5 %.
For high speed tool steels, a hardness above HRC 60
can be achieved. HSS steel is used in surgical
instruments and tools.
Vanadium stabilizes the beta form of titanium and
increases the strength and temperature stability of
titanium. Mixed with aluminium in titanium alloys it
is used in jet engines and high-speed airframes. One
of the common alloys is Titanium 6AL-4V, a titanium
alloy with 6% aluminium and 4% vanadium.
Safety
The Occupational Safety and Health Administration
(OSHA) has set an exposure limit of 0.05 mg/m3 for
vanadium pentoxide dust and 0.1 mg/m3 for
vanadium pentoxide fumes in workplace air for an
Metallurgy 203
8-hour workday, 40-hour work week. The National
Institute for Occupational Safety and Health
(NIOSH) has recommended that 35 mg/m3 of
vanadium be considered immediately dangerous to
life and health. This is the exposure level of a
chemical that is likely to cause permanent health
problems or death.
There is little evidence that vanadium or
vanadium compounds are reproductive toxins or
teratogens. Vanadium has not been classified as to
carcinogenicity by the United States Environmental
Protection Agency.
The four grades of commercially pure titanium
that are available for surgical implantation are
differentiated by the amount of impurities in each
grade. The microstructure of commercially pure
titanium is all-alpha titanium with relatively low
strength and high ductility. Oxygen has a great
influence on the ductility and strength: increasing
the oxygen content of a particular grade of titanium
makes it stronger and more brittle. Grade 4 titanium
contains the most oxygen and is therefore the
strongest of the commercially pure titaniums. The
material may be cold-worked for additional
strength, but it cannot be strengthened by heat
treatment because it has only a single phase.
One titanium alloy (Ti-6Al-4V) is widely used for
surgical implantation. The additional elements of
the alloy are aluminum (5.5% to 6.5%), which
stabilizes the alpha phase, and vanadium (3.5% to
4.5%), which stabilizes the beta phase. The beta
phase is stronger because of its crystallographic
arrangement, whereas the alpha phase is good for
welding. For applications in which high strength and
fatigue resistance are required, the material is
annealed, corresponding to a universal distribution
of alpha and beta phases. The Ti-6Al-4V alloy can be
heat-treated because it is a two-phased alloy and
not a single-phase commercially pure titanium.
Titanium alloy has greater specific strength per unit
density than any other implant material. The most
recently developed titanium alloy is Ti-6Al-7Nb; the
niobium produces mechanical characteristics
similar to those of the titanium-vanadium alloy but
with less toxicity.
Titanium is often selected as a material for metal
plates or femoral stem implants due to its lower
modulus of elasticity (as compared to other alloys);
its resistance to fatigue is excellent; it is easily
worked, and 1/16 plates are radiolucent. It has an
extremely low modulus of elasticity & low tensile
strength; titanium plates and implants, therefore,
have to be bulkier than stainless steel in order to
provide same rigidity.
Titanium is the most inert of metals. Resistance of
titanium to corrosion in a chloride environment is
excellent. Titanium has a high potential for oxidative
corrosion. Titanium and its alloys form oxide
passivation layers more rapidly than do substances
that contain chromium, such as cobalt-chromium
alloy and stainless steel. The titanium dioxide layer
which coats the outer metal layer provides a major
204 Plate Fixation in Orthopaedics
barrier to corrosion. While an active metal like
titanium forms its oxide passivation layer
spontaneously in any environment that contains
oxygen, strength of adhesion of the oxide layer to
the underlying titanium metal is not as great as that
of chromium oxide layer to its metal substrate. In
addition, chromium oxide passivation film is denser
than titanium oxide layer.
While CPTi is most commonly used in dental
applications, the stability of the oxide layer formed
on CPTi (and consequently its high corrosion
resistance) and its relatively higher ductility (i.e.,
the ability to be cold worked) compared to Ti-6Al-
4V have led to its use in porous coatings (e.g., fiber
metal) of joint arthroplasty components. Generally,
Ti-6Al-4V (ASTM F-136) is used for joint
replacement components because of its superior
mechanical properties in comparison to CPTi. The
Ti-6Al-4V alloy (also known as Ti-6-4) is composed
of grains of two phases: an HCP phase and a BCC
phase, referred to as the alpha and beta phases,
respectively. Aluminum (5.5–6.5 % by weight)
stabilizes the HCP phase and vanadium (3.5–4.5 %
by weight) stabilizes the BCC phase. The
microstructure and mechanical properties of this
alloy are highly dependent on the
thermomechanical processing treatments. The Ti-
6Al-4V alloy microstructure is generally composed
of a fine-grained HCP phase with a sparse
distribution of the BCC phase. If the material is
cooled too slowly the BCC phase becomes more
prominent and lowers the strength and corrosion
resistance of the alloy. Titanium alloys are
particularly good implant materials because of their
high corrosion resistance compared with stainless
steel and Co–Cr–Mo alloys. A passive oxide film
(primarily of TiO2) protects both Ti-6Al-4V and
CPTi. This stable and adherent passive oxide film
protects Ti alloys from pitting corrosion,
intergranular corrosion, and crevice corrosion
attack and in large part is responsible for the
excellent biocompatibility of Ti alloys. Generally the
strength of Ti-6Al-4V exceeds that of stainless steel,
with a flexural rigidity roughly half of stainless steel
and Co–Cr–Mo alloys. The torsional and the axial
stiffness (moduli) of Ti alloys are therefore closer to
bone and theoretically provide less stress shielding
than do Co alloys and stainless steel. This attribute,
along with excellent biocompatibility and corrosion
resistance, is primarily responsible for the
popularity of titanium alloys in fracture fixation
devices (plates, screws), spinal fixation devices, and
total hip replacement femoral components. Ti-6Al-
4V alloy is an example of a material which can be
approximately 15% softer than Co–Cr–Mo alloys,
thus, Ti alloys are seldom used as materials where
resistance to wear is a primary concern.
The fatigue strength of Ti-29Nb-13Ta-4.6Zr is
equal to that of Ti-6Al 4V, especially in the high
cycle fatigue life region by conducting aging after
solution treatment. The fatigue strength of Ti-29Nb-
13Ta-4.6Zr is not degraded in Ringer’s solution as
compared with the data in air. Therefore, the
corrosion fatigue resistance in the living body
environment will be sufficient.
Fretting fatigue sometimes occurs for example
between bone plate and screw or bone and stem.
Fretting fatigue is also a very important issue for
biomaterials. Plane fatigue limit, Pf, is the greatest in
Ti-15Mo-5Zr-3Al and the smallest in as-solutionized
Ti-29Nb-13Ta-4.6Zr. However, fretting fatigue limit,
Ff, is the greatest in Ti-29Nb-13Ta-4.6Zr conducted
with aging. The fatigue damage is more accelerated
by fretting in Ti-15Mo-5Zr-3Al. The fretting damage
on fatigue strength, Pf/Fp, can be related with
Young’s modulus. The low rigidity type titanium
alloy is less sensitive to fretting fatigue comparing
with the high modulus titanium alloy.
The fretting fatigue crack does not initiate from
pit in the low cycle fretting fatigue life region, but
initiates from pit in the high cycle fretting fatigue
life region.
The wear resistance of titanium alloys is in
general poor. However, when compared with Ti-
6Al-4V ELI, the wear resistance of Ti-29Nb-13Ta-
4.6Zr is better than that of Ti-6Al-4V ELI when the
mating material is a zirconia ball, as shown in Fig.
14 [25]. However, when the mating material is an
alumina ball, the wear resistance of Ti-29Nb-13Ta-
4.6Zr is inferior to that of Ti- 6Al-4V ELI. The wear
resistance of Ti-29Nb-13Ta-4.6Zr can be improved
by simple oxidation treatment in air at lower
temperature compared with Ti-6Al-4V ELI.
Titanium and its alloys are the most suitable
materials for structural biomaterials among metallic
biomaterials. Nowadays, Pure Ti and Ti-6Al-4V ELI
are the most widely used in the biomedical fields.
However, for replacing failed hard tissue, the
strength of pure Ti is not sufficient. For Ti-6Al-4V
ELI, V has been pointed out to be toxic. Therefore, V-
free titanium alloys such as Ti-6Al-7Nb, Ti-5Al-
2.5Fe, etc., have been developed for biomedical
applications. These alloys are certainly applicable
for replacing failed hard tissue. In general, the
rigidity of metallic biomaterials is much greater
than that of bone. Among the metallic biomaterials,
the rigidity of Ti-6Al-4V ELI is much lower than that
of stainless steels or Co-Cr type alloys for
biomedical applications. However, the rigidity of Ti-
6Al-4V ELI is still much greater than that of bone.
Bioactive Surface Modification
A method that is expected to be effective in further
improving the biocompatibility of Ti-29Nb-13Ta-
4.6Zr is to coat the surface of the alloy with calcium
phosphate recrystalized invert glass. In this method,
glass composed of 60CaO (90x) P2O5 3TiO2 (10-y)
Na2O is prepared, from which glass paste is made
using a ball mill. After drying, it is heat treated. -TCP
(Ca3(PO4)2) crystals and -CPP (CaPO7) crystals, both
of which have a high biocompatibility, precipitate,
and the precipitation of –TCP crystals prevails at
this heat treatment temperature. Ti-29Nb-13Ta-
4.6Zr coated with calcium phosphate crystallized

glass is dipped into the simulated body liquid, SBF
solution, and then the hydroxyapatite, which has
high biocompatibility, precipitates on the surface of
the coating layer.
Biocompatibility
In order to investigate the biocompatibility of the
developed titanium alloy of Ti-29Nb- 13Ta-4.6Zr,
columnar specimens of 510 mm were implanted
into lateral condyles of rabbit femurs. As control
materials, columnar specimens made of SUS316L
stainless steel and Ti-6Al-4V were also implanted in
the same manner. At 4, 8 and 24 weeks and 1 year
after the implantation, histological observation was
performed with Fuchsin staining and contact
microradiogram (CMR). At 4 weeks after
implantation, all the implanted materials were
surrounded by newly formed bone tissue, and the
direct contact was partially observed in the material
surface. Even in SUS316L stainless steel, which is
the biotolerable material showing distant
osteogenesis, bone tissue directly contacted to the
material surface because bone formation in
repairing phase is very active as a reaction to the
implantation. At 8 weeks, the implanted materials
were surrounded by mature bone tissue, and the
direct contact was observed at in both titanium
alloys of Ti-29Nb-13Ta-4.6Zr and Ti-6Al-4V.
However, in SUS316 stainless, a thin radiolucent
line was observed at the interface between the bone
tissue and the material surface, in which the
radiolucent line represents the interstitial fibrous
tissue. At 24 weeks, most of the circumference was
closely covered by mature bone tissue, and the
direct contact was often observed in both titanium
alloys. However, in SUS316L stainless steel mature
bone tissue was observed but away from the
material surface in which the wide radiolucent line
existed. At 1 year after implantation, the same
findings of bone formation and the direct contact
were obtained in both titanium alloys, but the
implanted material of SUS316L stainless steel fell off
from the femoral condyle during harvesting
operation.
From these results, the developed titanium alloy
Ti-29Nb-13Ta-4.6Zr is classified into the bioinert
material showing contact osteogenesis the same as
Ti-6Al-4V titanium alloy. And the biocompatibility of
the developed titanium alloy is far superior to
SUS316L stainless steel, and equal to Ti-6Al-4V, or
possibly greater than Ti-6Al-4V in the long term
because Ti- 29Nb-13Ta-4.6Zr consists of nontoxic
elements but Ti-6Al-4V contains aluminum and
vanadium, known as harmful elements.
Cytotoxicity
The cytotoxicity of Ti-29Nb-13Ta-4.6Zr and
conventional biocompatible pure titanium and Ti-
6Al-4V ELI were evaluated. The components of the
alloy were extracted by putting the plate shape
sample of the alloy on zirconia balls in a chamber
with culture solution and then rotating the vessel. A
Metallurgy 205
rotating speed was 240 rpm. The extract periods
were 7 days and 14 days. The raw extract and
filtrated extract were then prepared. The cell
viability of L929 cells derived from mice was
evaluated using the NR assay and MTT assay. The
results by the NR assay and MTT assay were nearly
the same. Ti-29Nb-13Ta-4.6Zr and pure Ti show
similar cell viability both in raw (nonfiltrated) and
filtrated extracts. On the other hand, Ti-6Al-4V ELI
shows lesser cell viability comparing with Ti-29Nb-
13Ta-4.6Zr and pure Ti. In consequence, the
developed alloy, Ti-29Nb-13Ta-4.6Zr, has a high
bicompatibility. As can be expected, the cell viability
of extract for 14 days is smaller than that of extract
for 7 days. Since the cell viability is higher in
filtrated extract than in nonfiltrated extract, the
wear debris is apparent to reduce the cell viability.
Bone tissue reaction to material rigidity
It is well known as Wolff’s law of functional
restoration that bone tissue is necessarily
remodeled under the influence of the mechanical
stress, in which the decrease or absence of
mechanical stress can cause atrophy or absorption
of bone tissue. Also in fracture healing, the
mechanical stress greatly influences callus
formation and following bone remodeling.
Conventional implant alloys with high mechanical
strength typically have a high rigidity of 150–200
GPa in the elastic modulus, which is approximately
ten times higher than 18–20 GPa of human living
cortical bone. The big difference in the material
rigidity causes a load transmission failure with the
reduction of the mechanical stress, in particular part
of the surrounding bone tissue, and induces the
bone atrophy or absorption and the further
component loosening in implant surgery. This is the
so-called stress-shielding phenomenon. Recently,
Ti-6Al-4V has become popular as an implant metal
with good biocompatibility and relatively lower
rigidity, around 100 GPa; however, the rigidity is
still five times higher than the living cortical bone.
The developed low rigidity titanium alloy is
expected to improve the reduction of the
mechanical stress, and promote bone formation and
bone remodeling in the implant surgery such as
internal fracture fixation and replacement
arthroplasty.
It is confirmed that the mechanical stress greatly
influences fracture healing and bone remodeling
corresponding to Wolff’s law of functional
restoration and the stress-shielding phenomenon. It
is suggested that Ti-29Nb-13Ta-4.6Zr as a low
rigidity titanium alloy can improve load
transmission failure, providing the moderate
mechanical stress to the surrounding bone tissue,
which promotes faster fracture healing and bone
remodeling as compared with conventional implant
metals with high rigidity.
206 Plate Fixation in Orthopaedics

COBALT-CHROMIUM ALLOYS
Cobalt
Cobalt is a hard, lustrous, gray metal, a chemical
element with symbol Co and atomic number 27.(fig
4.6-4) It is used in the preparation of magnetic,
wear-resistant, and high-strength alloys. Cobalt is a
ferromagnetic metal with a specific gravity of 8.9
(20°C). Metallic cobalt occurs as two
crystallographic structures: HCP and FCC.
Special cobalt-chromium-molybdenum alloys are Figure 4.6-5: Gross appearance of pure Molybdenum
used for prosthetic parts such as hip and knee
replacements. Cobalt alloys are also used for dental
prosthetics, where they are useful to avoid allergies Molybdenum (5% to 7%) increases strength by
to nickel. controlling crystalline size and also increases
After nickel and chromium, cobalt is a major cause corrosion resistance. Nickel (1%), manganese (1%),
of contact dermatitis and is considered and silicon (1%) are added to improve ductility and
carcinogenic. hardness. Vitallium is mechanically inferior to
stainless steel and much more difficult and
Molybdenum expensive to cast. It has low ductility, so, screws
Molybdenum is a chemical element with the symbol made of this material bond quite securely to bone
Mo and atomic number 42. The name is from Neo- and upon removing a screw that has become
Latin Molybdaenum, from Ancient Greek Μόλυβδος securely anchored, it is easy to break the head off.
molybdos, meaning lead, since its ores were The most attractive feature of these alloys is their
confused with lead ores. It readily forms hard, stable excellent corrosion resistance and biocompatibility.
carbides, and for this reason it is often used in high- The mechanical properties (tensile strength and
strength steel alloys.(Fig 4.6-5) fatigue resistance) of the wrought CoCrNiMo alloy
make it desirable for implants that must withstand a
long period of loading without fatigue failure. For
Applications this reason, this material has been chosen for the
Most high-strength steel alloys contain 0.25% to 8%
manufacture of stems for hip prostheses.
molybdenum. Molybdenum is also used in steel
Cobalt–chromium implant alloys fall into one of
alloys for its high corrosion resistance and
two categories, those with nickel and other alloying
weldability. Molybdenum contributes further
elements and those without. Of the many Co–Cr
corrosion resistance to "chrome-moly" type-300
alloys available, the two most commonly used as
stainless steels (high-chromium steels that are
implant alloys are (1) cobalt–chromium–
corrosion-resistant already due to their chromium
molybdenum (Co–Cr–Mo), which is designated
content).
ASTM F-75 and F-76, and (2) cobalt–nickel–
Two cobalt-chromium alloys are currently used
chromium–molybdenum (Co–Ni–Cr–Mo),
for manufacture of surgical implants. The first is
designated as ASTM F-562. Others approved for
CoCrMo (ASTM F-75), which is cast, and the second
implant use include one that incorporates tungsten
is CoCrNiMo (ASTM F-562), which is wrought.
(Co–Cr–Ni–W, ASTM F-90) and another with iron
Cobalt is the main component in both alloys. The
(Co–Ni–Cr–Mo–W-Fe, ASTM F-563). Co–Ni–Cr–Mo
cast CoCrMo was originally called Vitallium
alloys that contain large percentages of Ni (25–
(Howmedica, Inc., Rutherford, NJ), and this name is
37%) promise increased corrosion resistance yet
sometimes used incorrectly to describe all the
raise concerns of possible toxicity and/or
cobalt-based alloys. Chromium (7% to 30%)
immunogenic reactivity (discussed later) from
provides good corrosion resistance by forming
released Ni. The biologic reactivity of released Ni
chromic oxide at the surface cobalt based alloys,
from Co–Ni–Cr alloys is cause for concern under
especially to attack by chloride within crevices.
static conditions. Due to their poor frictional (wear)
properties, Co–Ni–Cr alloys are also inappropriate
for use in articulating components. Therefore the
dominant implant alloy used for total joint
components remains Co–Cr–Mo (ASTM F-75).

ZIRCONIUM AND TANTULUM ALLOYS

Zirconium
Zirconium is a chemical element with the symbol Zr
and atomic number 40. Its atomic mass is 91.224. It
is a lustrous, grey-white, strong transition metal
that resembles titanium. (Fig 4.6-6)
Figure 4.6-4: Gross appearance of pure Cobalt

Figure 4.6-6: Gross appearance of pure Zirconium
Zirconium is used as an alloying agent for its strong
resistance to corrosion. It is never found as a native
metal. It is ductile and malleable metal which is
solid at room temperature, though it becomes hard
and brittle at lower purities.
Applications
Because of zirconium's excellent resistance to
corrosion, it is often used as an alloying agent in
materials that are exposed to corrosive agents, such
as surgical appliances.
Biological
Zirconium has no known biological role, though
zirconium salts are of low toxicity. The human body
contains, on average, only 1 milligram of zirconium,
and daily intake is approximately 50 μg per day.
Zirconium content in human blood is as low as 10
parts per billion. Aquatic plants readily take up
soluble zirconium, but it is rare in land plants. 70%
of plants have no zirconium content at all, and those
that do have as little as 5 parts per billion.
Toxicity
Short-term exposure to zirconium powder can
cause irritation, but only contact with the eyes
requires medical attention. Inhalation of zirconium
compounds can cause skin and lung granulomas.
Zirconium aerosols can cause pulmonary
granulomas. Persistent exposure to zirconium
tetrachloride resulted in increased mortality in rats
and guinea pigs and a decrease of blood hemoglobin
and red blood cells in dogs. OSHA recommends a
5 mg/m3 time weighted average limit and a
10 mg/m3 short-term exposure limit.
Tantalum
Tantalum (previously known as tantalium) is a
chemical element with the symbol Ta and atomic
number 73. A rare, hard, blue-gray, lustrous
transition metal, tantalum is highly corrosion
resistant.
Tantalum is dark (blue-gray), dense, ductile, very
hard, easily fabricated, and highly conductive of
heat and electricity. The metal is renowned for its
resistance to corrosion by acids. (Fig 4.6-7)
Tantalum exists in two crystalline phases, alpha and
beta. The alpha phase is relatively ductile and soft; it
has body-centered cubic structure. The beta phase
is hard and brittle; its crystal symmetry is
tetragonal.
Metallurgy 207
Figure 4.6-7: Gross appearance of pure Tantalum
Applications
Tantalum is highly bioinert and is used as an
orthopedic implant material.
Precautions
The metal is highly biocompatible and is used for
body implants and coatings, therefore attention may
be focused on other elements or the physical nature
of the chemical compound. A single study is the only
reference in literature linking tantalum to local
sarcomas. It is possible the result was due to other
factors not considered in the study. The study was
quoted in IARC Monograph vol. 74 which includes
the following "Note to the reader": "Inclusion of an
agent in the Monographs does not imply that it is a
carcinogen, only that the published data have been
examined."
Zirconium (Zr) and tantalum (Ta) are
characterized as refractory metals (others include
molybdenum and tungsten) because of their relative
chemical stability (passive oxide layer) and high
melting points. Zr and Ta alloys are currently in use
and may be gaining popularity as orthopedic metals.
Because of the surface oxide layer stability, Zr and
Ta (like Ti) are highly corrosion resistant. Corrosion
resistance generally correlates with
biocompatibility (although not always) because
more stable metal alloys tend to be less chemically
active and less participatory in biologic reactions.
Additionally, these refractory metals generally
possess high levels of hardness (12 Gpa) and wear
resistance (approximately ten fold that of Co and Ti
alloys, using abrasion testing), which makes them
well suited for bearing surface applications. The
thickness of the surface oxide layer (approximately
5 m) and ability to extend ceramic-like material
properties (i.e., hardness) into the material through
techniques such as oxygen enrichment have
resulted in the production of TJA components using
these alloys (e.g., oxidized zirconium TKA femoral
components, Smith and Nephew). As difficulties
associated with forming and machining these metals
are overcome the use of these materials is expected
to grow.
New metal implant materials
High-strength alloys
Many materials have been proposed to solve special
problems, such as avoiding implant failure under
208 Plate Fixation in Orthopaedics
extreme mechanical load. Improved strength may
be achieved by using alloy components for titanium
(eg, vanadium), that are less biocompatible than
nickel. The extremely good corrosion resistance of
titanium alloys compensates for part of this
potential disadvantage. The choice of implant
material depends on the priority given to
mechanical advantages or biological tolerance. Ti-
15Mo is a relatively new alloy that due to its
superior notch sensitivity and reverse bending
properties offers improved implant design
opportunities, eg, for mandibular plates and hand
plates.
Shape memory alloys
A shape memory alloy (SMA, smart metal, memory
metal, memory alloy, muscle wire, smart alloy) is an
alloy that "remembers" its original, cold-forged
shape, and which returns to that shape after being
deformed by applying heat. Shape memory alloys
have applications in industries including medical.
The three main types of shape memory alloys are
the copper-zinc-aluminium-nickel, copper-
aluminium-nickel, and nickel-titanium (NiTi) alloys
but SMA's can also be created by alloying zinc,
copper, gold, and iron. NiTi alloys are generally
more expensive and change from austenite to
martensite upon cooling. Repeated use of the shape
memory effect may lead to a shift of the
characteristic transformation temperatures (this
effect is known as functional fatigue, as it is closely
related with a change of microstructural and
functional properties of the material).
One-way versus two-way shape memory
(Fig 4.6-8)
Shape memory alloys have different shape
memory effects. Two common effects are one-way
and two-way shape memory.
One-way memory effect
When a shape memory alloy is in its cold state, the
metal can be bent or stretched and will hold those
shapes until heated above the transition
temperature. Upon heating, the shape changes to its
original. When the metal cools again it will remain
in the hot shape, until deformed again.
Two way memory effect
The two-way shape memory effect is the effect
that the material remembers two different shapes:
one at low temperatures, and one at the high
temperature shape. This can also be obtained
without the application of an external force
(intrinsic two-way effect). The reason the material
behaves so differently in these situations lies in
training. Training implies that a shape memory can
"learn" to behave in a certain way. Under normal
circumstances, a shape memory alloy "remembers"
its high-temperature shape, but upon heating to
recover the high-temperature shape, immediately
"forgets" the low-temperature shape. However, it
can be "trained" to "remember" to leave some
reminders of the deformed low-temperature
condition in the high-temperature phases. There are
several ways of doing this. A shaped, trained object
heated beyond a certain point will lose the two way
memory effect; this is known as "amnesia". Metal
alloys with a so-called shape memory effect are an
attractive proposition. However, the currently
available materials with shape memory have not
seen general use because of the following problems:
1. The memory effect must be reliably inducible.
2. The amount of force developed must be
controllable.
3. The material must be properly machineable.
4. The cost must be appropriate in relation to the
advantages offered.
5. The biocompatibility must be good.
Applications
Medicine
Optometry
Eyeglass frames made from titanium-containing
SMAs are marketed under the trademarks Flexon
and TITANflex. These frames are usually made out
of shape memory alloys that have their transition
temperature set below the expected room
temperature. This allows the frames to undergo
large deformation under stress, yet regain their
intended shape once the metal is unloaded again.
The very large apparently elastic strains are due to
the stress-induced martensitic effect, where the
crystal structure can transform under loading,
allowing the shape to change temporarily under
load. This means that eyeglasses made of shape
memory alloys are more robust against being
accidentally damaged.
Orthopaedic surgery
Memory metal has been utilized in orthopaedic
surgery as a fixation device for osteotomies,
typically around the foot and ankle. The device,
usually a staple, is stored in a refrigerator in its
malleable form and is implanted into pre-drilled
holes in the bone across an osteotomy. As the staple
warms it returns to its non-malleable state and
compresses the bony surfaces together to promote
union of the osteotomy.
Figure 4.6-8: One-way versus two-way shape memory

Dentistry
Dentistry is another field in which SMA technology
is used to produce dental braces to exert constant
tooth-moving forces on the teeth.
Where implant removal is considered the shape
memory effect should be reversible. Today's shape
memory implant materials are very hard and thus
difficult to machine. Their effect is more or less an
all-or-nothing mechanism, while costs are above
average. Nitinol is a shape memory titanium alloy
that has potential for fracture treatment in
osteoporotic bone, providing a complex shape, low
modulus of elasticity, and low stiffness porous foam
that allows bone ingrowth. Nitinol foam produced
with nickel-CPTi powder can have interconnected
pores with porosity between 40-80% and a similar
modulus of elasticity to subchondral bone. This
offers interesting future possibilities as it can be
premolded, but must be tested for the production of
wear debris, due to the 50% of nickel. One
possibility is using these foams as solid sponges for
holding screws in osteoporotic bone. Shape memory
alloys, like Nitinol, exhibit an interesting material
property-super elasticity: They are able to exert a
recoil effect over a large range of deformation. This
effect seems to promise interesting applications
such as correction of spine deformities.
Polymeric implants
Biodegradable polymeric implants
It is recommended that implants are removed after
fracture healing in a number of clinical situations.
Biodegradable materials, after a certain period of
implantation, are resorbed in vivo in the body in the
form of non harmful by-products, such as H20 and
CO2, which are finally eliminated from the body by
normal metabolic processes. Polylactides and
polyurethanes are synthetic in origin and offer fair
tissue tolerance. Due to limited mechanical
properties they are of interest for implants which
must resist only minor loads and where surgical
removal is a major undertaking. Examples of such
implants are pins for the fixation of small chondral
or osteochondral defects of articular surfaces,
suture anchors or thin plates and screws used for
fracture treatment in the maxillofacial area,
including the orbit and skull. Resorbable
membranes have been tested for the treatment of
bone defects. They are also being tested for the
potential release of osteogenic substances to
enhance bone healing. Some caution is advised in
situations susceptible to infection as degradable
material sometimes exhibits a reduced resistance to
infection compared to the best metal implants.
Nonbiodegradable polymeric implants
Polyaryletherketone polymers including
polyetheretherketone (PEEK) and
polyetherketoneketone (PEKK) thermoplastics are
considered biocompatible in bone and can be
sterilized by most methods including steam, though
they have around 5% loss in strength when exposed
Metallurgy 209
to y-radiation. They are X-Ray translucent and not
magnetic, therefore not heated by MRI, and do not
cause magnetic artifacts that distort images of the
soft tissue (MR compatible). They do not corrode
like metals, but there are concerns about possible
leakage of their original components (softeners,
accelerators, nonpolymerized base components, and
solvents). The tensile strength of PEEK is about 90-
100 MPa, which can be improved by carbon
reinforcement. However, this may cause problems
due to possible release of microfibers after implant
breakage, or fretting, or wear, as the bond strength
of the fibers to the polymer decreases over time.
Barium sulfate is sometimes added as a contrast
media for X-Ray imaging. These materials have high
chemical resistance and are resistant to the
surrounding body milieu, but are hydrophobic and,
without coating or surface modification, will not
allow bony integration. The high costs of these
materials limit applications. The main use for this
type of polymer is currently in spine cages for
interbody lumbar fusion.
COMPARISON OF METALS
Mechanical Properties
The mechanical properties of a metal vary
depending on whether it is used as a pure base
metal or as an alloy with other metals. They also can
be altered significantly by processing (e.g., cold-
working, hot-forging, annealing). The mechanical
demands of the implant help determine the
appropriate materials and processing methods.
Fracture fixation implants require high yield
strength and high fatigue resistance. The metals that
can best meet these requirements are 316L
stainless steel and titanium alloys. The yield stress
of Ti-6Al-4V alloy is greater than that of
unprocessed 316L stainless steel, both Co-Cr alloys,
and commercially pure titanium. However, cold-
working of stainless steel results in a material with
a higher yield stress and fatigue resistance than Ti-
6Al-4V alloy. Stainless steel is an attractive implant
material because it has moderate yield and ultimate
strengths, is relatively low in cost, is easy to
machine, and maintains high ductility, even with
large amounts of cold-forging. Ti-6Al-4V is more
difficult to machine, more expensive, and sensitive
to external stress risers (scratches), which can
dramatically shorten its fatigue life. Its lower
ductility results in less forewarning of failure when
a screw is over-tightened. Stainless steel has
favorable fatigue characteristics in the relatively
low cycles, but in the higher cycles titanium alloy is
more resistant to fatigue.
Clinical studies have shown that there is no
significant advantage in healing time with steel- or
titanium-based dynamic compression (DC) plates
used for internal fixation of 256 tibial fractures.
Both Ti6Al4V and cold-worked 316L stainless steel
are used for implants that must withstand unusually
high stresses (e.g., intramedullary nails designed for
210 Plate Fixation in Orthopaedics
fixation of subtrochanteric fractures). The Russell-
Taylor reconstruction nail (Smith and Nephew) and
the ZMS reconstruction nail (Zimmer) are made
from cold-worked stainless steel; the Uniflex
reconstruction nail (Biomet, Warsaw, IN), the CFX
nail (Howmedica), and the TriGen nail system
(Smith and Nephew) are made from titanium alloy.
The process of casting the CoCrMo (F-75) alloy is
expensive and leaves minute defects, which
significantly reduce its strength, ductility, and
fatigue life. It has superior corrosion resistance. The
yield strength of wrought CoCrNiMo (F-562) can
range from 600 MPa for fully annealed alloy to 1400
MPa for severely cold-drawn wire. The
molybdenum is added to produce finer grains,
which results in higher strength after casting and
forging. Cobalt-chromium alloys are difficult and
expensive to machine because they have high
intrinsic hardness. They also have lower ductility
(i.e., they are very brittle), and their base alloy costs
are significantly higher. For these reasons, cobalt-
chromium alloys are not generally used to make
fracture fixation implants, but because of their
superior fatigue resistance, long-term corrosion
resistance, and biocompatibility, they are used for
stems of hip prostheses.
Although the discussion thus far has emphasized
the importance of implant strength and fatigue
resistance, it is not possible simply to maximize size
and stiffness of implants to meet the mechanical
demands of fracture fixation. Bone is a living tissue
that responds to mechanical loads. Both
maintenance of bone mineral content and fracture
healing require that the bone experience load
transmission; if bone is deprived of load by the
implant, stress shielding occurs. It is therefore
essential that the internal fixation implant be
designed to distribute stress to both the implant and
the bone, often referred to as load sharing.
Furthermore, to prevent stress concentrations and
stress shielding, the elastic modulus of the implant
should be similar to that of bone. The elastic
modulus of titanium alloys is 6 times greater than
that of cortical bone, but the elastic modulus of
stainless steel is 12 times greater, so titanium is the
better implant material for prevention of stress
shielding.
Biocompatibility
Biocompatibility is the ability of a metal and the
body to co-exist. Ideally, an implanted metal will
experience minimal corrosion and minimal host
reactivity. In 1972, ASTM adopted a greatest for stainless steel, followed by
biocompatibility standard (F-361) to assess the
effect of all implant metals on the body. Every metal
eventually corrodes in every environment; those
metals that are deemed acceptable for implantation
should demonstrate only a small amount of
corrosion over a long period. For optimal
biocompatibility, the products of this corrosion
should cause minimal inflammatory reaction.
Titanium has the greatest corrosion resistance
because it rapidly forms titanium oxide on its
surface. The oxide layer is tightly adherent and
resistant to breakdown; if it is damaged, it re-forms
in milliseconds. While implants made of other
metals are typically surrounded by a thin fibrous
capsule, implants made of titanium and its alloys
demonstrate a remarkable ability to form an
intimate interface directly with bone. Perren found
no avascular zone with titanium and a 0.02 mm
avascular zone with stainless steel. Additionally,
titanium promotes bone ingrowth, which can be a
problem if late extraction of the implant is
necessary.
A small percentage of the population is sensitive
to nickel and chromium. These persons cannot
tolerate implants made of metals such as stainless
steel or chromium cobalt alloy, which contain these
elements. Commercially pure titanium, however,
can be used in patients who are sensitive to nickel
and chromium.
Stainless steel implants have localized areas of
corrosion, mostly at microfracture sites, crevices,
and abrasion sites (screw-plate interfaces). A
capsule forms around stainless steel implants,
indicating poor integration at the surface-tissue
interface. Stainless steel is compatible but does not
promote bone ingrowth at the surface of the
implant. This fact confers some advantage in the
design of devices that eventually will be removed
from the body. Cast CoCrMo (F-75) has excellent
corrosion resistance compared with stainless steel,
and its fatigue strength can be increased by various
forging and pressing techniques, making it an
excellent material for high-cycle, high-stress
environments such as the femoral stem of a hip
prosthesis.
Infection is a major concern with internal fixation.
Although overt infection is a multifactorial problem,
the adherence of bacteria to biomaterials may be an
initial step in the process of implant loosening and
ultimate implant failure. There are minimal clinical
researches comparing bacterial adherence with
various biomaterials in humans. Bacteria have a
natural tendency to adhere to inert surfaces.
Bacteria that produce significant amounts of
glycocalyx have a greater adherence to biomaterials.
Fibronectin is a serum and matrix protein that binds
to various biomaterials. The presence of fibronectin
on the surface of these metals is an important
determinant of colonization by staphylococci. Chang
and Merritt found that the in vitro and in vivo
adherence of Staphylococcus epidermidis was
commercially pure titanium. Stainless steel was also
found to inhibit polymorphonuclear cell production
of superoxide, thereby decreasing the bactericidal
activity of these leukocytes. No effect on superoxide
production was found with commercially pure
titanium, Ti-6Al-4V, or cobalt-chromium alloy.
Beside the material, the optimal combination of
implant design (presence/absence of dead
space/liquid filled void) and surface properties
(soft-tissue adhesion and vascularization at the

implant surface) can result in improved bacterial
resistance. In experimental studies, the effect of the
plate material on infection under conditions of
fretting was observed. The difference between steel
and titanium is greater in a multicomponent plate
and screw system than when nails (single element
implants) are used. The incidence of infection is
higher for steel implants than for titanium implants.
When dynamic compression plates made of steel or
CPTi were tested in animals, in vivo there was
significantly better resistance to local infection with
CPTi when compared to steel.
Surface structure
When placing an implant into the body, protein
adsorption and cell adhesion usually occur within
minutes, followed by either soft-tissue adhesion or
matrix adhesion before mineralization. Without
protein adsorption and cell adhesion, under the
presence of micromotion, fibrous capsule formation
occurs. The development of a stable bone-implant
interface is critical for the success of osteosynthesis
implants, such as screws. The surface structure of
an implant in contact with bone is important
because force transmission occurs at this interface.
In conventional applications, the force transmission
of a plate or nail relies on friction between the
implant and the bone. An in vivo study in rabbits
showed that simple surface roughness modification
of steel internal fixation plates induced more bone
formation towards the implant surface without
fibrous tissue formation in between. These results
support the hypothesis that bony integration is
increased on implant surfaces with higher amounts
of protruding microdiscontinuities. Strong bony
integration between the screw thread and bone is a
disadvantage when considering removal of screws,
and the surface microstructure is the major
determinant of this. Bony integration is minimized
by using surfaces with minimal microstructure
reducing the forces required to remove screws.
Movement between soft tissue and an implant-
plate surface may cause fibrous capsule formation
surrounding a liquid filled void at the interface. The
liquid phase of the void allows accumulation of
cellular detritus and any fretting particles that may
be produced from screw/plate interfaces. There is
no vascularization in the void, which predisposes to
infection since mobile cellular defense mechanisms
are lacking. Shoulder and craniomaxillofacial
surgery are two surgical fields where adherence of
implant surfaces to soft tissues such as tendons or
muscles is undesirable. There are also such
situations in hand, foot and ankle, where this fibrous
capsule formation is desirable. Recent work with
polished titanium and titanium alloys has shown the
surfaces to be favorable for such areas. The
microstructure of the implant surface is more
important than the implant surface chemistry. In
clinical practice, fibrous capsule formation has been
observed to be more prevalent with standard
stainless steel than with CPTi plates.
Metallurgy 211
Magnetic resonance imaging (MRI)
compatibility
The term MRI safe is used for devices that can be
utilized in or around an MR scanner without risk to
patients, but with possible effects on image quality.
The term MR compatible is used for devices that are
safe and without influence on the diagnostic
information.
AO approved implants (made either of CPTi or
titanium alloys (TAN and Ti-15Mo) are completely
nonmagnetic and MRI in patients with these
implants, does not pose any difficulties. They
produce less MRI artifacts when compared to
stainless steel implants including low-nickel steels.
AO approved implant quality 316L stainless steel is
classified as a paramagnetic or nonferromagnetic
material. It is safe to perform MRI on patients who
have these implants.
External fixation devices can contain magnetic
parts and are contraindication for MRI.
In vivo comparison of metals
Bone and its several associated elements—cartilage,
connective tissue, vascular elements, and nervous
components—act as a functional organ. They
provide support and protection for soft tissues and
act together with skeletal muscles to make body
movements possible. Bones are relatively rigid
structures and their shapes are closely related to
their functions. Bone metabolism is mainly
controlled by the endocrine, immune, and
neurovascular systems, and its metabolism and
response to internal and external stimulations are
still under assessment. Long bones of the skeletal
system are prone to injury, and internal or external
fixation is a part of their treatment. Response of the
bone to biomaterial intervenes with the
regeneration process. Materials implanted into the
bone will, nevertheless, cause local and systemic
biological responses even if they are known to be
inert. Host responses to fixation materials will
initiate an adaptive and reactive process.
The interaction between osteoblasts and
biomaterial surfaces was evaluated extensively.
Response of osteoblastic cells toward commonly
used titanium and cobalt alloys revealed cellular
extension on both alloys during the first 12 h.
Osteoblasts spread relatively less on rough titanium
alloy than cobalt alloy. Vinculin immunostaining at
focal adhesion contacts distributed throughout the
cells adhering to titanium alloy, but were relatively
sparse and localized to cellular processes on cobalt
alloy. Cell attachment was directly to implant
materials through integrins. Thus, the initial
interaction between the implant and surrounding
bone might differ to the origin of osteoblastic cells.
Both titanium and cobalt alloys demonstrate good
biocompatibility. Osseointegration was less on
cobalt alloy surfaces though cartilage and osteoid
tissue was observed more frequently on the cobalt
alloy than on the titanium alloy surface. Cobalt
alloys were also presented to release large amounts
212 Plate Fixation in Orthopaedics
of metal ions, which could mediate cytokine release
and hypersensitivity reaction. Osseointegration
established extensively when titanium was
implanted into bone marrow. Thus, some bone
marrow cells formed an incomplete layer in contact
with the titanium implant and presented
morphologic characteristics of macrophages and
multinucleated giant cells. Implant wear is
identified as the most important cause of aseptic
loosening in artificial joint surgery. Generation of
wear debris and the subsequent tissue reaction to it
are the major concerns of this type of surgery.
Particles of wear debris of bone cement,
polyethylene, and metal itself initiate an
inflammatory reaction that induces bone resorption
and implant loosening. Metal debris is produced as a
result of adhesive, abrasive, or fatigue (also known
as delamination) wear. Corrosion is another
mechanism that can generate debris. Wear and
corrosion may couple their effects. Debris particles
elicit a cell-mediated inflammatory response that
results in either a foreign body giant cell granuloma
or a massive release of osteolytic factors affecting
bone biology and metabolism. Release of
chemokines by macrophages in response to wear
particles may contribute to chronic inflammation at
the bone–implant interface. Wear particles induce
endotoxins responsible of adverse tissue response
that can be controlled prior to implantation. Metal
particles are also defined to cause apoptosis in cells
of tissue around the implant. Numerous
macrophages, foreign body giant cells, and
fibroblasts generally surround abundant particle
debris. Phagocytosis of debris by macrophages may
serve as a stimulus for cellular activation with
synthesis and secretion of bone-resorbing factors.
Such factors include proinflammatory mediators
interleukin-1 (IL-1), interleukin-4 (IL-4),
interleukin-6 (IL-6), interleukin-8 (IL-8),
granulocyte macrophage colony stimulating factor
(GM-CSF), tumor necrosis factor-α (TNF-α), and
prostaglandin E2 (PGE2). Interleukin-4 was found
to down-regulate particle-induced activation of
macrophages, whereas titanium particles up-
regulated the expression of matrix
metalloproteinases stromelysin and collagenase in
fibroblasts. Nitric oxide and cyclooxygenase 2 (COX-
2) play important roles in wear debris. Thus, nitric
oxide production at titanium surface was not
detected in one study. Release of selected
chemokines (MCP-1, MIP- 1, and RANTES) was
found to initiate macrophage accumulation around
wear debris. Macrophages positive for ED-1 are
involved in the tissue response of titanium.
Chemokines and cytokines mediate inflammation.
Mononuclear osteoclast precursors, stimulated by
monocyte colony stimulating factor (M-CSF), initiate
osteoclastic activity, and bone resorption begins.
One article also demonstrated that even osteoblasts
that become positive for macrophage marker CD68
might play a role in periprosthetic bone resorption.
Osteoblasts present phenotypic differentiation
depending on the chemical composition of the
debris particles. Particles are usually found in the
cytosol of the cells following phagocytosis.
Osteoblasts present extensive ruffled cell
membranes, less developed endoplasmic reticulum,
swollen mitochondria, and vacuolar inclusions.
Metallic particles and their side effects are not only
limited to the peri-implant site; they are also found
in other organs, such as the peripheral blood, liver,
spleen, and lymph nodes.

CHAPTER
THE ROLE OF
KIDNEY
IN HANDLING THE METAL
IONS
CHAPTER OUTLINE
Metal ion/soluble metal levels
Nickel
Chromium
Cobalt
Titanium
Metal particles transport
Particle distribution and elimination
Metal ions released from the implanted materials
in the human body are a major concern for these
implants. The blood and urine levels of these ions
have been extensively studied and the local and
systemic effects of them have been elucidated.
These ions are especially important in implants with
a moving surface such as joint replacement
prosthesis, but in those implants which do not have
a moving surface (i.e. plates, screws nails), still are
of concern, because some of these implants can have
Metallurgy 213
4.7
Local effects of implant corrosion
Soluble corrosion debris
Systemic effects of corrosion
General considerations
Immunogenicity of metallic implants
Metal nephrotoxicity
Carcinogenesis
extensive ion release as a result of corrosion.
Although, in these implants, the blood and urine
levels of these ions are relatively low, they can be of
important consequences in pediatric patients or
patients with insufficient renal capacity. In this
chapter, we want to review the literature on the
effects of these ions on different body systems.
Different parts of the body undergo different types
and rates of corrosion. Wounds and infections can
significantly change pH. In vivo the equilibrium state
214 Plate Fixation in Orthopaedics
between a metal and its reaction products (oxide,
hydroxide, etc.), which causes passivation, may not
occur if the reaction products are removed by the
tissue fluid turnover. The replenishment of ions
accumulated at the implant-tissue interface may
cause an adverse increase in the rate of ion release
that may cause damage on the cellular level.
Relative motion between the implant and tissue
may have caused the release of additional debris,
possibly in the form of metal carbides.
METAL ION/SOLUBLE METAL
LEVELS
Normal human serum levels of prominent implant
metals are approximately as follows: 1–10 ng/mL
aluminum, 0.15 ng/mL chromium, 0.01 ng/mL
vanadium, 0.1–0.2 ng/mL cobalt, 0.14-0.65 ng/mL
nickel and 4.1 ng/mL titanium.
Nickel
The main carrier protein of nickel in serum is
albumin, but nickel is also bound to β2-
macroglobulin and histidine. The highest
concentrations of nickel are found in the lung and in
the thyroid and adrenal glands (about 20-25 μg/kg
wet weight). The values for urine are 0.9-4.1
μg/litre. The age or sex has no effect on the
concentration of nickel in body. But various diseases
(myocardial infarction, acute stroke, thermal burns,
hepatic cirrhosis) influence the kinetics of nickel
metabolism.
The intracellular release of nickel ion following
phagocytosis of particles of oxidic and/or sulfidic
nickel is an important metabolic pathway. Minute
particles containing nickel have been demonstrated
close to the nuclear membrane. Several
physiological divalent cations influence nickel
metabolism.
Absorbed nickel is eliminated in the urine.
Excretion via sweat, secretion via saliva and
deposition in hair has been reported. However,
urinary excretion is the main clearance route.
Nickel may precipitate autoimmune phenomena
and induce immunosuppression in vitro. Nickel can
cross the placental barrier, thus being able to
influence prenatal development by direct action on
the embryo. Fetal death and malformations have
been reported following injection of various species
of nickel compounds in experimental animals.
Reversible renal effects and allergic dermatitis
have been reported.
In contrast, there is evidence that nickel is
increasingly a major allergen in the general
population, especially in women. About 2% of males
and 11% of females show a positive skin reaction to
patch testing with nickel sulfate. Ear-piercing
considerably increases the risk of nickel
sensitization. Nickel was voted Allergen of the Year
in 2008 by the American Contact Dermatitis Society.
The significance of this is in the failure of a nickel-
containing implant in an allergic patient unexposed
to the surgeon.
Mutagenic effects: Many nickel compounds can
induce in vitro mammalian cell transformation and
are clastogenic to various degrees.
Elevated levels of sister chromatid exchanges and
chromosomal aberrations have been demonstrated
in those who are exposed to nickel.
Carcinogenic effects: Studies linking nickel
uptake from the environment and cancer incidence
in the general population are not available.
Chromium
Water insoluble chromium (III) compounds and
chromium metal are not considered a health hazard,
while the toxicity and carcinogenic properties of
chromium (VI) have been known for a long time.
Because of the specific transport mechanisms,
only limited amounts of chromium (III) enter the
cells. Several in vitro studies indicated that high
concentrations of chromium (III) in the cell can lead
to DNA damage.
In the body, chromium (VI) is reduced by several
mechanisms to chromium (III) already in the blood
before it enters the cells. The chromium (III) is
excreted from the body, whereas the chromate ion
is transferred into the cell by a transport
mechanism, by which also sulfate and phosphate
ions enter the cell. The acute toxicity of chromium
(VI) is due to its strong oxidational properties. After
it reaches the blood stream, it damages the kidneys,
the liver and blood cells through oxidation
reactions. Aggressive dialysis can improve the
situation.
But the major concern for chronic exposure to
chromium is its carcinogenetic effect. Three
mechanisms have been proposed to describe the
genotoxicity of chromium(VI).
The first mechanism includes highly reactive
hydroxyl radicals and other reactive radicals which
are by products of the reduction of chromium (VI)
to chromium (III).
The second process includes the direct binding of
chromium (V), produced by reduction in the cell,
and chromium (IV) compounds to the DNA.
The third mechanism attributed the genotoxicity
to the binding to the DNA of the end product of the
chromium (III) reduction.
Chromium salts (chromates) are also the cause of
allergic reactions in some people. Contact with
products containing chromates can lead to allergic
dermatitis.
Cobalt
Cobalt is an essential element for life in minute
amounts. The LD50 values of soluble cobalt salts
have been estimated to be between 150 and
500 mg/kg. Thus, for a 100 kg person the LD50
would be about 20 grams.
After nickel and chromium, cobalt is a major cause
of contact dermatitis and is considered
carcinogenic.
 Metallurgy 215

Cobalt poisoning is intoxication caused by Untoward biologic reactions, including

excessive levels of cobalt in the body. Cobalt is an hypersensitivity, should be minimized if corrosion
essential element for health in animals in minute phenomena are minimized.
amounts as a component of Vitamin B12. A Studies on Ti and Ti6Al4V have shown that
deficiency of cobalt, which is very rare, is also titanium is preferentially accumulated locally, with
potentially lethal, leading to pernicious anemia. elevated levels of Ti detected in adjacent soft tissue
and bone. Healy and Ducheyne further determined
Titanium that serum proteins increase the release rate
Titanium is non-toxic even in large doses and does kinetics of titanium compared with solutions
not play any natural role inside the human body. An containing only serum electrolytes.
estimated 0.8 milligrams of titanium is ingested by A study conducted to determine the ability of
humans each day but most passes through without hamsters to eliminate metal ions in the urine, or
being absorbed. store in the organs, indicated that the nickel was
rapidly eliminated in the urine, so, the level in the
Metal particles transport organs was similar to that of control animals, cobalt
was eliminated more slowly than was nickel, so, the
Metal ions released in vivo are bound by specific
organ levels of cobalt were similar to those of
serum proteins. Two molecular weight ranges of
control animals with a slight elevation in the liver of
human serum proteins were determined to be
the injected animals and chromium was eliminated
associated with the binding of Cr from Co–Cr–Mo
in the urine very slowly, was red cell associated, and
implant alloy degradation (at approximately 68 and
the levels were elevated in all the organs (liver, lung,
180 kDa), but only one range of serum protein(s) (at
spleen, kidney) compared to control.
approximately 68 kD) is associated with the binding
In subjects with no implanted metallic device, the
of Ti released from Ti6Al4V implant alloy. The role of
kidneys tend to conserve cobalt in the body. In
serum or tissue proteins in the mediation of metal-
patients with a metal-on-metal hip prosthesis, there
induced effects remains largely unknown. The
is a progressive increase in cobalt clearance with
toxicological importance of these findings is not
increasing in vivo wear at the levels of cobalt
known. Homogenates of organs and tissues
release expected in patients with an array of metal-
obtained postmortem from subjects with cobalt
on-metal bearing total joint arthroplasties. The
base alloy total joint replacement components have
threshold beyond which renal capacity to excrete
indicated that significant increases in cobalt and
these ions is overwhelmed is not determined yet.
chromium concentrations occur in the heart, liver,
In a retrospectively review of cementless THAs
kidney, spleen, and lymphatic tissue. Similarly,
with metal-on-metal bearings in five patients with
patients with titanium base alloy implants
chronic renal failure, the mean serum cobalt
demonstrated elevated titanium, aluminum, and
concentration was 12.5 microg/L in patients with
vanadium levels around their metal implants.
chronic renal failure; this was more than 100-fold
Spleen aluminum levels and liver titanium
higher than in patients with the same prosthesis
concentrations can also be markedly elevated in
type and similar follow-up period, but with no
patients with failed titanium alloy implants. It has
known renal disease. However, the mean serum
been found that even in the absence of significant
chromium concentration was 5.1 microg/L, which
elevations in serum metal concentrations,
was within the normal range in all control patients.
deposition of metal can occur locally and in remote
Side effects related to elevation of serum cobalt or
organ stores in association with a well-functioning
serum chromium concentration were not identified
device. Focusing on the major alloying elements in
and overall clinical results were good 4 years after
cobalt based materials (Co, Cr, and Ni), Co and Ni
surgery.
ions bind to serum albumin, and Cr6+ binds to red
Metallic particulates may have important
blood cells. Chemical analyses of urine from animals
sequelae. When present in sufficient amounts,
subjected to metal salts indicated that most Co and
particulates generated by corrosion can induce the
Ni is rapidly excreted, while less than 50% of the Cr
formation of an inflammatory, foreign body
is excreted, and this occasionally at a slower rate
granulation tissue with the ability to invade the
than Co or Ni. Furthermore, organ levels of Co and
bone–implant interface. This can result in
Ni are not significantly elevated, whereas they are
progressive, peri-implant bone loss that threatens
for Cr. In a study, it was determined that the form of
the fixation of implant. The response to metallic
the released chromium was Cr6+, a more biologically
debris in lymph nodes includes immune activation
active form of Cr than Cr3+.
of macrophages and associated production of
inflammatory cytokines. Their systemic effects may
Particle distribution and elimination include: polycythemia, hypothyroidism,
Nickel and cobalt ions are rapidly transported from cardiomyopathy, nephropathy, hypersensitivity,
the implant site and eliminated in the urine. eczematous dermatitis, cardiac and renal
Chromium is stored in the tissue and eliminated dysfunction, hypertension, depressive psychosis,
more slowly. The issue of host hypersensitivity to anemia, osteomalacia, neurological dysfunction,
these elements remains of concern. All 3 elements,
in ionic form, are known to cause contact dermatitis.
216 Plate Fixation in Orthopaedics
possibly including Alzheimer’s disease and
carcinogenesis.
LOCAL EFFECTS OF IMPLANT
CORROSION
Soluble Corrosion Debris
The tissues surrounding modern implants may
include areas of bone ingrowth (osseointegration),
fibrous encapsulation, and a variable presence of
the foreign body responses. There are no
generalizable types of metal release that are known
to occur with all metallic implants. However,
accelerated corrosion and a tissue response that can
be directly related to identifiable corrosion products
have been demonstrated in the tissues surrounding
multipart devices.
Stainless Steel
The work of Williams and Meachim, Winter, Sevitt,
and French et al provides correlated metallurgical
and histopathological observations of the local
tissue response to the corrosion products of
stainless steel implants used for fixation of long
bones. Histological sections of the tissue
surrounding stainless-steel internal fixation devices
generally show encapsulation by a fibrous
membrane with little or no inflammation over most
of the device. At the screw-plate junctions, however,
the membrane often contains macrophages, foreign-
body giant cells, and a variable number of
lymphocytes in association with two types of
corrosion products: iron-containing hemosiderin-
like granules, and microplates, which consist of
relatively larger particles of a chromium compound.
Microplates have variable morphological
characteristics and appear within the tissue as
closely packed, plate-like aggregates of particles
ranging in size from 0.5 to 5.0 millimeters. They
often are found free within acellular collagen or
necrotic tissue. Several multinucleated foreign-body
giant cells are usually present within or bordering
collections of these particles. Hemosiderin-like
granules often surround collections of microplates,
but the granules may be found alone as well. The
granules are yellow-brown, mainly spherical, and
0.1 to three micrometers or more in diameter. They
are predominantly intracellular and are found most
often in macrophages, but they may also be found in
fibrocytes. X-ray diffraction has indicated that the
granules consist of a mixture of at least two iron
oxides, αFe203 and σFe203, and the hydrated iron
oxides, αFe203H20 and σFe203H20.
Cobalt-Based Alloys
In vitro studies of the cellular response to particles
fabricated from commercial preparations of
chromium phosphate demonstrated that the
material is a potent macrophage-monocyte activator
and has the capacity to stimulate bone resorption in
organ culture in a dose-dependent manner.
Particles of the corrosion product found in the
tissue ranged in size from submicrometer to
aggregates as large as 500 micrometers. On
visualization with light microscopy, the particles
were similar in appearance to the chromium
containing microplates observed in association with
corroded stainless-steel implants. They were plate-
like, pale yellow or green, translucent, and usually
unstained in hematoxylin-and-eosin preparations.
The larger particles were free within areas of
marked fibrosis or necrosis or were associated with
foreign-body giant cells. Most particles were less
than five micrometers in size and were found within
macrophages. The particles were not birefringent in
polarized light. Mathiesen et al. reported extensive
necrosis of peri-implant tissue due to metal toxicity
in association with some of cobalt-chromium-alloy
implants. One of these patients had an extensive
soft-tissue reaction that clinically mimicked a
sarcoma. The patient had a history of possible
allergic skin reactions and, after the implant
revision, had a positive cutaneous reaction to cobalt
and chromium solutions on dermal tests. No
neoplastic cells were found in the specimens that
had been obtained at the surgery.
Histopathologically, there was extensive necrosis,
fibrosis, and inflammation. The inflammation was
dominated by lymphocytes, macrophages, and a
substantial number of eosinophils. Several small
vessels demonstrated obliterative, necrotizing
arteritis. Epithelioid granulomas and giant cells
containing metal particles also were observed.
These findings suggested a hypersensitivity
reaction, partly of the cell-mediated type, leading to
a chronic granulomatous inflammation and
vasculitis that probably were triggered by local
release of metal ions from the corroding modular
junction.
Titanium-Based Alloys
The degradation products that have been observed
in histological sections of tissue adjacent to
titanium-based alloys generally have been of a
different nature than the precipitates associated
with stainless-steel and cobalt-based alloys that
have undergone accelerated corrosion.
Despite the remarkable resistance of titanium-
based alloys to corrosion, there have been several
reports of discoloration due to metal debris in the
peri-implant tissue. Meachim and Williams studied
nineteen commercially pure titanium, non-
articulating implants (seventeen pin-and-plate
devices and two Harrington rods) and the
surrounding tissue. The specimens were examined
with histological and metallurgical techniques, and
the titanium content of the tissue adjacent to the
implant was estimated with neutron-activation
analysis. Variable amounts of titanium particles
within macrophages and fibrocytes were found
within densely collagenous membranes that were
adjacent to the implant. Foreign-body giant cells
were rare. No specimen had metallurgical evidence

of corrosion other than areas that appeared duller
than others on gross examination. No obvious
relationship was found between the titanium
content of the tissue and the presence of
inflammatory cells, the presence of granulation
tissue, or the amount of necrotic debris at the
tissue-implant interface.
In vitro investigations indicate that specific metals
in ionic form can affect the functionality of a variety
of peri-implant cells such as fibroblasts, osteoblasts,
macrophages, and lymphocytes within the ranges of
metal concentrations reported to exist in
periprosthetic tissue. Generally, the most toxic
metal ions have been found to be Ni, Fe, Cu, Mn, and
V, while others such as Na, Cr, Mg, Mo, Al, Ta, and Co
demonstrate relatively less cellular reactivity in
vitro. Different metals act through different cellular
mechanisms to induce distinct responses. There is
mounting evidence that adverse local and remote
tissue responses, which in the past have been
entirely associated with metal particles, to some
extent may be due to soluble forms of specific metal
degradation products. However, the effect of soluble
metals on periprosthetic cells is a complex function
of cell type, composition, and concentration of
metal. In vitro investigation has determined the
stimulatory effect of some metals (e.g., Al and V) on
cells such as lymphocytes and fibroblasts, while the
same metals (and concentrations) can suppress the
viability and proliferation of other cell types (e.g.,
osteoblast-like cells). This differential impact of
metal ions on some cell types and not others
(particularly fibroblasts and osteoblasts) may
potentially explain how fibrous membranes so
readily form around implants initially placed in
intimate contact with bone (i.e., osteoblasts).
Adverse local and remote tissue responses
purportedly associated with particulate debris may
be due in part to specific soluble metals resulting
from implant degradation. High concentrations of
metals negatively impact all types of cells at some
level. For certain cell types, such as human
osteoblasts, these effects have been somewhat
characterized. One of the main functions of
osteoblasts (if not the main function) is to produce
organic bone matrix, 90% of which is type I
collagen. Type I collagen is comprised of three
helical chains. Two of the three helical protein
chains are α. The third chain, β, is similar in
structure yet genetically distinct from α. Metal
particles and ions have been found to decrease gene
expression of procollagen α before decreases could
be observed in other more osteoblast-specific
markers of bone deposition, such as gene
expression of osteocalcin, osteonectin, and alkaline
phosphatase. Other metal-induced effects on
osteoblasts have been noted, such as the production
of cytokines which recruit, prime, and activate
inflammatory cells. Interleukin-6 is secreted by
osteblasts in response to Al, Fe, Mn, Na, Ni, and V
chloride solutions (more toxic metals). Comparison
of the effects of metal ions on osteoblasts to the
Metallurgy 217
effects of particles previously reported
demonstrates the potential of specific metal ions
released from implants or particulate implant
debris to play a clinical role in the pathogenesis of
osteolysis. This contention is supported by past
investigations where metal ions such as Al, V, and Ti
have been shown to inhibit apatite formation in
vitro by binding and blocking potential crystal
growth sites. This poisoning of crystal growth sites
by metal ions may thus act to interfere with normal
in vivo osteoid mineralization and remodeling
process of bone. Whether through indirect
osteoclast activation (i.e., IL-6 release via
osteoblasts) or direct inhibitory effects on
osteoblasts, it is apparent that metal ions released
from implants have the potential to diminish bone
formation, which previously has been largely
attributed to particulate implant debris alone.
Important to the assessment of metal-induced
osteolysis is the role of other peri-implant cells such
as fibroblasts, osteoclasts, macrophages, and
lymphocytes, which, after exposure to metal ions,
may affect osteoblast function through paracrine
mediators. Although osteoclast activity has been
reportedly impaired by exposure to metal ions at
sublethal concentrations, these effects may be
overridden by metal-induced autocrine and
paracrine induction of IL-6, which can act to directly
stimulate osteoclast activity. Thus, further study
using mixed cell populations is required to more
comprehensively assess released implant metal
effects within the peri-implant milieu.
SYSTEMIC EFFECTS OF
CORROSION
General Considerations
The concern about the release and distribution of
metallic degradation products is justified by the
known potential toxicities of the elements used in
modern orthopedic implant alloys—titanium,
aluminum, vanadium, cobalt, chromium, and nickel.
In general terms, metal toxicity may be by virtue of
(1) metabolic alterations, (2) alterations in host–
parasite interactions, (3)immunologic interactions
of metal moieties by virtue of their ability to act as
haptens (specific immunological activation) or
antichemotactic agents (nonspecific immunological
suppression), and (4) by chemical carcinogenesis.
Cobalt, chromium, nickel, and vanadium are all
essential trace metals in that they are required for
certain enzymatic reactions. In excessive amounts
however, these elements are also toxic. Excessive
cobalt may lead to polycythemia, hypothyroidism,
cardiomyopathy, and carcinogenesis. Chromium can
lead to nephropathy, hypersensitivity, and
carcinogenesis. Nickel can lead to eczematous
dermatitis, hypersensitivity, and carcinogenesis.
Vanadium can lead to cardiac and renal dysfunction,
and has been associated with hypertension and
depressive psychosis. The nonessential metallic
218 Plate Fixation in Orthopaedics
elements also possess specific toxicities. Titanium,
although generally regarded as inert, has been
associated with pulmonary disease in patients with
occupational exposure and in animal models.
Aluminum toxicity is well documented in the setting
of renal failure and can lead to anemia,
osteomalacia, and neurological dysfunction,
possibly including Alzheimer’s disease. However,
considering the litany of documented toxicities of
these elements, it is important to remember that the
toxicities generally apply to soluble forms of these
elements and may not apply to the chemical species
that are the degradation products of implants.
Immunogenicity of Metallic Implants
Some adverse responses to orthopedic biomaterial
corrosion are subtle and continue to foster debate
and investigation. One of these responses is ‘‘metal
allergy,’’ or hypersensitivity to metallic biomaterial
degradation. Dermal hypersensitivity to metal is
common, affecting about 10–15% of the population.
Dermal contact and ingestion of metals have been
reported to cause immune reactions, which most
typically manifest as skin hives, eczema, redness,
and itching. As previously stated, all metals in
contact with biological systems corrode and the
released soluble products, while not sensitizers on
their own, can activate the immune system by
forming complexes with native proteins. These
metal–protein complexes are considered to be
candidate antigens (or, more loosely termed,
allergens) for eliciting hypersensitivity responses.
Metals known as sensitizers include beryllium,
nickel, cobalt, and chromium, while occasional
responses have been reported to tantalum, titanium,
and vanadium. Nickel is the most common metal
sensitizer in humans followed by cobalt and
chromium. The prevalence of metal sensitivity
among the general population is approximately 10–
15%, with nickel sensitivity the highest
(approximately 14%). Cross-reactivity between
nickel and cobalt is most common. Hypersensitivity
can be either an immediate (within minutes)
humoral response (initiated by antibody or
formation of antibody–antigen complexes of types I,
II, and III reactions) or a delayed (hours to days)
cell-mediated response. It is the latter response
with which implant related hypersensitivity
reactions are generally associated, in particular type
IV delayed type hypersensitivity (DTH). Cell-
mediated delayed type hypersensitivity is
characterized by antigen activation of sensitized
TDTH lymphocytes releasing various cytokines,
which result in the recruitment and activation of
macrophages. TDTH lymphocytes are subset
populations of T helper (TH) lymphocytes
purported to be of the CD4 TH-1 subtype (and in
rare instances CD8, cytotoxic T cells, TC). This TH-1
subpopulation of T cells is characterized by their
cytokine release profile, e.g., interferon- (IFN-),
tumor necrosis factor (TNF-α), interleukin-1 (IL-1),
and interleukin-2 (IL-2). TH-1 cells are generally
associated with responses to intracellular
pathogens and autoimmune diseases. Although TH-
1 cells mediate a DTH reaction, only 5% of the
participating cells in corrosion have been shown in
case studies to be temporally associated with
specific responses such as severe dermatitis,
urticaria, vasculitis, and/or nonspecific immune
suppression. Generally there are more case reports
of hypersensitivity reactions associated with
stainless steel and cobalt alloy implants than with
titanium alloy components. One such case report
implicated cobalt hypersensitivity in the poor
performance of cobalt alloy plates and screws used
in the fracture fixation of a 45-year-old woman’s left
radius and ulna. In this case the patient presented
with periprosthetic fibrosis, patchy muscular
necrosis, and chronic inflammatory changes
peripherally 7 years after implantation. After
removal of all metal hardware, the swelling
disappeared and eventually the patient became
complaint-free. However, there remained a
hypersensitivity to cobalt as evaluated by patch
testing. This and similar case reports prompted a
number of larger patient cohort studies in the late
1970s and 1980s investigating the possible
correlation between metal sensitivity and implant
failure. Unfortunately, these studies include
heterogeneous patient populations and testing
methodologies and consequently reach a variety of
conclusions. The prevalence of metal sensitivity
among patients with well-functioning implants is
approximately 25%, roughly twice as high as that of
the general population. Overall, the prevalence of
metal sensitivity in patients with failed or failing
implants is approximately six times that of the
general population and approximately two to three
times that of all patients with metal implants. This
association does not prove cause and effect; that is,
are these patients sensitive because the device has
failed, or has the device failed because the patient
had a preexisting metal sensitivity, or are
alternative dominating mechanisms (e.g., genetic
autoimmunity) responsible for both? Specific types
of implants with greater propensity to corrode
and/or release metal in vivo may be more prone to
induce metal sensitivity. It is unclear whether
hypersensitivity responses to metallic biomaterials
affect implant performance in other than a few
highly predisposed people. It is clear that some
patients experience excessive eczemic immune
reactions directly associated with implanted
metallic materials. Metal sensitivity may exist as an
extreme complication in only a few highly
susceptible patients, or it may be a more common
subtle contributor to implant failure. Continuing
improvements in immunologic testing methods will
likely enhance future assessment of patients
susceptible to hypersensitivity responses. The
importance of this line of investigation is growing,
as the use of metallic implants is increasing and as
expectations of implant durability and performance
increase.

Metal nephrotoxicity
The kidney is the first target organ of metal toxicity.
The nephrotoxicity that metal ions can cause are of
four discrete patterns:
a. Acute renal failure
b. Fanconi’s syndrome
c. Chronic nephropathy
d. Nephritic syndrome
Since the exposure to metal ions following
implantation of orthopaedic implants is usually
small, it generally cannot lead to acute renal failure;
instead it may cause injury primarily in the
proximal tubules, leading to Fanconi’s syndrome, or
injury to the glomerulus, sometimes resulting in the
nephritic syndrome. The nephrotic syndrome may
also appear in association with a hypersensitivity
reaction that activates immune mechanisms.
The incidence of metal nephrotoxicity in children
has declined during the past three decades, but, in
recent years, with an increase in using the metallic
implants in the treatment of pediatric fractures, an
increase in the incidence of metal nephrotoxicity in
children is expected.
The metal ions may cause renal damage by four
pathogenetic mechanisms:
1- Interaction of metal with cell membranes,
affecting the surface active properties of cell
membrane lipids and altering membrane
permeability and carrier transport
mechanisms.
2- Binding of metal ions to certain ligands within
the cells.
3- Metal may act as a hapten, forming metal-
protein antigens that evoke a hypersensitivity
reaction.
4- Formation of glomerular immune complex by
metal ions.
The real significance of these effects of metal ions
on the kidney is still under investigation. But, what
is important is “In children, metal ions released
from the orthopaedic implants may cause renal
damage which has dramatic consequences for the
child, so in using these implants, the surgeon must
pay special attention to the renal function of the
child and if possible, uses an implant made of a
metal with least nephrotoxic effects”.
Metallurgy 219
Carcinogenesis
The carcinogenic potential of the metals used in
orthopaedic implants remains an area of concern.
Animal studies have documented the carcinogenic
potential of orthopedic implant materials. Small
increases in rat sarcomas were noted to correlate
with high serum cobalt, chromium, or nickel content
from metal implants. Furthermore, lymphomas with
bone involvement were also more common in rats
with metallic implants. Implant site tumors in dogs
and cats, primarily osteosarcoma and fibrosarcoma,
have been associated with stainless steel internal
fixation devices. Initially, epidemiological studies
implicated cancer incidence in the first and second
decades following total hip replacement. However,
larger more recent studies have found no significant
increase in leukemia or lymphoma. There are
constitutive differences in the populations with and
without implants that are independent of the
implant itself, which confound the interpretation of
epidemiological investigations. The association of
metal release from orthopedic implants with
carcinogenesis remains conjectural since causality
has not been definitely established in human
subjects. The identification of such an association
depends both on the availability of comparative
epidemiology and on the ability to perform tests on
the patient before and after device removal.
It is recommended that surgeons should (1) select
implants with minimal susceptibility to metal
corrosion, (2) replace implants when there is
evidence of corrosion and mechanical failure, (3)
carry out epidemiological studies to quantify cancer
risk in patients with various types of metal implants,
and (4) improve in vitro assays for carcinogenicity
of alloys intended for use in bone tissue. The actual
number of reported cases of tumors associated with
orthopedic implants is likely underreported.
However, with respect to the number of devices
implanted on a yearly basis the incidence of cancer
at the site of implantation is relatively rare.
Continued surveillance and longer-term
epidemiological studies are required to fully
address these issues.
220 Plate Fixation in Orthopaedics

CHAPTER
SURFACE COATING OF
METALS
CHAPTER OUTLINE
Effectiveness of metal coatings
Surface modification materials and
technologies
Photochemical coupling chemistry for
biomaterials
Tie layers for metal surface pretreatments
Polymer blends for drug-incorporation
coatings on devices
Technological advances in biomaterials have
enhanced both medical and pharmaceutical
applications. Many polymeric materials have been
designed with the required mechanical properties
necessary for manufacturing medical devices.
However, these materials are often inadequate
because of local and systemic reactions that occur at
the harsh interface between biological systems and
the biomaterial surface. Consequently, the
biotechnology revolution of the past decade has
spawned a vigorous interest in the emerging field of
surface modification science and interfacial
dynamics. Surface modification is the process of
Metallurgy 221
4.8
Processes for surface modification
Hydrophilic surfaces
Wettability
Passivation
Antimicrobial coatings
Antiadherent coatings
Active antimicrobial coatings
Engineering surfaces with peptides
changing the existing characteristics of a material
surface to a more desirable characteristic. This could
consist of changing a material from being
hydrophobic to hydrophilic or to creating a more
biocompatible product on a medical device. The
concept of altering surface characteristics is not
unique. Many methods have been examined for
coating biomaterials with a variety of synthetic
polymers or biologically active compounds. This can
be done either by passivation to prevent biofouling
or by activation to incorporate a specific
functionality into the interfacial environment.
222 Plate Fixation in Orthopaedics
EFFECTIVENESS OF METAL
COATINGS
Coatings or ion implantation are usually used to
improve the biocompatibility of implants and
decrease metallic wear and corrosion. Rough or
porous surfaces allow cell attachment. One in vitro
experimental study, on the other hand, revealed that
rough Ni-Ti surface promoted transforming growth
factor beta (TGF-) expression, a mediator of bone
healing and differentiation. Titanium surfaces were
modified using phosphoric acid in an in vitro study
to improve the biocompatibilty of dental implants.
Results indicated that pretreatment of the implant
with phosphoric acid caused no cytotoxicity to the
osteoblasts. Micro arc oxidation method in
phosphoric acid on titanium implants provided
chemical bonding sites for calcium ions during
mineralization. Hydoxyapatite coating increases
susceptibility to contamination of bacteria.
Hydroxyapatite coating may also increase the risk of
heterotropic bone formation. Fibronectin or type I
collagen coating of titanium alloys increased cell
binding and osseointegration.
SURFACE MODIFICATION
MATERIALS AND TECHNOLOGIES
Photochemical Coupling Chemistry for
Biomaterials
Biomaterials, in general, are relatively inert to
environmentally friendly thermochemical reactions
since they are rich in hydrocarbon groups, namely,
carbon–hydrogen bonds. High-energy, short-lived
reactive species, such as free radicals and diradicals,
are advantageous for bond formation with the
surfaces of these materials. Photochemistry and
plasma chemistry are two useful processes for
forming highly reactive chemical species that form
covalent bonds with hydrocarbon groups. Plasma
chemistry uses high radiofrequency electromagnetic
energy to form reactive radicals from oxygen found
in air and water, ammonia, low molecular weight
hydrocarbons, and other gaseous species in a
vacuum reaction chamber. Photochemical covalent
coupling of the coating molecules is a preferred
approach to surface modification for two reasons. It
can be used on preformed polymeric materials of
varying geometries, and the high-energy
intermediates involved in such processes are
capable of reacting with a variety of polymer
substrates. This short-lived species undergoes a
rapid intersystem crossing to generate the longer-
lived triplet state. This highly reactive intermediate
is then capable of insertion into carbon–hydrogen
bonds by abstraction of a hydrogen atom from the
polymer surface, followed by collapse of the
resulting radical pair to form a new carbon–carbon
bond. The high energy of the triplet state makes the
photochemical coupling process relatively
independent of the chemical composition of the
surface, with the efficiency of the process being
determined by the relative stability of the free
radicals formed on the surface of the polymer. The
photoactivated aryl ketones are not reactive with
water molecules and can revert back to the ground
state if no suitable substrate is available, thus
substantially improving the efficiency of photogroup
utilization. Photochemical diradical generation from
aromatic carbonyl groups provides numerous
advantages for biomaterial surface modification,
such as:
The reactive species (the triplet carbonyl) can be
reversibly generated by exposure to visible or long-
wavelength ultraviolet light from commonly
available, relatively inexpensive light sources.
Good coupling yields may be procured by
associating the photoactivatable coating derivatives
with the target surface in water or volatile alcohol
solvent before activating in the wet or dry state in
ambient atmosphere.
Stable carbon–carbon bonds are formed between
the activated carbonyl group and the hydrocarbon
groups on the biomaterial surface, providing
hydrolytic stability even in vivo.
The photoactivatable aromatic carbonyl group
may be chemically incorporated into essentially all
desired coating reagents, whether synthetic or
biomolecular, independent of molecular weight,
enabling the biomaterial device manufacturer to
purchase the coating reagents and incorporate
readily the coating step in its device manufacturing
line.
The diradical reactive species enables covalent
coupling, or crosslinking, within and between
polymeric coating molecules on the surface, while
being covalently coupled to the surface.
Classes of Photoreactive Coating
Reagents
In order to incorporate photoreactive functionalities
into surface-modifying molecules, they must possess
both a thermochemically reactive group and the
photoreactive component, which is the carbonyl
group of the aryl ketones. Preferably, this
attachment site is in the para position relative to the
photoreactive functionality to minimize the
possibility of intramolecular insertion reactions. For
example, 4-benzoyl-benzoic acid, anthraquinone,
and thioxanthone derivatives are representative
examples of the benzophenone, quinone, and
xanthone classes of aryl ketones. The carboxylic acid
of the former reagent is suitable for a variety of
coupling techniques, thereby coupling to the
surface-modifying molecule or permitting
introduction of a spacer containing another coupling
group. In summary, numerous functional groups can
be used for tethering the photoreactive group to the
coating molecule, generating bonds such as esters,
amides, ethers, carbamates, and ureas, the selection
of which is made according to hydrolytic stability
requirements in the desired application. The
photoreactive coating reagents can be divided into

two major classes: heterobifunctional reagents and
multifunctional reagents. The heterobifunctional
reagents are most often used to couple specific
biomolecules to the surface, while the
multifunctional reagents are used to change the
surface properties, i.e., to achieve wettability,
lubricity, or passivation. Surfaces can also be
designed that both repel nonspecific biomolecule
adsorption and covalently couple specific active
biomolecules. Heterobifunctional reagents consist of
three important components: (1) the photoreactive
group; (2) a spacer group; and (3) a
thermochemically reactive group. The photogroup is
typically an aryl ketone having a second group in the
para position to permit attachment of the spacer
group. The spacer group can be of varying length or
composition, depending on the requirements of the
application. In general, the spacer is used to hold the
functional molecule away from the hydrophobic
environment at the substrate surface. For example, a
hydrophilic species such as polyethylene glycol
(PEG) can be used to tether a biomolecule via
flexible chains of bound soluble polymer. This
method of attachment provides more protein
mobility and hence greater opportunities for
favorable interaction of the immobilized protein
with its environment.While the spacer group can be
terminated in a relatively nonreactive group, such as
a hydroxy or methoxy group, to provide for surface
passivation, the more common selection is a
thermochemically reactive species that is not
photochemically reactive. Selections for this group
include species such as N-oxysuccinimide (NOS)
esters, tresylate esters, isothiocyanates, aldehydes,
and epoxides for reaction with amines; maleimides
for reaction with sulfhydryls and amines; hydrazides
for reaction with aldehydes and ketones; and amine
groups for coupling to carboxylic acids. The three
components of these heterobifunctional reagents
can be substituted in unlimited combinations,
providing a means for engineering reagents with
precise characteristics and specifications. Multipoint
functionalized reagents are synthesized by reaction
of these heterobifunctional reagents with
polymerizable monomers, preformed polymeric, or
multifunctional monomeric molecules. In this
process, the heterobifunctional reagents are reacted
with polymers possessing multiple reactive sites
along their backbone. Thus, the resulting
photoreagent possesses the physical and chemical
properties of the polymer and with the photogroup
attached to the backbone of the polymer via the
spacer group of the heterobifunctional molecule.
These polymeric molecules can be either synthetic
or natural. For example, proteins frequently possess
numerous lysine residues, which can be derivatized
with the heterobifunctional photoreagents
containing amine-reactive end groups such as NOS
esters. The resulting protein can be analyzed to
determine the photogroup content and the level of
biological activity. Likewise, heparin and hyaluronic
acid have been photoderivatized in several different
Metallurgy 223
ways to provide reagents capable of imparting
anticoagulant and other activities to a polymeric
surface. In a similar manner, synthetic polymers
may be prepared which possess multiple
photoreactive groups along the backbone. In these
syntheses, a base monomer is copolymerized with a
controlled quantity of a second monomer possessing
a reactive group activatable either thermally or
photochemically, followed by dialysis to remove
residual monomer and low molecular weight
oligomers. The thermally reactive polymer so
produced is then reacted with the selected
heterobifunctional reagent to introduce the
photogroups. This copolymerization approach to
photopolymer preparation provides a multitude of
opportunities to incorporate a variety of
functionalities into the polymer, including cationic
and anionic groups.
Photocoupling for Uniform Ultrathin
Coatings
Another class of coatings has been developed
specifically for ultrathin applications. These coatings
are based on photoreactive diblock copolymers.
Block copolymers are known for their ability to self-
assemble into micelles in solution and into
monolayers on surfaces. This is due to one block
having a higher affinity for the surface and another
having a higher affinity for the solvent, usually
water. The structures they form are transient,
however, changing with solvent composition or
drying. By combining the ability of the block
copolymers to spontaneously form a coating from a
polar solvent on a hydrophobic device, with the
ability of photochemistry to fix the structure in
place, an ultrathin coating is obtained with
minimum effort. This can be done by simply
immersing a device in an aqueous solution of
photoreactive diblock copolymer, allowing time for
the monolayer to spontaneously form, then
illuminating with activating light to bond it in place.
Diblock copolymers are modified to contain the
photoreactive group in only one of the blocks,
typically the more hydrophobic block, as illustrated
in Fig. 3. This leaves the other block free to interact
with the aqueous solution, defining the surface
properties. If this hydrophilic block is chosen to be
poly(ethylene glycol), for instance, the surface will
have the biocompatibility and wettability properties
of poly(ethylene glycol). Each block may be tailored
to fit a given application, allowing wide versatility
and ease of processing for delivering ultrathin
coatings for different devices.
Restrained Multifunctional Reagent for
Surface Modification
Heterobifunctional reagents have also been used to
produce restrained, multifunctional photoreagents.
These reagents are useful for preparation of
photoreactive surfaces for subsequent photo
immobilization of added coating molecules, for
224 Plate Fixation in Orthopaedics
example, self-assembling monolayer polymers. They
are also used for simultaneous application with a
coating molecule to a support surface, thereby
providing both immobilization to the surface and
crosslinking within the coating polymer layer. A
reactive reagent molecule containing multiple
latent-reactive groups is ‘‘restrained’’ in that it is
conformationally and/or chemically restricted from
reacting with either itself or with other molecules of
the same reagent. Upon activation, this feature
causes the attachment of less than all of the reactive
sites of the multifunctional reagent to a surface,
thereby leaving the remaining sites free to react
with molecules desired to be immobilized onto the
surface or to be subjected to further crosslinking.
This type of multifunctional photoreagent is useful
for immobilizing molecules not readily converted to
photoreactive derivatives and for stabilizing
polymeric coatings against mechanical disruption.
Photochemical Graft Polymerization
Graft copolymers are generally defined as branched
copolymers with a backbone of one or more
monomers to which side chains of the same or
different monomers are attached. They are generally
prepared in order to impart dissimilar physical
properties to an existing polymeric material. In the
case of modification of biomaterials, changes in
hydrophilicity, frictional properties, and blood or
tissue compatibility illustrate property changes
which may be sought by this approach.
Polymerization to form grafted chains may be
initiated in a variety of ways. Chain transfer during
the formation of the original backbone polymer may
generate polymeric radical sites which lead to
polymerization of new grafted chains. Ionizing
radiation, such as gamma or electron beam
exposure, may lead to polymeric radicals by
numerous reaction pathways, and simultaneous or
subsequent contact with suitable monomers leads to
grafted chain formation. Redox techniques have
been widely studied which usually require polymer
backbone structures with readily oxidized functional
groups. Alcohol groups on carbohydrate polymers
can thus be converted to polymeric radical sites
useful for the growth of grafted chains. Graft
polymerization can also be achieved by radiation
involving ultraviolet light, often in the presence of a
photochemical agent such as benzoin molecules.
These photochemical agents can undergo processes
such as fragmentation and hydrogen atom
abstraction, resulting in polymeric radicals which
may lead to grafted polymer chain formation. A
highly versatile grafting technology has been
developed which potentially allows graft
copolymerization to be used for permanent surface
modification of any polymeric surface bearing
hydrogen atoms. This grafting technology may also
be used with a wide range of finished articles for
imparting changes in desired surface properties.
This approach involves the use of a family of
multifunctional compounds which contain two or
more photosensitive groups (e.g., benzophenones)
which are provided as anionic, cationic, or neutral
photochemical reagents. The application of the
multifunctional photoreagents to a polymer surface
bearing abstractable hydrogen atoms is followed by
illumination with ultraviolet light. This step brings
about photoattachment of the multifunctional
reagent to the polymer surface by the process of
excitation, hydrogen atom abstraction, and collapse
of the resulting radical pair to create a carbon–
carbon covalent bond linking the reagent to the
surface. Steric effects greatly reduce the probability
that the additional photogroups on the reagent will
become bonded to the polymer surface. Thus, the
remaining photogroups are available for a second
photochemical step which involves ultraviolet light
illumination of the modified surface in the presence
of the monomer(s) of choice, resulting in grafted
polymer chain formation. While a wide range of
monomers may be used, this process typically
employs monomers leading to hydrophilic grafted
chains (e.g., acrylamide, AMPS) in order to impart
properties such as wettability or lubricity to the
surface of the article. The particular properties of
the substrate polymer backbone or the intended use
of the modified surface may influence the choice of
anionic, cationic, or neutral multifunctional
photoreagents. The versatility of the grafting
process provides significant advantages relative to
earlier methods. Suitable ultraviolet light sources
are readily available, and brief ultraviolet light
exposure is generally not detrimental to the stability
or properties of polymeric materials. This is in
contrast to the high-energy radiation methods, such
as gamma radiation, where both equipment
accessibility and material degradation may be
significant issues. Chain transfer methods of graft
polymer chain formation are generally not
applicable to the modification of surfaces of
polymeric articles, such as medical devices. Redox
methods are only applicable to a relatively small
number of polymeric backbone materials, most of
which are not used for finished article fabrication.
The use of the two-step photochemical grafting
process also provides a high degree of assurance
that the intended graft polymer chains are
effectively covalently attached to the polymer
surface, and will provide a more permanent
modification of the surface of the biomaterial.
Tie Layers for Metal Surface
Pretreatments
Many medical devices are prepared partially or
wholly from metallic materials whose surface
characteristics may not be appropriate or optimal
for the intended use. Examples of such devices are
guidewires, stents, pacemaker components, vena
cava filters, and distal protection devices. These
devices contain metallic components based on
materials such as stainless steel, platinum, nitinol,
titanium, or aluminum. Examples of needed or
desired surface characteristics include wettability,

lubricity, improved tissue or blood compatibility, or
good adhesion of subsequent materials coatings on
the metallic surfaces. It is often difficult or
impossible to achieve such objectives by direct
application of known coating materials to metallic
surfaces due to the dissimilarity of most coating
materials relative to the metallic material surfaces. A
great deal of technology has been developed for the
purpose of providing uniform and durable surface
coatings on metallic materials and is widely used in
numerous industrial applications. Synthetic
polymers of several types have been developed
which incorporate carboxylic acid functionality in
order to achieve interaction and bonding to metallic
substrates. Notable examples include the
ethylene/acrylic acid family of materials and the
carboxyl-functional polyurethane (PU) materials.
Alternatively, a very wide range of silane
derivatives, typically trialkoxysilane compounds,
have been developed by several manufacturers to
undergo interaction and bonding to metallic
surfaces, usually involving oxide or hydroxy
functionality on the metal surface. Further
developments have resulted in the hydrosiloxane
materials, which are generally copolymer structures
involving hydrosiloxane and dialkylsiloxane units.
These materials are useful for treatment of clean,
oxidizable, metal surfaces and allow attachment of
silicone polymer segments to metallic surfaces. In all
of these approaches, the metallic surfaces have been
modified in ways that provide abstractable
hydrogen atoms attached to the organic components
of these surface pretreatments and are therefore
suitable surfaces for the entire photochemical
surface treatments described earlier.
Polymer Blends for Drug-Incorporation
Coatings on Devices
Polymer blends have been widely examined in the
fields of polymer science and engineering and have
enjoyed considerable success in industrial
commercial applications, particularly in the area of
molded plastic materials. Blends are typically used
in order to achieve combinations of properties that
are unavailable in single materials or would require
specific synthetic efforts to achieve. The majority of
polymer blends are described as immiscible having
distinct detectable separate phases made up of the
component polymers. Examples of miscible polymer
blends are also known, and blends have been
developed in which a third component is included to
stabilize the morphology of a polymer blend or
serve as a ‘‘compatibilizer’’ material. The polymer
blend approach was selected because of the
potential of being able to vary polymer component
identity, ratio, and coating process parameters to
give a wide range of mechanical properties,
including drug diffusion and release characteristics
in the resulting coatings. This approach has proven
to be successful in controlling a wide variety of
coating properties, while requiring the synthesis of
only a small number of polymer component
Metallurgy 225
materials. For example, variation in identity and
ratio of polymer components and coating process
changes involving solvent choice, environmental
conditions, and equipment parameters allow
regulation of many characteristics of the resulting
coatings. Coating modulus and durability may be
enhanced by the selection of higher modulus blend
components and by adjustment of the ratio of the
polymer blend components. Partially phase-
separated polymer blend morphologies may be
influenced by careful control of coating process
parameters, such as relative humidity, leading to
control of both burst and controlled release aspects
of the overall drug delivery properties of coatings.
The polymer blend approach to providing very
specific drug release characteristics has proven to be
particularly useful in drug release from implanted
medical devices with applicability to a wide range of
drug materials and release profiles.
PROCESSES FOR SURFACE
MODIFICATION
The methods for reagent application can be
classified as one-step or two-step, depending upon
the number of processing steps required in the
modification of the device. The one-step method
involves prederivatization of the coating molecule of
interest with the photoreactive moiety. The purified
photoreagent is then brought into solution and
applied to the device followed by illumination with
suitable wavelength light to activate the
photocoupling process. Alternatively, the two-step
method can be employed in which the device itself
can be prederivatized rather than the molecule of
interest. For this method, the substrate is treated
with the photoreactive heterobifunctional reagent in
solution, illuminated, and finally the molecule of
interest is coupled to the reactive surface using
conventional coupling techniques well recognized in
organic and protein chemistry. The one-step
approach is generally the preferred method for
integration into device manufacturing since it
minimizes the number of processing steps. In
addition, the method is more efficient than the two-
step approach, with minimal excess reagent being
wasted. The primary limitation of this approach is
the requirement that the coating reagent must not
be chemically degraded by the illumination source.
For example, some biologically active compounds
can show significant inactivation under UV
illumination. While photochemical surface
modification is a generic process across a broad
range of coating molecules and polymer surfaces,
each specific application typically requires some
optimization. It is critical that the surface to be
modified must be free of contaminants, such as
plasticizers or low molecular weight oligomers, to
insure coupling of the photoreagent to the base
polymer. Such cleaning processes can consist of
simple washing procedures, solvent extraction, or
226 Plate Fixation in Orthopaedics
plasma cleaning of the surface. The photoreagent is
then applied in a solvent compatible with both
polymer and photoreagent, typically an aqueous or
alcohol-based system. The solution application can
be accomplished in a number of ways. Dip coating
works well for many devices, especially catheters
and guidewires. Spraying, brushing, or ink jetting
the coating solution onto the device can be used for
parts with intricate geometries where dip coating
may not reach portions of the device. Illumination of
the device can occur in either the wet or dry state
and a variety of illumination systems, both UV and
visible, can be used to accommodate differing
geometries of the devices. For parts that do not
allow a film to form easily, such as very hydrophobic
substrates, the part can be illuminated in solution,
which will result in the binding of a thin layer of the
photoreagents to the substrate. The duration of the
illumination is determined by the incident beam
intensity (typically 1–3 min at 1mW/cm2), the
nature of the reagent being applied, and the type of
polymer substrate. Finally, the device may be rinsed
to remove any loosely adherent material, leaving
only the tenaciously bound layer. The two-step
approach is used for those situations in which the
user either wishes to prepare a more generic surface
to which can be added any one of a number of
molecules or has a molecule to be immobilized
which is subject to UV degradation. This process can
waste excess molecules that have not
thermochemically reacted with the derivatized
surface, and the user runs the risk of requiring an
extra reaction to block exposed surface-reactive
groups that were unable to couple the molecule,
either through suboptimal reaction conditions or
through steric hindrance. Webbing and pooling of
the coating solution can be common problems when
using conventional spraying and dipping techniques,
especially for complex geometries. This can lead to
durability issues, occluded holes, uneven coating,
and can limit the effectiveness of the medical device.
Another two-step approach is to polymerize
monomers directly onto the surface. The coating
process consists of priming the surface with a
photoreactive crosslinker followed by graft
polymerization with the appropriate monomers. The
outcome is a grasslike polymer coating that will not
occlude holes and will evenly coat irregular surfaces.
HYDROPHILIC SURFACES
Three commonly required surface characteristics of
biomaterials include wettability, lubricity, and
passivation. Each of these attributes can be achieved
by immobilizing hydrophilic photopolymers to the
device surface. Although wettability, lubricity, and
passivation are each imparted to the surface using
similar hydrophilic reagents, these attributes are not
necessarily related, nor are they mutually exclusive.
In fact, each of these surface characteristics can be
controlled by varying the polymer molecular weight,
degree of crosslinking, and/or the thickness of the
hydrogel matrix.
Wettability
Wettability is the ability of a liquid to maintain
contact with a solid surface, resulting from
intermolecular interactions when the two are
brought together. The degree of wettability is
determined by a force balance between adhesive
and cohesive forces.
Wettability is important in the bonding or
adherence of two materials.
Adhesive forces between a liquid and solid cause a
liquid drop to spread across the surface. Cohesive
forces within the liquid cause the drop to ball up and
avoid contact with the surface.(Fig 4.8-1)
The contact angle (θ), is the angle at which the
liquid-vapor interface meets the solid-liquid
interface. The contact angle is determined by the
resultant between adhesive and cohesive forces. The
tendency of a drop to spread out over a flat, solid
surface increases as the contact angle decreases.
Thus, the contact angle provides an inverse measure
of wettability. (Fig 4.8-2)
A contact angle less than 90° (low contact angle)
usually indicates that wettability of the surface is
very favorable, and the fluid will spread over a large
area of the surface. Contact angles greater than 90°
(high contact angle) generally means that
wettability of the surface is unfavorable so the fluid
will minimize contact with the surface and form a
compact liquid droplet.
For water, a wettable surface may also be termed
hydrophilic and a non-wettable surface
hydrophobic. Superhydrophobic surfaces have
contact angles greater than 150°, showing almost no
contact between the liquid drop and the surface. For
non-water liquids, the term lyophilic is used for low
contact angle conditions and lyophobic is used when
higher contact angles result.
Figure 4.8-1: Wetting ability of liquid A is very low,
while liquid C shows more wetting

High energy versus low energy surfaces
There are two main types of solid surfaces with
which liquids can interact. Traditionally, solid
surfaces have been divided into high energy solids
and low energy types. The relative energy of a solid
has to do with the bulk nature of the solid itself.
Solids such as metals, glasses, and ceramics are
known as 'hard solids' because the chemical bonds
that hold them together (e.g. covalent, ionic, or
metallic) are very strong. Thus, it takes a large input
of energy to break these solids so they are termed
“high energy.” Most molecular liquids achieve
complete wetting with high-energy surfaces.
The other type of solids is weak molecular crystals
(e.g. fluorocarbons, hydrocarbons, etc.) where the
molecules are held together essentially by physical
forces (e.g. van der waals and hydrogen bonds).
Since these solids are held together by weak forces it
would take a very low input of energy to break them,
and thus, they are termed “low energy.”
Depending on the type of liquid chosen, low-
energy surfaces can permit either complete or
partial wetting.
Wetting of low energy surfaces
Low-energy surfaces primarily interact with liquids
through dispersion (van der waals) forces.
Knowing the critical surface tension of a solid, it is
possible to predict the wettability of the surface. The
wettability of a surface is determined by the
outermost chemical groups of the solid. Differences
in wettability between surfaces that are similar in
structure are due to differences in packing of the
atoms. For instance, if a surface has branched chains,
it will have poorer packing than a surface with
straight chains.
Highly wettable surfaces are required for many
biomaterials. Hydrophobic, non-wettable surfaces
are undesirable due to adsorption and denaturation
of proteins, adherence and damage of cells, and
adherence of bacteria. Masking hydrophobic
surfaces with hydrophilic polymers reduces these
harmful effects. In addition, a hydrophilic material
will hold an evenly distributed fluid film over the
surface, enabling the device to deliver drugs, such as
antibiotics, to the site of implantation. This is likely
to result in a reduction of device-centered infections,
and may reduce the need for systemic antibiotics.
Figure 4.8-2: Contact angle (θ) of a liquid droplet wetted
to a rigid solid surface
Metallurgy 227
In addition to stabilizing a fluid film, a hydrophilic
surface will also discourage adhesion of gas bubbles
which is a common problem in purging tubing sets
used in surgery, and in blood filters, oxygenators,
and biosensors. Sessile drop contact angle analysis is
one commonly used method of determining surface
wettability. When performed properly, the angle of
contact between a small droplet (2.5 l) of filtered
deionized water and the substrate surface is a
reliable measure of wettability. Lower contact
angles result from the spreading of water across a
surface, whereas higher contact angles are
characteristic of water beading up on the
hydrophobic surface. This method was used to
compare unmodified and photopolymer-modified
biomaterials. All of the biomaterials tested are
frequently used in medical devices because of their
desirable bulk properties. Without any surface
modification, these materials demonstrate a wide
range of relatively high contact angles; such
hydrophobicity can compromise device
performance and efficacy. Modification of the
substrates with hydrophilic photopolymers results
in significant reduction in contact angle (increase in
wettability) for all materials tested, and all surface-
modified materials approach a similar contact angle
value.
PASSIVATION
When a medical device is subjected to the harsh in
vivo environment, its surface is exposed to the
body’s natural defense systems. Minerals, fatty acids,
proteins, host cells, macromolecules, and bacteria
deposit on the surface. Adsorption of proteins or
lipids can contribute to bacterial colonization on
almost any implantable product. Surfaces modified
with photoimmobilized hydrophilic polymers have
been shown to effectively reduce protein adherence
and bacterial colonization. By controlling the
polymeric composition and the extent of
crosslinking, hydrogel matrices can be designed to
provide optimal passivation characteristics for
enhancing the particular biomaterial and device
performance.
ANTIMICROBIAL COATINGS
Medical devices are essential tools in modern
patient care. Unfortunately, these useful implements
can often lead to serious complications, such as
device-related infection, if not managed properly.
Nearly every medical device is prone to infection by
a wide variety of pathogens. Implant devices account
for about 45% of all nosocomial infections. Infection
of fracture fixation devices, dental implants, joint
prostheses, vascular grafts, cardiac pacemakers and
leads, hip prostheses, artificial voice prostheses,
intrauterine devices, mammary implants,
mechanical heart valves, and heart assist devices are
associated with millions of infections at rates
between 1–50%. The pathogenesis of device-related
228 Plate Fixation in Orthopaedics
infection is not well understood. Several factors are
thought to be involved. Host immune mechanisms
are challenged soon after a device implantation or
similar procedure, reducing the normal infectious
dose. The medical device may itself act as a ‘‘wick’’
serving as a conduit for opportunistic pathogens.
Even under the best aseptic conditions, studies
found that 5000 to 50,000 skin particles are
delivered daily from each physician’s flora in
intensive care units. In the same study, 90% of clean
wounds at the time of closure harbored pathogenic
Staphylococcus aureus. A medical device’s
topographical features provide a niche for
microorganisms to adhere and subsequently
colonize forming biofilms. These biofilms, essentially
a microbiological community housed within a
exopolysaccharide matrix, are very tenacious and
require as much as 1000 times higher antibiotic
concentrations to kill the embedded
microorganisms compared to free-floating cells.
Device-related infections cause significant morbidity
and mortality. As with most maladies, prevention is
the preferred approach. Simple interventions can
reduce the device-related infection risk. For
instance, training of health care workers (HCW) in
the proper manipulation of medical devices reduces
preinsertion contamination. Full barrier protection
during insertion and proper skin preparation greatly
minimize the introduction of pathogens. Lastly,
localizing an antimicrobial(s) at the likely infection
site or at the device, or making the surface less
conducive for microbial attachment, offers a more
targeted approach compared to systemic dosing in
order to prevent and/or control device-related
infection. Antimicrobial coatings are perhaps the last
safeguard in this total system approach for
prevention of device-related infections. Some
PhotoLink coatings provide antiadherent properties
to devices; others can be engineered to serve as
reservoirs for antimicrobial agents, which may be
released at a measured rate from the device surface
or immobilized.
Antiadherent Coatings
Biofilm formation is a complex process, which
involves a variety of physical and chemical factors.
In simplistic terms, biofilm genesis proceeds in this
fashion: (1) organic molecules condition a device
surface; (2) planktonic microbes migrate to the
conditioned surface and attach; (3) genes are
expressed to generate an exopolysaccharide matrix;
(4) cell-to-cell communication occurs forming
microcolonies; (5) the microcolonies propagate
generating very high numbers of microorganisms
housed within a growing protective shell of
exopolysaccharide; and (6) sessile cells slough off
and travel to other sites to regenerate this process
and/or infect surrounding host tissue. Prevention of
biofilm formation is most likely to be successful if
the multiple steps listed above are disrupted. Once
the microcolonies start to propagate, it is very
difficult for systemic antibiotics to stop the process.
A means to prevent the onset of biofilm formation at
the early stages is to passivate the surface with a
hydrophilic coating. Keeping a medical device
surface free from organics in vivo is highly unlikely;
however, this surface can be coated to address some
of the biofilm formation dynamics. Surface
roughness, charge, material of construction, and
hydrophobicity all contribute to biofilm initiation.
Photoactivated hydrophilic coatings ‘‘smooth out’’
the topography of many medical devices making
them less susceptive to microbial attachment.
Active Antimicrobial Coatings
Development of Drug Delivery Coatings
Local drug delivery coatings can be fabricated in
several ways using biodegradable or biostable
materials. Biodegradable coatings have the
advantage of being present in the body only
transiently and thus do not pose a long-term
biocompatibility risk. Such coatings are capable of
being loaded with a high concentration of drug and
can have release rates tailored to a variety of
durations. The degradation products of a
biodegradable coating, however, must be tolerated
by the host. The chemical breakdown products must
not provoke any significant inflammatory response,
nor should the coating create unwanted particulates
during the degradation process. A biostable coating
must possess good long-term biocompatibility that
meets or exceeds the biocompatibility of the implant
itself. If a coating must be exposed to the
bloodstream during implantation, the coating should
be no more thrombogenic than the bare implant
device. In addition to biocompatibility issues, which
are of concern for any implant material, there are
several challenges that are unique in designing and
implementing a drug delivery coating for a medical
device. For example, there are limits to the thickness
of the coating that can be applied to the device. This
will constrain the quantity of drug that can be
incorporated onto the surface of the device. Some
devices have very small surface areas, such as
coronary stents and ophthalmic devices, which also
limit the amount of drug which can be incorporated
onto the surface of the device. Another challenge in
creating drug delivery coatings is that the chemical
properties (e.g., size, solubility, charge) of the drug
may limit the quantity of drug that can be
formulated in the coating. Because of the limitations
on the amount of drug that can be incorporated in a
drug delivery coating, it is important that drugs of
sufficient potency be available for specific
applications. Drug delivery coatings must adhere
well to the device surface with the desired goal of no
delamination during use of the device. These
coatings must be capable of surviving the physical
challenges of manufacturing, sterilization, and
implantation. For example, stent coatings must
survive balloon mounting procedures; sterilization
by gamma, ethylene oxide, or e-beam methods;
travel through the lumen of a guide catheter; and the
balloon expansion process in the target vessel. In

addition, drug delivery coatings must not interfere
with the primary function of the device. Drug
delivery coatings must provide a sufficient dose of
drug during a desired time frame. As discussed
previously, there are limitations to the amount of
drug that can be incorporated in a coating. This sets
an upper limit to the amount and duration of
delivery. Therefore, for effective performance, the
delivery of the drug should be timed and controlled
by the components of the coating to match with the
timing of the biological process the drug is intended
to modulate. Because of the variety of drug
candidates available, this emerges as a new
challenge with each drug which must be delivered. It
is probably not possible to design a coating system
that works with all drugs, but coating systems
should be flexible enough to work with many
compounds.
Matrices for Incorporating
Antimicrobials
Antimicrobials can be incorporated into medical
device coating matrices. This ‘‘targeted’’ approach is
favored over systemically delivered antibiotics since
the antimicrobial agent is concentrated at the site
where infection is most likely to occur. Fewer side
effects are realized for a targeted antimicrobial
application compared to systemic dosing. Also, a
broader range of antimicrobial agents may be used
in medical device coatings compared to systemic
application since far less active agent is dosed, and
the agent is generally localized in the device
microenvironment. Depending on the antimicrobial
chosen, this may minimize the issue of microbial
resistance associated with systemic antibiotics.
Antimicrobial agents, such as chlorhexidine, can
easily be imbedded within a photoimmobilized
hydrogel. A negatively charged hydrogel coating
reservoir is particularly well suited for a positively
charged antiseptic like chlorhexidine. The
antimicrobial agent slowly percolates out of the
hydrogel matrix into the microenvironment where it
provides its antimicrobial benefit. Various methods
exist for controlling the rate of release of active
agents into the microenvironment. For instance, the
application of a topcoat over an antimicrobial-
containing coating extended the release of active
agents over time. A photoactivatable hydrogel can
serve as a reservoir for active antimicrobial agents.
As with most medical devices, infections are a
frequent and a serious complication with orthopedic
fixation devices. To address this problem, a
photoimmobilized hydrogel drug reservoir
containing chlorhexidine was evaluated using a 14-
day rabbit tibial intramedullary model. In this study,
stainless steel pins were incubated with 1106 CFU of
a clinical isolate of S. aureus from a chronic
osteomyelitis infection. After the planktonic
organisms were washed away, inoculated pins were
inserted into the medular cavity of a rabbit leg
through a hole drilled into the proximal tibia.
Animals were sacrificed 2 weeks after the surgery.
Metallurgy 229
The explanted pins were sonicated to remove
bacteria, which were enumerated by plate counting.
In addition, the bone adjacent to each pin was
collected and homogenized and the bacteria
enumerated. Coated pins containing antiseptic
reduced the number of bacteria by approximately 3
logs and prevented osteomyelitis in 80% of the
animals. Therefore, the photoimmobilized hydrogel
coating containing chlorhexidine was shown to be
efficacious in preventing osteomyelitis caused by S.
aureus.
Immobilization of Antimicrobials
Another coating strategy is to immobilize
antimicrobials directly to the medical device surface
using a ‘‘linker’’ molecule. Immobilized
antimicrobials on medical devices must have at least
three characteristics: (1) a surface-active mode of
action; (2) activity against a broad spectrum of
pathogenic microorganisms; and (3) a chemical
structure which allows linkage to the device surface
while retaining its antimicrobial activity. There are
some advantages and disadvantages associated with
immobilizing antimicrobials directly to the device
surface versus antimicrobials that are eluted from a
coating matrix. A potential benefit of immobilization
is longer lasting activity. A few drawbacks include
(1) the microorganisms must intimately contact the
immobilized antimicrobial for the surface-active
agent to exert its effect; (2) if the device surface is
fouled, biologically or otherwise, contact between
the microbe and the immobilized antimicrobial may
be masked; and (3) there may be a limited selection
of surface-active antimicrobials which meet the
criteria above. However, a group of novel cationic
antimicrobial peptides fulfill these requirements.
These peptides have been isolated from a variety of
sources and include peptide derivatives of human
platelet factor IV. These peptides, which kill a broad
spectrum of bacteria, possess an amphiphilic-helical
structure and form holes in artificial membrane
systems. Hence, the mechanism of bactericidal
activity of these peptides is probably by insertion of
the helix into the bacterial membrane, causing
osmotic lysis. Finally, these peptides (1) are surface-
active (2) are microbicidal to variety of pathogens
including Staphylococcus epidermidis, Escherichia
coli, Pseudomoas aeruginosa, and Pseudomonas
mirabilis, all of which play a role in device-centered
infections; (3) contain functional groups available
for covalent coupling to support materials; and (4)
are available as synthetic peptide products with high
specific activities.
ENGINEERING SURFACES WITH
PEPTIDES
Adherence of osteoblasts to a biomaterial surface
is dependent on topography, chemistry, and surface
energy. Cell attachment activity is also related to a
tripeptide sequence, arginine-glycine-aspartic acid
230 Plate Fixation in Orthopaedics
(RGD), located in the cell-binding domain of many
adhesion molecules. Following attachment, there is
reorganization of cytoskeletal proteins, resulting in
the flattening and spreading of the cell and
formation of focal contacts, replete with clustered
integrins. This form of cytoskeletal organization
participates in cell signaling events and serves to
regulate cell behavior. However, the adsorption of
attachment proteins may not be successful in
promoting long-term cell attachment to biomaterials
in vivo because of several limitations. These include
protein desorption and/or exchange and
denaturation, the removal of the oligopeptide
sequences due to proteolysis, difficulties in
controlling the sequence presentation (i.e. C- or N-
terminal binding), and specifically arranging a
sequence or a series of sequences on the surface. In
order to derivatize in a stable manner the surfaces
with RGD-sequence peptides, covalent
immobilization of the active peptide is necessary.
References:
Bhadeshia HKDH. Steels, microstructures and properties. 3rd
ed. Elsevier. 2006.pp: 17-38
Bronzino J.: The Biomedical Engineering Handbook,
Hartford, CT, CRC Press, 1995.
Cobb AG, Schmalzreid TP. The clinical significance of metal
ion release from
cobalt–chromium metal-on-metal hip joint arthroplasty. J.
Engineering in Medicine.Vol. 220. 2006
Coburn JW, Norris KC, Nebeker HG. Osteomalacia and
bone disease arising from aluminum. Semin Nephrol 1986;
6:68–89.
Cundy TP, et al. Chromium Ion Release From Stainless Steel
Pediatric Scoliosis Instrumentation. SPINE Volume 35,
Number 9, pp 967–974.2010
El-Ghannan A,Ducheyne P. biomaterials. In Mow VC: basic
orthopaedic biomechanics and Mechanobiology, third edit.
LWW. 2005.pp: 495-525
Ellerbe D.M.K., Frodel J.L.: Comparison of implant
materials used in maxillofacial rigid internal fixation.
Otolaryngol Clin North Am 1995; 28:2.
Jacobs JJ, Gilbert JL, Urban RM. Corrosion of metal
orthopaedic implants. J Bone Joint Surg [Am]1998; 80:268–
282.
Jacobs JJ, Silverton C, Hallab NJ, Skipor AK, Patterson L,
Black J, Galante JO. Metal release and excretion from
cementless titanium alloy total knee replacements. Clin
Orthop 1999; 358:173–180.
Jacobs JJ, Skipor AK, Patterson LM, Hallab NJ, Paprosky
WG, Black J, Galante JO. Metal release in patients who have
The use of covalently coupled small peptide mimics
allows control over the density and orientation of
ligand attachment. Many investigators have bound
RGD peptides to polymeric surfaces and evaluated
cell activity. These studies have shown that the
chemistry of the surface layer can modify the
conformation of the peptide and thereby change its
interaction with cells. Thus, neither surface
roughness nor the amine group alone of the APTS
layer account for improved cell-biomaterial
interaction. The combination of surface roughness
and RGD modification provides the most favorable
surface for cell spreading and cytoskeletal
organization. These events significantly enhanced
downstream maturation related activities such as
those linked to cytodifferentiation and
mineralization of the extracellular matrix.
had a primary total hip arthroplasty. A prospective,
controlled, longitudinal study. J Bone Joint Surg [Am] 1998;
80:1447–1458.
Kasai Y, et al. Metal Concentrations in the Serum and Hair
of Patients With Titanium Alloy Spinal Implants. SPINE
Volume 28, Number 12, pp 1320–1326. 2003
Kasuga T, Watanabe M, Nogami M, Niinomi M. Calcium
phosphate glass-ceramic joined by selfdevelopment of
compositionally gradient layers on a titanium alloy.
Biomaterials 2001; 22:577–582
Kim YJ, et al. Serum Levels of Nickel and Chromium After
Instrumented Posterior Spinal Arthrodesis. SPINE Volume
30, Number 8, pp 923–926.2005
Kummer FJ. Introduction to the biomechanics of fracture
fixation. In: Noredin, Basic biomechanics of musculoskeletal
system. Third edit. LWW. 2001.pp: 390-399
Luckey TD, Venugopal B. Metal Toxicity in Mammals. NY:
Plenum, 1979.
Mazzocca AD, et al. Principles of internal fixation. In:
Browner: skeletal trauma, 4th ed. 2008. Chapter 4
Merritt K, Brown SA. Metal sensitivity reactions to
orthopedic implant. J. Dermat. 1981; 20:89–94.
Morais S, Sousa JP, Fernandes MH, Carvalho GS, de Bruijn
JD, van Blitterswijk CA. Effects of AISI 316L corrosion
products in in vitro bone formation. Biomaterials 1998;
19:999–1007.
Niinomi M. Mechanical properties of biomedical titanium
alloys. Mater Sci & Eng A 1998; A243:231–236.
Niinomi M, Kuroda D, Fukunaga K, Morinaga M, Kato Y,
Yashiro T, Suzuzki A. Corrosion wear fracture of new type

biomedical titanium alloys. Mater Sci Eng A 1999;
A263:193–199.
Okazaki Y, Ito Y, Tateishi T, Ito A. Effect of heat treatment
on microstructure and mechanical properties of new titanium
alloys for surgical implantation. J. Jpn Inst. Metals 1995;
59:108–115.
Smallman RE, Physical Metallurgy and Advanced Materials.
7ed. Elsevier. 2007.pp: 1-37
Rackham MD, et al. Predictors of Serum Chromium Levels
After Stainless Steel Posterior Spinal Instrumentation for
Adolescent Idiopathic Scoliosis. SPINE Volume 35, Number
9, pp 975–982.2010
Metallurgy 231
Standard specification for wrought titanium 6Al-7Nb alloy
for surgical implant. ASTM Designation F1295-92, ASTM,
Philadelphia, PA, USA, 1994.
Vermes C, Chandrasekaran R, Carpenter C, Jacobs JJ,
Galante JO, Roebuck KA, Glant TT. Altered osteoblast
functions achieved by phagocytosis of particulate wear
debris, proinflammatory cytokines and growth factors. J
Bone Joint Surg [Am] 2000.
Wishey A, Gregson PJ, Peter LM. Effect of surface treatment
on the dissolution of titanium based implant materials.
Biomaterials 1991; 12:470–473.
232 Plate Fixation in Orthopaedics
 Conventional Plates and Screws 233

SECTION 5
CONVENTIONAL
PLATES AND SCREWS

SECTION OUTLINE

CHAPTER 5.1
Structure and Design 235
CHAPTER 5.2
Types 239
CHAPTER 5.3
Functions 253
234 Plate Fixation in Orthopaedics
 Conventional Plates and Screws 235

CHAPTER 5.1
STRUCTURE AND DESIGN
OF
CONVENTIONAL
PLATES AND SCREWS
CHAPTER OUTLINE

Evolution of plate structure and design

Orthopaedic surgeons and their patients continue to optimal clinical results, disruption of the bone blood
benefit from rapidly improving orthopaedic supply by the plate-screw-bone construct should be
technology. Devices and instruments available today minimized. To accomplish this goal, there should be
allow surgical treatment of conditions that were minimal operative dissection and periosteal contact
difficult to treat, or were untreatable, just 20 years to promote bone union. Ideally, the plate-screw-
ago. bone construct will permit the restoration of the
Since their initial introduction in the late mechanical limb alignment and reestablish joint
nineteenth century and their subsequent congruity to within <2 mm. Finally, to be successful,
popularization by Danis and the plate fixation must provide reproducible results,
Arbeitsgemeinschaft fur Osteosynthesefragen (AO) must be simple to perform, and must have broad
group in the 1960s, conventional nonlocked plates clinical applicability. Fixation with conventional
have proven, over time, to successfully stabilize compression plates, although for the most part
many types of fractures and osteotomy sites. The successful, has its limitations. Today, the classical
plate-screw-bone construct must resist open reduction with considerable exposure of the
physiological loads to allow fracture union by fracture and internal fixation by plates and screws is
limiting fracture gap stress, provide sufficient being challenged by less invasive and more elastic
stability to permit early limb motion, and not fail fixation methods, so called biological techniques.
before fracture union occurs. Additionally, for Nevertheless, osteosynthesis with plates providing
236 Plate Fixation in Orthopaedics

absolute stability still has an important place in allowed angulation of the screw in different
fracture treatment. Intraarticular fractures require directions (Fig 5.1-1 B). The use of special drill
anatomical reduction and absolute stability and guides precisely placed the screws in relation to the
plates are often used for fixation of the metaphysis. plate hole in neutral or compression mode (Fig 5.1-1
In these fractures, anatomical reduction is essential C). These features of the DCP greatly extended and
to minimize arthrosis, and callus formation is not facilitated the possibilities of application of plates.
desired. Diaphyseal fractures of long bones are often While the original plates were all straight and of two
treated with intramedullary nailing, but good sizes only (4.5-mm narrow and broad), smaller sizes
indications for plating include the need for soon followed, as did different designs for special
anatomical reduction (eg, forearm) and the presence applications such as the angle blade plates for the
of a short distal or proximal fragment, which makes proximal and distal femur, tubular plates,
nailing technically difficult. Plate osteosynthesis may reconstruction plates, the sliding hip screw, dynamic
be preferred for some cases of nonunion and condylar screws, and other form plates.
malunions and in some poly-traumatized patients. A further advancement was the limited contact-
However, for most diaphyseal fractures of the femur DCP which featured a new design of the under-
and tibia, intramedullary nailing is the criterion surface reducing the area of contact between the
standard. plate and the bone to reduce the adverse effects of
The classical plating technique, providing absolute pressure and friction on bone vascularity.(Fig 5.1-2
stability, requires strict adherence to the principles A) It had become evident that considerable
of interfragmentary compression. Errors of structural changes occur in the cortex directly
technique and misapplied principles may lead to underneath a plate and, to a lesser extent, in the
complications such as delayed healing, implant vicinity of an intra medullary nail. These changes
failure, and nonunion. Absolute stability results in were first attributed to the metallic implant being
direct fracture healing, which generally takes longer much stiffer than bone and considered as "stress
than healing by callus. Appearance of callus after protection".
attempted rigid plate fixation is unexpected and a
sign of unplanned instability, which may lead to
implant failure, healing delay, or nonunion. The
classical technique of compression plating relies on
pressing the plate to the bone surface, which may
disturb the blood flow to the underlying cortex,
leading to local cortical necrosis. This so called
footprint of the plate induces a slow cortical
remodelling by creeping substitution and
revascularization and leads to local osteoporosis.
What was once considered stress protection is now A.
partly interpreted as disturbed vascularity of the
cortex. The disturbance of the cortical blood supply
can be decreased by minimizing stripping of the
periosteum. The plate can be placed on top of it.
Gentle use of small pointed hooks and pointed
reduction forceps is recommended for reduction,
and, whenever possible, indirect reduction
techniques should be used to reduce the insult to
bone and soft tissues. It also has been addressed by
new plate designs with limited bone contact or more B.
effectively by the internal fixator principle, which do
not rely on compression and friction between the
plate and bone for stability, so there is no direct
contact between plate and bone.

EVOLUTION OF PLATE STRUCTURE

AND DESIGN
Early modern plates had round holes in which the
conical screw head had a firm fit. Axial compression
was obtained with a removable external device. In
1967, the dynamic compression plate (DCP)
designed by Perren introduced a new principle of
applying axial compression by leveraging the
interaction of a spherical screw head and an inclined
oval screw hole (Fig 5.1-1 A). The oval hole also
C.
Figure 5.1-1: Basic concepts in DCP: A) Applying axial
compression by the interaction of a spherical screw head and
an inclined oval screw hole, B) The oval hole allows
angulation of the screw in different directions, C) Special drill
guides allow to place the screw in relation to the plate hole in
neutral or compression mode

A.
B.
Figure 5.1-2: LC-DCP: A) The cut undersurface of
LC-DCP reduces the contact surface between plate and bone
and distributes the material evenly along the plate, B)
Reducing the area of contact significantly reduced the
vascular changes caused by pressure on the cortex
Further research gave rise to the theory that
disturbed blood flow within the cortical bone was
responsible for the intense remodeling processes
observed underneath every plate that was pressed
against bone by screws. Reducing the area of contact
between plate and bone, as achieved by the LC-DCP
design, significantly reduced the vascular changes
caused by pressure on the cortex.(Fig 5.1-2 B) This
plate generation, designed with finite element
analysis, displayed an even distribution of strength
throughout its length, irrespective of the plate holes.
However, the LC-DCP also has to be pressed against
the bone in order to create the friction needed to
fulfill its function.
All conventional plates usually had to be
contoured to match the shape of the bone, as the
plate was either pressed against the bone or the
bone was pulled towards the plate. The most recent
and most revolutionary design changes to modern
plates that also introduced a completely new
principle of fixation are the internal fixators or
locking plates. The key change is the coupling
between the screw head and the plate, which results
in some unique biomechanical properties. With the
solid lock between the screw or bolt and the plate
hole, the plate do not need to be pressed against the
underlying bone, thus abolishing the undesired side
effects caused by plate to bone contact.
Furthermore, the use of monocortical self-tapping
screws seemed, in vitro experiments, as effective as
external fixation in obtaining a stable construction.
This new and quite different technique of applying a
plate is similar in principle to the external fixator
and has been termed the locked internal fixator: The
implant functions more like a fixator than a plate,
but the whole construction is covered by soft tissues
and skin.
Since they are designed to avoid the negative
effects of conventional plating, such devices
theoretically have a higher resistance to infection
Conventional Plates and Screws 237
and other complications. The first implant designed
to fulfill these new requirements was the small point
contact fixator (PC-Fix) for forearm bones. The PC-
Fix is a narrow plate-like implant designed with
small points on the undersurface that come into
contact with bone. The screws are self-tapping,
monocortical and available in one length only. The
screw head locks firmly in the plate hole with a fine
thread. The PC-Fix was the forerunner of the less
invasive stabilization system and the locking
compression plate (LCP). The latter implant
combines the technology of a conventional plate
design with that of a locked internal fixator. The
locking compression plate (LCP) can be applied to
function like any other plate, ie, it can provide
compression, protection, bridging, etc, whereas
other plates, such as the less invasive stabilization
system (LISS), act as internal fixators and can only
provide a bridging function. Conically threaded
undersurfaces of the screw heads fit matching
threads in the plate, allowing the screws to
effectively bolt into the plate and bone. This has
significant biomechanical implications. Because of
the angular-stable screws, the construction does not
require the plate to be compressed to the bone for
stability. Locking plates can be used as internal
fixators: Ideally, there is no contact with the
periosteum. This provides relative stability and
maximizes the possible blood supply to allow rapid,
indirect healing through callus formation. Angular-
stable screws also allow load to be more evenly
distributed along the entire construction, rather
than being concentrated at a single bone-screw
interface, which is a difference to traditional plates.
Failure of fixation with traditional plates often starts
at one screw, which may then propagate to other
screws. Because a similar phenomenon does not
occur with locked plates, they may be particularly
useful in osteoporotic bone. In addition, the screw-
plate locking mechanism functions as a surrogate
cortex, sometimes precluding the need for bicortical
screws. This allows the insertion of monocortical
locking screws through percutaneous aiming arms
without precise measurement of screw length.
Devices such as the LISS and other special plates
contain round threaded holes to accommodate a
single threaded screw. However, the LCP and
specific regions of some specialty plates contain
combination holes, which allow insertion of either
conventional screws or locking head screws into the
same hole. The combination hole comprises a
dynamic compression unit for the insertion of
conventional screws and a threaded part for the
insertion of locking head screws. The LCP is
versatile: It can be used as an internal fixator,
provide any of the five biomechanical functions of a
plate, and can also be used as a reduction tool.
238 Plate Fixation in Orthopaedics
 Conventional Plates and Screws 239

CHAPTER 5.2
TYPES
OF
CONVENTIONAL SCREWS
AND PLATES
CHAPTER OUTLINE

Screws Taps
Definition Modes of failure of screws
Structure and design Plates
Types Dc plate
Comparison of self-tapping and non-self- Lcdc plate
tapping screws Point contact devices
Different functions of a screw Semi-tubular, one-third-tubular, and quarter-
Forces in screws tubular plates
Screw-tightening and torque-limiting Reconstruction plate
screwdrivers Angled plates
Drills Sliding screw and compression plates

SCREWS nonlocked screws and plates and locked plates as

Operative fracture fixation can be performed with
devices applied either externally (percutaneously)
or internally (underneath the soft tissue cover).
Internal fixation devices stabilize the bone from
within the medullary canal (intramedullary nails) or
are fixed to the exterior of the bone (conventional
well as tension band wires).
Definition
Screws are the basic and most efficient tool for
internal fixation, especially in combination with
plates. A screw is a powerful element that converts
240 Plate Fixation in Orthopaedics

rotation into linear motion. Most screws are partially threaded (shaft screw) and is commonly
characterized by some common design features: available in diameters from 1.0 to 4.5 mm. Each size
has a pair of drill bits corresponding to the screw's
1. A central core that provides strength major and minor diameter and a tap. The drill
2. A thread that engages the bone and is corresponding to the major diameter is used for
responsible for the function and purchase drilling the gliding hole for a lag screw while the
3. A tip that may be blunt or sharp, self-cutting drill corresponding to the minor diameter is used for
or self-drilling and –cutting drilling the threaded hole. Today, self-tapping cortex
4. A head that engages in bone or a plate screws are available and also recommended, except
5. A recess in the head to attach the for hard cortical bone of the young adult. Some of
screwdriver the screws are also available in a cannulated
version.(Fig 5.2-2)
Basically, they can be named according to: The cancellous bone screw has a deeper thread, a
larger pitch, and typically a larger outer diameter
1. design (eg, cannulated, locking head) (4.0- to 8.0-mm) than the cortex screws. They are
2. dimension (eg, 4.5 mm) indicated for metaepiphyseal cancellous bone. The
3. characteristics (eg, self-tapping, self- screw may be partially or fully threaded. Tapping is
drilling) recommend to open the cortex and in dense bone of
4. area of application (cortex, cancellous, the young adult. (Fig 5.2-3)
monocortical, bicortical) The locking head screws of locking plate systems
5. function or mechanism are primarily characterized by the threaded screw
head. They may have a larger core diameter and a
Since the introduction of locking head screws, all relatively shallow thread with blunt edges. This
other types of screws are referred to as increases the strength and interface between screw
"conventional" screws. One and the same screw can and cortical bone compared to conventional screws.
have different functions, depending on the screw Locking screws are used in combination with plates
design and way of application. that have holes able to accommodate the threaded
screw head. The head of the screw is also threaded.
Structure and design The shallow profile of the thread demands a precise
Any discussion about different types of screws and insertion technique with the power drive to prevent
their applications should be based on an any loss of purchase (no toggle during tapping or
understanding of basic screw design. insertion). When inserting a locking head screw, the
The outer diameter is defined as the outermost last revolutions must always be done by hand using
diameter of the threads. a torque-limiting screwdriver.(Fig 5.2-4)
Pitch is defined as the longitudinal distance
between the threads.
The bending strength and shear strength of a
screw depend on its root, or core, diameter. This
dimension is the solid section of the screw from
which the threads protrude. The core diameter also
determines the size of the drill bit used for the pilot
hole. Many screws have a common core diameter.
For example, the 4.5-mm cortical, 6.5-mm
cancellous, and 4.5-mm malleolar screws all have
the same core diameter (3.0 mm). The core diameter
of a screw determines its strength in bending
because strength is a function of the cross-sectional
moment of inertia, which is proportional to the third
power of the radius. If the thickness of the core is
increased, a significant increase in bending strength
is obtained.
The core or root diameter is often confused with
the shaft diameter, which is the unthreaded portion
of the screw between the head and the screw
threads. (Fig 5.2-1)
Purchase is defined as the perception that the
screw is meeting resistance and becoming tight
rather than slipping and spinning.
In general, three different types of screws are
differentiated:
The cortex screw thread is designed for use in
Figure 5.2-1: Basic structure of a “screw”
cortical bone. It is typically fully threaded but maybe

Figure 5.2-2: A cortical (left) and a shaft (right) screw
Figure 5.2-3: A fully threaded (left) and partially
threaded (right) cancellous screw
The design of the threads can also influence the
strength of the screw and its resistance to breakage.
Stress on the core can be increased if the surfaces of
adjoining threads intersect with the core at a sharp
angle. This sharp notch acts as a stress concentrator,
increasing the possibility of screw failure. To
minimize this problem, bone screws are designed so
that the intersection of the thread surfaces with the
core contains curves without a sharp angle.(Fig 5.2-
5)
Screw tip
Different designs are available for the tip of the
screw, and these include:
1. smooth, conical tips for insertion into a
tapped drill hole(Fig 5.2-6 A)
2. self-tapping, which will cut a channel for the
thread(Fig 5.2-6 B)
3. self-tapping/self-drilling, which will cut a drill
hole and channel for the thread(Fig 5.2-6 C)
To insert a screw, a hole has to be drilled into the
bone with a drill bit slightly larger in diameter than
the minor diameter of the selected screw. To ensure
safe purchase of the screw, it is recommended to cut
a thread with a matching tap before the screw is
inserted especially in cortical as well as in hard
cancellous bone in young patients. In bone of softer
quality, such as cancellous bone, screw insertion
may be done without tapping.
Conventional Plates and Screws 241
Figure 5.2-4: A typical “Locking Head Screw”
Figure 5.2-5: Effect of thread design on screw failure: A
sharp intersection between the screw and the thread acts as an
area of stress concentration
Alternatively, there are also self-tapping screws,
which reduce insertion time but require some
practice. The screw design and the technique of
screw insertion influence the amount of damage
done and ultimately the holding power of a screw.
Thermal necrosis may be caused by dull drill bits or
by inserting pins and wires with a diameter larger
than 2 mm without predrilling, leading to loosening
and ring sequester. It is the surgeon's responsibility
to adequately prepare the holes.
Screw Types
In practice, screws are most commonly referred to
by the outer diameter of the threads (3.5, 4.5, 6.5,
and 7.3 mm). Screws are also described as self-
tapping or non-self-tapping, solid or cannulated,
cortical or cancellous, and fully or partially threaded.
The final variables are the overall length of the
screw and the thread length of a partially threaded
screw.
Figure 5.2-6: Designs of the screw tip: A) smooth
conical, B) self-tapping, C) self-tapping/self-drilling.
242 Plate Fixation in Orthopaedics
Non-Self-Tapping Screws
Non-self-tapping screws do not have flutes and are
designed with a blunt tip. These screws require a
predrilled pilot hole and threads cut with a tap. The
most important advantage of non-self-tapping
screws is that less axial load and torque are applied
during tapping and screw insertion than with self-
tapping screws. This difference allows the screws to
be used more effectively for interfragmentary
compression, lessening the chance of fracture
displacement. In addition, unlike self-tapping
screws, these screws can be replaced accurately
because they cannot cut their own channel.
Self-Tapping Screws
Self-tapping screws are designed to cut their own
thread path during insertion without prior use of a
tap. The feature that differentiates these screws
from others is the tip shape and design. Most
commonly, the tip has cutting flutes that allow the
leading threads to cut a path. Because the flutes are
only at the tip and do not extend the full length of
the screw, debris cannot be removed completely and
is instead impacted into the thread path. These
fluted-tipped, self-tapping screws are designed
primarily for use in cortical bone. Some screws are
designed to drill the pilot hole and tap the threads.
These screws usually have a trochar, diamond-
shaped tip as well as flutes. This design is most
commonly used in cannulated screw systems. If self
tapping screws are inadvertently angled, they will
cut a new path and destroy already cut thread,
which is a disadvantage.
Although not designated as self-tapping screws,
cancellous screws are commonly inserted without
tapping of the cancellous bone. The thread tip of
these screws has a corkscrew pattern with a
gradually increasing thread diameter. The
corkscrew shape impacts the bone around the sides
of the pilot hole rather than cutting and removing
debris. The purchase of the cancellous screw is
enhanced by this impaction. Tapping of the entire
length of the cancellous threads removes essential
bone, reducing the pullout strength.
An advantage of self-tapping screws is that the
number of steps necessary for the operation is
reduced, decreasing the operative time. An intimate
fit of the screw thread in the bone occurs because
the screw cuts its own thread and bone is impacted
in the thread path. A disadvantage of self-tapping
screws is the increased torque required for screw
insertion. Ansell and Scales found that three flutes
extended over three threads required the least
torque for insertion. However, these flutes weaken
the pullout strength of this portion of the screw
because the fluted threads have 17% to 30% less
thread surface than threads farther up the screw.
Therefore, the screw should be advanced so that the
cutting flutes protrude beyond the far cortex.
Because additional axial load and torque are
necessary for insertion of self-tapping screws,
fracture displacement may occur. This is one reason
why self-tapping screws are not recommended for
interfragmentary lag screw fixation.
Self tapping/Self drilling Screws
(See LHS types)
Comparison of self-tapping and non-self-
tapping screws
Baumgart and colleagues evaluated the insertion
torque, pullout force, and temperature on insertion
of a self-tapping screw and compared the results
with those of non-self-tapping screws with or
without the process of proper tapping. They found
that 1 to 1.5 N-m of insertion torque was required to
insert a 4.5-mm self-tapping screw into human
cortical bone. This value is slightly more than the
torque required to insert a non-self-tapping screw
into a pretapped hole. Placement of a non-self-
tapping screw into an untapped pilot hole required
twice the torque. The pullout force of a self-tapping
screw is 450 to 500 N per millimeter of cortex,
which is less than but not significantly different from
the pullout force of a tapped screw in cortical bone.
The heat generated during introduction of the self-
tapping screw causes an increase in temperature at
the screw tip, but little heat is transferred to the
surrounding bone. The increase in temperature does
not depend on the rate of insertion as long as the
insertion is not hindered.
Cortical Screws
Cortical screws are made with a shallow thread,
small pitch, and relatively large core diameter.(Fig
5.2-2 A) The large core diameter increases the
strength of the screw, which is important for
attachment of plates to bone and for resistance to
the deforming loads experienced by
interfragmentary compression. These screws are
fully threaded throughout their length and are
commonly non-self-tapping. The thread and the
polished surface allow easy removal and
replacement if incorrect insertion has been
performed.
Shaft Screws
The shaft screw is a partially threaded cortical screw
in which the shaft diameter equals the external
diameter of the thread.(Fig 5.2-2 B) This screw is
used for interfragmentary compression, either in
bone alone or positioned through a plate. The
nonthreaded shaft presents a smooth surface to sit
in the glide hole, eliminating binding. Klaue and
associates reported that almost 40% of the
compressive effect of a fully threaded cortical lag
screw through a plate may be lost because of
binding of the screw on the side of the glide hole in
the proximal cortex. They termed this binding
phenomenon parasitic force. The absence of binding
removes the parasitic force, resulting in a 60%
improvement in lag screw compression.
 Conventional Plates and Screws 243

Cancellous Screws followed by outer diameter, pitch, and root

Cancellous screws are characterized by a thin core diameter. Pullout strength depends on two basic
diameter and wide, deep threads.(Fig 5.2-3) The parameters: screw fixation and screw design. The
higher ratio of outer to core diameter increases the patient's variable bone density is the primary factor
holding power, which is especially important for affecting screw fixation. There are many variables to
cancellous trabeculae commonly found at the screw design. The larger the outer diameter, the
epiphysis and metaphysis. Cancellous screws are greater the pullout strength. A 6.4-mm screw has
available in either fully or partially threaded forms significantly greater holding power than a 4.5-mm
with variable thread lengths. The choice of the screw in bone of comparable density. A smaller pitch
specific thread length depends on fracture also increases holding power. This variable is
configuration and bone anatomy. When a cancellous limited because as the number of threads per inch
screw is used as a lag screw, the entire length of increases, they become tight and remove too much
thread must be contained within the fracture bone.
fragment. Allowing the thread to cross the fracture
site inhibits compression and may cause distraction.
Choosing the correct thread length is critical to
ensure maximal purchase while avoiding
displacement. Compression of cancellous bone by
screw threads does not cause resorption but actually
causes hypertrophy and realigns the trabeculae with
the force on the side exposed to pressure. The
design of a cancellous screw takes into account the
fact that cancellous bone is softer than the denser
cortical bone. The root diameter is decreased,
allowing for increased thread depth. This
configuration results in greater holding capacity at
the expense of loss of bending and shear strength.

Cannulated Screws
A cannulated screw has a hollow center that allows
it to be passed over a guide wire.(Fig 5.2-7) The root
diameter is increased to account for placement of
the screw over the wire. The increased size of the
screw is necessary to account for the cannulation
wire, which must be of adequate strength to hold A.
steady in bone without bending. The screw cannot
be too large or it would remove too much bone and
decrease the strength of the construct. Guide pins
are used to determine the optimal screw position
and aid in the fracture reduction. The guide pin
makes a relatively small defect in the bone, allowing
modification with little effect on the ability of the
screw to compress and hold bone. It is threaded to
aid in its fixation and to prevent migration when the
screw is inserted. The guide pin also makes the pilot
hole for the cannulated screw. When combined with
fluoroscopic imaging, cannulation improves the
precision of cancellous screw placement
significantly. This method is important in areas
where errant placement could result in catastrophic
complications. Once the guide pin is in position, the
screw is advanced through the soft tissues in a
counterclockwise fashion to avoid tissue damage. At
the proximal cortex, the screw is turned clockwise
and self-tapped to the desired level of insertion.
Cannulated screw systems are commonly used in B.
areas with abundant cancellous bone; tapping of this
type of bone decreases the pullout strength.
The mechanics of a cannulated screw are different Figure 5.2-7: A) Cannulated screw; inner, outer and core
from those of solid screws. The most important hole diameters, B) A comparison between these parameters of
factor in maximizing the overall pullout strength of a cannulated screws abd cortical, cancellous and malleolar
cannulated screw is the host material density, screws
244 Plate Fixation in Orthopaedics
Comparison of cortical, cancellous, and
cannulated screws
A cortical screw can handle four times the stress of a
cancellous screw of similar size and 1.7 times the
stress of a cannulated screw. The thread design and
larger root diameter enable it to handle 6.2 and 1.7
times the maximal bending stress of a solid
cancellous or cannulated screw, respectively. The
increase in strength caused by increased root
diameter comes with the disadvantage of decreased
thread depth. However, this decrease in thread
depth does not decrease holding power in cortical
bone. The resistance of a screw to bending stresses
does increase with the root diameter.
For screws to have cannulation, the root diameter
must be increased. In relation to solid screws of the
same external diameter, the thread depth of a
cannulated screw is decreased and the root
diameter is increased, resulting in the decreased
pullout strength of cannulated screws. Leggon and
coworkers found a 20% decrease in holding power
between cannulated and solid screws of similar
diameter. To compensate for this difference, larger
diameter cannulated screws are recommended.
Hearn and colleagues found no significant difference
in pullout strength between solid 6.5-mm cancellous
screws and 7.0-mm cannulated cancellous screws.
Malleolar Screws
Malleolar screws were originally designed for the
fixation of the medial malleolus. They are partially
threaded cortical screws with a trephine tip that
allows them to cut their own path in cancellous
bone. To achieve stable fixation of the malleolar
fragment, two points of fixation are necessary.
Medial malleolar fractures often have distal
fragments that are too small to permit fixation with
two of these screws; the large size of the screw often
shatters these small fragments. The prominence of
the large screw head at the tip of the medial
malleolus also causes excessive patient discomfort.
Different Functions of a Screw
The two basic principles of a conventional screw are
to compress a fracture plane (lag screw) and to fix a
plate to the bone (plate screw). The more recent
designed locking head screws provide angular
stability between the implant and the bone. The
locking head screws have a head with a thread that
engages with the reciprocal thread of the plate hole.
This creates a screw-plate device with angular
stability. Screw tightening does not press plate
against the bone surface. The load transfer occurs
through the locking head screws and the plate,
similarly to an external fixator, and not by friction
and preload. As the locked plate lies underneath the
soft tissues, the principle of this purely locked
construct has been termed internal fixator. If a
combination of conventional and locked screws is
used in one plate ("hybrid fixation"), the principle
must be followed that in each fragment, all
conventional screws are inserted before inserting
locked screws. Lag screws can be applied
independently or through a plate hole. In both
situations, compression between two fragments or
between the plate and the bone produces preload
and friction, which oppose fragment displacement
by other forces including shear force.
Interfragmentary compression is the basic element
responsible for absolute stability of fracture fixation.
Lag Screw. One of the basic principles of modern
internal fixation is absolute stability, which thanks
to interfragmentary compression provided by a lag
screw. A fully threaded conventional cortex screw is
acting as a lag screw when the thread engages only
in the cortex opposite to the fracture line (far
cortex) and not in the cortex close to the screw head
(near cortex).
The partially threaded cancellous bone screw will
also produce interfragmentary compression,
provided that the thread engages only in the
fragment opposite to the fracture plane.
It has been written that if more than one lag screw
can be positioned across a fracture site, then plate
fixation of the fracture is not necessary, fortunately,
only one or two disaters with this statedgy are
required for the orthopaedist to realize that this is
not true.
Plate Screws. Conventional nonlocked cortex
screws used to fix a plate to the bone are called plate
screws. They are introduced with a special drill
guide that fits into the plate hole either centrally or
eccentrically depending on whether axial
compression is demanded. The drill bit has the
diameter of the minor diameter of the screw, which
may be self-tapping or not. By driving home the
plate screws, the plate is pressed against the bone
which produces preload and friction between the
two surfaces.
Positioning Screw. A positioning screw is a fully
threaded screw that joins two anatomic parts at a
defined distance without compression. The thread is
therefore tapped in both cortices. An example is a
screw placed between fibula and tibia in a malleolar
fracture to secure the syndesmotic ligaments
Interlocking screw: an interlocking screw
couples an intramedullary nail to the bone to
maintain length, alignment, and rotation. Its use has
extended the indications of intramedullary nails.
Anchor screw: Anchor screw acts as a point of
fixation to anchor a wire loop or strong suture. It is
used extensively in shoulder and hip surgeries.
Push-pull screw: It acts as a temporary point of
fixation to reduce a fracture by distraction and/or
compression. It is especially used for open reduction
of pelvic fractures.
Reduction screw: It is a conventional screw
inserted through a plate to pull fracture fragments
towards the plate; this screw may be removed or
exchanged once alignment is obtained.
Poller screw: Screw used as a fulcrum to redirect
an intramedullary nail. It is inserted in the
medullary canal but outside the nail, usually

perpendicular to nail, to change the nail direction or
prevent the future nail displacement.
Forces in screws
In the clinical setting, the screw must be tight
enough to avoid plate sliding but not so tight as to
exceed the maximal shear strength of the screw
itself. Several factors affect how tight the screw-
plate-bone interface can be made, including the
maximal torque applied during insertion, thread
design, and bone quality. Because of the variation in
bone quality among individuals and among
anatomic locations, it is not possible to determine
the insertional torque necessary to optimally tighten
all screws. For this reason, a torque screwdriver
cannot be used, and screw purchase is best assessed
empirically.
The axial force produced by a screw results from
rotating it clockwise, whereby the inclined surface of
its thread glides along a corresponding surface of
the bone.(Fig 5.2-8) The inclination of the thread -
the pitch - must be small enough to provide
purchase of the screw in bone, ie, to prevent the
screw from unwinding and becoming loose.
However, the pitch must be large enough to allow
full insertion with an acceptably low number of
revolutions. To improve the advancement per turn
of a screw in bone, double helix screws may be used.
Two forces are active, one along the circumference
of the screw thread (tangential), the other along the
axis of the screw (axial). The first results from the
torque of insertion. The second results from the
displacement along the inclined surface between
screw thread and bone thread, which produces axial
tension. At the same time, the axial force acting upon
the inclined surface produces torque, which tries to
unwind the screw. This force increases with the
inclination. As the friction remains constant, the
range of angle of inclination that can be used is
limited. The torque applied to a conventional 4.5
mm cortex screw during tightening is divided into
three components: 50% is used to overcome friction
at the screw head interface; 40% is transformed into
axial force; 10% overcomes the friction of the
thread.
Figure 5.2-8: Force conversion in a screw.
Conventional Plates and Screws 245
Thus, during bench testing, a screw inserted
through a plate hole can be tightened to nearly twice
the torque that an isolated screw can. The reason for
this is that the cortex under the head of an isolated
screw is more likely to fail. In cortical bone, the
countersink can be used to allow an increased area
of contact between the head of the screw and the
cortex. This reduces contact stress and the risk of
local microfracture beneath the screw head,
especially if the screw is inclined. The relation
between torque applied and axial force induced is
about 670 N/Nm for a standard 4.5 mm cortex
screw. In locking head screws, once the screw head
engages within the plate hole, practically all torque
is used for locking, and the torque applied to the
screw thread is minimal. The screw thread is,
therefore, protected, as it will only withstand
functional forces without preload. This explains the
observation that in a closely monitored clinical
series of more than 2,000 inserted titanium locking
head screws not one failure occurred. However, if a
surgeon applies uncontrolled torque during
tightening, something will have to give way. This
could be the connection to the drive where, at higher
torque values, the hexagonal recess may strip,
especially if a worn-out screwdriver is used. It is
important that the hexagonal shape of the
screwdriver is checked regularly before use.
However, surgeons might be stronger than the
engineer's calculations. The compression applied by
a screw affects a comparatively small area of the
surrounding bone. Therefore, a single screw
compressing an oblique fracture does not effectively
counteract rotation of the bone fragments around
the axis of that screw. The area of the compression
induced around the screw is small. This is of
importance with respect to torque acting upon
smooth osteotomy surfaces: A single screw applied
to a surface does not provide much resistance
against torque between the two fragments. Such
situations require a second screw placed well apart
from the first one and, if possible, in a different
direction. The leverage then corresponds to the
distance between the screws plus twice the leverage
of the single screw.
Although bending strength and shear strength are
important mechanical features, the pullout strength
of a screw is of even greater significance in internal
fixation. The ability of a screw to achieve
interfragmentary fixation or stable attachment of a
plate relates to its ability to hold firmly in bone and
resist pullout. The pullout strength of a screw is
proportional to the surface area of thread that is in
contact with bone. There are two methods to
increase this surface contact. The first is to increase
the difference between the core and the external
diameters; this maximizes the amount of screw
thread surface that is in contact with bone, resulting
in stronger fixation. The second method is to
increase the number of threads per unit length—
that is, to decrease the point-to-point distance
between successive threads (pitch). The smaller the
246 Plate Fixation in Orthopaedics
pitch, the greater the number of threads that can
engage in the bone and the more secure the fixation.
A screw can break in two ways. The first is
through the application of a torque that exceeds the
shear strength of the screw. Von Arx determined the
range of torque applied by surgeons during
insertion to be 2.94 to 5.98 N-m. This force can
break a screw with a root diameter of 2.92 mm or
less if it becomes incarcerated. The second way is
through application of bending forces when a load is
applied perpendicularly to the long axis of the
screw. If the screws fixing the plate to the bone are
not secure enough, the plate will slide between the
bone and the screw head. This sliding permits
application of an excessive bending force
perpendicular to the axis of the screw, which
ultimately can result in fatigue failure of the screw.
The design of the threads can also influence the
strength of the screw and its resistance to breakage.
Stress on the core can be increased if the surfaces of
adjoining threads intersect with the core at a sharp
angle. This sharp notch acts as a stress concentrator,
increasing the possibility of screw failure. To
minimize this problem, bone screws are designed so
that the intersection of the thread surfaces with the
core contains curves without a sharp angle.
Screw-tightening and torque-limiting
screwdrivers
When an experienced surgeon tightens a screw to
the degree which he considers optimal, the surgeon
achieves torque that is close to the thread-stripping
torque. Because screws produce very high amounts
of axial force, it does not make sense to tighten the
screws to the utmost limit. Furthermore, when the
holding force of a screw is fully achieved by preload,
there is little holding force left to sustain additional
functional load. In early days, the surgeon tried to
achieve the utmost axial force, including repeated
retightening. Today the surgeon is advised to apply
lag screws (and plate screws) at about 2/3 of the
possible torque. This principle of safe application
should be the guideline for the surgeon striving for
adequate axial compression; it is not achieved by
applying the highest axial force possible. The locking
head screws of the LISS and LCP lock upon
tightening within the threaded plate hole and thus
protect the screw thread and the bone. With these
screws a torque-limiting screwdriver must be used
to prevent the screw heads from jamming because
the mechanical properties of the screw and plate are
constant. However, torque-limiting screwdrivers are
of no practical use when applied to conventional
screws, because the quality and thickness of the
bone exhibits large individual and topographic
variations.
Tests with expert surgeons have shown that 4.5
mm screws were routinely tightened to a torque
that produced between 2,000-3,000 N of axial
compression. In vivo measurements of compression
applied to living bone demonstrated that the initially
applied compression slowly decreases over months,
which means that compression outlasts the time
required for the osteons to bridge the fracture gap.
In vivo, loosening of well placed screws is induced
by micromotion at the interface between thread and
bone, and not by pressure. If the strain produced by
micromotion is greater than the strain tolerance of
bone, the screw will become loose and thus place
additional strain on the adjacent screw. There will
be progressive loosening of the implant. This is a
particular problem in osteoporotic bone that has
low strain tolerance. Micromotion becomes more
important with progression of screw loosening. In
most cases loosening is due to poor technique. When
excessive forces result in destruction of the screw-
bone interface, the overall stability will also be
irreversibly lost and the fracture may not heal.
Turning the screw within bone creates friction,
which in turn generates heat. Screw design and the
method of insertion will have a major influence on
the amount of heat generated. This heat has the
potential to cause thermal necrosis of bone with
subsequent loosening of the screw, and thus must be
avoided. Thermal necrosis can also be caused by
blunt drill bits or by inserting large diameter (> 2
mm) wires and pins into cortical bone without
appropriate predrilling.
The size, shape, and quality of bone and the
physiologic stress on the fracture site determine the
number of screws required for adequate fixation.
The AO/ASIF group has performed retrospective
clinical reviews of large numbers of fracture
fixations. These studies have empirically determined
the number of screws that should be used to attach a
plate to each long bone. Because the diaphysis of
long bones is tubular, it is possible to achieve thread
purchase in the cortex on one or both sides of the
intramedullary canal. The recommended number of
cortices on each side of the fracture is seven in the
femur, six in the tibia or humerus, and five in the
radius or ulna.
Circumstances may dictate the use of a longer
plate that has more holes than required. The
question arises whether all of the holes should be
filled. Placement of a screw limits micromotion and
reduces stress by increasing the area of surface
contact between the plate and the bone. On the
other hand, every drill hole in bone represents a site
of stress concentration and a point of potential
fracture. Brooks and colleagues found that a single
hole can reduce overall bone strength by 30%.
However, leaving screw holes empty may cause
concern about plate failure. Plates can fail because of
stress concentration caused by the fracture type or
by the screw hole itself. A short defect has an
increased stress concentration because the forces
are distributed over a smaller area than with a
longer, more oblique defect. In addition, the screw
hole is the plate's weakest portion because it has the
highest stress concentration. Stress equals force
divided by area; the presence of a screw hole
reduces the area of the plate, so the stress on the
plate is greater at the screw hole. Although each hole
 Conventional Plates and Screws 247

in the plate acts as a stress concentrator, the load

experienced at each hole relates to its location in
terms of the fracture site and the shape and stability
of the fracture. Empty holes at the ends of the plate
experience less stress than those closer to the
fracture. Pawluk and associates reported bending
strains for screws proximal to the fracture at 240 με
and for those distal to the fracture at 87 με under
bone-to-bone contact conditions. Filling of these
holes is of limited value because the screw does not
reinforce the plate and may needlessly increase the
risk of fracture at the screw site. When a long plate
is used, it is desirable to intersperse screws and
open holes at the ends of the plate while
concentrating screw placement close to the fracture
site. Empty screw holes in bone, both those drilled Figure 5.2-9: Configuration of the drill bit.
but not filled and those left after screw removal,
weaken the bone. Burstein and co-workers reported
1.6 times greater stresses around empty holes than A three-fluted drill bit has been developed for use
in the surrounding bone when in torsion. Within with oscillating drill attachments. To work
approximately 4 weeks, these holes are filled with effectively, a two-fluted drill bit must rotate beyond
woven bone, which eliminates the stress- 180°. Because the excursion of the oscillating device
concentrating effect. This point is important for is less than 180°, a three-fluted drill bit must be used
postoperative management after implant removal. to achieve cutting. This drill bit also provides an
added advantage when drilling on an oblique angle.
Although the oscillating three-fluted drill bit may be
DRILL BITS safer for soft tissue, the two-fluted rotary drill bit
cuts through bone more efficiently and is used more
Fundamental to screw placement is proper
commonly.(Fig 5.2-9)
preparation of the bone with drilling. The most
Drilling into bone is different from drilling into
important aspect of this process is the design of the
wood because bone is a living tissue. The process of
drill bit. The central tip is the first area to bite into
drilling in bone must minimize physiologic damage.
the bone. The sharper the tip, the better the bite and
Jacob and Berry determined the optimal drill bit
the less skive or shift in the proposed drill site. The
design and method for bone drilling. They found that
cutting edge, located at the tip of the drill bit,
the cutting forces are higher at lower rotational
performs the actual cutting and is crucial to efficient
speeds and suggested a physiologic bone drilling
penetration. Flutes are helical grooves along the
method that includes the following: (1) bone drill
sides of the bit that direct the bone chips away from
bits with positive rake angles between 20° and 35°;
the hole. Failure to remove bone debris could cause
(2) a point on the drill to avoid walking (skiving);
the drill bit to deviate from its intended path,
(3) high torque and relatively low drill speeds (750
decreasing drilling accuracy. The land is the surface
to 1250 rpm) to take advantage of a decrease in flow
of the bit between adjacent flutes. The reaming edge
stress of the material; (4) continuous, copious
is the sharp edge of the helical flutes that runs along
irrigation to reduce friction-induced thermal bone
the entire surface, clearing the drill hole of bone
necrosis; (5) reflection of the periosteum to prevent
debris while performing no cutting function.
bone chips from being forced under the tissue,
Disruption of these edges diminishes reaming
clogging the drill flutes; (6) drill flutes that are steep
performance. The rake or helical angle is the angle
enough to remove chips at any rake angle; (7) sharp
made by the leading edge of the land and the center
and axially true drill bits to decrease the amount of
axis of the drill bit. A larger rake angle reduces the
retained bone dust; and (8) drilling of the thread
cutting forces regardless of the direction in which
hole exactly in the direction in which the screw is to
the bone is cut. This angle can be positive, negative,
be inserted for accuracy and strength. These
or neutral. Positive rake angles cut only when
techniques reduce local bone damage significantly.
rotated clockwise. Most drill bits are constructed
Most drill bits are constructed with high-carbon
with two flutes; they are used with rotary-powered
stainless steel and are heat-processed for increased
drills and are provided in standard fracture fixation
hardness. Damaged or dull bits decrease drilling
sets. To limit drilling damage to the soft tissues
efficiency significantly and may cause local trauma
adjacent to bone, an attachment has been developed
to bone. A damaged drill bit can increase drilling
that converts a drill's action from rotary to
time by a factor of 35. Damage is frequently caused
oscillating drive. With the oscillating drive, there is
by contact with other metal (plate or drill sleeve).
less tendency for the drill bit to damage neighboring
AO/ASIF recommends certain procedures to
soft tissue. An oscillating drill bit can be placed on
decrease drill bit damage. The first is to drill only
skin and will not cut it because of the skin's
bone. Pohler found that drilling of 110 bone cortices
elasticity.
248 Plate Fixation in Orthopaedics
had a negligible effect on the bit itself. The second is
to always use the drill guide. This minimizes
bending, which is the leading cause of drill failure.
The drill guide or sleeve should be of correct size; an
excessively large guide results in a larger hole
because of wobbling of the drill. The third
recommendation is to start the drill only after the
drill bit has been inserted into the drill guide. This
technique limits contact with the drill guide and
consequent damage to the cutting and reaming
edges. These recommendations combined with the
defined physiologic bone drilling method limit local
damage to bone and result in optimal holes for
screw fixation.
Most standard fracture fixation sets provide
specific drill bits that are used to drill tap and glide
holes appropriate for all screws contained in the set.
Drill bits are named by their diameter and, because
they should always be used with soft tissue
protective sleeves, they have both a total and an
effective length, the latter being the portion of the
bit that extends past the drill sleeve and is
responsible for cutting. The diameters of drill bits
correspond to specific screws in the fracture fixation
set. Generally, the size of the drill bit used to make
the pilot hole for the screw threads is 0.1 to 0.2 mm
larger than the core diameter of the corresponding
screw. The size of the drill bit used to make glide
holes is the same size as the diameter of the shaft of
a shaft screw or the outer diameter of a fully
threaded cortical screw. The cutting edge of the bit
is at its tip; it should always be protected and should
frequently be examined for flaws.
TAPS
Taps are designed to cut threads in bone that
resemble exactly the profile of the corresponding
screw thread. The process of tapping facilitates
insertion and enables the screw to bite deeper into
the bone.(Fig 5.2-10) This allows the torque applied
to the screw to be used for generating compressive
force instead of being dissipated by friction and
cutting of threads. Tapping also removes additional
material from the hole, thereby enlarging it. The
screw pullout strength depends on the material
density. The larger hole created by the tap does not
decrease pullout strength in cortical bone because of
its density; in less dense trabecular or osteopenic
bone, the larger hole has a progressively larger
effect and can decrease pullout strength by as much
as 30%. Taps are threaded throughout their length
and increase gradually in height up to the desired
thread depth. A flute extends from the tip through
the first 10 threads to facilitate clearing of bone
debris, which can collect and jam the tap. Proper
technique calls for two clockwise and one
counterclockwise turn to facilitate bone chip
removal. The entire far cortex should always be
tapped, because screw pullout strength increases
substantially with full cortical purchase. The tap
size, which corresponds to its outer diameter,
should be the same as the outer diameter of the
screw. For example, a 4.5-mm cortical screw has an
outside diameter of 4.5 mm and uses a 4.5-mm tap; a
6.5-mm cancellous screw with an outside diameter
of 6.5 mm uses a 6.5-mm tap.
The original, smooth, conical-tipped screws were
designed for insertion after the drill hole had been
tapped. Self-tapping screws have several
advantages, including ease and speed of application.
However, it is still necessary to use a tap in hard
cortical bone in young adults. Tapping may reduce
the pull-out strength of screws, probably because
inadvertent toggling of the tap causes the hole to be
enlarged to a size greater than actually needed.
Tapping using the power drive reduces toggle, but
deep penetration can be more difficult to control
and is potentially dangerous. Self-tapping screws are
now generally recommended. However, in dense
cortical bone the flutes may clog and a tap may need
to be used. Self-tapping screws must be accurately
inserted without toggling and may be difficult to use
during MIPO techniques as soft-tissue tension may
cause misdirection of the screw. Removal of self-
tapping screws may be difficult when the cutting
flutes are filled by bony ingrowth, or if the friction
between screw and bone surfaces is very high. To
avoid problems with screw removal the surgeon
should try to disengage bone in the flutes by first
tightening the screw, thereby shearing off the
ingrown bone from the cutting flutes. Thus, the first
turn should be clockwise followed by anticlockwise
removal of the screw. The design of the flutes of self-
tapping screws must meet these special demands.
The obvious advantage of using self-drilling
screws, ie, the ease of application, is offset by the
fact that advancement of the drill bit and of the
thread must be compatible and synchronous. Many
self-drilling screws fail to offer good purchase
because the pitch of their thread requires rapid
progression of the drill-bit tip of the screw, which
often cannot be achieved. A further disadvantage of
self-drilling screws is that measurement of the
proper screw length is not possible. The use of
bicortical, self-drilling screws with a long, sharp
protruding tip that may damage nerves, vessels, or
tendons is not recommended. The use of self-
drilling/self-tapping monocortical locking head
screws appears to provide adequate purchase,
especially in the femoral diaphysis of young patients.
Figure 5.2-10: Tap cuts threads in bone the same as the
profile of the corresponding screw thread

MODES OF FAILURE OF SCREWS
Screws can fail because of axial pull out, bending
forces, torque, or a combination of all of these
factors.
Screws can fail during insertion by overtorquing
when the surgeon attempts to apply maximum
torque.(Fig 5.2-11 A) Surgeons with experience in
the use of steel screws tend to twist off titanium
screws at insertion. Surgeons will tighten until they
feel that the torque does not increase due to plastic
deformation. As steel allows larger plastic
deformation than titanium, inadvertent twisting
failure may occur. Von Arx determined the range of
torque applied by surgeons during insertion to be
2.94 to 5.98 N-m. This force can break a screw with a
root diameter of 2.92 mm or less if it becomes
incarcerated. As outlined earlier, screws should not
be torqued to maximum values: They efficiently
produce axial force at lower levels of torque. While
screws usually resist axial pull out well, most
conventional screws poorly resist bending and
torque due to their small core diameter.
Another way of failure is through application of
bending forces when a load is applied
perpendicularly to the long axis of the screw. If the
screws fixing the plate to the bone are not secure
enough, the plate will slide between the bone and
the screw head. This sliding permits application of
an excessive bending force perpendicular to the axis
of the screw, which ultimately can result in fatigue
failure of the screw.(Fig 5.2-11 B) Based on the
knowledge that the core diameter of a screw may be
increased without unduly forfeiting the pull out
force, the resistance to bending may be increased 3-
fold by only a 30% increase of the core of a standard
size screw. Today, we tend to design implants that
are safe for a wide variety of applications, provided
they are applied correctly. This requires an implant
that tolerates intermittent peak (over-)load without
irreversible loss of the bone-implant interface.
A.
B.
Figure 5.2-11: Screw failure; A) Shear failure secondary
to excessive torque, B) Bending failure secondary to a loose
junction between the plate and the screw
Conventional Plates and Screws 249
While today's plates, intramedullary nails,
external and internal fixators give way and spring
back into their former shape, screws are less
tolerant of peak load. With overload, the bony
thread may strip and the screw will lose its holding
power forever. This behavior must be considered in
the application of pure lag screw fixation and in
combinations of screws and flexible devices such as
intramedullary nails and external fixators.
Thermal necrosis, which is another cause of screw
failure, may be caused by dull drill bits or by
inserting pins and wires with a diameter larger than
2 mm without predrilling, leading to loosening and
ring sequester. It is the surgeon's responsibility to
adequately prepare the holes.
PLATES
An important concept is that different plates can be
used for various biomechanical problems. Some
plates are specifically designed for function; others
can be functionally modified for the same
application. The idea of design versus function
versus anatomic location is important for the
general understanding of plates. For example, the
LCDC plate is designed primarily as a self-
compression plate, but it can also be used as a
bridging plate or tension band plate or further
modified as a medial femoral condylar buttress
plate. Therefore, depending on anatomic location
and bending modification, it can function in most
other biomechanical applications.
To understand the decisions orthopaedic surgeons
make in using different plates for different
applications, it is important to have a general
understanding of the different types of plates
manufactured and the mechanics of their designs.
This section includes the basic designs such as DC
plates, LCDC plates, point contact (Schuhli) plates,
semi-tubular and one-third tubular plates,
reconstruction plates, angled plates, and sliding
screw plates. Locking plates are addressed
separately.
DC Plate (Fig 5.2-13 A)
The special geometry of the DC plate hole allows for
two basic functions: independent axial compression
and the ability to place screws at different angles of
inclination. (Fig 5.1-1 B)
Perren and colleagues designed a screw housing
in which an inclined and a horizontal cylinder meet
at an obtuse angle, permitting a downward and
horizontal movement of the screw head for axial
compression in one direction. (Fig 5.1-1 A) Sideways
movement of the screw head is impossible. A screw
placed at the inclined plane (i.e., eccentrically in the
load position) moves the plate horizontally in
relation to the bone until the screw head reaches the
intersection of the two circles. Eccentric position
refers to circles with different centers, whereas
concentric position refers to circles with the same
center.
250 Plate Fixation in Orthopaedics

The act of compression is accomplished through

the merging of two eccentric circles to become
concentric. At this point, the screw has optimal
contact with the hole, ensuring maximal stability
and producing axial compression of the bone and
tension on the plate. There are three areas in which
to place a screw in an oval hole: one at each end
(eccentrically) and one in the middle
(concentrically). (Fig 5.2-12)
The plate can be placed for neutralization,
compression, or buttressing, depending on the
insertion of the screw. In the neutral mode, the
screw is placed in a relatively central position. In the
compressive mode, the screw is inserted 1.0 mm
Figure 5.2-13: a) DCP, b) LC-DCP, c) PCF
eccentrically to its final position in the hole on the
side away from the fracture site. In buttress mode,
The design of the screw holes allows for a
the screw is placed eccentrically in the horizontal
displacement of up to 1.0 mm. After the insertion of
tract closest to the fracture. This position results in
no horizontal movement of the plate when an axial one compression screw, additional compression
using one more eccentric screw is possible before
load is placed.
the first screw is completely tightened. For axial
Under certain circumstances, the screw position
may not be perpendicular to the plate. The design of compression over a distance greater than 2.0 mm,
the use of the articulated tension device is
the DC plate allows for inclined insertion of the
recommended. The oval shape of the holes allows up
screw head up to angles of 25° longitudinally and 7°
to 7° inclination in the transversal plane.
laterally. The DC plate can be modified for use in
most biomechanical applications of fracture fixation,
and its use is based on fracture pattern and location. Point Contact Fixator (PCF) (Fig 5.2-13 C)
The point contact fixator (PC-FIX; Synthes, Paoli, PA)
LC-DC Plate was developed in a joint venture by the AO Research
Institute and the AO Development Institute. This
The limited-contact dynamic compression plate (LC-
implant has minimal contact with the bone and is
DCP) was introduced by Perren in 1990 and has
secured by monocortically inserted screws. The
become the gold standard for plate fixation. The
screw's tapered head ensures that it jams in the
plate is available in two sizes, 3.5 and 4.5 mm, which
plate hole and provides the required angular
is determined by the thread diameter of the cortex
screws used together with the plate. The screw hole stability. Minimal contact between the plate and the
bone is still necessary to ensure axial stability. Like
design allows for axial compression by eccentric
the limited-contact dynamic compression plate (LC-
screw insertion.
The LC-DCP design is available in both stainless DCP), the PC-Fix has shown to disrupt the
underlying blood supply significantly less than the
steel and pure titanium,(Fig 5.2-13) and in three
dynamic compression plate; the monocortical
sizes for large and small bones. The screw holes in
screws appear to damage the endosteal blood
the LC-DCP are best described as a portion of an
supply less than conventional bicortical screws.
inclined and angled cylinder. Like a ball, the screw
The point contact fixator device (PC-Fix; Synthes,
head slides down the inclined shoulder of the
Paoli, PA) incorporates monocortical screws that
cylinder. In practice, when the screw is inserted in
lock into a plate using a Morse cone mismatch that
such a hole and tightened, this results in movement
prevents screw toggle as the screws are tightened to
of the bone fragment relative to the plate, and
the plate. The undersurface of the plate is undercut
consequently, compression across the fracture site.
to allow minimal points of contact with the bone,
further reducing bony devascularization. The clinical
success of this type of treatment was astonishing:
indirect healing resulted in early and reliable solid
union. At the same time, the severity of
complications declined, as there was a shift away
from biological complications due to necrosis with
sequestration of bone and soft tissues toward rare
complications resulting from inadequate mechanical
stability.
Multiple European clinical series have
documented high union rates and low complication
rates using the PC-Fix for fractures of the forearm.
Figure 5.2-12: Compression with a DCP: a) Neutral
position, b) Compression, c) Buttressing

Schuhli Nut
A device consists of a three-pronged nut and a
washer. It functions to lock a cortical screw to a
plate if pullout failure due to osteopenic bone is a
concern, and to elevate the plate from the bone,
decreasing periosteal blood flow compromise. It
elevates the plate from the periosteal surface farther
than the LCDC plate does. The nut engages the screw
and locks it to the plate at a 90° angle, producing a
fixed angle construct.(Fig 5.2-14) This device has
been shown to be effective in withstanding both
axial and torsional loads to failure. Matelic and
associates reported its use in treatment of femoral
nonunions in which the lateral cortex of the femur
was deficient.
Semi-Tubular, One-Third Tubular, and
Quarter-Tubular Plates
The semi-tubular plate provides compression
through eccentrically placed oval plate holes. The
semi-tubular plate is 1 mm thick and very malleable,
so it is prone to fatigue and fracture, especially in
areas of high stress. Its main indication is for tension
resistance. The one-third tubular plate is commonly
used as a neutralization plate in the treatment of
lateral malleolar fractures. It may be useful in areas
with minimal soft-tissue covering, such as the lateral
malleolus, the olecranon, and the distal end of the
ulna. The one-third tubular plate exists only in the
3.5 mm version. Its counterpart in the 4.5 mm
system is the semitubular plate. The one-third
tubular plate is available in either titanium or
stainless steel.(Fig 5.2-15) The quarter-tubular
plates have been used in small bone fixation (e.g., in
hand surgery).
Figure 5.2-14: The Schuhli device
Figure 5.2-15: One-third tubular plates, Stainless Steel
(left) and Titanium (right)
Conventional Plates and Screws 251
5.2-16: Reconstruction plate
Reconstruction Plate
Reconstruction plates have deep notches on the
edge of the plate. These notches are situated
between the holes and allow accurate contouring of
the plate in all planes. Two plate sizes are available
for use with 3.5 and 4.5 mm cortex screws. These
plates are especially useful in fractures of bone with
complex 3-D geometry, such as the pelvis,
acetabulum, distal humerus, distal tibia, calcaneus
and clavicle. The plate has relatively low strength,
which is further diminished with contouring. (Fig
5.2-16)
Angled Plates
Angled plates were developed in the 1950s for the
fixation of proximal and distal femur fractures. They
are a one-piece design with a U-shaped profile for
the blade portion and a 95° or 130° fixed angle
between the blade and the plate.
The 130° Blade Plate (Fig 5.2-17 A)
The 130° blade plate was originally designed for
fixation of proximal femur fractures and has
different lengths to accommodate different fracture
patterns. The 4- and 6-hole plates are used for
fixation of intertrochanteric fractures, while the 9-
to 12-hole plates are used for treatment of
subtrochanteric fractures. The placement of the
blade is critical; improper placement can lead to
various healing deformities. In the femoral head,
there is a zone where the tension and compression
trabeculae intersect. The plate is inserted so it is
below this trabecular intersection (6 to 8 mm above
the calcar) and in the center of the neck, with no
anterior or posterior angulation. It has been
replaced for the most part by the dynamic hip screw,
which allows for compression of the fragments.
The 95° Condylar Blade Plate (Fig 5.2-17 B)
The 95° condylar blade plate was designed for use
with supracondylar and bicondylar distal femur
fractures, and the length employed is also fracture
specific. It can be used for subtrochanteric fractures
where more purchase on the fracture fragment can
be gained with a sharper angled plate. With the 130°
blade plate, the blade enters the proximal femoral
fragment close to the subtrochanteric fracture site,
precluding insertion of plate screws into the
proximal fragment. In contrast, the blade of the 95°
blade plate can be introduced into the proximal
fragment just below the tip of the greater
trochanter, allowing placement of screws proximal
252 Plate Fixation in Orthopaedics

to the fracture site into the calcar for added stability.

Although the device is strong and provides stable
fixation, its insertion is technically demanding. The
need for precise alignment in all three planes
demands careful preoperative planning and
intraoperative radiographic control.

Sliding Screw and Compression Plates

Compression/Telescoping Hip Screw (Fig
5.2-18)
The compression/telescoping or sliding hip screw
system is designed for internal fixation of
basicervical, intertrochanteric, and selected
subtrochanteric fractures. It uses the principle of
dynamic compression, which modifies functional
physiologic forces into compression at the fracture
site. The implant consists of two major parts: a
wide-diameter cannulated lag screw that is inserted
into the femoral head and a side plate with a barrel
at a set angle that is attached to the femoral shaft.
Weight-bearing and abductor muscle activity cause
the screw shaft to slide through the barrel, resulting
in impaction of the fracture surfaces and, optimally,
a stable load-sharing construct.
Some sliding hip screw systems include two side
plates, with one long and one short barrel. Usually,
the long barrel is chosen to ensure adequate support
and unimpeded lag screw sliding. Lag screws are
available in varying lengths (60 to 120 mm) to
accommodate patient anatomy and fracture
configuration. If a lag screw of 80 mm or smaller is
used, there may not be enough space between the
base of the threads on the screw and the tip of the
long barrel to allow full impaction of the fracture.
In this small proportion of cases, the short-barrel
side plate should be used. Some of these systems are
slotted and provide rotational control as a result.
However, the fragment still may rotate around the
screw itself despite implant geometry. Various
manufacturers produce systems containing a range
of side plate-lag screw angles; the angle used
depends on the fracture configuration and the
patient's anatomy. The basic principle of these
devices is that they collapse and shorten to
accommodate comminution, osteopenia, and bone
lysis at the fracture site.
Figure 5.2-18: A DHS 135o, six-hole side plate
Dynamic Condylar Screw (Fig 5.2-19)
The condylar compression screw system has
basically the same design as the 95° condylar blade
plate except that the blade is replaced by a
cannulated screw. The angle between screw and
plate is fixed at 95°, in contrast to the sliding hip
screw, which allows different angles to be selected.
The compression generated by the large cannulated
screw placed across the femoral condyles permits
greater compression of the fracture fragments than
can be achieved with a blade plate. The plate is
contoured to fit the distal end of the femur. It is a
two-piece device that can allow for some correction
in the lateral and coronal planes after the lag screw
is inserted, unlike a blade plate. This system is used
for fixation of low, supracondylar, and intercondylar
T- and Y-fractures.
Precise positioning of the implants is critical for
fixation and proper alignment. If the screw is
inserted in a valgus position (angled away from the
midline), a varus deformity will develop on healing.
Conversely, if the plate is angled in varus (toward
the midline), a valgus deformity will develop. The
screw systems allow for some correction of
alignment, whereas blade plates do not, and,
correspondingly, are technically more forgiving.

A.

A B
B.
Figure 5.2-17: o
Angled plates, A) 135 blade plate, B) Figure 5.2-19: A) Dynamic Condylar Screw, B) 95o
o Side-Plate
95 condylar blade plate

CHAPTER
FUNCTIONS
OF
CONVETIONAL
SCREWS AND PLATES
CHAPTER OUTLINE
Biomechanical aspects of plate functions
Neutralization or protection plate
Compression plate
Compression using the dcp
Compression by additional lag screws through
plate holes
Compression by overbending
Although the protagonists of modern operative
fracture fixation, starting with Albin Lambotte,
stressed 100 years ago the importance of gentle soft
tissue handling and minimal stripping of the
periosteum in order to preserve bone vascularity,
the request for anatomic reduction seemed
somehow in contradiction with this principle. In
inexperienced hands, too wide exposures and
extensive denudation of bone occurred all too often,
resulting in catastrophes such as delayed or non-
unions, infections, or the combination of the two.
Mast et al. described in detail the advantages of
indirect reduction techniques without exposing the
fracture fragments and created the term of
"biological plate fixation" with long bridging angle
253
5.3
Compression using the tension device
Buttress plate
Tension band plate
Biomechanical principles of tension band
Bridge plate
Anti-gliding plate
blade or straight plates. In a study comparing a
series of subtrochanteric fractures treated by
conventional open technique with indirection and
bridge plating, it was demonstrated that in the
bridge plating group, the time for union was shorter
and predictable even without bone graft, the
complication rate was lower, and the functional
outcome better. An important prerequisite was,
however, that the procedure was carefully planned
and well performed. We have learned from closed
intramedullary nailing with interlocking that in
complex diaphyseal fractures, correct axial and
rotational alignment is all that is needed for early
callus formation and that anatomic reduction of
every fragment is not required.
254 Plate Fixation in Orthopaedics

Krettek et al. further developed these

observations and ideas by minimizing the
approaches to short incisions far away from the
fracture focus and by inserting extra long plates via
a bluntly prepared submuscular space close to the
bone and across the fracture. The screws were
inserted through equally short incisions and straight
through the muscles. In cadaver studies, Farouk et
al. could show that the perforator vessels were not
injured by these tunnelling maneuvers. Similar to
the rapid appearance of callus in intramedullary
nailing, the healing of these minimally exposed
fractures fixed with only relatively stable bridge
plates occurred very consistently with early callus
formation. The drawback of minimally invasive
techniques is the higher incidence of axial and
rotational malalignment just as in intramedullary
nailing, especially in the femur. Furthermore, the Figure 5.3-1: A plate applied with a neutralization
intraoperative radiation exposure of the patient and mechanism
staff is higher, but may be reduced when navigation
techniques are refined and used more in the future. When comparing two plates of the same design, a
For high-energy articular fractures of the distal longer plate provides greater neutralization
femur and proximal and distal tibia that often show capability. A simple, torsion, or butterfly fracture of
extensions into the diaphysis, a combination of open the diaphysis or metaphysis, caused by indirect
anatomic reduction and stable fixation of the rotational forces, is best reduced anatomically and
articular block with minimally invasive bridging fixed by one or two lag screws providing
fixation of the metadiaphysis can be recommended. interfragmentary compression. It is normally
recommended to protect the lag screw fixation with
the addition of a plate in order to protect it or to
Biomechanical aspects of Plate neutralize any shearing or rotational forces, thereby
Functions improving the stability. This type of classical plate
application can also be performed with minimal
While there are many different designs and exposure of the fracture site and percutaneous
dimensions of plates, the function that is assigned to reduction with the help of pointed reduction
a plate by the surgeon and how it is applied is forceps.(Fig 5.3-1)
decisive for the outcome. There are six key functions
or modes any plate can have. In order to assign a COMPRESSION PLATE
specific function to a plate, the preoperative plan has
to take into account the fracture pattern, its location, Compression plates can be used to reduce and
the soft tissues, and biomechanical surrounding. stabilize transverse or short oblique fractures when
The six functions are: lag screw fixation alone is impossible to insert or
inadequate. The plate can produce static
1. Neutralization or protection compression in the direction of the long axis of bone.
2. Compression
3. Buttressing Methods of interfragmentary compression
4. Tension band by plate
5. Bridging In order to achieve absolute stability, compression
6. Antigliding?? must sufficiently neutralize all forces (bending,
tension, shear, and rotation) along the whole cross
NEUTRALIZATION OR section of a fracture.
There are four ways of obtaining interfragmentary
PROTECTION PLATE compression with a plate:
A neutralization plate is used to protect lag screw
1. Compression with the dynamic compression
fixations from various external forces. Torsional and
unit in a plate (LC-DCP)
bending forces on long bone fractures are too great
2. Compression by additional lag screws through
to be overcome by lag screw stabilization alone. A
plate holes
plate can protect the interfragmentary compression
3. Compression by contouring (overbending) the
achieved with the lag screw from torsional, bending,
plate
and shear forces exerted on the fracture. This
4. Compression with the articulated tension
technique achieves fracture fixation that is
device
sufficiently stable to allow early motion.

Compression using the DCP
Axial compression can be generated with the DCP,
LC-DCP and LCP.(Fig 5.3-2) However, the
compression force achievable is lower than with the
tension device.
Compression by additional lag screws
through plate holes
Simple fracture patterns are best reduced
anatomically and fixed with a technique of absolute
stability using a combination of lag screws and
protection plate.(Fig 5.3-3) In meta-/epiphyseaI
split fractures, lag screw fixation often needs to be
combined with a buttress plate to protect these
screws from shearing forces.(Fig 5.3-4) A lag screw
correctly inserted in good bone generates forces up
to 3,000 N. Since the same effect cannot be brought
about by any of the other methods of obtaining
interfragmentary compression, lag screws should be
used whenever the fracture pattern permits. A lag
screw can be placed either freestanding or through
the plate. To avoid any additional soft-tissue
stripping, placement through the plate is preferred.
Figure 5.3-2: Interfragmentary compression by Dynamic
Compression Plate
Figure 5.3-3: The lag screw results in static compression
across the fracture site, protected by a “protection plate”
Conventional Plates and Screws 255
A. B.
Fig 5.3-4: Lag screw in a epiphyseal fracture (A), due to
shear forces, some of these fractures need a plate applied with
a buttressing mechanism to protect the lag screw(B)
Compression by overbending
If a straight plate is applied to a straight bone,
compressive forces are greatest directly underneath
the plate. At the far cortex a small gap results due to
tension. This may prevent adequate concentric
compression across the entire fracture surface. If the
placement of an additional lag screw is not possible,
prebending of the plate is essential. By applying
tension, the overbent plate is straightened, which
leads to compression of the opposite cortex, thereby
adding to stability.(Fig 5.3-5) There are special
instruments available for prebending or contouring
plates.
Compression using the tension device
In transverse or short oblique fractures of the
diaphysis, placement of a lag screw is not always
possible. The articulated tension device was
developed to achieve adequate compression (over
100 kp) in these instances.(Fig 5.3-6) Furthermore,
it is recommended for fractures of the femur or
humeral shaft, when the gap to be closed exceeds 1-
2 mm, as well as for the compression of osteotomies
and nonunions. Most plates have a notch at either
end, which fits the hook of the tension device. Before
use, the two branches of the tension device should
be opened completely. After fixation of the plate to
one main fragment, the fracture is reduced and held
in position with a reduction forceps. The tension
device is now connected to the plate and fixed to the
bone by a short cortex screw.
Figure 5.3-5: Prebending of the plate. By applying
tension, the overbent plate is straightened, which leads to
compression of the opposite cortex
256 Plate Fixation in Orthopaedics
A.
B.
Figure 5.3-6: A) An articulated tensioning device, B)
Interfragmentary compression by an external tensioning
For the application of forces of 100-120 kp, or in
osteoporotic bone, bicortical fixation is
recommended. The wrench with universal joint is
used for tightening. In oblique fractures, to prevent
displacement, the tension must be applied in such a
way that the spike of the mobile fragment is pressed
into the axilla that is formed by the plate and the
other main fragment to which it has been fixed.
Biomechanical studies have shown that the bending
and rotational stability of such fractures is greatly
increased if a lag screw is added through the plate
once axial compression has been established. For
transverse fractures, it is essential that the plate is
prebent at the fracture site to prevent tension and a
gap at the opposite cortex. (Fig 5.3-5)
Axial compression of a transverse fracture is best
obtained by a compression plate. In short oblique
fractures, in addition to axial compression, a lag
screw inserted through the plate and across the
oblique fracture plane will significantly increase the
stability of the fixation. In oblique fractures, the
plate is fixed first to the fragment with an obtuse
angle, so that when compression is added on the
opposite side of the fracture, the fragment locks in
the axilla between plate and bone.
BUTTRESS PLATE
A buttress is a construction that resists a load by
applying force at 90° to the axis of potential
deformity. The buttress plate is used to counteract
bending, compressive, and shearing forces at the
fracture site when an axial load is applied. Buttress
plates are used commonly to stabilize intra-articular
and periarticular fractures at the ends of long bones.
Without fixation or with lag screw fixation alone,
epiphyseal and metaphyseal fragments can displace
when they are subjected to axial compression or
bending forces. The buttress plate supports the
underlying cortex and effectively resists
displacement and the resulting angular deformity of
the joint. In this manner, the plate acts as a buttress
or retaining wall. This will protect the screw from
shear forces across the fracture. Plates can be used
without lag screws to provide a buttress and, in
plates with DC holes, the screws should be inserted
in the buttress position.
In articular fractures such as malleolar fractures,
tibia plateau, or distal radius fractures, we can
observe how a large fragment has been displaced by
shearing forces. To counteract these forces and keep
the reduced fragment in place, a plate is best applied
in a position that locks the spike of the fragment
back in place, thereby preventing any further
shearing or gliding of the fragment. Buttress plates
are often combined with lag screws either through
the plate or independently.
To minimize the potential for angular deformity,
the screws attaching the plate to the bone must be
inserted in such a manner that when a load is
applied there will be no shift in the position of the
plate in relation to the bone. A screw inserted
through an oval hole closest to the fracture is said to
be in buttress mode. This mode minimizes axial
movement at the fracture site. To avoid the
possibility of displacing the fracture fragment
during application of the plate, the plate should be
accurately contoured to match the anatomy of the
underlying cortex. Screw placement in a buttress
mode does not always imply that the plate is
functioning as a buttress plate. A buttress plate
applies force to the bone in a direction normal
(perpendicular) to the flat surface of the plate, in
contrast to a compression plate application, in which
the direction of stress is parallel to the plate.
Buttress plates are designed to fit specific anatomic
locations. If the fracture extends from the
metaphysis into the diaphysis, a long plate with a
condylar end can be used to combine buttressing
with other plate functions. A spring plate is a
specialized form of buttress in which the plate is
affixed with screws to only one of the two fracture
fragments.(Fig 5.3-7)
Plates designed to provide compression (DC or
LCDC plates) can be used as buttress plates with
proper contouring.(Fig 5.3-8) Other plates are
designed specifically to function as buttress plates in
particular locations. Some examples of buttress
plates by design are the T-buttress plate for lateral
tibial plateau fractures, the spoon plate for
treatment of anterior metaphyseal fractures of the
distal tibia, the cloverleaf plate for the medial distal
tibia, and the distal femoral condylar buttress plate.
Fig 5.3-7: A plate applied with a buttressing mechanism

Figure 5.3-8: Application of a DCP in the buttress
function: to prevent any inferior sliding of the plate, the screw
at the shoulder is placed as proximal as possible in the hole.
TENSION BAND PLATE
Certain bones such as the femur are loaded
eccentrically. The studies of Pauwels revealed that,
with weight-bearing, the concave, medial side of the
femur is undergoing compressive forces, while the
convex, lateral cortex is under tension. An
eccentrically applied plate on the convex side of the
bone will theoretically convert tensile forces into
compression, provided the opposite medial cortex is
stable.
Biomechanical principles of tension
band
Early concepts of load transfer within bone were
developed and described by Frederic Pauwels. He
observed that a curved, tubular structure under
axial load always has a compression side as well as a
tension side. From these observations the principle
of tension band fixation evolved. A tension band
converts tensile force into compression force at the
opposite cortex. This is achieved by applying a
device eccentrically, on the convex side of a curved
bone. The concept can most easily be understood by
examining the femur under mechanical load. If a
fracture is to unite, it requires mechanical stability,
which is obtained by compression of the fracture
fragments. Conversely, distraction or tension
interferes with fracture healing. Therefore, tension
forces on a bone must be neutralized or, more
ideally, converted into compression forces to
promote fracture healing. This is especially
important in articular fractures, where stability is
essential for early motion and a good functional
outcome.(Fig 5.3-9) The principles of tension band
fixation with a plate can also be applied in
diaphyseal fractures such as the femoral shaft. In
curved long bones, the convex side of the diaphysis
indicates the tension side. Similarly, in delayed bony
unions or in nonunions, where the presence of
angular deformity creates a tension side in the bone,
adherence to the tension band principles becomes
extremely important. Whenever feasible, any
internal or external fixation device should be
applied to the tension side. Bony union will then
occur quite consistently. When appropriately placed,
intramedullary nails, plates, and external fixators
Conventional Plates and Screws 257
can also fulfill the function of a tension band. A
tension band that produces compression at the time
of application is called a static tension band, as the
forces at the fracture site remain fairly constant
during movement. Tension band application to the
medial malleolus is an example of a static tension
band. If the compression force increases with
motion, the tension band is a dynamic one. A good
example is the application of the tension band
principle to a fracture of the patella. Upon knee
flexion, the increased tensile force is converted to
compression force.
Tension band principals are best understood by
examining the forces that occur at discontinuity in
an I-beam. The stretching and compressing of
springs can be used to demonstrate the different
forces. As shown in this analogy, forces applied in
line with the central axis of the I-beam produce
uniform compression in both springs on either side
of the neutral axis and uniform closure of the
discontinuity in the beam. In contrast, when the
force is applied eccentrically at a distance from the
central axis to the beam, a bending moment is
created. This bending moment produces tension on
the opposite side of the beam. This change is
demonstrated by opening of the discontinuity and
spring distraction. On the same side of the beam on
which the weight is applied, the moment creates
compression, as evidenced by closing of the
discontinuity with spring compression. In
anticipation of this eccentrically applied weight, an
unyielding band can be applied to the side on which
tension will be created by the bending moment. This
band is used to create a small amount of
compression, which results in partial closure of the
discontinuity and compression of the spring on the
same side as the band. Under these conditions, the
application of an asymmetric force to the opposite
side of the beam leads to uniform compression on
both sides of the discontinuity, further closing of the
space and compression of the springs. This
technique, which is placed before the functional
application of the eccentric load, is called the tension
band.
Figure 5.3-9: The “tension band” principle: An
eccentrically loaded bone has a tension and a compression
side (left). A “tension band” converts tension into
compression at the opposite cortex (right)
258 Plate Fixation in Orthopaedics
The following four criteria must be fulfilled for a
plate to act as a tension band:
1. The fractured bone must be eccentrically
loaded
2. The plate must be placed on the tension
(convex) surface
3. The plate must be able to withstand the
tensile forces
4. The opposite cortex must be able to withstand
compressive force
The last point is of paramount importance. The
function of a tension band is to convert tensile force
into compressive force. After fracture reduction, the
opposite cortex must provide a bony buttress to
prevent cyclic bending and failure of fixation. A good
example of an eccentrically loaded bone is the
femur. If a plate is placed on the lateral (tension)
side of a transverse fracture, the distraction forces
are converted to compressive forces across the
whole fracture interface provided the medial cortex
is intact. If the same plate is placed medially, it
cannot counteract the tensile force, and the fixation
will fail under load.(Fig 5.3-10)
In a subtrochanteric fracture that is fixed with a
plate, this implant will function as a tension band
provided the medial cortex, opposite to the plate,
has been reduced anatomically without any residual
gap.
The most common complication is implant failure.
A wire put under pure tension is very strong.
However, if bending forces are added, it will break
quite rapidly due to fatigue. This principle of fatigue
failure also holds true for plates. In simple
diaphyseal fractures undergoing plate fixation, the
plate should be placed on the tension side of the
bone, assuming that the opposite cortex is able to
withstand compression forces. When the cortex
opposite the plate is comminuted, the plate is
exposed to repeated bending stresses, which
invariably will lead to plate breakage, if the fracture
does not unite rapidly.
Figure 5.3-10: A plate placed on the lateral (tension)
side of a transverse fracture of femur acts by a “tension
band” mechanism, but the same plate placed medially
cannot counteract the tensile force, leading to fixation
failure under load
Figure 5.3-11: Bridging mechanism: intended to
maintain length and alignment of severely comminuted and
segmental fractures without approaching directly to the
comminution area, A) A “Bridge Plate”. B) A “Wave Plate”.
Early bone grafting may be required to create
enough strength to withstand compression forces
along the cortex opposite to the plate.
BRIDGE PLATE
Since the introduction of more biological indirect
reduction and minimally invasive techniques with
less rigid or elastic fixations providing relative
stability, a plate can also be applied as an internal
bridging device, similar to an external fixator.(Fig
5.3-11) It is called a bridge plate because its fixation
is out of the main zone of injury at the ends of the
plate to avoid additional injury in the comminuted
zone. The best indications for bridge plating are
comminuted diaphyseal or metaphyseal fractures
that are not suited for intramedullary nailing. The
bridge plating principle is used in order to respect
the biology of a complex, multifragmentary fracture
and to minimize any additional soft-tissue injury.
Bridging plates provide relative stability and
fracture healing occurs by callus formation. The key
concept of bridge plating is that the plate is fixed
only to the two main fragments leaving the fracture
zone untouched to maximize the blood supply. If
feasible, the fracture should be reduced indirectly
and bridge plates should be applied through
minimal exposure in order to restore length, axial
alignment and rotation.
There are some important biomechanical
principles to consider when using this technique. To
maximize implant stability in this flexible fixation,
long plates with few screws should be used to
increase the lever arm and distribute the bending
forces. A plate length greater than three times the
fracture length in comminuted fractures and greater
than eight to ten times the fracture length in simple
fractures has been advocated. Screw to plate hole
ratios of less than 0.5 create a long lever arm and
decrease the bending loads on the distal screws. In
addition, a span of at least two or three screw holes
should be left open over the fracture to decrease
stress concentration. If the vascularity of bone and
surrounding soft tissue has not been overly
disturbed, the physiological response to this

relatively flexible construction is rapid callus
formation that bridges the fragments, as occurs in
nonoperative treatment or after intramedullary
nailing.
Plate fixation of fractures is a form of stabilization
with the potential for both load bearing and load
sharing properties. Functional treatment of the limb
for preservation of muscle strength, coordination,
and joint mobility depends on the stability provided
by the plate-bone construction. Fracture
consolidation is to be expected if the mechanics of
fixation and the biology of the fracture are
compatible and mutually beneficial. Biological
bridge plating uses the plate as an extramedullary
splint fixed to the two main fragments. The complex
fracture zone is virtually left untouched; however, it
is bridged by the plate. Length, alignment, and
rotation are restored, but anatomical reduction of
each fragment is not attempted. This concept
combines the relative stability provided by the plate
with the preservation of natural fracture biology to
achieve rapid callus formation and fracture
consolidation.
Bridge plating techniques are applicable to all
long-bone fractures with complex fragmentation
and where intramedullary nailing or conventional
plate fixation is not suitable. With "classical" direct
fracture reduction and plate fixation with absolute
stability, the viability of soft tissues and bone
fragments may be jeopardized. This risk exists to a
lesser degree in simple fractures (with less soft-
tissue injury) and thus has less consequence on
fracture healing. It is the goal of fracture surgery to
maintain vascularity at the fracture site. This calls
for the use of bridging techniques in fracture
patterns with significant fragmentation. Simple type
A diaphyseal fractures can be successfully treated
with intramedullary nailing, a technique of relative
stability, or by anatomic reduction and compression
plate fixation, providing absolute stability.
Experience has shown that bridge plating, providing
relative stability, has a high risk of nonunion or plate
failure in simple type A diaphyseal fractures. This is
because the strain at the fracture site is above the
strain tolerance of the granulation tissue within the
fracture site and so normal fracture healing will not
take place. In complex type C diaphyseal fractures
with numerous intermediate fragments, the bridging
plate allows micromovement between the different
fragments, while tissue strain is within the strain
tolerance of granulation tissue, allowing normal
callus formation. If a complex, multifragmentary
fracture is splinted in a cast, there will be some
movement between fragments. However, the system
as a whole will tolerate a significant amount of
deformation, since it is distributed along the whole
distance of the fracture zone. Thus, strain will be low
and this allows tissue differentiation to progress.
Callus formation between intermediate fragments
can occur rapidly, even in the presence of
considerable fragment displacement. This is the
basis of Perren's strain theory. The prerequisites for
Conventional Plates and Screws 259
successful bone healing in this situation are optimal
preservation of fragment vascularity and a favorable
mechanical and cellular environment for the
production of callus. Bone fragments, once they have
been stripped of their soft tissue attachments
(periosteum, muscles, etc), will not be incorporated
into the early callus, since they will first need to be
revascularized. In diaphyseal type C fractures, the
endosteal blood supply of fragments is, as a rule,
interrupted. Preservation of bone vitaliity relies on
periosteal vascularity, which also contributes to
fracture healing. In the absence of mechanical
continuity between the two main fragments,
maintenance of stability entirely lies with the
bridging plate. Wide exposure with periosteal
stripping to allow precise fragment reduction and
fixation by interfragmentary compression and
plating further compromises the vascularity and
must be avoided, as it increases the risk of bone-
healing complications in type C fractures.
Mechanistic thinking and technique, together with
misapplication and misinterpretation of the
principles of interfragmentary compression, are
probably responsible for the majority of failures and
complications. Simple metaphyseal fractures (type
A) that require fixation are best treated with
techniques of absolute stability that provide
anatomic reduction and compression with screws
and plates. In general, the same principle should be
applied to simple metaphyseal fractures with simple
articular fractures (C1). However, this technique is
not suitable for complex metaphyseal fractures (A1
and A3) or those associated with articular fractures
(C2 and C3). Anatomical reconstruction and
absolute stability of the joint surface is paramount.
The metaphyseal bone, given its good healing
qualities, will withstand a higher degree of
iatrogenic damage from manipulation than will the
diaphysis. The critical area is not the metaphysis but
its junction with the more compact bone of the
diaphysis. These regions of transition remain under
significant bending loads and show a tendency to
delayed or failed fracture healing. In the past, liberal
use of bone grafting was advocated in attempts to
restore the biologic activity that was compromised
by the injury and the subsequent treatment. Current
plating concepts embrace the principle of placing
biology before mechanics. This development has led
to a more flexible and individualistic approach to
internal fixation, based on the "personality" of a
fracture. The surgeon attempting operative
stabilization of a complex multifragmentary fracture
must be able to reduce the fracture without further
interfering with the blood supply and, at the same
time, apply a fixation device that provides adequate
fixation to maintain length, alignment and rotation,
and produce a biological and mechanical
environment that stimulates rapid healing by callus.
Biological or bridge plating is usually applied
following some form of indirect reduction. The goal
of indirect reduction is to manipulate fragments into
the correct position without opening the fracture
 260 Plate Fixation in Orthopaedics

site, thus minimizing further damage to the bone opposite cortex. These factors make the wave plate
blood supply. The mechanical principle underlying an efficient tool in the treatment of nonunions.
indirect reduction is distraction. This principle
applies to diaphyseal as well as to metaphyseal ANTI-GLIDING PLATE
bone. The muscular envelope surrounding the
diaphysis of long bones provides the mechanical
The anti-glide plate is another example of the
environment for indirect reduction, since a
buttress plating principals.(Fig 5.3-12) Although
controlled pull on the muscle and periosteal
there are many potential applications, the construct
attachments of any single fragment tends to align it
is most commonly used for oblique, Weber type B
in the desired way. A muscle envelope under
fractures of the distal fibula. A plate applied to the
distraction exerts concentric (hydraulic) pressure
posterior surface of the proximal fragment forms an
on the shaft, easing fragments into place. This also
axilla into which the spike of the distal fragment fits.
holds true for metaphyseal and epiphyseal bone,
The axial loads of walking are converted into
although the distraction required to align fragments
compression of the surfaces of the two fracture
is transferred through capsular tissues, ligaments,
fragments. The plate acts as a buttress to prevent
tendons, and muscular attachments. This
external rotation of the distal fragment.
phenomenon, regularly seen as part of nonoperative
A buttress is a construction that resists axial load
fracture management, is described by the term
by applying force at 90° to the axis of potential
"ligamentotaxis", coined by Vidal. Traction applied
deformity. In a meta-/epiphyseal shear or split
by a traction table to an entire limb produces
fracture, fixation with lag screws alone often is
indirect reduction of a fracture. However, the use of
insufficient. A lag screw should therefore be
an implant or large distractor to a single bone
combined with a plate with buttress or antiglide
controls reduction more effectively and permits
function. This will protect the screw from shear
subtle adjustments as well. Indirect reduction
forces across the fracture. Plates can be used
techniques with distractor or external fixator and
without lag screws to provide a buttress and, in
plate can sometimes be combined.
plates with DC holes, the screws should be inserted
While we do not know the ideal working length of
in the buttress position.
a plate precisely, it is recommended to choose a
plate about three times as long as the fracture zone
and to fix it with only a few firmly anchored screws
proximally and distally.
The wave plate is similar to a bridge plate;(Fig 5.3-
11 B) it is primarily used in areas of delayed healing.
The wave plate is contoured away from the
comminuted area or pseudarthrosis to be bridged.
This contour leaves some distance between the
cortex of bone and the plate, where autologous bone
graft can be placed. In the treatment of nonunions,
this space allows for better ingrowth of vessels into
the graft beneath the plate. The bending of the plate
distributes force over a greater area, decreasing
local stress at the fracture site. The plate also can act
as a tension band, creating compression on the Figure 5.3-12: A typical antiglide plate which acts as a
“Dynamic Compressor” at the fracture site, as well

References:
Bhattacharyya t, the natural history of new orthopaedic devices.
Clinical orthopaedics and related research number 451, pp.
263–266, 2007
Bucholz rw, rockwood and green's fractures in adults, seventh
edi. Lww. 2010
Dijkman dg, et al. When is a fracture healed? Radiographic and
clinical criteria revisited. J orthop trauma 2010;24:s76–s80
Droll kp, et al. Outcomes following plate fixation of fractures
of both bones of the forearm in adults. J bone joint surg am.
2007;89:2619-2624

Cole pa, et al. What's new in orthopaedic trauma. J bone joint Giannoudis pv, et al. Principles of fixation of osteoporotic
surg am. 2008;90:2804-2822 fractures. J bone joint surg [br] 2006;88-b:1272-8.
 Conventional Plates and Screws 261

Hearn t.c., schatzker j., wolfson n.: extraction strength of Tencer a.f., asnis s.e., harrington r.m., et al: biomechanics of
cannulated cancellous bone screws. J orthop cannulated and noncannulated screws.
trauma 1993; 7:138-141. In: asnis s.e., kyle r.f., ed. Cannulated screw fixation: principles
and operative techniques, new york: springer-verlag; 1997.
Hugate rr, et al. Fixed-angle screws vs standard screws in
acetabular prosthesis fixation a cadaveric biomechanical study. Stannard jp, et al. Surgical treatment of orthopaedic trauma,
The journal of arthroplasty vol. 24 no. 5 2009 thieme, 2007

Jacob c.h., berry j.t.: a study of the bone machining process:
drilling. J biomech 1976; 9:343.
Kolodziej p., lee f.s., ashish p., et al: the biomechanical
evaluation of the schuhli nut, detroit, mi, wayne state
university, 1992.
Wolf j.w., white iii a.a., panjabi m.m., et al: comparison of
cyclic loading versus constant compression in the treatment of
long bone fracture in rabbits. J bone joint surg
am 1981; 63:805-810.

Kregor pj, et al. Biomechanical evaluation of the less invasive

stabilization system, angled blade plate, and retrograde
intramedullary Nail for the internal fixation of distal femur
fractures. J orthop trauma • volume 18, number 8, september
2004

Krishna kr, et al. Analysis of the helical plate for bone fracture
fixation. Injury, (2008) 39, 1421—1436

Leggon r., lindsey r.w., doherty b.j., et al: the holding strength
of cannulated screws compared with solid core screws in
cortical and cancellous bone. J orthop trauma 1993; 7:450.

Mast j., jakob r., ganz r.: planning and reduction technique in
fracture surgery, new york, springer-verlag, 1989.

Matelic t.m., monroe m.t., mast j.w.: the use of endosteal

substitution in the treatment of recalcitrant nonunions of the
femur: report of seven cases. J orthop trauma 1996; 10:1-6.

Mazzocca ad, et al. Principles of internal fixation. In: browner:

skeletal trauma, 4th ed.2008

Miclau t, et al. A mechanical comparison of the dcp, lc-dcp and

pcf. Jot, vol. 9. No. 1. Pp:17-22. 1995

Nunamakver d, et al. A radiological and histological analysis of

fracture healing using prebending of compression plates.
Clinical onhopaedica and related researchnumber 138 january-
february, 1979

Owsley kc, gorczyca jt. Fixation of humeral fractures

displacement/screw cutout after open reduction and locked
plate. J bone joint surg am. 2008;90:233-240

Papakostidis c. Et al. Femoral biologic plate fixation. Clinical

orthopaedics and related research number 450, pp. 193–202.
2006

Perren s.m.: the concept of biological plating using the limited

contact-dynamic compression plate (lcdcp): scientific
background, design and application. Injury 1991; 22(1):1-41.

Perren s.m., russenberger m., steinemann s., et al: a dynamic

compression plate. Acta orthop scand suppl 1969; 125:31-41.

Ruedi tp, et al. Ao principles of fracture management. Second

expanded edition. Thieme. 2007

Schaffer j.j., manoli a.: the antiglide plate for distal fibular
fixation. J bone joint surg am 1987; 69:596.
262 Plate Fixation in Orthopaedics