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Failure of Trauma Plating Fixation due to Poor Strength of Screw-Bone Integration
Development of bone multi-fragmentary fracture plating fixation with minimal complication rate and higher satisfactory clinical outcomes.
Integration of the bone tissue through the screw threads could be introduced as the main reason of complications in treatment of bone fractures using trauma plating systems. Today, specific trauma plates are developed to be placed in wider aspects of the bones for effective buttressing and capturing of the bone fragments. In view of operation methods, minimal invasive and open invasive operation methods are nowadays extensively used in fixation of bone fractures and would allow accessibility of the surgeon through the fracture site. Surgical tools and instruments would also provide temporary reduction of the bone fragments in anatomical position and insertion of various types of screws through the bone. Utilization of image processing pre, intra, and post-operatively have enhanced management of fracture fixation in rigorous controlled plan. Incorporation of allograft or autografts has facilitated healing of the bone in cases with bone loss after trauma injury.
With consideration of all mentioned accomplishments, fixation of bone fracture with multiple fragments is still in challenge. In fact, if all above considerations related to the plate design, operation method, utilization of instruments, utilization of image processing facilities, etc. are managing perfectly, there would be still doubt on success of the plating fixation in treatment of multi-fragmentary fractures. In general, the main technique of multi-fragmentary fractures is to capture the all bone fragments by one or multiple screw(s), at which the mechanical-biological interaction between the bone and screw is greatly important. Mechanical mismatch between the bone and screw and ability of the bone cells for formation and mineralization of new bone tissues influence on this biological interaction. Mechanical mismatch in poor quality bone (e.g. in osteopenia or osteoporosis), is significantly higher compared to the bone in natural condition. Likewise, the bone remodeling in poor bones is not as effective as natural bones.
Due to lower mechanical strength of poor bones, higher strain (under physiological loading conditions) is transferred to the bone fragments which may challenge the bone remodeling in mineralization of the new bone cells and formation/strengthen of the soft callus at the fracture gaps. In cases with poor bones and multi-fragmentary fracture pattern, the formation and mineralization of the new bone cells is in more complicated conditions in view of sufficient mechanical strength and optimum mechanical stimulation for biological bone remodeling. It is therefore, the fracture fixation is in higher risk of dislocation.
When the bone fragment is captured by one screw, the fragment would be free in rotation and translation in respect to longitudinal axis of the screw. If the fragment is captured by more than one screws, this freedom might be constrained. However, under dynamic physiological loading conditions, the bone cellular matrix at the bone-screw interface might be damaged and caused suppressing of the bone at the interface. Therefore, the bone fragments should be constrained by effective formation/mineralization of the callus at the fracture gaps after couple of weeks post-operatively to strengthen the bone fixation under dynamic loading. Due to the ineffective mechanical-biological interaction between the bone and screw, higher amount of strain is transferred to the poor bone with multi fragmentary fracture pattern which causes inadequate formation/mineralization of callus at the fracture site and ultimately dislocation of the bone fragments post-operatively. This failure would be the main cause of reported malunion and nonunion complications in fracture fixation of proximal humerus, proximal femur, mid shaft radius and ulna, calcaneus, metatarsal, phalanges, clavicle, and pelvic bones.
Trauma Plating Systems reviews above concerns more comprehensively in chapter 1 (in general) and chapter 10 to 15 (individually for each bone fracture plating fixation). Based on the popularity of the complications for each bone fracture fixation, constructive and insight discussion and elaboration have been provided in these chapters. In order to open a science/industry breakthrough in development of screw-bone integration, particularly in poor quality bones, a novel development concept is comprehensively presented in chapter 16, from which the early integration of bone-screw could be significantly enhanced, while the risk of bone suppressing at the bone-screw interface is remarkably reduced. This novel concept has other biomechanical, biological, and clinical benefits to the trauma plating fixation and is disclosed as “Advance Healing Fixation System – AHealFS”. To achieve this scientific concept, a new plate and screw with different structuring and materials than current titanium implants, is hypothesized for further development.
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