title: Prospects of implant with locking plate in fixation of subtrochanteric fracture: experimental demonstration of its potential benefits on synthetic femur model with supportive hierarchical nonlinear hyperelastic finite element analysis.
abstract: BACKGROUND
  Effective fixation of fracture requires careful selection of a suitable implant to provide stability and durability. Implant with a feature of locking plate (LP) has been used widely for treating distal fractures in femur because of its favourable clinical outcome, but its potential in fixing proximal fractures in the subtrochancteric region has yet to be explored. Therefore, this comparative study was undertaken to demonstrate the merits of the LP implant in treating the subtrochancteric fracture by comparing its performance limits against those obtained with the more traditional implants; angle blade plate (ABP) and dynamic condylar screw plate (DCSP).
  
  
  METHODS
  Nine standard composite femurs were acquired, divided into three groups and fixed with LP (n = 3), ABP (n = 3) and DCSP (n = 3). The fracture was modeled by a 20 mm gap created at the subtrochanteric region to experimentally study the biomechanical response of each implant under both static and dynamic axial loading paradigms. To confirm the experimental findings and to understand the critical interactions at the boundaries, the synthetic femur/implant systems were numerically analyzed by constructing hierarchical finite element models with nonlinear hyperelastic properties. The predictions from the analyses were then compared against the experimental measurements to demonstrate the validity of each numeric model, and to characterize the internal load distribution in the femur and load bearing properties of each implant.
  
  
  RESULTS
  The average measurements indicated that the constructs with ABP, DCPS and LP respectively had overall stiffness values of 70.9, 110.2 and 131.4 N/mm, and exhibited reversible deformations of 12.4, 4.9 and 4.1 mm when the applied dynamic load was 400 N and plastic deformations of 11.3, 2.4 and 1.4 mm when the load was 1000 N. The corresponding peak cyclic loads to failure were 1100, 1167 and 1600 N. The errors between the displacements measured experimentally or predicted by the nonlinear hierarchical hyperelastic model were less than 18 %. In the implanted femur heads, the principal stresses were spatially heterogeneous for ABP and DCSP but more homogenous for LP, meaning LP had lower stress concentrations.
  
  
  CONCLUSIONS
  When fixed with the LP implant, the synthetic femur model of the subtrochancteric fracture consistently exceeds in the key biomechanical measures of stability and durability. These capabilities suggest increased resistance to fatigue and failure, which are highly desirable features expected of functional implants and hence make the LP implant potentially a viable alternative to the conventional ABP or DCSP in the treatment of subtrochancteric femur fractures for the betterment of clinical outcome.
authors.affiliation: National Orthopaedic Centre of Excellence in Research and Learning, University of Malaya, 50603 Kuala Lumpur, Malaysia.
authors.forename: Mohammed Hadi
authors.initials: MH
authors.lastname: Latifi
authors.forename: Kunalan
authors.initials: K
authors.lastname: Ganthel
authors.forename: Shanmugam
authors.initials: S
authors.lastname: Rukmanikanthan
authors.forename: Azura
authors.initials: A
authors.lastname: Mansor
authors.forename: Tunku
authors.initials: T
authors.lastname: Kamarul
authors.forename: Mehmet
authors.initials: M
authors.lastname: Bilgen
mesh_terms: D001860:Bone Plates; D004548:Elasticity; D005269:Femur / Q000293:injuries* / Q000601:surgery; D020342:Finite Element Analysis; D005593:Fracture Fixation, Internal / Q000295:instrumentation*; D006620:Hip Fractures / Q000601:surgery*; D008422:Materials Testing; D017711:Nonlinear Dynamics; D013314:Stress, Mechanical