Elsevier

The Journal of Hand Surgery

Volume 42, Issue 8, August 2017, Pages 659.e1-659.e9
The Journal of Hand Surgery

Scientific article
Evaluation of Bone Atrophy After Treatment of Forearm Fracture Using Nonlinear Finite Element Analysis: A Comparative Study of Locking Plates and Conventional Plates

https://doi.org/10.1016/j.jhsa.2017.03.041Get rights and content

Purpose

Forearm diaphysis fractures are usually managed by open reduction internal fixation. Recently, locking plates have been used for treatment. In the long-term period after surgery, some patients present with bone atrophy adjacent to the plate. However, a comparison of locking and conventional plates as a cause of atrophy has not been reported. The aim of this study was to investigate long-term bone atrophy associated with use of locking and conventional plates for forearm fracture treatment.

Methods

In this study we included 15 patients with forearm fracture managed by either locking or conventional plates and with more than 5 years of follow-up. Computed tomographic imaging of both forearms was performed to assess bone thickness and local bone mineral density and to predict bone strength without plate reinforcement based on finite element analysis.

Results

Mean patient age at surgery was 48.0 years. Eight patients underwent reduction with fixed locking plates and were followed up for a mean of 79.5 months; the remaining 7 patients were treated with conventional plates and were followed up for a mean of 105.0 months. Compared with the conventional plate group, the locking plate group had the same fractured limb–contralateral limb ratio of cortex bone thickness, but had significantly lower ratios of mineral density adjacent to the plate and adjusted bone strength.

Conclusions

This study demonstrated bone atrophy after locking plate fixation for forearm fractures. Treatment plans for forearm fracture should take into consideration the impact of bone atrophy long after plate fixation.

Type of study/level of evidence

Therapeutic IV.

Section snippets

Subjects

This study enrolled 21 patients who had undergone open reduction internal fixation with plates that remained in place after treatment of forearm (ulna and/or radius) fractures between January 1999 and December 2007, at 1 of the 3 hospitals. The regional medical ethics committees of each hospital approved the study. Only patients who consented and remained in contact with study coordinators for 5 years or more were included in the final analysis. AO classification, joint range of motion (ROM),

Long-term clinical results after forearm fracture

Of the 21 subjects enrolled, 15 patients were observed for the minimum period required for the project (Table 1). Of these, mean age at surgery was 48.0 years (range, 19–66 years). Eight patients were treated with locking plates (3 men and 5 women) whereas 7 were treated with conventional plates (4 men and 3 women). All locking plates were the Limited Contact–Locking Compression Plate (Synthes, Davos, Switzerland). Conventional plates used for treatment included the Limited Contact–Locking

Discussion

Through a number of assessment parameters, the current study demonstrated that open reduction of forearm fractures with locking plates resulted in more bone atrophy in long-term follow-up, compared with that after using conventional plates. In addition, one of these assessments was a novel computational prediction of bone strength that can be used to determine resistance to refracture after plate removal.

Previous biomechanical studies demonstrated the advantages of stabilization using locking

Acknowledgments

The authors thank Makoto Otsuka, PhD, Masatsune Yamagata, PhD, Masaya Mimura, PhD, and Tadashi Tanaka, PhD for assistance with data collection.

References (17)

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    Surgical fixation of fractures may lead to local bone atrophy by impairing blood flow, as seen in animal models.34,35 Stress shielding and impaired periosteal circulation also drive local bone loss, as confirmed in diaphyseal forearm fractures treated with ORIF.36,37 However, bone loss in the hand after DRF treated with volar plates has not been widely reported.

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    Matsuura et al6 previously reported that bone strength was 56% at an average of 91.4 months after plate fixation. They also reported that bone strength was up to 45% with the locking plate, significantly different from 72% with the conventional plate.6 Hirashima et al18 measured bone strength over 5 years after surgery in patients with locked plate fractures of the diaphysis of the forearm and confirmed that bone strength was decreased 3 years after plate fixation.

  • Comparison study of bone strength of the proximal femur with and without hip osteoarthritis by computed tomography-based finite element analysis

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    Regarding bone density, Dequeker et al. showed that osteoarthritis patients not only have higher apparent and real-bone density but also wider skeletal geometrical measures and diameters of long bones and trabeculae, both contributing positively to better strength and fewer fragility fractures (Dequeker et al., 2003). FEA is useful in fracture strength assessment and has recently been used to simulate bone strength (Matsumoto et al., 2009; Matsuura et al., 2017a, 2017b). This study utilized Keller’s equations for the analysis of the vertebra, considering Miura et al.’s cadaveric study findings that these equations are the most reproducible for the proximal femur in elderly individuals (Miura et al., 2017).

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