The Internal Fixation Selection and Positioning for Proximal Femoral Basicervical  Fractures: A Biomechanical Study Through Finite Element Analysis

doi:10.21203/rs.3.rs-4955832/v1

Objectives: This study aims to determine the most suitable implant for proximal femoral basicervical fractures by comparing the biomechanical characteristics of the Dynamic Hip Screw (DHS), Proximal Femoral Nail Anti-Rotation (PFNA), and InterTAN implants through finite element analysis (FEA).

Methods: Thefive fixation styles, namely DHS with a central hip screw in Anteroposterior view , PFNA with a centrally positioned helical blade (PFNA-center), PFNA with an inferiorly positioned helical blade (PFNA-inferior), InterTAN with a centrally positioned hip screw (InterTAN-center), and InterTAN with an inferiorly positioned hip screw (InterTAN-inferior), were simulated. After a three-dimension model of an intact femur was constructed and validated, three distinct basicervical fracture patterns, namely simple, intertrochanteric defect, and lateral wall defect, characterized by increasing displacement and/or bone loss with subsequent instability, were created and incorporated with the aforementioned implants. The models were subjected to FEA, and A load of 700 N was applied to simulate a 70 kg patient standing on one leg. The displacement and stress distributions on implants were analyzed for comparison between implants. Under each basicervical fracture type, we mainly compared DHS, PFNA-center, and InterTAN-center to assess the best implant performance. In addition, we compared PFNA-center and InterTAN-center with PFNA-inferior and InterTAN-inferior to assess the best hip screw position.

Results: In the simple basicervical fracture, DHS, PFNA, and InterTAN exhibited similar and small results in displacement and maximum stress in implants. In the intertrochanteric defect and lateral wall defect basicervical fractures, notable differences were observed within implants. The displacement was greatest with the DHS, followed by the PFNA, then InterTAN(minimal different between PFNA and InterTAN). In contrast, the maximum stress was highest with InterTAN and was higher with PFNA than with DHS, with none of them exceeding the fatigue limit of medical titanium. Regarding the hip screw position with the cephalomedullary nails, the inferior position showed biomechanical parameters advantages compared with the central position.

Conclusion: DHS, PFNA, and InterTAN are all suitable for the management of simple basicervical fractures. In the intertrochanteric defect and lateral wall defect basicervical fracture types, the cephalomedullary nail showed better mechanical stability and is preferred over DHS, with InterTAN showing slightly better stability compared to PFNA. The inferior hip screw position in cephalomedullary nails is preferable over the central hip screw position.

Health sciences/Medical research/Experimental models of disease

Health sciences/Anatomy/Musculoskeletal system

Proximal Femoral Basicervical Fractures

dynamic hip screw

PFNA

InterTAN

Biomechanics

Finite element analysis

Proximal femoral basicervical fractures represent a rare subset (0.6–4.3%) of proximal femoral fractures [1, 2]. While clinical studies generally agree on defining the fracture line's location within the medial aspect of the intertrochanteric line, there is inconsistency regarding the presence of an accompanying intertrochanteric defect [1, 2]. The internal fixation methods used to treat basicervical fractures are diverse, resulting in varying outcomes in terms of fixation failure rates and fracture site collapse rates [1, 2]. Consequently, it is challenging to rely fully on the results of individual studies or to ascertain the superiority or effectiveness of specific internal fixation techniques for these fractures, complicating their treatment [1, 2].

Basicervical fractures are characterized by increased shearing forces due to the parallel orientation of the fracture line to the femoral neck. The proximal fragment tends to slide along the fracture line because of the medial migration of the femur. Additionally, the narrow proximal fragment tends to impact into the wider trochanteric region, leading to a high incidence of displacement, varus collapse, and cut-out [3].

Implants in this context are subjected to significant stress due to the femur's anatomical configuration, and high stress on the implant increases the risk of implant failure [4]. To prevent high stress concentrations and undesired displacement of the femoral head, it is crucial to select the appropriate implant. This study utilized finite element analysis to investigate the maximum displacement and maximum stress on implants to evaluate the biomechanical stability of three internal fixators: dynamic hip screw (DHS), proximal femoral nail anti-rotation (PFNA), and intertrochanteric antegrade nail (InterTAN) in the treatment of proximal femoral basicervical fractures. The objective was to provide a theoretical basis for selecting the biomechanically optimal implant design to ensure optimal stability.

Ethical approval

Informed consent was obtained from the subject before the beginning of this study.Additionally,the study had been approved by the Ethics Committee of Shengjing Hospital Affiliated to China Medical University, and the ethics number is 2024PS850K.All methods were performed in accordance with the Declaration of Helsinki.

Design and construction of different basicervical fracture models

Femoral CT images were obtained from a healthy 60-year-old male volunteer (70 kg, 172 cm) with no history of femoral trauma or radiographic abnormalities. (Informed consent was obtained from the subject.Additionally,this study had been approved by the Ethics Committee of Shengjing Hospital Affiliated to China Medical University, and the ethics number is 2024PS850K.)The CT data were imported into Mimics 17.0 software (Materialise, Leuven, Belgium) to reconstruct a three-dimensional femoral model, which was then processed using Geomagic 2016 software (Geomagic, USA) for surface construction. The femoral cortical and cancellous bones were reconstructed using the offset function. Basicervical fractures were designed using SolidWorks software (Dassault, France). We observed variations in the definitions of basicervical fractures across studies. Some studies categorized them as simple fractures (Figure 1A) [3], while others depicted bone loss in the intertrochanteric region (Figure 1B) [5,6]. Additionally, certain studies included both intertrochanteric and lateral wall defects (Figure 1C) [7]. To address these discrepancies, we developed different fracture models characterized by increasing displacement and/or bone loss, leading to subsequent instability. In clinical practice, bone defects commonly arise due to the displacement of a narrow proximal femur fragment, enforced by body weight, into a wider intertrochanteric region.

Design and Construction of Fracture Fixation Devices, Assembly, and Meshing

The geometries of the internal fixation devices—DHS, PFNA, and InterTAN—were modeled using SolidWorks software. To determine the optimal hip screw position, we simulated the two most recommended positions: the central position in the sagittal plane and either the central or inferior position in the frontal plane for both PFNA and InterTAN. These five configurations were incorporated into the three established basicervical fracture models, resulting in fifteen models, which were then transferred to Abaqus 6.13 software (Dassault, France) to create finite element models.

For meshing, the internal fixation devices were edited as standard tetrahedral meshes with a size of 2 mm. The femoral cortical and cancellous bones were divided into standard tetrahedral meshes with a size of 3.5 mm.

Material Properties and Contact Settings

Consistent with previous studies [4,8], bone and implant materials were considered isotropic, linear, and elastic. Different material properties were applied to various regions of the bone and implant. The implants were constructed from medical titanium TiAl6V4 (Table 1).

The contact conditions were established with the fracture surface completely separated and in contact, with a friction coefficient of 0.2 [4]. Bone-metal contact properties were defined with a friction coefficient of 0.2. The threaded area was designated as binding, while the non-threaded area was specified as having a contact attribute with a friction coefficient of 0.2 [4]

Table 1: Material attributes of the model

Material name	Elastic modulus (Mpa)	Poisson's ratio
Cortical bone	16800	0.29
cancellous bone	260	0.2
Internal fixations (Ti-6Al-7NB)	110000	0.3

According to Schneider et al. [9], the femur is subjected to 2-5 N·m torque when standing with weight. Duda et al. [10] reported that the maximum torsional load on the femur is approximately 0.01 body weight per meter . Therefore, based on a body weight of 70 kg, the maximum torque on the femur is 7 N·m. Consequently, a vertical load of 700 N and an external rotation torque of 7 N·m were applied to the proximal end of the femur. The specific role of muscles was omitted for simplicity, and the distal end was fixed as the boundary condition.

Evaluation Criteria

Using finite element analysis with Abaqus software, the following biomechanical parameters were recorded: the Von Mises stress on the implants, which indicates the risk of implant failure, and displacement, which serves as an index of stability. The variations in these biomechanical parameters were measured and observed in each basicervical fracture group. We primarily compared the DHS, PFNA central screw, and InterTAN central screw to evaluate optimal implant performance. Additionally, we compared cephalomedullary nails (CMN) with central screws versus inferior screws to determine the optimal position for the hip screw.

Stress distribution in a normal femur

Figure 2A indicates that the primary stress distribution in a normal femur is concentrated in the lower and middle regions of the femur, the femoral neck, and around the greater and lesser trochanters. Notably, there is a significant stress concentration at the lesser trochanter, which is consistent with findings in the literature [11,12], thereby confirming the validity and reliability of the established model. The maximum displacement in a normal femur is 1.37 mm (Figure 2B).

As anticipated, with increasing complexity of the basicervical fracture patterns, both the maximum stress distribution on the implants and the maximum displacement significantly increased. Further details are provided in Table 2.

Table 2:Comparison of mechanical parameters between internal fixations in each basicervical fracture type. Abbreviations: Center - the hip screw located in the central position in both the sagittal and frontal planes; Inferior - the hip screw located in the central position in the sagittal plane and in the inferior position in the frontal plane; Max. Dis. - maximum displacement; Max. VMS - maximum Von Mises Stress.

Basicervical Fracture	Simple		Intertrochanteric Defect		Lateral Wall Defect
Mechanical Parameter	Max.Dis.	Max.VMS	Max.Dis.	Max.VMS	Max.Dis.	Max.VMS
PFNA Center	1.38 mm	168 MPa	2.13 mm	474 MPa	2.41 mm	515 MPa
PFNA Inferior	1.11 mm	120 MPa	1.67 mm	353 MPa	2.17 mm	494 MPa
InterTAN Center	1.16 mm	192 MPa	1.83 mm	600 MPa	1.99 mm	767 MPa
InterTAN Inferior	0.95 mm	146 MPa	1.65 mm	400 MPa	1.88 mm	583 MPa
DHS	1.16 mm	147 MPa	3.32 mm	424 MPa	4.12 mm	485 MPa

Table 2:Comparison of mechanical parameters between internal fixations in each basicervical fracture type. Abbreviations: Center - the hip screw located in the central position in both the sagittal and frontal planes; Inferior - the hip screw located in the central position in the sagittal plane and in the inferior position in the frontal plane; Max. Dis. - maximum displacement; Max. VMS - maximum Von Mises Stress.

The displacement of the femoral head

In all models, the greatest displacement occurred at the proximal femur (Figure 3). In the simple fracture type, the DHS, PFNA center screw, and InterTAN center screw showed similar displacements of the femoral head with minor differences (1.16 mm, 1.38 mm, and 1.16 mm, respectively). Additionally, the maximum femoral head displacements of all internal fixators were very close to those in the intact femur model (1.37 mm). Thus, any of these implants can be effectively used for fixation in the simple fracture type.

In the more unstable basicervical fracture types (intertrochanteric defect and lateral defect), significant differences were observed between the implants. The DHS exhibited the highest displacement of the femoral head (3.32 mm and 4.12 mm, respectively), followed by the PFNA center screw (2.13 mm and 2.41 mm, respectively), and the InterTAN center screw (1.83 mm and 1.99 mm, respectively). The DHS had a larger maximum displacement compared to CMN, while the PFNA had a slightly higher displacement than the InterTAN. Therefore, CMN is considered more suitable for fractures with intertrochanteric and lateral defects as they provide more stable fixation.

Stress distribution on the implants

The maximum stress on the implants was located at the junction of the hip screw with the main device (Figure 4). In the simple fracture type, the maximum stress on the implants was lower, with smaller differences between the implants (DHS = 147 MPa, PFNA center screw = 168 MPa, and InterTAN center screw = 192 MPa). In the intertrochanteric defect and lateral wall defect types, the InterTAN center screw had the highest maximum stress (600 MPa and 767 MPa, respectively), followed by the PFNA center screw (474 MPa and 515 MPa, respectively), and then the DHS (424 MPa and 485 MPa, respectively). However, the maximum stress levels on all implants in different fracture types did not exceed the fatigue limit of medical titanium (900 MPa), indicating their safety.

Effect of screw position on stress

Regarding the position of the hip screws, the inferior position (PFNA inferior screw and InterTAN inferior screw) showed lower displacement of the femoral head and lower maximum stress on the implants compared to the center position (PFNA center screw and InterTAN center screw) in all fracture types (refer to Figure 5 and Table 2 for more details).

In the simple basicervical fracture models, all fixation devices resulted in approximately the same femoral head displacement. The magnitude of femoral head displacement with the implants was similar to that of the intact bone, indicating that proper fixation can be achieved with all the implants. Good contact between the proximal femoral part and the distal femoral shaft in simple basicervical fractures effectively transfers the axial load distally through the femur shaft. This significantly reduces femoral head displacement and protects the internal implants. Therefore, anatomical reduction of a basicervical fracture, which has been repeatedly emphasized in previous literature, should be a priority for surgeons [13].

Biomechanical experiments by Kim JW et al. [14], involving finite element analysis of a simple basicervical fracture type, showed insignificant differences in the maximum femoral head displacement between DHS and PFNA. Their conclusion that both implants could be applied to simple basicervical fractures aligns with our findings, validating our study's results.

In models with intertrochanteric defects and lateral wall defects, incomplete bone contact between the proximal and distal fragments due to bone defects resulted in a high propensity for femoral head displacement and varus collapse. In these cases, the implant becomes the primary load-bearing path at the fracture site, making the strength and biomechanics of the implant crucial for preventing complications. The femoral head displacement was greater with the DHS compared to the CMN, increasing by 1.5 times in intertrochanteric defects. This could be due to the shorter distance from the fracture line to the CMN (short lever arm), which results in greater resistance to compressive force. Additionally, the central intramedullary nail, lying in the more stable diaphysis of the femur shaft, provides sufficient mechanical strength and greater fracture stability [15]. Conversely, the DHS design increases the length of the lever arm, amplifying the compressive force. Its eccentric design primarily provides stability through screw fixation in the proximal fragment, which may not offer the same level of axial stability [15]. Due to its high stability, CMN may allow for early weight-bearing and mobilization, leading to improved patient outcomes, faster recovery, and reduced complications associated with prolonged immobilization.

Blair [16] observed that the lateral position of the basicervical fracture line reduces the support provided by the lateral cortex, causing more collapse and failure in lateral wall defects. Ignoring incomplete lateral bone insufficiency before the operation or recurring fractures on the lateral wall after surgery may result in shortened fractures, delayed healing, and even revision [17]. Our experiment showed that in a basicervical fracture model with a lateral wall defect, the DHS had nearly twice the femoral head displacement compared to the CMN. Additionally, femoral head displacement with the lateral wall defect fixed by DHS was markedly increased compared to the intertrochanteric defect. With CMN, femoral head displacement increased slightly from intertrochanteric defect to lateral wall defect. Therefore, DHS was the most unstable implant due to the largest displacement, while CMN exhibited more stability in lateral wall defects. In most cases of lateral wall injuries, the thickness of the lateral wall decreased, but the top of the greater trochanter was intact. In CMN, the interlocking mechanism structure formed by the top of the greater trochanter with the proximal end of the nail and the femoral shaft with the main nail may act as the lateral wall to buttress the proximal fragments and decrease femoral head displacement [18]. Femoral displacement was slightly smaller with InterTAN than PFNA, despite both being intramedullary implants. This difference is mainly due to structural differences between the single blade and the two screws. InterTAN, consisting of two head screws, could effectively share more external compressive loads on the femoral head [19], and the larger cross-sectional area of the two screws in the femoral neck provides greater support [20], thereby providing more stability and less femoral head displacement.

Regarding Von Mises stress on implants, the CMN design facilitates stress relief. CMN experiences low stress distribution compared to DHS, which demonstrates high stress distribution. This could be attributed to CMN's short lever arm allowing more direct load transfer from the femoral head to the main nail, with the central main nail distributing the load more evenly over a large implant-bone interface (load-sharing). Conversely, DHS cannot efficiently share the upcoming stress with the surrounding bone, resulting in high stress distribution on the DHS device, further evidencing the load-bearing character of DHS [21]. Our study also examined the maximum stress values along with stress trends. The maximum stress in all implant models was located at the junction between the hip screw and the main implant. Liang et al. [22], in their finite element study, found that the highest stress point on the implant was at the junction of the hip screw with the main nail, resulting from the hip screw resisting the forces acting on the femoral head. Thus, high stress in the hip screw-device junction indicates that the implant fixation sustains more stress and reduces stress on the bone tissue, with the majority of the forces acting on the femoral head being absorbed by the implant, resulting in decreased femoral head displacement [23]. This phenomenon aligns with our findings: InterTAN, with the lowest displacement, has the greatest stress at the hip screw-nail intersection, while DHS, with the greatest displacement, has the lowest stress at the hip screw-barrel intersection. However, the maximum stress values of these implants in all fracture types do not exceed the yield strength of medical titanium (850–900 MPa) [4,24], indicating their theoretical safety for use.

The position of the hip screw can be controlled during surgery to reduce cut-out. Goffin et al. suggested placing the screw in the middle or lower part of the femoral head and neck, where bone density is high, to resist axial pressure and prevent cut-out [25]. Our experimental results showed that in all basicervical fracture types fixed by CMN, all mechanical parameters improved in the inferior hip screw position compared to the central position. The primary reason is that when the hip screw is in the inferior location, it is closer to the inferior femoral head and neck cortical bone, which has a very high elastic modulus, providing greater support to the hip screw than central cancellous bone. We suggest that the inferior position could be an ideal choice in different basicervical fractures, as also observed in previous computational [26] and experimental [27] biomechanical studies on other proximal femur fracture types.

To the best of the authors' knowledge, this is the first study to use finite element analysis to examine the biomechanical effectiveness of intramedullary and extramedullary treatments for different basicervical fracture types. Despite these interesting findings, this computational simulation study has some limitations. The model and mechanics analysis methods were simplified to some extent. The material parameters of the model are set as isotropic elastic materials, which differ from the anisotropic properties of actual human bone. Additionally, this study only performed static mechanical analysis and did not include dynamic mechanical analysis. However, these considerations should not have affected our results, as all implant and fracture types were investigated under the same simplified conditions. Many other research studies have also applied similar methods to simulate bones and implants with acceptable outcomes [4,14]. Furthermore, the finite element model used in this study was comparable to those used in previous in vitro studies [28]. Future studies should include clinical trials and observations for further validation..

For simple basicervical fractures, the DHS, PFNA, and InterTAN all exhibited similar and good biomechanical stability. In cases of intertrochanteric defect and lateral wall defect basicervical fractures, CMN significantly improved stability by decreasing femoral head displacement and reducing the likelihood of screw cut-out compared to extramedullary DHS fixation. The InterTAN device had relatively less femoral head displacement compared to PFNA. The inferior position of the hip screw demonstrated better biomechanical behavior compared to the central position.

Ethical approval

Informed consent was obtained from the subject before the beginning of this study.Additionally,the study had been approved by the Ethics Committee of Shengjing Hospital Affiliated to China Medical University, and the ethics number is 2024PS850K.All methods were performed in accordance with the Declaration of Helsinki.

Author contributions:

These authors contributed equally:Tianhao Yang,Faez Noraddin,Baozhe Liu and Zegen Zhang.

T.H.Y:Data analysis and revise manuscript. F.N.:Write original manuscript. B.Z.L:Data statistics and interpretation. Z.G.Z:Design the experiment.

All authors reviewed the results and approved the final version of the manuscript.

Data availability：

The original data obtained in the study is included in the article,and for further inquiries,please consult the corresponding author.

Competing interests：

The authors declare that there are no competing interests regarding the publication of this paper.

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No competing interests reported.

The Internal Fixation Selection and Positioning for Proximal Femoral Basicervical Fractures: A Biomechanical Study Through Finite Element Analysis

Status:

Version 1

Abstract

Figures

INTRODUCTION

MATERIALS & METHODS

RESULTS

DISCUSSION

CONCLUSION

Declarations

Ethical approval

References

Additional Declarations

Status:

Version 1