A new combined reduction anatomical plate for the treatment of acetabular anterior column and posterior hemi-transverse fractures: a finite element analysis study

doi:10.21203/rs.3.rs-4964573/v1

Background: Acetabularanterior column and posterior hemi-transverse fractures pose a significant challenge for orthopaedic surgeons. Traditional treatment methods are associated with high rates of post-operative complications and lengthy surgical procedures. To enhance treatment efficacy, this study developed a novel internal fixation device called the Combined Reduction Anatomical Plate (CRAP) and conducted a finite element analysis to compare its biomechanical properties to those of traditional internal fixation methods.

Methods: A standard finite element model of an anterior column and posterior hemi-transverse fracture of the acetabulum was established using finite element software. Subsequently, four different internal fixation devices were applied: CRAP, double-column locking plates (DLP), supra-pectineal quadrilateral anatomical plate (SQAP), and iliositus + anterior column plate (LACP). After determining the boundary conditions and material properties, the model was simulated in three different body positions (standing, sitting, and lying on the affected side) and subjected to vertical downward forces of 200 N, 400 N, and 600 N. Subsequently, the stress distribution and peak values among the four fixation methods were analyzed, and the maximum pelvic displacement and fracture fragment displacement were evaluated.

Results: In this study, the CRAP maximum stress on the steel plate and screws was 159.540 N, 160.540 N, 157.050 N, 177.330 N, 64.756 N, and 30.003 N, which was less than that of the SQAP and LACP and greater than that of the DLP. The maximum tangential micromotion of the CRAP was only 0.016 mm, and the maximum displacement of the pelvis was 0.855 mm. The results showed that the new type of plate developed and designed in this study exhibited a relatively uniform stress distribution and high stiffness, providing sufficient strength. However, the four groups showed no obvious difference in tangential fretting.

Conclusion: Compared with the other three fixation methods, the newly designed sectional anatomical reduction plate and screws showed a uniform stress distribution, greater rigidity, sufficient strength, and improved mechanical stability. The CRAP can therefore provide sufficient biomechanical stability and help fracture healing.

combined reduction anatomical plate

acetabular fractures

finite element analysis

internal fixation

Biomechanics

Acetabular fractures, intricate fractures occurring within the joint, are primarily the result of high-impact trauma. Recently, their frequency has risen due to a higher occurrence of traffic and industrial accidents^[1]. To maximize the restoration of hip joint function, improve prognosis, and reduce the occurrence of complications, the preferred method for treating displaced acetabular fractures is now open reduction and internal fixation^{[2, 3]}. According to the Judet-Letournel^[4] classification system, quadrilateral plate fractures are not classified separately, except for simple anterior and posterior wall fractures; still, 80% of the other fracture types may involve the quadrilateral plate^[5–7]. This is particularly true in elderly patients, who often have osteoporosis and comminuted fractures^{[5, 8]}.

Anterior column-posterior hemi-transverse fractures (ACPHTFs) are a common type of acetabular fracture, often accompanied by femoral head protrusion and quadrilateral plate displacement ^[9–11]. This fracture impacts both the anterior and posterior columns and involves the quadrilateral plate. Presently, it is considered that only anatomical reduction, which restores the smoothness and flatness of the hip joint, preserves the blood supply to the femoral head and intra-articular fractures, provides stable internal fixation, and can achieve good clinical outcomes ^[12]. However, due to the deep location of the quadrilateral plate, limited surgical space, difficulty in intra-operative exposure, and issues with traditional pelvic plates, such as difficulty in shaping during surgery, poor fit with pelvic anatomical structures, single fixation points, inadequate reduction, fixation of quadrilateral plate fractures, and screws easily entering the hip joint, leading to femoral head necrosis and traumatic arthritis ^{[6, 13, 14]}, these traditional methods no longer meet the requirements for precise reduction and strong fixation of this type of fracture.

Therefore, we designed a specially shaped reconstruction plate (the Combined Reduction Anatomical Plate, CRAP) based on the anatomical characteristics of the acetabulum, which has been granted a Chinese national patent (Patent No.: CN202222137846.2). This fixation system includes two components: a locking plate and a reduction plate. The locking plate is a curved strip designed to fit above the greater sciatic notch, while the reduction plate is contoured to align with the anatomical structures above the acetabulum and the quadrilateral plate. This system is primarily used for treating acetabular fractures that involve the quadrilateral plate, such as posterior column fractures, T-type fractures, ACPHT, and both-column fractures. Considering the extremely irregular shape of the pelvis and the difficulty in shaping plates during surgery, we previously conducted an anatomical study on the CRAP fixation trajectory using computer-aided anatomical measurements. This study led to the design of anatomical plates and reduced the difficulty of shaping traditional plates during surgery ^[15]. However, comparative studies on the biomechanical properties of the newly designed CRAP and traditional plates have not been conducted, particularly regarding the biomechanical mechanisms during bone healing.

Therefore, this study aimed to use the finite element method to compare the biomechanical properties and stability differences of four internal fixation methods for treating anterior column-posterior hemi-transverse fractures: combined reduction anatomical plate (CRAP), anterior column-posterior column plate (DLP), supra-pectineal quadrilateral plate (SQAP), and ilio-ischial-anterior column plate (LACP). This research offers a theoretical foundation for the expanded clinical use of the CRAP.

2.1 Establishment of the three-dimensional Finite Element Model for Anterior Column-Posterior Hemi-transverse Fractures

A healthy 23-year-old male volunteer provided informed consent. Pelvic radiography excluded fractures, deformities, tumors, and other pathologies. This research received approval from our hospital's Medical Ethics Committee (ethics no. KLLY-2022-017). The DICOM data from the volunteers were imported into Mimics software (version 21.0, Materialise Company, Leuven, Belgium). The hemi-pelvic model was reconstructed and exported in STL format, followed by software construction of a standard finite element model (Fig. 1a).

The ACPHTF model was established according to the Judet and Letournel classification of acetabular fractures^{[16, 17]}. ACPHTFs primarily have two fracture lines: one extends from the anterior superior iliac spine to the inferior edge of the obturator foramen. The other extends from the midpoint of the first fracture line to the uppermost end of the sciatic notch (Fig. 1b) ^[18].

2.2 Modelling of Four Internal Fixation Models for Anterior Column-Posterior Hemi-transverse Fractures

In this study, four internal fixation models (CRAP, DLP, SQP, and LCAP) were accurately constructed using SolidWorks 2017 software (SolidWorks Corporation, Dassault, France) based on the actual dimensions and shapes of the fixation devices. During the construction process, special attention was paid to the design characteristics of each fixation device, such as shape, size, and intended biomechanical application, to ensure model realism and functionality. After construction, these models were precisely assembled onto the ACPHTF model for subsequent finite element analysis (Fig. 2).

2.3 Definition of Boundary Conditions, Material Properties, and Loads

The analysis was conducted using the ANSYS Workbench 2022 R1 (Ansys, Canonsburg, PA) software to generate standardized finite element models.

2.3.1 Boundary Conditions

In the model, the contact between the bone surface and the internal fixation devices or between the internal fixation devices themselves was set as bonded contact. The contact between fracture fragments and cartilage was set as frictional contact with a friction coefficient of 0.2 to simulate physiological conditions.

2.3.2 Material Properties

To construct the model, we assumed that all cortical bones, cancellous bones, plates, and screws were homogeneous and isotropic. To make the finite element model closer to physiological conditions, acetabular cartilage was included, and the ligaments were defined based on their anatomical locations. The standard finite element model defined the iliofemoral, ischiofemoral, pubofemoral, inferior iliofemoral, and superior iliofemoral ligaments. The material properties of the cortical bone, cancellous bone, articular cartilage, and ligaments were determined based on previous literature ^[19–23]. The material properties are listed in Tables 1 and 2.

Table 1

The composition of the various parts of the pelvic bone and the material characteristics of the internal fixation
Material type	Material type	Poisson's ratio (%)
Iliaccrest cortical bone	12400	0.3
Iliaccrest cancellous bone	77	0.3
Acetabular cartilage	12	0.42
femoral cortical bone	15100	0.3
femoral cancellous bone	445	0.22
Plates	110000	0.3
Screws	110000	0.3

Table 2

Material properties of the major ligaments
ligament	Stiffness N/mm
Teres ligament	68 ± 25
Ischiofemoral ligament	39.6 ± 24.4
Pubofemoral ligament	36.9 ± 24.4
Inferior iliofemoral ligament	100.7 ± 54
Superior iliofemoral ligament	97.8 ± 67.5

2.3.3 Loading and Constraints

In this study, four different internal fixation methods were simulated and analyzed using the ACPHTF 3D model. The pubic symphysis and sacroiliac joint were securely fixed, restricting their six degrees of freedom to establish the boundary conditions of the model. To simulate partial and full weight-bearing conditions post-operatively for patients with fractures, the load on each assembly model was gradually increased, with forces of 200 N, 400 N, and 600 N applied at the center of the hip joint. Additionally, to simulate the different post-operative positions that patients might adopt, forces were applied at different locations on the pelvis, representing the standing, sitting, and affected side-lying positions. This loading method aimed to simulate various load conditions under real biomechanical scenarios, thereby allowing for a more accurate assessment of the biomechanical performance of different internal fixation methods.

3.1 Stress Distribution and Peak Stress

First, the strengths of the four internal fixation methods were evaluated. The stress contour maps show that the stress concentration mainly occurred near the fracture lines. Regarding the stress distribution on the plates, in both the standing and affected side-lying positions, as the loading force increased, the anterior column plate of the LACP consistently bore the greatest stress. In the sitting position, with a loading force of 200 N, the ilio-ischial plate of the LACP bore the greatest stress. However, as the loading force increased to 400 N and 600 N, the SQAP exhibited the greatest stress.

Compared to the other three plates, the DLP exhibited a lower Von Mises stress under loading forces of 200 N, 400 N, and 600 N. Additionally, under different loading forces and positions, the maximum stress of the CRAP was less than that of the SQAP and LACP but slightly greater than that of the DLP. This indicates that the CRAP system has a more uniform stress distribution, reducing the possibility of stress concentration and internal fixation failure and providing sufficient strength and better mechanical stability (Figs. 3–5 and Table 3).

Figures 3 to 5 are stress contour maps of the four plate groups in standing, sitting, and affected side-lying positions. A-C represent loading forces of 200N, 400N, and 600N, respectively. A, D, G, and J represent the DLP, LACP, SQAP, and CRAP groups, respectively. In A-C, the left side represents the anterior column plate, and the right side represents the posterior column plate. In D-F, the left side represents the anterior column plate, and the right side represents the ilioischial plate. In J-L, the left side represents the reduction plate, and the right side represents the obtained plate. The red areas indicate high stress, while the blue areas indicate low stress.

Table 3 Von Mises stress peak values of four groups of plates under different loading modes (MPa)

From the stress contour maps, it can be observed that for almost all internal fixation methods, the maximum stress on the screws occurs in the middle-upper part of the screw and at the screw-plate junction. Therefore, these areas must be reinforced to prevent fatigue fractures. In the standing position, as the loading force increased, the stress on the locking screws (LS) of the CRAP was slightly higher than that in the other three groups. Similarly, in the sitting position with loading forces of 200 N and 400 N, the stress on the LS was slightly higher for the CRAP than for the other three plates. When the loading force increased to 600 N, the reduction screws in the CRAP bore the greatest stress. In the affected side-lying position, there were no significant differences in the maximum stress on the screws among the four plates under different loading forces (Figs. 6–8 and Table 4).

Figures 6 to 8 are stress contour maps of the corresponding screws in the four plate groups in standing, sitting, and affected side-lying positions. A-C represent loading forces of 200N, 400N, and 600N, respectively. A, D, G, and J represent the DLP, LACP, SQAP, and CRAP groups, respectively.In A-C, the left side represents the anterior column screws, and the right side represents the posterior column plate. In D-F, the left side represents the anterior column screws, and the right side represents the ilioischial screws. In J-L, the left side represents the reduction screws, and the right side represents the locking screws.The red areas indicate high stress, while the blue areas indicate low stress.

3.2 Micromotion and Maximum Displacement

Next, the tangential micromotion at the fracture site and maximum displacement of the pelvis were evaluated for the four internal fixation methods. Micromotion, also known as intermittent motion at the fracture end, is defined as a slight movement between the ends of fracture segments. It not only promotes callus formation and accelerates fracture healing but is also an important mechanical parameter in fracture healing ^{[24, 25]}. Based on the tangential micromotion contour maps, the LACP exhibited the smallest micromotion (0.001 mm), followed by the combined reduction anatomical plate CRAP at 0.003 mm, with the SQAP showing the largest micromovement at 0.027 mm. The tangential micromotion of the four internal fixation methods showed no significant differences, indicating that the CRAP can offer adequate biomechanical stability. The maximum displacement of the pelvis under the four different internal fixation methods was compared to evaluate the stability of each fixation. It is well-known that displacement is one of the key indicators reflecting the stability of internal fixation ^[26]. The maximum displacement of the pelvis includes deformation and rigid-body displacement. The displacement contour maps showed that the maximum displacement of the pelvis with the CRAP (0.855 mm at 600 N in the sitting position) was slightly greater than with the other three fixation methods. The double-column plate group showed relatively smaller displacement in ACPHTF treatment, indicating better stability (as shown in Figs. 9–14 and Tables 5–6).

Table 4 Von Mises stress peak values of the four groups of screws under different loading modes and loading forces（MPa）

Figures 9 to 11 are contour maps showing the maximum displacement of the pelvis under different loading forces and positions for the four internal fixation methods. A-C represent loading forces of 200N, 400N, and 600N, respectively. A, D, G, and J represent the DLP, LACP, SQAP, and CRAP groups, respectively. The deeper the red, the greater the displacement; the lighter the blue, the smaller the displacement.

Figures 12 to 14 are contour maps showing the tangential micromotion at the fracture ends under different loading forces and positions for the four internal fixation methods. A-C represent loading forces of 200N, 400N, and 600N, respectively. A, D, G, and J represent the DLP, LACP, SQAP, and CRAP groups, respectively.The deeper the red, the greater the micromotion; the lighter the blue, the smaller the micromotion.

Table 5

Maximum displacement of the pelvis under different loading modes and loading forces for the four groups of internal fixation models(mm)
Internal fixation model	maximum displacement (mm)
Internal fixation model	Standing position			Sitting position			Standing position
	200N	400N	600N	200N	400N	600N	200N	400N	600N
CRAP	0.208	0.420	0.670	0.311	0.579	0.855	0.095	0.201	0.276
DLP	0.072	0.097	0.270	0.167	0.335	0.652	0.048	0.090	0.170
SQAP	0.078	0.145	0.212	0.174	0.328	0.495	0.042	0.099	0.151
LACP	0.090	0.099	0.136	0.178	0.377	0.567	0.067	0.121	0.192

Table 6

Tangential fretting of the four groups of internal fixation models under different loading methods and loading forces(mm)
Internal fixation model	Tangential micromotion(mm)
	Standing position		Sitting position			Standing position
	200N	400N	600N	200N	400N	600N	200N	400N	600N
CRAP	0.007	0.011	0.016	0.005	0.009	0.013	0.003	0.006	0.010
DLP	0.007	0.017	0.025	0.008	0.017	0.021	0.006	0.011	0.017
SQAP	0.006	0.014	0.020	0.008	0.017	0.027	0.006	0.012	0.018
LACP	0.001	0.003	0.005	0.001	0.003	0.004	0.001	0.002	0.004

ACPHTFs are complex acetabular fractures resulting from high-energy trauma, comprising approximately 7% of all acetabular fractures. With an increasingly aging population, its incidence is gradually increasing and is often accompanied by femoral head protrusion and quadrilateral surface displacement, making treatment difficult ^{[18, 27]}. Open reduction and stable internal fixation have established themselves as the gold standard for treatment ^{[2, 3]}.

Currently, the ideal treatment for the most complex acetabular fractures is the placement of a reconstruction plate from the inner surface of the ilium to the upper surface of the superior pubic ramus. However, single plates often fail to yield satisfactory results. Therefore, surgeons combine posterior column screws, quadrilateral screws, and other plates to reduce the risk of fixation failure ^[28–31]. Although these methods often yield relatively satisfactory clinical outcomes, the complex and deep anatomical structure of the acetabulum poses surgical risks, such as nerve and vascular damage and screw penetration into the hip joint ^[32]. Additionally, these fixation techniques may require more surgical trauma, longer operative times, and greater blood loss. Therefore, based on the anatomical characteristics of the acetabulum, this study reports the design of a specially shaped reconstruction plate (CRAP). However, we have not yet compared the new steel with the traditional method of internal fixation. Therefore, this study used finite element analysis ^[33] to compare the biomechanical characteristics and stability differences between the CRAP and traditional fixation methods, thereby providing a theoretical basis for further clinical applications.

First, the stress distributions of the new plate and its screws were compared with those of traditional plates and their corresponding screws to evaluate the stiffness of the plate structure based on stress and deformation. Stress distribution indicates the ability of the plate or screws to resist elastic deformation under force. Stress concentration may lead to deformation or even fracture of plates or screws ^[34]. From the stress contour maps, it can be observed that under different loading forces, the stresses on the plates and screws were mainly concentrated near the fracture line in all four groups. This indicates that the screws and plates connecting the fracture line bear more force than other positions, which is consistent with the results of previous studies ^{[31, 35]}. Regarding the stiffness of the plates and screws, under the same load and position, the stress on the CRAP and its screws was greater than that on the SQAP and LACP, but less than that on the DLP. This suggests that the new plate provides sufficient strength and good mechanical stability with a more uniform stress distribution, thereby avoiding internal fixation failure. The maximum stress on the screws mainly occurred in the middle and upper parts of the screws at the screw-plate junction. Therefore, it is necessary to enhance the strength of these parts to prevent fatigue fractures. However, as the loading force increased, there was no significant difference in the maximum stress on the screws among the four groups. Although the new plate and screws bear greater stress, the maximum stress is far below the yield strength of the titanium alloy material, which can withstand a maximum stress of 795 MPa ^[36]. Finally, the plates and screws in the double-column plate group bore less stress because the fixation included two plates, which could effectively distribute the stress, consistently with previous studies ^{[37, 38]}.

Next, we assessed four internal fixation methods for tangential micromotion at the fracture site and maximum pelvic displacement. Micromotion not only promotes callus formation and accelerates fracture healing but is also an important mechanical parameter in the fracture healing process ^{[24, 25]}. Therefore, we evaluated the micromotion of the four internal fixation methods. From the tangential micromotion contour maps, there is no significant difference in tangential micromotion among the four internal fixation methods, indicating that CRAP provides sufficient biomechanical stability. The maximum displacement of the pelvis under the four internal fixation methods was compared to evaluate their stability. As is well-known, displacement also reflects the stability of internal fixation ^[26]. The maximum displacement of the pelvis includes both deformation and rigid-body displacement. The displacement contour maps showed that the maximum pelvic displacement was slightly larger with the CRAP than that with the other three internal fixation methods. The smallest maximum displacement was observed in the double-column plate group when treating ACPHTFs, demonstrating the best stability. However, the insertion of double-column plates requires a combined anterior-posterior approach, which has disadvantages such as greater exposure, increased risk of soft tissue damage, neurovascular injury, and longer operative time ^{[20, 39]}. Although the maximum displacement with the CRAP is larger, previous studies have shown that under stress, there will be some relative displacement between the fracture fragments. This relative displacement in the range of 0.2–1.0 mm can stimulate callus formation and promote fracture healing, whereas displacements greater than 2 mm are detrimental to fracture healing. In this study, the maximum displacement of fractures with all four internal fixation devices under different loads was less than 1 mm, indicating that they are biomechanically conducive to fracture healing ^{[26, 40–42]}. Therefore, compared to the other three internal fixation methods, CRAP provides sufficient stability and can be considered the preferred choice for the treatment of ACPHTFs.

This study is the first to conduct a finite element analysis of the lateral decubitus position, which is relevant because patients may rest in the lateral decubitus position on the affected side post-operatively. The analysis focused on stress distribution, stress peaks, and other factors when patients rest in this position post-operatively. From the stress contour maps, it can be observed that as the load increases, the new plate and its screws provide sufficient strength and biomechanical stability, preventing internal fixation failure. Micromotion and maximum displacement of the pelvis indicate that in the lateral decubitus position, the CRAP provides adequate stability. Therefore, using CRAP to treat ACPHTFs ensures that regardless of the post-operative position the patient adopts, there will be no internal fixation failure or femoral head dislocation. The CRAP is considered a safe and effective treatment option.

In summary, this study demonstrated that the double-column plate group endured the least stress and provided the highest stability when treating ACPHTFs, which is consistent with previous research on acetabular fracture treatment ^{[10, 37, 43]}. However, double-column plate fixation has drawbacks, such as significant surgical trauma, a higher risk of neurovascular injury, and prolonged operative time ^{[20, 39]}. Single-column plate fixation for acetabular fractures shows greater stress concentration and poorer biomechanical stability ^{[20, 37, 44]}. To address these limitations, we designed a novel combination of anatomical reduction plates. This fixation system benefits from the stress distribution and stability provided by the two plates and allows effective reduction and fixation of the acetabular quadrilateral, posterior column, and posterior wall fractures through a simple posterior Kocher-Langenbeck approach. This approach overcomes the difficulties associated with traditional combined anterior and posterior approaches for treating complex acetabular fractures. Furthermore, the CRAP was designed based on the acetabular morphology of Chinese patients, making it more anatomically compatible than traditional plates. This novel plate is pre-contoured to match the acetabular surface, avoiding intra-operative pre-bending and shaping, thereby significantly reducing operative time and trauma ^[15].

In this study, the establishment of the finite element models and their parameters followed those of previous studies ^[45, 46] that employed similar loading and boundary conditions. Therefore, we consider this study reasonable and reliable. However, our study had some limitations. First, our study was based on computer simulations rather than real-world experiments. The finite element models used in this study were simplified and did not account for the influence of surrounding soft tissues on the fixation methods; therefore, they may not accurately reflect physiological conditions. Nevertheless, previous studies have shown that biomechanical studies based on computer simulations can still provide effective theoretical support for pelvic fracture fixation ^[37, 38]. Therefore, further biomechanical studies using artificial or cadaveric pelvises are needed to validate these findings. Finally, this study compared only four types of internal fixation methods for ACPHTF; other fixation methods for acetabular fractures should be compared in future research.

In conclusion, compared to the traditional three internal fixation methods, the CRAP and its accompanying screws exhibit more uniform stress distribution and greater stiffness, providing sufficient strength and superior mechanical stability. Additionally, no significant differences were observed in interfragmentary motion among the four internal fixation methods, indicating that the CRAP can offer adequate biomechanical stability and is more favorable for fracture healing. Therefore, the CRAP fixation method presented in this study is a safe and effective option for treating ACPHTFs.

Ethics approval and consent to participate：This study was approved by the Institutional Review Board of the Afliated Hospital of Zunyi Medical University, Zunyi, Guizho, China, Ethics number KLLY-2022-017. All subjects provided informed consent to take part in the study. All procedures were conducted according to the 1964 Declaration of Helsinki and its amendments.

Conflict of Interest: The authors declare that there are no conflicts of interest.

Author Contributions: Chen Lin: Participated in study design, Data measurement, data analysis, and main contributor to writing the paper. Bao Chongshuai and Wang Ansu: Prepared figures and tables. Ao Jun: data analysis, and paper revision. All the authors read and approved the final manuscript.

Funding: The work was supported by the Project of the Provincial and Ministerial Collaborative Innovation Center (No.39 [2020] of the Science and Technology Agency).

Acknowledgments: The authors are grateful to the research participants and all the hospital staff who took an interest and helped with the study.

Data Availability Statement:The data used and analyzed during the current study are available from the corresponding author upon reasonable request.

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No competing interests reported.

A new combined reduction anatomical plate for the treatment of acetabular anterior column and posterior hemi-transverse fractures: a finite element analysis study

Status:

Version 1

Abstract

Figures

1 Introduction

2 Materials and Methods

2.3.1 Boundary Conditions

2.3.2 Material Properties

2.3.3 Loading and Constraints

3 Results

4 Discussion

5 Conclusion

Declarations

References

Additional Declarations

Status:

Version 1