Biomechanical investigation of external fixators for the treatment of supracondylar humerus fractures.,Journal of Orthopaedic Surgery and Research

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Biomechanical investigation of external fixators for the treatment of supracondylar humerus fractures.
Journal of Orthopaedic Surgery and Research ( IF 2.8 ) Pub Date : 2020-07-28 , DOI: 10.1186/s13018-020-01815-2
Christoph Castellani ₁ , Holger Till ₁ , Annelie-Martina Weinberg ₂

Affiliation

In children, supracondylar humerus lesions rank among the most common fractures. Closed reduction and percutaneous pinning remains the gold standard of treatment (summarized in [1]). Elastic stabile intramedullary nailing (ESIN) has been proposed as alternative. However, these techniques may not provide adequate stability especially in case of comminution zones or oblique fractures. Thus, external fixation (EF) with various technical configurations has been suggested as alternative. Additionally, EF may have advantages in open fractures with contamination or impending compartment syndrome. In the past, EF has been the subject of biomechanical stability testing. In this regard, Li et al. published an analysis comparing different k-wire configurations and external fixation in your Journal in 2018 [2]. They concluded: “External fixator could provide enough stability for pediatric supracondylar humerus fractures without the injury of the ulnar nerve. Besides, it could enhance the rotational stiffness of the construct in rotation loading to avoid the complication of cubitus varus” [2]. In the discussion section, they state that “there have been no published reports of biomechanical analysis in the external fixator in supracondylar humerus fractures” [2].

This statement of Li et al. being the first to report biomechanical data on EF is not correct. Already in 2007, Weinberg et al. have published a study with a biomechanical comparison of crossed pinning, elastic stabile intramedullary nailing (ESIN), and two different configurations of EF in a cadaver model in PubMed listed Clinical Biomechanics [3].

In our study, we found no significant differences for the 4 methods tested in quasi-static flexional, extensional, and torsional loading [3]. In contrast to Li et al., specimen in our tests was also subjected to cyclic loading simulating movement during fracture healing. In this test, EF had worse outcomes with higher irreversible axial deformations compared to crossed k-wires and ESIN. The irreversible angular deformation was highest for the EF using k-wires followed by ESIN and the EF with Schanz screws and crossed pinning [3].

Regarding other publications, a study by Kamara et al. compared k-wire osteosynthesis with different pin configurations, ESIN and EF with Schanz screws in different static loading conditions [4]. They described that ESIN provided the best overall stability in proximal fractures while pinning was superior to stabilize fractures in the distal supracondylar region. Regarding pin placement, they found two lateral and one medial pin to be the most stable pin configuration. Their data reflects our findings with good stability of crossed pinning in distal fractures. Finally, Hohloch et al. reported the superior stability of ulnar over radial anti-rotation wires in EF with Schanz screws under static loading conditions [1].

Possible reasons for the discrepancy between the different biomechanical studies may be attributed to the experimental model: cadaver or synthetic bone, fracture type, and mode of biomechanical testing. Especially, the fracture type will have impact on the test results of EF. While we tested our specimens with a fracture gap simulating fracture comminution, other authors used models without gaps. This could explain the different data regarding EF: if a compression of the fracture gap is applied it is superior to other methods, if a gap remains it is less stable than crossed pinning or ESIN.

We congratulate Li and co-workers to their work, but would recommend being more careful with their statement being the first to report biomechanical data on EF in supracondylar fractures because extensive experimental work has already been published regarding this issue a decade before.

Not applicable.

1.
Hohloch L, Konstantinidis L, Wagner FC, Strohm PC, Sudkamp NP, Reising K. Biomechanical evaluation of a new technique for external fixation of unstable supracondylar humerus fractures in children. Technol Health Care. 2015;23(4):453–61.
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2.
Li WC, Meng QX, Xu RJ, Cai G, Chen H, Li HJ. Biomechanical analysis between Orthofix(R) external fixator and different K-wire configurations for pediatric supracondylar humerus fractures. J Orthop Surg Res. 2018;13(1):188.
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3.
Weinberg AM, Castellani C, Arzdorf M, Schneider E, Gasser B, Linke B. Osteosynthesis of supracondylar humerus fractures in children: a biomechanical comparison of four techniques. Clin Biomech (Bristol, Avon). 2007;22(5):502–9.
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4.
Kamara A, Ji X, Liu T, Zhan Y, Li J, Wang E. A comparative biomechanical study on different fixation techniques in the management of transverse metaphyseal-diaphyseal junction fractures of the distal humerus in children. Int Orthop. 2019;43(2):411–6.
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We would like to acknowledge the contribution of Michael Arzdorf, Berend Linke, Beat Gasser, and Erich Schneider to our original manuscript published in Clinical Biomechanics in 2007.

Affiliations

Department of Pediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
Christoph Castellani & Holger Till
Department of Orthopaedics and Traumatology, Medical University of Graz, Graz, Austria
Annelie-Martina Weinberg

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Christoph CastellaniView author publications
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Holger TillView author publications
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Annelie-Martina WeinbergView author publications
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Contributions

CC has written the letter, AMW and HT have critically revised it. The authors read and approved the final manuscript.

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Correspondence to Christoph Castellani.

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Castellani, C., Till, H. & Weinberg, A. Biomechanical investigation of external fixators for the treatment of supracondylar humerus fractures. J Orthop Surg Res 15, 286 (2020). https://doi.org/10.1186/s13018-020-01815-2

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Received: 30 June 2020
Accepted: 22 July 2020
Published: 28 July 2020
DOI: https://doi.org/10.1186/s13018-020-01815-2

中文翻译：

外固定架治疗肱骨con上骨折的生物力学研究。

在儿童中，con上肱骨病变是最常见的骨折之一。闭合复位和经皮固定仍是治疗的金标准（在[1]中进行了总结）。已经提出了弹性稳定的髓内钉（ESIN）作为替代方案。但是，这些技术可能无法提供足够的稳定性，尤其是在粉碎区域或倾斜裂缝的情况下。因此，已经提出了具有各种技术配置的外固定（EF）作为替代。另外，EF在具有污染或即将发生的室综合征的开放性骨折中可能具有优势。过去，EF一直是生物力学稳定性测试的主题。对此，Li等。发表了一项分析，比较了2018年《 Journal》中不同的k线配置和外部固定[2]。他们得出结论：外固定器可以为小儿con上肱骨骨折提供足够的稳定性，而不会损伤尺神经。此外，它可以提高结构在旋转载荷下的旋转刚度，从而避免肘内翻的复杂化[2]。在讨论部分，他们指出“尚无关于肱骨sup上骨折外固定架生物力学分析的报道” [2]。

李等人的这种说法。率先报告有关EF的生物力学数据是不正确的。温伯格（Weinberg）等人早在2007年。在发表于《 PubMed临床医学力学》的尸体模型中，已发表了一项研究，对交叉钉扎，弹性稳定髓内钉（ESIN）和EF的两种不同配置进行了生物力学比较[3]。

在我们的研究中，我们发现在准静态弯曲，拉伸和扭转载荷下测试的4种方法没有显着差异[3]。与Li等人相反，我们测试中的标本还经受了模拟荷载在骨折愈合过程中运动的循环载荷。在该测试中，与交叉k线和ESIN相比，EF的不良结果具有更高的不可逆轴向变形。对于使用k线的EF，EF的不可逆角变形最高，其次是ESIN和使用Schanz螺钉和交叉销钉的EF [3]。

关于其他出版物，Kamara等人的研究。比较了在不同静态载荷条件下具有不同销配置，ESIN和EF与Schanz螺钉的k线骨合成[4]。他们描述了ESIN在近端骨折中提供了最佳的整体稳定性，而钉扎优于稳定con上远端区域的骨折。关于引脚的放置，他们发现两个外侧和一个内侧引脚是最稳定的引脚配置。他们的数据反映了我们的发现，在远端骨折中交叉钉扎具有良好的稳定性。最后，Hohloch等。报道了在静态载荷条件下，使用Schanz螺钉在EF中尺骨的稳定性优于径向防旋转线[1]。

不同生物力学研究之间差异的可能原因可能是实验模型：尸体或合成骨，骨折类型和生物力学测试模式。特别是，断裂类型会影响EF的测试结果。当我们用模拟裂缝粉碎的裂缝间隙测试样本时，其他作者使用的模型没有裂缝。这可以解释关于EF的不同数据：如果施加骨折间隙的压缩效果优于其他方法，如果仍然存在间隙，则其稳定性不如交叉钉扎或ESIN。

我们祝贺Li和他的同事的工作，但是建议他们更加谨慎，因为他们的陈述是第一个报告con上骨折中EF的生物力学数据的陈述，因为十年前已经对此问题进行了广泛的实验工作。

不适用。

1。
Hohloch L，Konstantinidis L，Wagner FC，Strohm PC，Sudkamp NP，ReisingK。一种新技术的儿童外of不稳定肱骨external上骨折外固定的生物力学评估。技术保健。2015; 23（4）：453-61。
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2。
李WC，孟QX，徐荣杰，蔡刚，陈红，李宏杰。小儿con上肱骨骨折Orthofix（R）外固定器与不同K线配置之间的生物力学分析。J Orthop外科水库。2018; 13（1）：188。
文章Google学术搜索
3。
Weinberg AM，Castellani C，Arzdorf M，Schneider E，Gasser B，LinkeB。儿童con上肱骨骨折的骨合成：四种技术的生物力学比较。Clin Biomech（布里斯托尔，雅芳）。2007; 22（5）：502–9。
CAS文章Google学术搜索
4。
Kamara A，Ji X，Liu T，Zhan Y，Li J，Wang E.不同固定技术在儿童肱骨远端干meta端-干dia端连接骨折处理中的比较生物力学研究。Int Orthop。2019; 43（2）：411–6。
文章Google学术搜索

下载参考

我们要感谢Michael Arzdorf，Berend Linke，Beat Gasser和Erich Schneider对我们于2007年在《临床生物力学》上发表的原始手稿的贡献。

隶属关系

奥地利格拉茨格拉茨医科大学儿科和青少年外科
克里斯托夫·卡斯特拉尼（Christoph Castellani）和霍尔格·蒂尔（Holger Till）
奥地利格拉茨格拉茨医科大学骨伤科
安妮莉·马丁娜·温伯格

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会费

CC已写信，AMW和HT已对其进行了严格修订。作者阅读并批准了最终手稿。

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对应克里斯托弗·卡斯特拉尼。

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