A systematic review of the use of titanium versus stainless steel implants for fracture fixation

Abstract

Background: Controversy exists regarding the use of titanium and stainless steel implants in fracture surgery. To our knowledge, no recent, comprehensive review on this topic has been reported.

Purpose: To perform a systematic review of the evidence in the current literature comparing differences between titanium and stainless steel implants for fracture fixation.

Methods: A systematic review of original research articles was performed through the PubMed database using PRISMA guidelines. Inclusion criteria were English-language studies comparing titanium and stainless steel implants in orthopaedic surgery, and outcome data were extracted.

Results: The search returned 938 studies, with 37 studies meeting our criteria. There were 12 clinical research articles performed using human subjects, 11 animal studies, and 14 biomechanical studies. Clinical studies of the distal femur showed the stainless steel cohorts had significantly decreased callus formation and an increased odds radio (OR 6.3, 2.7-15.1; P < .001) of nonunion when compared with the titanium plate cohorts. In the distal radius, 3 clinical trials showed no implant failures in either group, and no difference in incidence of plate removal, or functional outcome. Three clinical studies showed a slightly increased odds ratio of locking screw breakage with stainless steel intramedullary nails compared with titanium intramedullary nails (OR 1.52, CI 1.1-2.13).

Conclusion: Stainless steel implants have equal or superior biomechanical properties when compared with titanium implants. However, there is clinical evidence that titanium plates have a lower rate of failure and fewer complications than similar stainless steel implants in some situations. Although our review supports the use of titanium implants in these clinical scenarios, we emphasize that further prospective, comparative clinical studies are required before the conclusions can be made.

Keywords: clinical evidence; fracture fixation; stainless steel; titanium.

Figure 1

Schematic of studies included in this review.

Figure 2

Fatigue failure of a stainless steel implant used for fixation of a comminuted distal femoral fracture in a 34-year-old male, 12 months postoperatively, with varus deformity and shortening.

Figure 3

(A) A stainless steel antegrade femoral nail with fatigue failure of the nail through the proximal locking hole. (B) A close-up photograph of the fatigue failure of the nail.

Figure 4

(A) A long titanium precontoured distal humeral plate was used to repair a complex distal humeral fracture in an 18-year-old male patient. (B) Due to local soft-tissue irritation and the patient's request, hardware removal was performed. The procedure was uncomplicated and took only 35 minutes. Modern titanium alloys have much better handling characteristics than older implants and cold-welding, screw breakage, and screw stripping are infrequent.