Determination of the internal loads experienced by proximal phalanx fracture fixations during rehabilitation exercises

Abstract

Phalangeal fractures are common, particularly in younger patients, leading to a large economic burden due to higher incident rates among patients of working age. In traumatic cases where the fracture may be unstable, plate fixation has grown in popularity due to its greater construct rigidity. However, these metal plates have increased reoperation rates due to inflammation of the surrounding soft tissue. To overcome these challenges, a novel osteosynthesis platform, AdhFix, has been developed. This method uses a light-curable polymer that can be shaped in situ around traditional metal screws to create a plate-like structure that has been shown to not induce soft tissue adhesions. However, to effectively evaluate any novel osteosynthesis device, the biomechanical environment must first be understood. In this study, the internal loads in a phalangeal plate osteosynthesis were measured under simulated rehabilitation exercises. In a human hand cadaver study, a plastic plate with known biomechanical properties was used to fix a 3 mm osteotomy and each finger was fully flexed to mimic traditional rehabilitation exercises. The displacements of the bone fragments were tracked with a stereographic camera system and coupled with specimen specific finite element (FE) models to calculate the internal loads in the osteosynthesis. Following this, AdhFix patches were created and monotonically tested under similar conditions to determine survival of the novel technique. The internal bending moment in the osteosynthesis was 6.78 ± 1.62 Nmm and none of the AdhFix patches failed under the monotonic rehabilitation exercises. This study demonstrates a method to calculate the internal loads on an osteosynthesis device during non-load bearing exercises and that the novel AdhFix solution did not fail under traditional rehabilitation protocols in this controlled setting. Further studies are required prior to clinical application.

Keywords: CT derived models; customizable osteosythesis; finite element modeling; non-contact measurement; patient-specific treatment.

FIGURE 1

Surgical procedure. (A) Braided steel cable attached to the flexor tendon with sutures. (B) Exposed proximal phalanx through extensor tendon split with periosteum separated to access the bone. (C) Osteotomy guide attached to phalanx with cortical screws and blunt retractor protecting tendons on volar side of the hand. (D) Osteotomized phalanx.

FIGURE 2

(A) Computer aided design (CAD) model of PEEK plate. (B) Representative picture of PEEK plate instrumented on a cadaveric proximal phalanx.

FIGURE 3

Mechanical test setup showing the hand specimen fixated to the wooden substrate, the steel cable connecting the tendon to the testing machine via a pulley and the red optimal markers attached to each bone fragment via K-wires.

FIGURE 4

Finite element model of a representative phalanx with (A) boundary conditions of a pin support and applied displacement show in red. (B) The same model is shown with calculated displacements with cut plane at center of the plate shown as a red line. (C) Zoomed-in view of region of interest highlighting cut plane of plate.

FIGURE 5

(A) Representative picture of an AdhFix patch applied to the proximal phalanx. (B) slice view from CT scan of the AdhFix patch after application. (C) Testing set up of the AdhFix patches to failure with loadcell seen in black.

FIGURE 6

Exemplary figure of the calculated bending moment across the 10 evenly spaced time steps.

FIGURE 7

Box plot of the maximum bending moment calculated in the osteosynthesis, grouped by digit.