Research progress in biomechanics of common internal fixation for femoral neck fracture_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WANG Fuyang , LIU Yuchen , CHENG Liangliang ,  ZHAO Dewei

Department of Orthopedics, Affiliated Zhongshan Hospital of Dalian University, Dalian Liaoning, 116001, P. R. China;

Corresponding author：

ZHAO Dewei, Email: zhaodewei2016@163.com

Keywords：

Femoral neck fracture; internal fixation; biomechanics

DOI：

10.7507/1002-1892.202204040

Video：

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Objective To summarize the characteristics and biomechanical research progress of common internal fixation for femoral neck fractures in recent years, so as to provide reference to clinical treatment of femoral neck fracture. Methods The domestic and foreign relevant literature on biomechanics of internal fixation of femoral neck fracture in recent years was reviewed, and the biomechanical research progress was summarized. Results Among the internal fixations currently used in the treatment of femoral neck fractures, three cannulated screws can provide sliding compression at the end of the fracture, but the shear resistance is weak, and the risk of long-term internal fixation failure is high; dynamic hip screw and proximal femoral locking plate have excellent angle stability and overall strength; medial buttress plate can transform vertical shear force into compressive stress to promote fracture healing and produce a certain anti-rotation effect; femoral neck system can support the fracture in multi-axial direction, with excellent anti-rotation and anti-shortening properties; and cephalomedullary nails have high overall strength and failure load. Different internal fixations have their own indications due to differences in structure and biomechanics. Conclusion At present, there is no detailed standard guidance of internal fixation selection. Clinically, the appropriate treatment should be selected according to the fracture types of patients.

Citation： WANG Fuyang, LIU Yuchen, CHENG Liangliang, ZHAO Dewei. Research progress in biomechanics of common internal fixation for femoral neck fracture. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(7): 896-901. doi: 10.7507/1002-1892.202204040 Copy

1.	Wang Y, Ma JX, Yin T, et al. Correlation between reduction quality of femoral neck fracture and femoral head necrosis based on biomechanics. Orthop Surg, 2019, 11(2): 318-324.
2.	Schemitsch EH, Sprague S, Heetveld MJ, et al. Loss of independence after operative management of femoral neck fractures. J Orthop Trauma, 2019, 33(6): 292-300.
3.	Sekeitto AR, Sikhauli N, van der Jagt DR, et al. The management of displaced femoral neck fractures: a narrative review. EFORT Open Rev, 2021, 6(2): 139-144.
4.	Augat P, Bliven E, Hackl S. Biomechanics of femoral neck fractures and implications for fixation. J Orthop Trauma, 2019, 33 Suppl 1: S27-S32.
5.	Cha YH, Yoo JI, Hwang SY, et al. Biomechanical evaluation of internal fixation of Pauwels type Ⅲ femoral neck fractures: A systematic review of various fixation methods. Clin Orthop Surg, 2019, 11(1): 1-14.
6.	Cristofolini L, Juszczyk M, Martelli S, et al. In vitro replication of spontaneous fractures of the proximal human femur. J Biomech, 2007, 40(13): 2837-2845.
7.	Schileo E, Balistreri L, Grassi L, et al. To what extent can linear finite element models of human femora predict failure under stance and fall loading configurations? J Biomech, 2014, 47(14): 3531-3538.
8.	Augat P, Reeb H, Claes LE. Prediction of fracture load at different skeletal sites by geometric properties of the cortical shell. J Bone Miner Res, 1996, 11(9): 1356-1363.
9.	Dinçel VE, Sengelen M, Sepici V, et al. The association of proximal femur geometry with hip fracture risk. Clin Anat, 2008, 21(6): 575-580.
10.	Guo J, Dong W, Yin Y, et al. The effect of configuration of rhombic cannulated screws on internal fixation of femoral neck fractures. Orthopedics, 2020, 43(2): e72-e78.
11.	Duffin M, Pilson HT. Technologies for young femoral neck fracture fixation. J Orthop Trauma, 2019, 33 Suppl 1: S20-S26.
12.	Li J, Wang M, Zhou J, et al. Optimum configuration of cannulated compression screws for the fixation of unstable femoral neck fractures: Finite element analysis evaluation. Biomed Res Int, 2018, 2018: 1271762. doi: 10.1155/2018/1271762.
13.	Schottel PC, Blankstein M, Sprague S, et al. Optimal technical factors during operative management of low-energy femoral neck fractures. J Orthop Trauma, 2021, 35(2): 92-99.
14.	Jiang D, Zhan S, Wang L, et al. Biomechanical comparison of five cannulated screw fixation strategies for young vertical femoral neck fractures. J Orthop Res, 2021, 39(8): 1669-1680.
15.	Hollensteiner M, Sandriesser S, Bliven E, et al. Biomechanics of osteoporotic fracture fixation. Curr Osteoporos Rep, 2019, 17(6): 363-374.
16.	楼宇梁, 洪建军, 余可和, 等. 不同直径空心钉闭合复位内固定治疗股骨颈骨折疗效分析. 中国骨伤, 2015, 28(9): 792-795.
17.	何晓君, 徐红伟, 季康, 张中伟, 等. 股骨颈骨折2枚空心螺钉内固定的力学稳定性研究. 中国骨伤, 2016, 29(11): 994-1000.
18.	Panteli M, Rodham P, Giannoudis PV. Biomechanical rationale for implant choices in femoral neck fracture fixation in the non-elderly. Injury, 2015, 46(3): 445-452.
19.	Zhao D, Qiu X, Wang B, et al. Epiphyseal arterial network and inferior retinacular artery seem critical to femoral head perfusion in adults with femoral neck fractures. Clin Orthop Relat Res, 2017, 475(8): 2011-2023.
20.	Zhan S, Jiang D, Ling M, et al. Fixation effects of different types of cannulated screws on vertical femoral neck fracture: A finite element analysis and experimental study. Med Eng Phys, 2021, 97: 32-39.
21.	Zhang B, Liu J, Zhang W. Ordinary cannulated compression screws or headless cannulated compression screws? A synthetic bone biomechanical research in the internal fixation of vertical demoral neck fracture. Biomed Res Int, 2018, 2018: 4898301. doi: 10.1155/2018/4898301.
22.	Filipov O, Stoffel K, Gueorguiev B, et al. Femoral neck fracture osteosynthesis by the biplane double-supported screw fixation method (BDSF) reduces the risk of fixation failure: clinical outcomes in 207 patients. Arch Orthop Trauma Surg, 2017, 137(6): 779-788.
23.	Tianye L, Peng Y, Jingli X, et al. Finite element analysis of different internal fixation methods for the treatment of Pauwels type Ⅲ femoral neck fracture. Biomed Pharmacother, 2019, 112: 108658. doi: 10.1016/j.biopha.2019.108658.
24.	Lim EJ, Shon HC, Cho JW, et al. Dynamic hip screw versus cannulated cancellous screw in Pauwels type Ⅱ or type Ⅲ femoral neck fracture: A systematic review and meta-analysis. J Pers Med, 2021, 11(10): 1017. doi: 10.3390/jpm11101017.
25.	Stoffel K, Zderic I, Gras F, et al. Biomechanical evaluation of the femoral neck system in unstable Pauwels Ⅲ femoral neck fractures: A comparison with the dynamic hip screw and cannulated screws. J Orthop Trauma, 2017, 31(3): 131-137.
26.	Zeng W, Liu Y, Hou X. Biomechanical evaluation of internal fixation implants for femoral neck fractures: A comparative finite element analysis. Comput Methods Programs Biomed, 2020, 196: 105714. doi: 10.1016/j.cmpb.2020.105714.
27.	Knobe M, Altgassen S, Maier KJ, et al. Screw-blade fixation systems in Pauwels three femoral neck fractures: a biomechanical evaluation. Int Orthop, 2018, 42(2): 409-418.
28.	Samsami S, Augat P, Rouhi G. Stability of femoral neck fracture fixation: A finite element analysis. Proc Inst Mech Eng H, 2019, 233(9): 892-900.
29.	Bliven E, Sandriesser S, Augat P, et al. Biomechanical evaluation of locked plating fixation for unstable femoral neck fractures. Bone Joint Res, 2020, 9(6): 314-321.
30.	Zhang YL, Chen S, Ai ZS, et al. Osteonecrosis of the femoral head, nonunion and potential risk factors in Pauwels grade-3 femoral neck fractures: A retrospective cohort study. Medicine (Baltimore), 2016, 95(24): e3706. doi: 10.1097/MD.0000000000003706.
31.	Ye Y, Chen K, Tian K, et al. Medial buttress plate augmentation of cannulated screw fixation in vertically unstable femoral neck fractures: Surgical technique and preliminary results. Injury, 2017, 48(10): 2189-2193.
32.	Kunapuli SC, Schramski MJ, Lee AS, et al. Biomechanical analysis of augmented plate fixation for the treatment of vertical shear femoral neck fractures. J Orthop Trauma, 2015, 29(3): 144-150.
33.	Giordano V, Alves DD, Paes RP, et al. The role of the medial plate for Pauwels type Ⅲ femoral neck fracture: a comparative mechanical study using two fixations with cannulated screws. J Exp Orthop, 2019, 6(1): 18. doi: 10.1186/s40634-019-0187-3.
34.	Ma C, Liu Y, Liu J, et al. The role of the medial buttress plate in the treatment of Pauwels type Ⅱ and Ⅲ femoral neck fracture in nonelderly patients: a retrospective study and preliminary results. BMC Musculoskelet Disord, 2022, 23(1): 100. doi: 10.1186/s12891-022-05056-8.
35.	Mubark I, Nafady M, Motawea BA. Locking plate fixation system for intracapsular fracture neck of femur in young patients. Ortop Traumatol Rehabil, 2021, 23(1): 27-32.
36.	Basso T, Klaksvik J, Foss OA. Locking plates and their effects on healing conditions and stress distribution: A femoral neck fracture study in cadavers. Clin Biomech (Bristol, Avon), 2014, 29(5): 595-598.
37.	Viberg B, Rasmussen KMV, Overgaard S, et al. Poor relation between biomechanical and clinical studies for the proximal femoral locking compression plate. Acta Orthop, 2017, 88(4): 427-433.
38.	Schneider K, Oh JK, Zderic I, et al. What is the underlying mechanism for the failure mode observed in the proximal femoral locking compression plate? A biomechanical study. Injury, 2015, 46(8): 1483-1490.
39.	Wazen RM, Currey JA, Guo H, et al. Micromotion-induced strain fields influence early stages of repair at bone-implant interfaces. Acta Biomater, 2013, 9(5): 6663-6674.
40.	Wang G, Tang Y, Wu X, et al. Finite element analysis of a new plate for Pauwels type Ⅲ femoral neck fractures. J Int Med Res, 2020, 48(2): 300060520903669. doi: 10.1177/0300060520903669.
41.	Medda S, Snoap T, Carroll EA. Treatment of young femoral neck fractures. Journal of Orthopaedic Trauma, 2019, 33(1): S1-S6.
42.	Schopper C, Zderic I, Menze J, et al. Higher stability and more predictive fixation with the femoral neck system versus Hansson Pins in femoral neck fractures Pauwels Ⅱ. J Orthop Translat, 2020, 24: 88-95.
43.	Lee YK, Yoon BH, Hwang JS, et al. Risk factors of fixation failure in basicervical femoral neck fracture: Which device is optimal for fixation? Injury, 2018, 49(3): 691-696.
44.	Imren Y, Gurkan V, Bilsel K, et al. Biomechanical comparison of dynamic hip screw, proximal femoral nail, cannulated screw, and monoaxial external fixation in the treatment of basicervical femoral neck fractures. Acta Chir Orthop Traumatol Cech, 2015, 82(2): 140-144.
45.	Guo J, Dong W, Yin B, et al. Intramedullary nails with cannulated screw fixation for the treatment of unstable femoral neck fractures. J Int Med Res, 2019, 47(2): 557-568.
46.	Slobogean GP, Sprague SA, Scott T, et al. Complications following young femoral neck fractures. Injury, 2015, 46(3): 484-491.

1. Wang Y, Ma JX, Yin T, et al. Correlation between reduction quality of femoral neck fracture and femoral head necrosis based on biomechanics. Orthop Surg, 2019, 11(2): 318-324.
2. Schemitsch EH, Sprague S, Heetveld MJ, et al. Loss of independence after operative management of femoral neck fractures. J Orthop Trauma, 2019, 33(6): 292-300.
3. Sekeitto AR, Sikhauli N, van der Jagt DR, et al. The management of displaced femoral neck fractures: a narrative review. EFORT Open Rev, 2021, 6(2): 139-144.
4. Augat P, Bliven E, Hackl S. Biomechanics of femoral neck fractures and implications for fixation. J Orthop Trauma, 2019, 33 Suppl 1: S27-S32.
5. Cha YH, Yoo JI, Hwang SY, et al. Biomechanical evaluation of internal fixation of Pauwels type Ⅲ femoral neck fractures: A systematic review of various fixation methods. Clin Orthop Surg, 2019, 11(1): 1-14.
6. Cristofolini L, Juszczyk M, Martelli S, et al. In vitro replication of spontaneous fractures of the proximal human femur. J Biomech, 2007, 40(13): 2837-2845.
7. Schileo E, Balistreri L, Grassi L, et al. To what extent can linear finite element models of human femora predict failure under stance and fall loading configurations? J Biomech, 2014, 47(14): 3531-3538.
8. Augat P, Reeb H, Claes LE. Prediction of fracture load at different skeletal sites by geometric properties of the cortical shell. J Bone Miner Res, 1996, 11(9): 1356-1363.
9. Dinçel VE, Sengelen M, Sepici V, et al. The association of proximal femur geometry with hip fracture risk. Clin Anat, 2008, 21(6): 575-580.
10. Guo J, Dong W, Yin Y, et al. The effect of configuration of rhombic cannulated screws on internal fixation of femoral neck fractures. Orthopedics, 2020, 43(2): e72-e78.
11. Duffin M, Pilson HT. Technologies for young femoral neck fracture fixation. J Orthop Trauma, 2019, 33 Suppl 1: S20-S26.
12. Li J, Wang M, Zhou J, et al. Optimum configuration of cannulated compression screws for the fixation of unstable femoral neck fractures: Finite element analysis evaluation. Biomed Res Int, 2018, 2018: 1271762. doi: 10.1155/2018/1271762.
13. Schottel PC, Blankstein M, Sprague S, et al. Optimal technical factors during operative management of low-energy femoral neck fractures. J Orthop Trauma, 2021, 35(2): 92-99.
14. Jiang D, Zhan S, Wang L, et al. Biomechanical comparison of five cannulated screw fixation strategies for young vertical femoral neck fractures. J Orthop Res, 2021, 39(8): 1669-1680.
15. Hollensteiner M, Sandriesser S, Bliven E, et al. Biomechanics of osteoporotic fracture fixation. Curr Osteoporos Rep, 2019, 17(6): 363-374.
16. 楼宇梁, 洪建军, 余可和, 等. 不同直径空心钉闭合复位内固定治疗股骨颈骨折疗效分析. 中国骨伤, 2015, 28(9): 792-795.
17. 何晓君, 徐红伟, 季康, 张中伟, 等. 股骨颈骨折2枚空心螺钉内固定的力学稳定性研究. 中国骨伤, 2016, 29(11): 994-1000.
18. Panteli M, Rodham P, Giannoudis PV. Biomechanical rationale for implant choices in femoral neck fracture fixation in the non-elderly. Injury, 2015, 46(3): 445-452.
19. Zhao D, Qiu X, Wang B, et al. Epiphyseal arterial network and inferior retinacular artery seem critical to femoral head perfusion in adults with femoral neck fractures. Clin Orthop Relat Res, 2017, 475(8): 2011-2023.
20. Zhan S, Jiang D, Ling M, et al. Fixation effects of different types of cannulated screws on vertical femoral neck fracture: A finite element analysis and experimental study. Med Eng Phys, 2021, 97: 32-39.
21. Zhang B, Liu J, Zhang W. Ordinary cannulated compression screws or headless cannulated compression screws? A synthetic bone biomechanical research in the internal fixation of vertical demoral neck fracture. Biomed Res Int, 2018, 2018: 4898301. doi: 10.1155/2018/4898301.
22. Filipov O, Stoffel K, Gueorguiev B, et al. Femoral neck fracture osteosynthesis by the biplane double-supported screw fixation method (BDSF) reduces the risk of fixation failure: clinical outcomes in 207 patients. Arch Orthop Trauma Surg, 2017, 137(6): 779-788.
23. Tianye L, Peng Y, Jingli X, et al. Finite element analysis of different internal fixation methods for the treatment of Pauwels type Ⅲ femoral neck fracture. Biomed Pharmacother, 2019, 112: 108658. doi: 10.1016/j.biopha.2019.108658.
24. Lim EJ, Shon HC, Cho JW, et al. Dynamic hip screw versus cannulated cancellous screw in Pauwels type Ⅱ or type Ⅲ femoral neck fracture: A systematic review and meta-analysis. J Pers Med, 2021, 11(10): 1017. doi: 10.3390/jpm11101017.
25. Stoffel K, Zderic I, Gras F, et al. Biomechanical evaluation of the femoral neck system in unstable Pauwels Ⅲ femoral neck fractures: A comparison with the dynamic hip screw and cannulated screws. J Orthop Trauma, 2017, 31(3): 131-137.
26. Zeng W, Liu Y, Hou X. Biomechanical evaluation of internal fixation implants for femoral neck fractures: A comparative finite element analysis. Comput Methods Programs Biomed, 2020, 196: 105714. doi: 10.1016/j.cmpb.2020.105714.
27. Knobe M, Altgassen S, Maier KJ, et al. Screw-blade fixation systems in Pauwels three femoral neck fractures: a biomechanical evaluation. Int Orthop, 2018, 42(2): 409-418.
28. Samsami S, Augat P, Rouhi G. Stability of femoral neck fracture fixation: A finite element analysis. Proc Inst Mech Eng H, 2019, 233(9): 892-900.
29. Bliven E, Sandriesser S, Augat P, et al. Biomechanical evaluation of locked plating fixation for unstable femoral neck fractures. Bone Joint Res, 2020, 9(6): 314-321.
30. Zhang YL, Chen S, Ai ZS, et al. Osteonecrosis of the femoral head, nonunion and potential risk factors in Pauwels grade-3 femoral neck fractures: A retrospective cohort study. Medicine (Baltimore), 2016, 95(24): e3706. doi: 10.1097/MD.0000000000003706.
31. Ye Y, Chen K, Tian K, et al. Medial buttress plate augmentation of cannulated screw fixation in vertically unstable femoral neck fractures: Surgical technique and preliminary results. Injury, 2017, 48(10): 2189-2193.
32. Kunapuli SC, Schramski MJ, Lee AS, et al. Biomechanical analysis of augmented plate fixation for the treatment of vertical shear femoral neck fractures. J Orthop Trauma, 2015, 29(3): 144-150.
33. Giordano V, Alves DD, Paes RP, et al. The role of the medial plate for Pauwels type Ⅲ femoral neck fracture: a comparative mechanical study using two fixations with cannulated screws. J Exp Orthop, 2019, 6(1): 18. doi: 10.1186/s40634-019-0187-3.
34. Ma C, Liu Y, Liu J, et al. The role of the medial buttress plate in the treatment of Pauwels type Ⅱ and Ⅲ femoral neck fracture in nonelderly patients: a retrospective study and preliminary results. BMC Musculoskelet Disord, 2022, 23(1): 100. doi: 10.1186/s12891-022-05056-8.
35. Mubark I, Nafady M, Motawea BA. Locking plate fixation system for intracapsular fracture neck of femur in young patients. Ortop Traumatol Rehabil, 2021, 23(1): 27-32.
36. Basso T, Klaksvik J, Foss OA. Locking plates and their effects on healing conditions and stress distribution: A femoral neck fracture study in cadavers. Clin Biomech (Bristol, Avon), 2014, 29(5): 595-598.
37. Viberg B, Rasmussen KMV, Overgaard S, et al. Poor relation between biomechanical and clinical studies for the proximal femoral locking compression plate. Acta Orthop, 2017, 88(4): 427-433.
38. Schneider K, Oh JK, Zderic I, et al. What is the underlying mechanism for the failure mode observed in the proximal femoral locking compression plate? A biomechanical study. Injury, 2015, 46(8): 1483-1490.
39. Wazen RM, Currey JA, Guo H, et al. Micromotion-induced strain fields influence early stages of repair at bone-implant interfaces. Acta Biomater, 2013, 9(5): 6663-6674.
40. Wang G, Tang Y, Wu X, et al. Finite element analysis of a new plate for Pauwels type Ⅲ femoral neck fractures. J Int Med Res, 2020, 48(2): 300060520903669. doi: 10.1177/0300060520903669.
41. Medda S, Snoap T, Carroll EA. Treatment of young femoral neck fractures. Journal of Orthopaedic Trauma, 2019, 33(1): S1-S6.
42. Schopper C, Zderic I, Menze J, et al. Higher stability and more predictive fixation with the femoral neck system versus Hansson Pins in femoral neck fractures Pauwels Ⅱ. J Orthop Translat, 2020, 24: 88-95.
43. Lee YK, Yoon BH, Hwang JS, et al. Risk factors of fixation failure in basicervical femoral neck fracture: Which device is optimal for fixation? Injury, 2018, 49(3): 691-696.
44. Imren Y, Gurkan V, Bilsel K, et al. Biomechanical comparison of dynamic hip screw, proximal femoral nail, cannulated screw, and monoaxial external fixation in the treatment of basicervical femoral neck fractures. Acta Chir Orthop Traumatol Cech, 2015, 82(2): 140-144.
45. Guo J, Dong W, Yin B, et al. Intramedullary nails with cannulated screw fixation for the treatment of unstable femoral neck fractures. J Int Med Res, 2019, 47(2): 557-568.
46. Slobogean GP, Sprague SA, Scott T, et al. Complications following young femoral neck fractures. Injury, 2015, 46(3): 484-491.

Chinese Journal of Reparative and Reconstructive Surgery

Research progress in biomechanics of common internal fixation for femoral neck fracture

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