SUPPLEMENT ARTICLE
Biomechanical Concepts for Fracture Fixation
Michael Bottlang, PhD,* Christine E. Schemitsch, Aaron Nauth, MD, FRCSC,
Milton Routt, Jr, MD, Kenneth A. Egol, MD,k Gillian E. Cook, MHSc,
and Emil H. Schemitsch, MD, FRCSC**
Summary: Application of the correct xation construct is critical for
fracture healing and long-term stability; however, it is a complex issue
with numerous signicant factors. This review describes a number of
common fracture types and evaluates their currently available fracture
xation constructs. In the setting of complex elbow instability, stable
xation or radial head replacement with an appropriately sized implant
in conjunction with ligamentous repair is required to restore stability.
For unstable sacral fractures with vertical or multiplanar instabilities,
standard iliosacral screw xation is not sufcient. Periprosthetic femur
fractures, in particular Vancouver B1 fractures, have increased stability
when using 90/90 xation versus a single locking plate. Far cortical
locking combines the concept of dynamization with locked plating to
achieve superior healing of a distal femur fracture. Finally, there is no
ideal construct for syndesmotic fracture stabilization; however, these
fractures should be xed using a device that allows for sufcient motion
in the syndesmosis. In general, orthopaedic surgeons should select
a fracture xation construct that restores stability and promotes healing
at the fracture site, while reducing the potential for xation failure.
Key Words: coronoid fracture, radial head fracture, unstable sacral
fractures, iliosacral screws, far cortical locking, interfragmentary
motion
(J Orthop Trauma 2015;29:S28S33)
INTRODUCTION
Selection of the appropriate fracture xation method is
a multifaceted issue that depends on the location and type of
fracture, the inherent stability at the fracture site, and the
Accepted for publication September 17, 2015.
From the *Portland Biomechanics Laboratory, Legacy Research Institute, Port-
land, OR; Division of Orthopaedic Surgery, Department of Surgery,
St. Michaels Hospital, Toronto, ON, Canada; Division of Orthopaedic
Surgery, St. Michaels Hospital, University of Toronto, Toronto, ON,
Canada; Department of Orthopedic Surgery and Sports Medicine, Univer-
sity of Texas Health Science Center at Houston, Houston, TX; kNYU
Hospital for Joint Diseases, Department of Orthopaedic Surgery,
New York, NY; Institute of Biomaterials and Biomedical Engineering,
University of Toronto, Toronto, ON, Canada; and **University of Toronto,
Toronto, ON, Canada.
Dr M. Bottlang declares that he receives royalties from the sale of far cortical
locking screws. The other authors report no conict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journals Web site (www.jorthotrauma.com).
The authors alone are responsible for the content and writing of this article.
Reprints: Emil H. Schemitsch, MD, FRCSC, St. Michaels Hospital, Univer-
sity of Toronto, 55 Queen St. E., Suite 800, Toronto, Ontario M5C 1R6,
Canada (e-mail: schemitsche@smh.ca).
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
S28 | www.jorthotrauma.com J Orthop Trauma  Volume 29, Number 12 Supplement, December 2015
Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
desired degree of exibility and motion required for healing.
This review assesses current xation devices used in radial
head and coronoid fractures, sacral fractures, periprosthetic
and distal femur fractures, and syndesmosis injuries and
discusses the biomechanics of each.
RADIAL HEAD AND CORONOID FRACTURES:
BIOMECHANICAL EVIDENCE FOR
MODERN APPROACHES
Several biomechanical studies have provided important
evidence that can help to guide the management of radial
head and coronoid fractures of the elbow. The majority of
these have focused on the importance of appropriate man-
agement of these fractures when combined with ligamentous
injury (ie, complex elbow instability or fracture-dislocations
of the elbow). From these studies, several noteworthy
concepts can be obtained.
First, stable xation or replacement of the radial head in
the setting of traumatic elbow instability is critical. Multiple
biomechanical investigations have demonstrated that the
radial head is critically important to elbow stability when
the ligaments of the elbow have been disrupted.13 These
studies have further shown that elbow stability is best restored
by ligamentous repair combined with stable radial head xa-
tion or replacement. This biomechanical literature, combined
with the clinical evidence which has shown that signicantly
displaced radial head fractures are an important predictor of
elbow dislocation,4 suggests that these fractures are best trea-
ted with stable xation or replacement in combination with
ligamentous repair. Practically speaking, this means that
radial head excision is contraindicated in the setting of com-
plex elbow instability and that if stable xation cannot be
achieved, radial head replacement should be performed. This,
combined with the clinical evidence of poor outcomes in
comminuted, displaced, radial head fractures treated with
open reduction and internal xation (ORIF),5 has led to a dis-
tinct shift by orthopaedic trauma surgeons toward radial head
replacement in the setting of complex elbow instability, even
in young patients.
Second, correct sizing of a radial head replacement is
critical to restoring joint kinematics and contact pressures, and
yet improper sizing is one of the most commonly encountered
surgical errors. This is typically due to overstufng of the joint
in an effort to compensate for instability of the elbow.
Biomechanical studies have demonstrated that improper sizing
of the radial head replacement results in increased joint contact
pressures, elbow instability, and altered biomechanics in the
 J Orthop Trauma  Volume 29, Number 12 Supplement, December 2015
forearm.6,7 These studies have shown that the best restoration of
elbow stability and mechanics occurs with accurate radial head
sizing and ligamentous repair. Several anatomic and radio-
graphic landmarks for accurate radial head sizing have been
described in the literature and should be used accordingly.8
Third, stable xation of a complete radial head fracture
is best achieved with crossed screws or a xed angle device,
particularly in the setting of incomplete cortical contact
between the head and the neck. Two separate biomechanical
studies have shown the importance of using such constructs to
obtain stable radial head xation in the setting of a complete
articular fracture of the radial head.9,10
Finally, when considering the need for xation of the
coronoid in the setting of complex elbow instability, both the
size and location of the coronoid fragment is important. Several
biomechanical studies evaluating the inuence of coronoid
fragment size and xation in the setting of terrible triad injuries
have shown that it is not necessary to perform xation of
coronoid fragments involving less than 40%50% of the coro-
noid, provided that radial head stability is restored and ligament
repair is performed.1113 This literature suggests that previous
thinking, which recommended that coronoid fragments of any
size be xed in the setting of terrible triad injuries, was incor-
rect. Subsequent clinical literature has provided further support
for this notion.14 Biomechanical research has shown that the
location of the coronoid fracture is also important in elbow
stability because even small anteromedial facet fractures (.5
mm) can be signicantly unstable and likely warrant xation.15
UNSTABLE SACRAL FRACTURES: IS STANDARD
ILIOSACRAL SCREW FIXATION ADEQUATE?
Unstable pelvic ring injuries usually result from high-
energy traumatic events, such as automobile accidents, and in
osteopenic patients due to less violent incidents such as falls.
Sacral fractures are common in pelvic ring injuries; their
instability depends on numerous factors, and the foremost
among them is the magnitude of the applied traumatic load.
Iliosacral screw insertion became a popular xation
method for unstable posterior pelvic ring injuries because
they could be safely inserted via small surgical incisions,
which lowered wound complication rates, operative blood
losses, and operative times signicantly, while avoiding deep
pelvic hematoma.16 Furthermore, high-quality intraoperative
uoroscopic imaging was available to guide and assess closed
posterior pelvic reduction techniques and iliosacral screw in-
sertions. Standard iliosacral screw xation was commonly
dened as a single, cannulated, 7-mm screw inserted from the
lateral iliac cortical surface, across the sacroiliac joint,
through the sacral ala below the alar cortical surface and
above the nerve root tunnel, and ending in the upper sacral
vertebral body or contralateral ala (see Figure, Supplemental
Digital 1 Content, http://links.lww.com/BOT/A546). The
screw starting point, directional aim, and length were deter-
mined by the particular injury pattern and osteology. The
development of longer, 7-mm-diameter, cannulated, cancel-
lous screws allowed for transiliactranssacral (TITS) screw
orientations to be used (see Figure, Supplemental Digital
Content, http://links.lww.com/BOT/A546). One clinical
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Biomechanical Concepts for Fracture Fixation
study showed that xation failure rates were signicantly
lowered in patients with unstable posterior pelvic injuries
when TITS screws were used compared with shorter length
screws.17 Patient compliance must also be considered when
planning the sacral xation construct because early unpro-
tected weight bearing after surgery can lead to xation failure.
Standard iliosacral screw xation alone is therefore not
advocated for potentially noncompliant patients.
In several clinical series, a standard iliosacral screw in
the upper sacral segment xation construct failed to maintain the
reduction, especially with certain injury patterns.16,18 The most
common factor associated with standard xation failure was
a highly displaced sacral fracture that had been poorly reduced,
either after closed manipulation or after open reduction. Poor
reduction of a sacral fracture was also noted to diminish the safe
region available for iliosacral screw insertion.19 Unsurprisingly,
the more unstable fracture patterns also correlated with higher
failure rates.18 Another factor noted to increase failure in clinical
practice was insufcient stabilization of the other pelvic ring
injury sites. This correlates with biomechanical studies, which
found that reduction and xation of each injury site improved the
overall xation construct strength.20 Transverse sacral fracture
patterns require additional consideration with regard to iliosacral
screw xation. U-shaped sacral fractures cause instability of the
entire spine, along with the upper sacral segment and the rest of
the pelvis. U-shaped fractures exclude overall ring involvement,
but xation failures, have occurred in association with standard
iliosacral screw xation.21 Thus, for U-shaped sacral fractures,
TITS screws located in the safe sacral osseous xation pathway,
cranial to the transverse fracture, provide stable and durable
xation. Y-shaped and H-shaped sacral fracture patterns are
U-shaped fractures that are further complicated by associated
pelvic ring injuries. For these injuries and U-shaped fractures
that require spinal decompression due to cauda equina syndrome,
supplementary spinopelvic xation should be considered.
Based on clinical and biomechanical studies in addition
to clinical experience, standard iliosacral screw xation
(one upper sacral segment screw) is more likely to be a suc-
cessful treatment for patients with rotationally unstable inju-
ries, especially when the anterior pelvic injury and the sacral
fracture are accurately reduced and stabilized. For more
unstable sacral fracture patterns with vertical or multiplanar
instability, standard iliosacral screw xation will not pro-
vide adequate stability. Following accurate sacral fracture
reduction, several iliosacral screws of appropriate lengths,
located at multiple sacral levels, are optimal. Other important
factors that contribute to overall pelvic ring stability and the
durability of the xation construct include anterior pelvic
injury reduction quality and the choice of implant. Poor ante-
rior pelvic reductions and less stable anterior pelvic xation
devices, such as external xation, place additional stress on
the sacral fracture xation construct. Lumbopelvic xation
can also be used to supplement iliosacral screw xation.
PERIPROSTHETIC FEMUR FRACTURES: 90/90
FIXATION VERSUS A SINGLE LOCKING PLATE?
Periprosthetic femur fractures are a complication of
total hip arthroplasty, and although uncommon, they are
www.jorthotrauma.com | S29
 Bottlang et al J Orthop Trauma  Volume 29, Number 12 Supplement, December 2015
increasing in frequency with the aging population.22,23 Clas-
sication of periprosthetic femur fractures is based on the
Vancouver system.24 The focus of this review is Vancouver
B1 fractures, which account for a majority of periprosthetic
femur fractures.22,25 Vancouver B1 fractures occur around or
just distal to a stable prosthesis. Correctly identifying the
fracture type is imperative to providing the best chance for
a successful outcome.24,26 Vancouver B1 fractures are partic-
ularly difcult to treat because they have a high complication
rate, and the proper treatment method is still under debate.23,27
A 90/90 xation construct for a periprosthetic femur
fracture involves a plate placed laterally and a cortical
allograft strut placed anteriorly. Strut allografts allow greater
mechanical stability and increase bone stock, leading to
improved fracture healing.28,29 Benets of using a locking
plate alone include a minimally invasive technique of inser-
tion, increased angular stability, and a decreased need for
plate contouring.23,28
Biomechanical studies have indicated that a lateral
cable plate with an allograft strut placed anteriorly may
provide superior xation for periprosthetic femoral fractures.
A study by Zdero et al27 showed that 90/90 xation achieved
equal or superior results in axial stiffness, lateral bending
stiffness, and torsional stiffness tests compared with locking
plates alone. Moreover, the results seen with the single lock-
ing plate constructs were similar to nonlocked cable plates.
These results were maintained with cyclic loading. A locked
plate alone was less stiff in bending and had a lower load to
failure than 90/90 allograft strutplate constructs with or
without locking screws.30
A systematic review conducted by Dehghan et al26
compared different operative treatments for Vancouver B1
periprosthetic femur fractures. Two of the treatments that
were compared included ORIF with cable plates and cortical
strut allografts and ORIF with locking plates. This systematic
review indicated that locking plates had a higher rate of non-
union and hardware failure compared with a cable plate with
a cortical strut allograft (90/90 xation construct).
Both the biomechanical evidence and systematic review
suggest that 90/90 xation yields superior results compared
with a single locking plate and should be used in the treatment
of patients with a Vancouver B1 periprosthetic femur fracture
when maximum rigidity is required. In particular, a locking
plate should be avoided if there is no medial cortical contact
at the fracture site and with transverse fractures.
DISTAL FEMUR FRACTURES: FAR CORTICAL
VERSUS CONVENTIONAL LOCKING SCREWS
IS THERE A NEW GOLD STANDARD?
Far cortical locking (FCL) is a strategy to dynamize
a locked plating construct to promote biologic fracture
healing by callus formation.31 Applying a locking plate with
FCL screws instead of conventional locking screws reduces
the construct stiffness and enables controlled axial motion
that leads to faster and stronger fracture healing.32,33
The original gold standard for exible fracture stabili-
zation promoted callus formation using elastic xation
constructs, such as intramedullary nails, external xators,
S30 | www.jorthotrauma.com
Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
and functional bracing.34,35 This exible xation strategy is
supported by more than 50 years of research demonstrating
that controlled dynamization of a fracture promotes callus
formation and improves the speed and strength of fracture
healing.3640 For example, Goodship and Kenwright37 dem-
onstrated that 1-mm axial dynamization delivered more than
3 times stronger and 2 times faster healing compared with
rigid xation. Conversely, decient fracture motion caused by
overly stiff xation constructs can suppress secondary frac-
ture healing, contributing to delayed union, nonunion, osteol-
ysis, and xation failure.41,42
Locking plates can provide stronger and more durable
xation than nonlocked plates. However, locked plating
constructs are also inherently stiff and can suppress motion at
the fracture site to levels insufcient for stimulation of callus
formation.41,43 Consequently, locked plating of distal femur
fractures causes decient and asymmetric callus formation, with
the least amount of callus being deposited at the near cortex.41,42
This concern is corroborated in recent studies on locked plating
of distal femur fractures, documenting nonunion rates of 10%
23%,4447 and a 31% reoperation rate for open fractures.48
Yet with the advent of locked plating came novel
strategies for dynamization31,38,49 because locking plates
derive stability from xed-angle locking screws and thus no
longer require plate compression onto the bone surface. The
strategy of FCL enables controlled and symmetric interfrag-
mentary motion through elastic exion of screw shafts within
a motion envelope at the near cortex.31 A biomechanical
study demonstrated that FCL screws enable axial dynamiza-
tion without sacricing construct stability.32 In an ovine frac-
ture healing study, FCL constructs delivered consistent and
circumferential callus bridging and yielded 157% stronger
healing compared with standard locked plating.33 Clinically,
a prospective study of 31 consecutive distal femur fractures
stabilized with FCL constructs reported no implant or xation
failure, an average time to union of 16 weeks, and a nonunion
rate of 3%.50 The FCL strategy has been implemented in
commercial implants (MotionLoc FCL screws; Zimmer, War-
saw, IN and Dynamic Locking Screws; Synthes, West Ches-
ter, PA) and has been clinically used for the xation of distal
femur fractures,5052 tibial fractures,53 and humeral fractures.54
FCL xation has also been simulated using standard locking
screws by means of overdrilling55 or slotting56 of the near
cortex. Moreover, active locking plates have been devel-
oped that provide controlled axial dynamization through elas-
tic suspension of the locking holes within the plate, while
using standard locking screws.49 However, to date, only
FCL screws have been fully evaluated by benchtop and
cadaveric testing,32,57 a prospective, randomized, animal
study,33 and clinical trials.50 Alternative strategies for dynam-
ization should therefore be viewed with caution until they
have been fully evaluated.
In conclusion, FCL combines the superior xation
strength of xed-angle locking screws with controlled
dynamization to promote biologic healing. Given the estab-
lished benets of dynamization and the evidence that stiff
locking constructs can suppress healing, a new standard for
locked plating of distal femur fractures should account for
dynamization to promote healing.
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
 J Orthop Trauma  Volume 29, Number 12 Supplement, December 2015
SYNDESMOTIC INJURIES: WHAT IS THE IDEAL
FIXATION CONSTRUCT?
Physiologic motion at the syndesmosis is complex.
Normal motion at the ankle necessitates translational, rotational,
and migrational movements of the bula at the syndesmosis.58
During plantarexion, the bula migrates distally, translates
anteromedially, and internally rotates. Dorsiexion results in
migration of the bula proximally, posterolateral translation,
and external rotation. External rotation of the foot causes
a medial translation, posterior displacement, and external rota-
tion of the bula through the syndesmosis.59 Screw xation
alters bular translation and rotation.6062 As a result, syndes-
motic screw xation has been shown to restrain the mortise-
width variations during foot dorsiexion and plantarexion
with reduced range of motion for horizontal translation.63
Likewise, syndesmotic screws cannot prevent syndes-
motic widening when subjected to weight bearing.64 Rigid
xation of the syndesmosis restricts normal physiologic
motion of the distal tibiobular joint, which may adversely
affect ankle biomechanics, as reected in a smaller joint con-
tact area and a decrease in anterior and posterior drawer
tests.65 Clinically, outcomes 1 year after syndesmotic screw
xation were signicantly better in patients with removed,
fractured, or loosened screws, according to a retrospective
analysis.66
Tricortical screws may allow for more physiologic
motion, with a resultant higher rate of associated hardware
loosening.67 Bioabsorbable screws as an alternative to metal-
lic screws have comparable biomechanical properties and out-
comes, while obviating the need for removal.68 Similar
outcomes exist for all xation constructs regarding pain,
range of motion, and functional assessments.
Suture-button devices are still a relatively new technol-
ogy. Klitzman et al conducted a cadaveric study to analyze
suture-button biomechanics in comparison to screw xation.
They found that suture-button xation preserved reduction
after cycling with submaximal loads to a degree similar to an
intact syndesmosis. Also, increased physiologic movement of
the bula in the sagittal plane was noted when compared with
tricortical screw xation.69 This must be tempered with
Teramoto et al,70 who found a potential limitation of suture-
button devices to be insufcient xation in multidirectional
testing.
One study found screw xation to be closer to native
ankle kinematic motion in anterior/posterior and medial/
lateral motions, although suture-buttons were closer to native
bular rotation. They also concluded that FiberWire buttons
were consistently unable to maintain reduction with the forces
applied, whereas suture endobuttons had a performance equal
to or greater than screw xation when subjected to rotational
torque.71
There are other construct types and concepts that have
been reported. Kirschner wire xation has been shown to be
comparable to screw xation in Weber C fractures with regard
to joint motion and contact surface.62 This technique may pro-
vide sufcient stabilization in select fractures with syndesmotic
injury.72 Posterior malleolus fracture xation reestablishes the
posterior tibiobular ligament of the syndesmosis, while
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Biomechanical Concepts for Fracture Fixation
potentially allowing for normal ankle kinematics. Posterior
malleolus xation alone has been shown to result in better
clinical outcomes than when combined with transsyndesmotic
screw placement.73
With regard to clinical outcomes, no major differences
have been noted in functional outcomes between single and
double screws, tricortical and quadricortical screws, trans-
syndesmotic and suprasyndesmotic screws, stainless steel and
titanium, or metal and bioabsorbable screws to date.72,7476 At
present, there is no ideal construct for syndesmotic xation,
and as such, it should be selected based on surgeon preference
and experience. Screw xation remains the most stable and
reliable construct in moderate-to-severe ankle injuries involv-
ing the syndesmosis.
CONCLUSIONS
Depending on the fracture type, different xation
constructs may be optimal. Orthopaedic surgeons should
carefully select the fracture xation construct to optimize
stability and promote healing.
REFERENCES
1. King GJ, Zarzour ZD, Rath DA, et al. Metallic radial head arthroplasty
improves valgus stability of the elbow. Clin Orthop Relat Res. 1999;368:
114125.
2. Beingessner DM, Dunning CE, Gordon KD, et al. The effect of radial
head excision and arthroplasty on elbow kinematics and stability. J Bone
Joint Surg Am. 2004;86:17301739.
3. Charalambous C, Stanley J, Siddique I, et al. Radial head fracture in the
medial collateral ligament decient elbow; biomechanical comparison of
xation, replacement and excision in human cadavers. Injury. 2006;37:
849853.
4. Rineer CA, Guitton TG, Ring D. Radial head fractures: loss of cortical
contact is associated with concomitant fracture or dislocation. J Shoulder
Elbow Surg. 2010;19:2125.
5. Ring D, Quintero J, Jupiter JB. Open reduction and internal xation of
fractures of the radial head. J Bone Joint Surg Am. 2002;84:18111815.
6. Van Glabbeek F, Van Riet R, Baumfeld J, et al. Detrimental effects of
overstufng or understufng with a radial head replacement in the medial
collateral-ligament decient elbow. J Bone Joint Surg Am. 2004;86:
26292635.
7. Lanting BA, Ferreira LM, Johnson JA, et al. The effect of radial head
implant length on radiocapitellar articular properties and load transfer
within the forearm. J Orthop Trauma. 2014;28:348353.
8. Frank SG, Grewal R, Johnson J, et al. Determination of correct implant
size in radial head arthroplasty to avoid overlengthening. J Bone Joint
Surg Am. 2009;91:17381746.
9. Gifn JR, King GJ, Patterson SD, et al. Internal xation of radial neck
fractures: an in vitro biomechanical analysis. Clin Biomech. 2004;19:
358361.
10. Burkhart KJ, Mueller LP, Krezdorn D, et al. Stability of radial head
and neck fractures: a biomechanical study of six xation constructs
with consideration of three locking plates. J Hand Surg Am. 2007;32:
15691575.
11. Jeon I, Sanchez-Sotelo J, Zhao K, et al. The contribution of the coronoid
and radial head to the stability of the elbow. J Bone Joint Surg Br. 2012;
94:8692.
12. Hartzler RU, Llusa-Perez M, Steinmann SP, et al. Transverse coronoid
fracture: when does it have to be xed? Clin Orthop Relat Res. 2014;472:
20682074.
13. Beingessner DM, Stacpoole RA, Dunning CE, et al. The effect of suture
xation of type i coronoid fractures on the kinematics and stability of the
elbow with and without medial collateral ligament repair. J Shoulder
Elbow Surg. 2007;16:213217.
www.jorthotrauma.com | S31
 Bottlang et al J Orthop Trauma  Volume 29, Number 12 Supplement, December 2015
14. Papatheodorou LK, Rubright JH, Heim KA, et al. Terrible triad injuries
of the elbow: does the coronoid always need to be xed? Clin Orthop
Relat Res. 2014;472:20842091.
15. Pollock JW, Brownhill J, Ferreira L, et al. The effect of anteromedial
facet fractures of the coronoid and lateral collateral ligament injury
on elbow stability and kinematics. J Bone Joint Surg Am. 2009;91:
14481458.
16. Routt MC Jr, Simonian PT, Mills WJ. Iliosacral screw xation: early
complications of the percutaneous technique. J Orthop Trauma. 1997;11:
584589.
17. Blaisdell GY, Krieg JC, Routt MLC Jr, Transiliac-transsacral screw
xation in c-type pelvic ring injuries reduces postoperative failure.
Presented at: OTA Annual Meeting; October 5, 2012; Minneapolis, MN.
18. Grifn DR, Starr AJ, Reinert CM, et al. Vertically unstable pelvic frac-
tures xed with percutaneous iliosacral screws: does posterior injury
pattern predict xation failure? J Orthop Trauma. 2003;17:399405.
19. Reilly MC, Bono CM, Litkouhi B, et al. The effect of sacral fracture
malreduction on the safe placement of iliosacral screws. J Orthop
Trauma. 2003;17:8894.
20. Simonian PT, Routt MC. Biomechanics of pelvic xation. Orthop Clin
North Am. 1997;28:351367.
21. Nork SE, Jones CB, Harding SP, et al. Percutaneous stabilization of
u-shaped sacral fractures using iliosacral screws: technique and early
results. J Orthop Trauma. 2001;15:238246.
22. Pike J, Davidson D, Garbuz D, et al. Principles of treatment for peri-
prosthetic femoral shaft fractures around well-xed total hip arthroplasty.
J Am Acad Orthop Surg. 2009;17:677688.
23. Graham SM, Moazen M, Leonidou A, et al. Locking plate xation for
vancouver b1 periprosthetic femoral fractures: a critical analysis of 135
cases. J Orthopaedic Sci. 2013;18:426436.
24. Brady OH, Garbuz DS, Masri BA, et al. The reliability and validity of the
vancouver classication of femoral fractures after hip replacement.
J Arthroplasty. 2000;15:5962.
25. Sariyilmaz K, Dikici F, Dikmen G, et al. The effect of strut allograft and
its position on vancouver type b1 periprosthetic femoral fractures: a bio-
mechanical study. J Arthroplasty. 2014;29:14851490.
26. Dehghan N, McKee MD, Nauth A, et al. Surgical xation of vancouver
type b1 periprosthetic femur fractures: a systematic review. J Orthop
Trauma. 2014;28:721727.
27. Zdero R, Walker R, Waddell JP, et al. Biomechanical evaluation of
periprosthetic femoral fracture xation. J Bone Joint Surg Am. 2008;
90:10681077.
28. Buttaro MA, Farfalli G, Nez MP, et al. Locking compression plate
xation of vancouver type-b1 periprosthetic femoral fractures. J Bone
Joint Surg Am. 2007;89:19641969.
29. Haddad FS, Duncan CP, Berry DJ, et al. Periprosthetic femoral fractures
around well-xed implants: use of cortical onlay allografts with or with-
out a plate. J Bone Joint Surg Am. 2002;84:945950.
30. Talbot M, Zdero R, Schemitsch EH. Cyclic loading of periprosthetic
fracture xation constructs. J Trauma. 2008;64:13081312.
31. Bottlang M, Feist F. Biomechanics of far cortical locking. J Orthop
Trauma. 2011;25(suppl 1):S21S28.
32. Bottlang M, Doornink J, Fitzpatrick DC, et al. Far cortical locking can
reduce stiffness of locked plating constructs while retaining construct
strength. J Bone Joint Surg Am. 2009;91:19851994.
33. Bottlang M, Lesser M, Koerber J, et al. Far cortical locking can improve
healing of fractures stabilized with locking plates. J Bone Joint Surg Am.
2010;92:16521660.
34. Uhthoff HK, Poitras P, Backman DS. Internal plate xation of fractures:
short history and recent developments. J Orthop Sci. 2006;11:118126.
35. McKellop H, Hoffmann R, Sarmiento A, et al. Control of motion of tibial
fractures with use of a functional brace or an external xator. A study of
cadavera with use of a magnetic motion sensor. J Bone Joint Surg Am.
1993;75:10191025.
36. Claes LE, Heigele CA, Neidlinger-Wilke C, et al. Effects of mechanical
factors on the fracture healing process. Clin Orthop Relat Res. 1998
(suppl 355):S132S147.
37. Goodship AE, Kenwright J. The inuence of induced micromovement
upon the healing of experimental tibial fractures. J Bone Joint Surg Br.
1985;67:650655.
38. Richter H, Plecko M, Andermatt D, et al. Dynamization at the near cortex
in locking plate osteosynthesis by means of dynamic locking screws: an
S32 | www.jorthotrauma.com
Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
experimental study of transverse tibial osteotomies in sheep. J Bone Joint
Surg Am. 2015;97:208215.
39. Uhthoff HK. Current concepts of internal xation of fractures. Can J
Surg. 1980;23:213214.
40. Woo SL, Lothringer KS, Akeson WH, et al. Less rigid internal xation
plates: historical perspectives and new concepts. J Orthop Res. 1984;1:
431449.
41. Lujan TJ, Henderson CE, Madey SM, et al. Locked plating of distal
femur fractures leads to inconsistent and asymmetric callus formation.
J Orthop Trauma. 2010;24:156162.
42. Roderer G, Gebhard F, Duerselen L, et al. Delayed bone healing follow-
ing high tibial osteotomy related to increased implant stiffness in locked
plating. Injury. 2014;45:16481652.
43. Claes L. Biomechanical principles and mechanobiologic aspects of ex-
ible and locked plating. J Orthop Trauma. 2011;25(suppl 1):S4S7.
44. Henderson CE, Lujan TJ, Kuhl LL, et al. 2010 mid-america orthopaedic
association physician in training award: healing complications are com-
mon after locked plating for distal femur fractures. Clin Orthop Relat
Res. 2011;469:17571765.
45. Hoffmann MF, Jones CB, Sietsema DL, et al. Outcome of periprosthetic
distal femoral fractures following knee arthroplasty. Injury. 2012;43:
10841089.
46. Rodriguez EK, Boulton C, Weaver MJ, et al. Predictive factors of
distal femoral fracture nonunion after lateral locked plating: a retrospec-
tive multicenter case-control study of 283 fractures. Injury. 2014;45:
554559.
47. Vallier HA, Immler W. Comparison of the 95-degree angled blade plate
and the locking condylar plate for the treatment of distal femoral frac-
tures. J Orthop Trauma. 2012;26:327332.
48. Ricci WM, Streubel PN, Morshed S, et al. Risk factors for failure of
locked plate xation of distal femur fractures: an analysis of 335 cases.
J Orthop Trauma. 2014;28:8389.
49. Tsai S, Fitzpatrick DC, Madey SM, et al. Dynamic locking plates provide
symmetric axial dynamization to stimulate fracture healing. J Orthop
Res. 2015;33:12181225.
50. Bottlang M, Fitzpatrick DC, Sheerin D, et al. Dynamic xation of distal
femur fractures using far cortical locking screws: a prospective observa-
tional study. J Orthop Trauma. 2014;28:181188.
51. Adams JD Jr, Tanner SL, Jeray KJ. Far cortical locking screws in distal
femur fractures. Orthopedics. 2015;38:e153e156.
52. Ries ZG, Marsh JL. Far cortical locking technology for xation of peri-
prosthetic distal femur fractures: a surgical technique. J Knee Surg. 2013;
26:1518.
53. Freude T, Schroter S, Gonser CE, et al. Controlled dynamic stability as
the next step in biologic plate osteosynthesisa pilot prospective
observational cohort study in 34 patients with distal tibia fractures.
Patient Saf Surg. 2014;8:3.
54. Freude T, Schroeter S, Plecko M, et al. Dynamic-locking-screw (dls)-
leads to less secondary screw perforations in proximal humerus fractures.
BMC Musculoskelet Disord. 2014;15:194.
55. Linn MS, McAndrew CM, Prusaczyk B, et al. Dynamic locked plating of
distal femur fractures. J Orthop Trauma. 2015;29:447450.
56. Gardner MJ, Nork SE, Huber P, et al. Less rigid stable fracture xation in
osteoporotic bone using locked plates with near cortical slots. Injury.
2010;41:652656.
57. Doornink J, Fitzpatrick DC, Madey SM, et al. Far cortical locking en-
ables exible xation with periarticular locking plates. J Orthop Trauma.
2011;25(suppl 1):S29S34.
58. Norkus SA, Floyd R. The anatomy and mechanisms of syndesmotic
ankle sprains. J Athl Train. 2001;36:68.
59. Beumer A, Valstar ER, Garling EH, et al. Kinematics of the distal tibio-
bular syndesmosis: radiostereometry in 11 normal ankles. Acta Orthop
Scand. 2003;74:337343.
60. Huber T, Schmoelz W, Blderl A. Motion of the bula relative to the
tibia and its alterations with syndesmosis screws: a cadaver study. Foot
Ankle Int. 2012;18:203209.
61. Ogilvie-Harris D, Reed S, Hedman T. Disruption of the ankle syndes-
mosis: biomechanical study of the ligamentous restraints. Arthroscopy.
1994;10:558560.
62. Peter RE, Harrington R, Henley M, et al. Biomechanical effects of inter-
nal xation of the distal tibiobular syndesmotic joint: comparison of two
xation techniques. J Orthop Trauma. 1994;8:215219.
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
 J Orthop Trauma  Volume 29, Number 12 Supplement, December 2015
63. Bragonzoni L, Russo A, Girolami M, et al. The distal tibiobular syn-
desmosis during passive foot exion. Rsa-based study on intact, ligament
injured and screw xed cadaver specimens. Arch Orthop Trauma Surg.
2006;126:304308.
64. Beumer A, Campo MM, Niesing R, et al. Screw xation of the syndes-
mosis: a cadaver model comparing stainless steel and titanium screws
and three and four cortical xation. Injury. 2005;36:6064.
65. Needleman RL, Skrade DA, Stiehl JB. Effect of the syndesmotic screw
on ankle motion. Foot Ankle Int. 1989;10:1724.
66. Manjoo A, Sanders DW, Tieszer C, et al. Functional and radiographic
results of patients with syndesmotic screw xation: implications for
screw removal. J Orthop Trauma. 2010;24:26.
67. Hiness P, Strmse K. Tricortical versus quadricortical syndesmosis x- 74. Kukreti S, Faraj A, Miles J. Does position of syndesmotic screw affect
ation in ankle fractures: a prospective, randomized study comparing two
methods of syndesmosis xation. J Orthop Trauma. 2004;18:331337.
68. Thordarson DB, Samuelson M, Shepherd LE, et al. Bioabsorbable versus
stainless steel screw xation of the syndesmosis in pronation-lateral rota-
tion ankle fractures: a prospective randomized trial. Foot Ankle Int. 2001;
22:335338.
69. Klitzman R, Zhao H, Zhang LQ, et al. Suture-button versus screw xa-
tion of the syndesmosis: a biomechanical analysis. Foot Ankle Int. 2010;
31:6975.
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Biomechanical Concepts for Fracture Fixation
70. Teramoto A, Suzuki D, Kamiya T, et al. Comparison of different xation
methods of the suture-button implant for tibiobular syndesmosis inju-
ries. Am J Sports Med. 2011;39:22262232.
71. den Daas A, van Zuuren WJ, Pelet S, et al. Flexible stabilization of the
distal tibiobular syndesmosis: clinical and biomechanical considera-
tions: a review of the literature. Strategies Trauma Limb Reconstr.
2012;7:123129.
72. Van Heest TJ, Lafferty PM. Injuries to the ankle syndesmosis. J Bone
Joint Surg Am. 2014;96:603613.
73. Gardner MJ, Demetrakopoulos D, Briggs SM, et al. Malreduction of
the tibiobular syndesmosis in ankle fractures. Foot Ankle Int. 2006;
27:788792.
functional and radiological outcome in ankle fractures? Injury. 2005;36:
11211124.
75. DeGroot H, Al-Omari AA, El Ghazaly SA. Outcomes of suture button
repair of the distal tibiobular syndesmosis. Foot Ankle Int. 2011;32:
250256.
76. Wikery AK, Hiness PR, Andreassen GS, et al. No difference in func-
tional and radiographic results 8.4 years after quadricortical compared
with tricortical syndesmosis xation in ankle fractures. J Orthop Trauma.
2010;24:1723.
www.jorthotrauma.com | S33