GSTF International Journal of Engineering Technology (JET) Vol.1 No.
1, 2012
Orthopedic bone plates:
Evolution in Structure, Implementation
technique and biomaterial
Javad Malekani1 Beat Schmutz1 Yuantong Gu1 Michael Schuetz1 Prasad Yarlagadda1,a
1
Faculty of Built Environment and Engineering
Queensland University of Technology (QUT)
Brisbane, Australia
a
y.prasad@qut.edu.au
Abstract- With many important developments over the last
century, nowadays orthopedic bone plate now excels over other
types of internal fixators in bone fracture fixation. The
developments involve the design, material and implementation
techniques of the plates. This paper aims to review the evolution
in implementation technique and biomaterial of the orthopedic
bone plates. Plates were initially used to fix the underlying bones
firmly. Accordingly, Compression plate (CP), Dynamic
compression plate (DCP), Limited contact dynamic compression
plate (LC-DCP) and Point contact fixator (PC-Fix) were
developed. Later, the implementation approach was changed to
locking, and the Less Invasive Stabilization System (LISS) plate
was introduced as a result. Finally, a combination of both of these
approaches has been used by introducing the Locking
Compression Plate (LCP). Currently, precontoured LCPs are
mainly used for bone fracture fixation.
In parallel with structure and implementation techniques,
numerous advances have occurred in biomaterials of the plates.
Titanium and stainless steel alloys are now the most common
biomaterials in production of orthopedic bone plates. However,
regarding the biocompatibility, bioactivity and biodegradability
characteristics of Mg alloys, Ta alloys, SMAs, carbon fiber
composites and bioceramics, these materials are considered as
potentially suitable for plates. However, due to poor mechanical
properties, they have very limited applications. Therefore,
further studies are required in future to solve these problems and
make them feasible for heavy-duty bone plates.
Index terms: Orthopedic bone plate, LCP, LISS, PC-Fix, LC-
DCP, Biomaterial, Biometal, Biocopmosites, Bioceramics, Inert,
Bioactive, Biocompatible, Biodegradable
I. INTRODUCTION
C onsidering the principles, most fractures can be treated by
a variety of fixation methods [1]. However, internal
fixators offer a flexible fixation and allow long-term treatment
[2]. In addition, providing primary strength to bone, internal
fixation allows early functional mobilization [3, 4] with at least
a partial weight bearing. Despite being disruptive to the
biologic environment, patients are usually more comfortable
with it after surgery [4]. It provides the best articular anatomy
and patients treated by this method have less possibility of
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developing secondary osteoarthritis [5]. Using this method,
healing occurs successfully even if there is a gap at fracture [6].
Internal fixation can be done by means of wires, nails or
rods, pins, screws and plates. Currently, bone plates are the
most frequently used among all these implants [6]. Bone plates
resist well against tension, compression, shearing, rotational
forces and bending forces [6]. In addition, bone plates are
available in an abundance of sizes, shapes and designs. All
these advantages have come after the developments in different
aspects of the orthopedic bone plates, including structure,
material, mechanical and biological characteristics, and
implementation techniques. This paper reviews the
improvements in structure, implementation techniques and
biomaterials to date, and explores trends for the future.
II. STRUCTURE AND IMPLEMENTATION TECHNIQUES
The first invented plates worked just as a retainer, and did
not allow approximation of the bone fragments. Fractures
treated with this method had insufficient stability, and often
required additional splinting. On the other hand, severe
corrosion, breaking, loosening screws and some bacterial
infections in bones usually led to a reduction of blood supply to
the bone [7] and they were eventually abandoned [8]. Studies
on structure of bone plates lead to the Compression Plate
(CP) in 1949 [7]. Widespread use of this plate was limited by
its structural weakness, resulting in instability of the fixation
and problems in healing [8]. So studies continued and the
Dynamic Compression Plate (DCP) was introduced in 1969
[3]. The advantage of DCP included stable internal fixation and
removal of the external immobilization [8]. This plate included
holes for axial compression, which was achieved with eccentric
screw insertion.
Despite significant improvement in bone fracture healing,
DCP delayed mating, cortical bone loss under the plate and
microscopic gaps on the bone after removing the plate. It also
acts as a stress concentrator raising the probability of bone re-
fracture [8]. DCP plating methods were based on using an
adequate number of bicortical anchoring screws to press the
plate with high compressive force against the bone fragments.
Thereby it created a stable boneimplant connection which
caused disturbance of the periosteal blood circulation and bone
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necrosis. This led to development of the limited-contact
dynamic compression plate (LC-DCP) in which the contact
surface was reduced by more than 50% compared with the
conventional DCP [3]. However, the principle of plate
osteosynthesis with compressive forces acting against the bone
was present and the problems had not been totally solved.
In order to eliminate the ill-effects of any plate to bone
contact, a completely different approach had to be chosen. The
point contact fixator (PC-Fix) was the first version of these
plate-fixators in which angular stability was achieved by a
conical connection between screw heads and screw holes.
Furthermore, the use of unicortical self-tapping screws seemed
as equally effective as external fixation in obtaining a stable
construct [3, 9]. During healing, the head of a screw had
produced a nearly cold-forged connection between the screw
head and the screw hole, which sometimes made it difficult to
remove individual screws. Therefore, Less Invasive
Stabilization System (LISS) was introduced by developing a
new thread connection between the screw head and screw hole.
In LISS, the plate is inserted through the skin and fixed to the
bone with locked unicortical screws. Locking head screws are
used to lock the plate tightly. Unlike the compression screw,
this screw-plate combination does not require friction between
the plate and the underlying bone for stabilization. Therefore,
in this system the plate does not have to be adapted exactly to
the shape of the bone [9, 10].
Locking Compression Plate (LCP), released in 2000, was
based on a combination of the anchorage technologies of PC-
Fix and LISS systems in one implant [11]. To date, nearly all
plate shapes have been equipped with the new locked
compression plate (LCP) hole that allows use of either
conventional cortex screws or angular-stable screws [3].
Depending on the approach of the surgery, LCPs can be
applied in three manners as a conventional LCP, pure internal
fixator (PIF) or combination of both LCP and PIF [9].
Selecting the method for surgery depends on the quality of
bone, situation of fracture, anatomical region and the surgeons
preference.
Despite the significant advantages of LCP, improvement
was still required for a better healing process. Therefore, an
anatomically pre-shaped LCP bone plate was introduced, in
2001, for fracture fixation of various anatomical regions. This
pre-shaped plate allows all screws to be centrally anchored in
the bone when fixed laterally. Pre-shaped LCP is very helpful
in corrective surgery of the bone when the fracture is close to
joints.
Figure 1. Different types of internal fixators [3, 12]
Although the pre-shaped LCP has significant advantages it
is not ideal yet. Generally it is non-biodegradable, and then has
136
to be removed via surgery or to be kept in the limb forever. Its
structure is fixed and then it cannot comply with the changes
during fracture healing. An ideal fixator facilitates fast healing
leading to full functionality of the injured extremity with the
least suffering during healing and minimum aftermath.
Advances in biomaterials of bone plates can significantly
improve their characteristics and then a new generation of bone
plates can be introduced.
I. BIOMATERIALS OF BONE PLATES
The origin of biomaterials dates back thousands of years, as
archaeologists have found that metal dental implants have been
used since 200 A.D. However, they underwent significant
development after World War II [13]. Today, biomaterials are
defined as artificial or natural materials used in the
manufacturing structures for replacing the lost or diseased
biological structure to restore its form and function [14]. Since
a biomaterial can exhibit specific interactions with cells that
will lead to a stereotyped response [15], its performance is
controlled by two characteristics of biofunctionality and
biocompatibility [14, 16, 17]. Biofunctionality refers to
mechanical properties of the biomaterial, whereas
biocompatibility determines the compatibility of the material
with the body [18]. Application of any biomaterial depends on
various factors Such as osteoinduction, osteoconduction
angiogenesis, growth rate of cells, and degradation rate of the
biomaterials in case of temporary scaffolds [15].
Biomaterials can be classified as organic if they contain
carbon, or inorganic if they do not. In parallel, they can be
classified into bioinert, bioactive, biodegradable, and materials
with a possibility of bimolecular incorporation [17, 19].
Bioinert biomaterials decrease the potential for a negative
immune response to the implant, while bioactive materials
interact in a positive manner with the body to promote
localized healing [13]. Although biodegradable materials are
the latest advance, the other two generations are used widely in
manufacturing orthopedic devices including bone plates. Since
any kind of improvement in biomaterials of bone plates directly
affect on developments in structure and implementation
techniques of bone plates, recent developments and future
trends of the biomaterials of orthopedic bone plates are
reviewed in the following sessions. It will cover the biometals,
polymers, biocomposites and bioceramics.
II. BIOMETALS
Biometals are the most common biomaterials for
manufacturing medical devices including bone plates [20].
Biometals are inorganic metallic biomaterials [13]. They are
neither bioactive [15, 17] nor biodegradable. Among biometals,
stainless steel, cobalt alloys and titanium alloys have the most
applications in orthopedics.
A. Stainless steel
Stainless steel is the most common biomaterial in
manufacturing bone plates due to its advantages such as
mechanical strength, cost, manufacturing implants, and
deformation of implant during surgery [20]. In practice,
Stainless steel AISI 316L (ASTM F138 & F139) has the most
biomedical applications because of its better fatigue strength,
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more ductility and better machinability [21]. However, it
contains Nickel which has the potential for toxicity,
sensitization and allergy [22]. Therefore, Ni-free stainless
steels have been recently developed for use in orthopedic field
[23-26]. In general, stainless steel is suitable in temporary
implant devices such as fracture plates, screws and hip nails
[21]. A temporary implant is expected to provide support and
assist in cell/tissue growth until the tissue/cell regains its
original shape and strength [15].
B. Cobalt-Chromium Alloys
ASTM has recommended four types of cobalt-chromium
(Co-Cr) alloys for surgical implant applications including cast
Co-Cr-Mo alloy (F75), wrought Co-Cr-W-Ni alloy (F90),
wrought Co-Ni-Cr-Mo alloy (F562) and wrought Co-Ni-Cr-
Mo-W-Fe alloy (F563) [27]. Although cobalt based alloys are
highly resistant to fatigue and cracking caused by corrosion
[17], especially to attack by chloride within crevices [28], they
may fail because of fatigue fracture. Of course its probability is
less than stainless steel stems [28]. In vitro studies [27] have
indicated that some types of Co-alloys are toxic to human
while other types are well tolerated by cells. It is also observed
that cobalt alloys have lower biocompatibility and higher
mechanical resistance compared with titanium alloys [23, 29].
In general, poor fabricability and high costs mean that Co-
based alloys are currently unsuitable for broad use in bone
plates [29].
C. Titanium alloys
Only four grades of commercially pure titanium (cpTi) are
distinguished for medical applications (ISO 5832-2) [29].
These alloys (ASTM F67) and Ti-6Al-4V ELI alloy (ASTM
F136) are widely used for biomedical applications [30].
However, the strength of cpTi is insufficient, and the metals of
vanadium (V) and Aluminum (Al) in Ti-6Al-4V ELI alloy are
harmful elements. So Ti alloys without any harmful elements
have been recently developed [31]. Furthermore, other studies
[14] are conducted to improve the wear resistance of Ti-based
materials. In this way, the alloys of Titanium and Zirconium
(Ti-Zr) have been advised because of good responses in terms
of biofunctionality and biocompatibility [26].
Shape memory alloys (SMA) possess certain original
properties, particularly their ability to return to their memorized
shape by a simple change of temperature [32]. SMAs have
been considered for medical applications because of their
capabilities for recovering their original shape after large
deformations induced by mechanical load and for maintaining
the deformed shape up to the heat induced recovery of the
original shape [33]. Despite the disadvantages of nickel, Ni-Ti
(Nitinol) [16, 33, 34] and Ti-Ni-Ag [35] alloys have been
studied for orthopedics and it has been shown [35] that it does
not make toxicity and sensitization problems.
Due to excellent properties such as mechanical properties,
corrosion resistance, fatigue-corrosion resistance, low-density
and relatively low modulus, , the advantages of Ti alloys over
stainless steel, Co-Cr alloys and other industrially available
biomaterials, is remarkable [20, 36]. However, they cannot be
recommended as the golden standard for fracture fixation
because of foreign-body reaction in local tissues and poor
processing capabilities [17, 20]. In general, Ti alloys have been
seen as the best available biomaterial for bone plate fabrication
137
[37]. Additionally its coating possibility with layers of
bioactive ceramics induces specific reactions of the biological
system and improves its biocompatibility and bioactivity for
permanent implantation.
D. Other biometals
Several other metals have been studied for implant
applications. Among the biodegradable metallic materials
Magnesium has attracted the greatest interest [38, 39]. It is
non-toxic to the human body and its excessive amounts can be
readily excreted by the kidneys. Magnesium is also very
important for biological functions of the human body [38].
However, Magnesium alloys corrode too rapidly in
physiological environments which produce hydrogen pockets
near the implant and retard the healing process. Studies on Mg
Zn alloys [38, 40, 41] highlights that they have high tensile
strengths and no adverse effects because of the zinc released.
Similarly studies on Mg-Zn-Ca [40], Mg-Y-Zn [38, 42], Mg
Ca [40], Mg-Dy [43] acknowledge their high potential for use
in fabrication of internal fixation implants.
Regarding the excellent ductility, toughness, corrosion
resistance, biocompatibility, bioactivity, cellular adherence,
growth and differentiation with abundant extracellular matrix
formation, Tantalum (Ta) is known as an excellent biomaterial
for bone plates [44]. However, its application has been limited
because of poor mechanical properties, high density [27] and
processing challenges [44]. Platinum group metals (PGM) such
as Platinum (Pt), Palladium (Pd), Rhodium (Rh), Iridium (Ir),
Ruthenium (Ru), and Osmium (Os) are extremely corrosion
resistant. But they have poor mechanical properties [27] and
then are not currently feasible for making bone plate with.
Considering the advantages of reviewed materials,
currently none of them are suitable for bone plates.
Furthermore thorough studies are required to solve the
problems in order to make them feasible for manufacturing
bone plates.
III. POLYMERS AND BIOCOMPOSITES
Biometals are mostly unresorbable and can cause toxicity
by accumulation of metal ions due to corrosion. They also can
lead to premature failure due to heterogeneous stress
distribution, which is caused by higher elastic modulus of the
implant compared with bone [17]. Consequently, numerous
studies [15, 17, 19, 45-47] have been done on organic
biomaterials and biocomposites. Polymethyl-methacrylate
(PMMA), Poly lactic acid (PLA), Poly glycolic acid (PGA), L-
PLA (PLLA), D-PLA (PDLA), Polyglycolic acid (PGA),
Polycaprolactone (PCL), Polyhydroxybutyrate (PHB), poly
etherether-ketone (PEEK), Poly (2-hydroxy-ethyl-
methacrylate) (PHEMA), and Polydioxanone (PDS) have been
widely studied [17, 19]. While these studies show that the
orthopedic implants of biocomposites and biopolymers can be
used instead of metallic ones, in practice they only have limited
application in dental implants and also in small flexible internal
fixators [48]. Their poor mechanical properties have been
introduced as the main obstacle for their application in
orthopedics [17].
Studies on development of carbon fiber-reinforced-epoxy-
resin for use in bone plates were started in the early 1970s [49].
Generally, studies on biocomposites [17, 48-55], bioglass
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fibers [56], Carbon/PEEK composite material [57], non-
homogenous stiffness graded (SG) [58-60] and flexible
Kevlar/BCP (biphasic calcium phosphate) [61-63] demonstrate
that the mechanical properties of the biocomposites plates are
comparable with biometals. Additionally, biodegradable
polymers should be seriously considered in the design of new
plates. Finite element studies acknowledge these results [19,
45, 50, 64].
According to findings, stress shielding in bone SG plate is
less compared to Stainless Steel plate [58]. Since SG plates are
more flexible, they permit more bending of the fractured bone,
higher compressive stress at the fractured interface which
induces accelerated healing and higher tensile stress in the
intact portion of the bone [59]. Similarly, it is shown [61-63]
that the Kevlar/BCP plate generates the most appropriate strain
distributions at the fracture site during the early healing
process. It provides higher healing rates compared to
conventional steel plates, and improves callus generation at the
fracture site. It also reduces the contact stress at the contact
area.
Although polymer and composite biomaterials show good
results in studies, they should be surface compatible and
structurally compatible with the host tissue to be used in
orthopedic implants. Moreover, due to lack of the experimental
and clinical supporting data, further studies should be
conducted to elucidate the long-term durability of these
biomaterials in human body conditions. Furthermore, surgeons
must be convinced about the long-term durability and
reliability of polymer and composite biomaterials [48].
IV. BIOCERAMICS
Bioceramics are classified as inorganic biomaterials.
Bioactive ceramics such as Alumina [65, 66], Zirconia [66, 67],
Yttria-stabilized Zirconia (Y-TZP) [66], (HA) and Hydroxy
Carbonate Apatite (HCA) [24, 26, 52-55, 68], tricalcium
phosphate (TCP) [66, 69], Bioglass (BG) [70, 71], and glass-
ceramic (A-W G-C1) [70, 72] have been studied for orthopedic
applications. Regarding the results, due to their low tensile
strength and lower fracture toughness compared with the
human cortical bone they cannot be used independently as a
bone substitute or bone plate for a high load bearing joint [44].
In the case of highly porous ceramics this can be a serious
concern. Despite the promotion of bone in-growth and induced
prosthesis stabilization they cannot be used in load bearing
applications [17]. As a solution bioceramics are usually used in
coatings of other bioinert materials such as titanium alloys
[70]. Among the bioceramics calcium phosphate biomaterials
(mainly HA and TCP) are the most popular because of their
close properties to the bone [66]. However, delamination, and
decomposition in long-term implementation [44], micro and
macro porosities which affect on biological properties, low
crack resistance and toughness [66] are the major
shortcomings in applying these materials in coating. Y-TZP has
the most toughness and strength among current bioceramics;
however it is not stable in long-term implementation [66] and
therefore cannot be used in permanent implants.
In general, currently bioceramics are not suitable for bone
plates unless for coating or composition with other
1 Apatite-wollastonite Glass-ceramic
138
biomaterials. Future studies in this area will solve their
drawbacks such as delamination and decompositions in order
to make them applicable for bone plate.
V. CONCLUSION
Since the introduction of orthopedic bone plates in 1896
[3], they have evolved substantially in design, implementation
techniques and materials. Consequently CP, DCP, LC-DCP,
PC-Fix, LISS plate, LCP and Precontoured LCP have been
introduced. Plates have been changed from a solid fixator to
bioactive healing facilitator. While all advances in structure
and implementation techniques are highly important, further
improvements are needed. Current plates are mostly
unresorbable, and then can cause toxicity by accumulation of
metal ions due to corrosion. They also can lead to premature
failure due to heterogeneous stress distribution, which is caused
by higher elastic modulus of the implant compared with bone.
Biomaterials play a prominent role in the efficiency of the
plates, and therefore numerous studies have been conducted in
this field. Consequently, mechanical and biological properties
of biomaterials used in manufacturing bone plates have been
significantly improved, and new materials have been
introduced. Also, many investigations have been performed to
maximize their biocompatibility, bioactivity, biodegradability,
and cellular interaction. However, regarding the direct and
indirect effects of biomaterials on design, implementation
technique and healing process, it is highly important to conduct
further studies on improving the characteristics of current
biomaterials and introducing new materials.
This paper also implies that:
In spite of significant advantages, the latest type of the
bone plates, Pre-shaped LCP, is not perfect yet. It is
not bioresorbable. In addition it cannot completely
comply with the changes during fracture healing.
Ideal biomaterial for bone plate should have reasonable
corrosion resistance, wear resistance, strength,
biocompatibility, bioactivity, and biodegradability. It
also should have close mechanical properties,
especially Youngs modulus, to bone. Furthermore, it
should not cause toxicity, allergy and sensitivity.
Micro and Nano-scale properties of biomaterials and
their cellular interactions play significant roles in their
performance and therefore they should be considered
in future studies. Also, multi-disciplinary studies
including biology, material science, chemistry and
mechanics should be conducted in developing
biomaterials to improve both characters of
biofunctionality and biocompatibility.
Manufacturing techniques directly affect
biofunctionality of the bone plates, and so they should
be the focus of future studies.
In some circumstances it is necessary to use a
permanent implant for treatment. Unresorbable,
biocompatible and bioactive biomaterials should be
used in these cases. Otherwise biodegradable
biomaterials are preferred.
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Magnesium and tantalum alloys are potentially
applicable because of their bioactivity,
biocompatibility, and biodegradability. However, their
mechanical properties and production process remain
the major concerns in terms of their application.
Further studies should be conducted to solve these
problems.
Polymers and biocomposites have many advantages
over current biomaterials because of biodegradability,
better biocompatibility, and higher bioactivity.
However, they are limited to implementation in small-
size flexible implants. Further studies should be
conducted to improve their biomechanics to enable
them to be used in heavy-duty bone plates.
Although bioceramics are bioactive and biocompatible,
they cannot be used independently in bone plates, due
to loading factors. Despite having high potential for
use as coating of inert biometals, they have some
serious drawbacks including cracks, porosities and
delamination. Further studies should be conducted to
address these problems. They can then be used as a
suitable coating for bone plates.
(1) ACKNOWLEDGEMENT
This work is supported by an Australian Research Council
(ARC) Linkage Grant (ARC LP: LP0990250). The authors are
grateful to ARC, faculty of Built Environment and Engineering
(BEE), and Institute of Health and Biomedical Innovation
(IHBI) of Queensland University of Technology (QUT) for
scholarships and Grants that made this work possible.
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Professor Prasad Yarlagadda worked as an academic and Researcher in
industry and universities for over 27 years in India, Hong Kong, Singapore,
Papua New Guinea, and Australia. He obtained his Ph.D. from Indian
Institute of Technology, Mumbai, India. . Prof. Yarlagadda was Founding
Director of Smart Systems Research theme (2005-2009) in QUT and in this
role he lead over 150 higher degree research students, a large number of
researchers in various disciplines of engineering and overseen large number of
research projects for both commonwealth government and private sector. At
Present he is Project Director, Airport of the Future project which is multi-
disciplinary and integrated research project in the field of airport security,
facilitation, risk and continuity planning. He received significant amount of
funding to undertake this research from Australian Research Council, various
Commonwealth agencies such as Office of Transport Security, Department of
Customs, Department of Immigration, Australian Federal Police, AQIS,
number of Australian airports and airlines. Prof. Yarlagadda has published
more than 325 quality papers in high quality international Journals and
conference proceedings. He is Deputy Editor-In Chief of International Journal
of Advances in Manufacturing and Materials Engineering and was also guest
editor to number of international journals. He received significant amount
of research funding from various government and industrial organizations.
Prof. Yarlagadda received number of awards from various national and
international agencies for his outstanding contribution to engineering field in
particular to discipline of manufacturing. He recently received Fryderyk
Staub Golden Owl Award from World Academy of Manufacturing and
Materials, Poland, for his outstanding contribution to the discipline of
materials and manufacturing engineering in the international arena. He is a
fellow of professional organizations such as Institution of Engineers,
(Poland), Institution of Engineers, India, Society of Manufacturing Engineers,
USA, American Society of Mechanical Engineers, USA, Institution of
Mechanical Engineers, UK and Society of Professional Engineers, PNG.
2012 GSTF