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Orthopedic Materials
Strength of Materials:

Definitions:
❖ Biomaterials: synthetic or naturally derived materials that can be used for
biological purpose to support or replace diseased tissues.
 Types:
1. Metals: molecules composed of many repeating units (mers).

2. Polymers: Synthetic organic (non-metal) materials consist of long chains of

hydrocarbons & may include other nonmetals as N, O, Si, S. They are giant
molecules produced by polymerization (Condensation) which is a process of
repetition of simple units called mers or monomers.

3. Ceramics: composed of a metal plus a nonmetal.

4. Composites: any combination of previous types.

 Uses: internal fixation of fractures, osteotomies, arthrodesis, wound

closure, tissue substitution & total joint arthroplasty.

❖ Alloy: combination of two or more elements (metallic alloy) or polymers

(polymeric alloy) that are soluble (miscible) in the molten condition & it may also
contain nonmetallic elements e.g. C, N, O, P, S.

❖ Beam: bar or rod of constant cross-sectional shape & area.

❖ Material Strength: it is a branch of mechanics studying the relations between
externally applied loads & resulting internal effects.

❖ Deformations: temporary (elastic) or permanent (plastic) change in shape.

(N.B.: - Load changes produce deformational changes).

❖ Rigid body: maintains the relative position of any two particles inside it when
subjected to external loads as bone.

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 ❖ Deformable body: undergoes significant changes when subjected to external
loads as intervertebral disk.
❖ Elasticity: ability to return to resting length after undergoing lengthening or
shortening.
❖ Extensibility: ability to be lengthened.

Metal processing:
❖ Cast: molten metal poured into a mold then cooled.
❖ Wrought or forged: shaping metal by blows or pressure from hammer or machine.
❖ Annealing: The material is heated then slowly cooled & shaped. It increases
ductility & reverses microstructural defects.
❖ Forging: Forming metals to near final shape by mechanical force deformation at
room temperature (Cold-Working). It increases strength & stiffness but reduces
ductility.
❖ Hot isostatic pressing (HIPing): Liquid alloy atomized to powder then powder is
consolidated at high temperature & pressure. It produces void- free solid & fine
grain structure thus increasing strength.
………………………………………………………………………………………………………
Load:
➢ it is the forces and/or moments acting on a structure (construct of material).
Types:
1. Compression: equal & opposite loads applied at apposite surfaces of a structure
causes shortening & widening.
2. Tension: equal & opposite loads are applied at apposite surfaces which tend to
cause lengthening & narrowing of the structure (Poisson effect).
3. Shear: loads applied parallel to surface of the structure.
4. Torsion: loading that causes a structure to twist about an axis.
5. Bending: load applied to a structure at a point at which it is not directly supported.
Material on concave side is in compression while on convex side is tension.
o Neutral axis: it is a line within the structure where stresses & strains are
zero.
o Bending rigidity (stiffness): resistance of a structure to bending.
Types of bending:
 Three-point bending.
 Four-point bending.
 Cantilever bending.

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 6. Buckling: bending produced by force along the long axis of a structure. - Loss of
transverse trabeculae & thickening of longitudinal trabeculae in osteoporosis lead
to buckling failure.
In children buckling failure produces green stick fracture.
7. Combined loading (commonest): application of 2 or more of the above types to a
structure.

Stress:
➢ intensity of internal force i.e. internal resistance of a body to a load. (i.e.: Stress =
force / area & Unit of measure: Pascal (Pa) = N/m²)
Types:
1. Normal stresses:
• Compressive or tensile.
• Perpendicular to the surfaces on which they act.
2. Shear stresses:
• Parallel to the surfaces on which they act.
• Cause a part of a body to be displaced in relation to another part.
N.B.: Depending on how you slice the material you can get combinations of stress & shear.
Properties:
* It helps in selection of materials.
* Stress differs from pressure:
Pressure is the distribution of an external force to a solid body; however, they share the
same definition (force/area) & unit of measure (Pa).
In pure tension or compression: plane of maximum shear is at 45 degrees to axis of
loading.

“Hoop” Stress:
* It is the stress in a direction perpendicular to the axis of an object (as the thickness of
the object decreases the hoop stress increases).
* It is important because when humans age: the diameter of their bones increase but the
thickness decreases (this change is not bad for ordinary human activity but it matters
most when we as surgeons intervene).

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 Strain:
Relative measure of deformation of a material as a result of loading.
Strain = Change in length: (6 components).
(𝑓𝑖𝑛𝑎𝑙 𝑙𝑒𝑛𝑔𝑡ℎ−𝑜𝑟𝑖𝑔𝑖𝑛𝑎𝑙 𝑙𝑒𝑛𝑔𝑡ℎ)
𝑆𝑡𝑟𝑒𝑠𝑠 = 𝑥 100
𝑜𝑟𝑖𝑔𝑖𝑛𝑎𝑙 𝑙𝑒𝑛𝑔𝑡ℎ
➢ Types: can also be normal or shear.
➢ Shear strain usually expressed in units called radians (one radian = 57.3
degrees).
➢ Methods of measuring the strain include the following:
• Direct mechanical measurement.
• Electrical resistance strain-gauge measurement.
• Model studies with photo-elastic materials.
• Brittle lacquer coatings.
• X-ray analysis.
➢ Strain is a proportion (relative quantity) so it has no units & often expressed as a
percent (it may be positive or negative percent).
Strain rate: strain divided by the time in which the load is applied (units = sec-1).

Stress-Strain curve:
➢ Definition: standardized curves used to help quantify how a material will
respond (Strain) to a given load (Stress).
➢ t is derived by loading a body & plotting stress versus strain.
➢ The curve’s shape varies by material.
Curve Analysis:
1. Modulus of elasticity: the linear slope of the materials in elastic stress-strain
behavior (i.e. elastic range of the curve).
2. Proportional limit:
▪ Transition point at which stress & strain are no longer proportional.
▪ The material returns to its original length when stress removed: elastic
behavior.
▪ Hooke’s law: basically, stress is proportional to strain up to a limit (the
proportional limit).
3. Elastic limit (yield point):
▪ This is the transition point from elastic to plastic behavior.
▪ Beyond this point: the material’s structure is irreversibly changed.
▪ The elastic limit equals 0.2% strain in most metals.

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4. Yield Strength: it is the stress level at which a material begins to deform
plastically.
5. Plastic Deformation:
▪ It is the irreversible change after load is removed.
▪ Occurs in the plastic range of the curve (after the elastic limit & before the
breaking point).
6. Ultimate Strength: it is the maximum strength obtained by the material (the
stress level at which a material fails).
7. Ductility: the deformation to failure.
8. Breaking Point "failure point":
▪ It is the point at which the material fractures.
▪ Types of failure: Ductile or Brittle.
▪ If deformation between elastic limit & breaking point is large: the material
is ductile.
▪ If this deformation is small: the material is brittle.
9. Strain Energy (Toughness): energy to failure
▪ It is the capacity of material (as bone) to absorb energy (area under the
curve).
▪ Total strain energy = recoverable strain energy (resilience) + dissipated
strain energy.
▪ A measure of the toughness of material (ability to absorb energy before
failure).
▪ N.B: Fatigue failure: occur with cyclic loading at stress below ultimate
tensile strength.

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Young’s modulus of elasticity:

Stiffness:
➢ it is a measure of material stiffness & also a measure of the material’s ability
to resist deformation in tension.
➢ "E" is the slope in the elastic range of the stress-strain curve,
(E=stress/strain).
➢ It is the critical factor in load-sharing capacity.
➢ Linearly perfect elastic material: straight stress-strain curve to the point of
failure.
➢ Modulus = stress at failure (ultimate stress) divided by strain at failure
(ultimate strain)
➢ "E" is unique for every type of material i.e. a material with a higher "E" can
withstand greater forces than can material with a lower "E".
➢ Comparison of Young’s modulus (E) for common orthopedic materials:
1. Al2O3 (Ceramic).
2. Co-Cr-Mo (Alloy).
3. Stainless steel.
4. Titanium.
5. Cortical bone.
6. Matrix polymers.
7. PMMA.
8. Polyethylene.
9. Cancellous bone.
10. Tendon/ligament.
11. Cartilage.
(From 1 to 11 Stress is decreased while Strain is increased)

Shear Modulus:
➢ Definition: ratio of shear stress to shear strain.
➢ It is a measure of stiffness.
➢ Unit of measure: Pascal (Pa).

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Poisson Effect & Ratio:
➢ Poisson effect: under tensile loading a material elongates & also tends to become
thinner because there is a compressive strain in the transverse direction to the axis
of loading even if there is no stress acting in this direction.
➢ Poisson ratio: the absolute value ratio of the transverse compressive strain divided
by the longitudinal tensile strain.
➢ This ratio is an indication of the compressibility of materials & it is inherent
mechanical constant for each material:
▪ It may take on values from 0 (for a fully compressible material) to 0.5 (for a
material that maintains constant volume during deformation).
▪ Most materials have Poisson ration between 0.2 & 0.5.
▪ Values greater than 0.5 simply expansion of volume during deformation which
is unknown for simple materials.
Material Testing:
➢ materials of standardized sizes & shapes are placed in testing machines
➢ & loaded following standardized protocols (standardize methods to test materials
& document their behavior).
➢ In USA the American Society for Testing and Materials "ASTM standards" are the
most widely used while in Europe the most widely used is the ISO standards.
Finite Element Analysis:
➢ Complex geometric forms & material properties are modeled.
➢ A structure is modeled as a finite number of simple geometric forms (typically
triangular or trapezoidal elements).
➢ A computer matches forces & moments between neighboring elements.
➢ Finite element analysis is often used to estimate internal stresses & strains.
(example: stress/strain at bone-implant interface).

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 Materials & Structures:
❖ Material:
➢ Definition: it is a term related to a substance or an element.
➢ Properties:
A. Mechanical properties:
a. Homogenous.
b. Isotropy.
c. Anisotropy.
d. Force.
e. Stress.
f. Strain.
B. Rheological properties:
a. Elasticity.
b. Plasticity.
c. Brittle.
d. Ductile.
e. Viscosity (resistance to flow or shear stress).
f. Hardness.
g. Toughness.
h. Strength.
i. Stiffness (Rigidity).
◆ Homogenous materials: both physical & mechanical properties are identical
throughout the material (uniform structure or composition).
◆ Isotropic materials:
▪ The mechanical properties are the same for all directions of applied loads.
▪ For example: Steel & Aluminum & golf ball.
◆ Anisotropic materials:
▪ The mechanical properties vary with the direction of the applied load.
▪ For example: bone (stronger with axial load than with radial load), tendons,
ligaments & cement.
◆ Brittle materials:
▪ Its stress-strain curve is linear up to failure e.g.: PMMA
"Polymethylmethacrylate".
▪ These materials undergo only elastic (recoverable) deformation before
failure.
▪ They have little or no capacity for plastic deformation.
◆ Ductile materials:

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 ▪ These materials undergo large plastic deformation before failure e.g.: Metals.
▪ Ductility is a measure of post-yield deformation.
◆ Viscoelastic materials:
▪ These materials exhibit both fluid (viscosity) & solid (elasticity) properties.
▪ Stress-strain behavior is time-rate dependent (i.e. properties depend not only
on load magnitude "as elastic materials" but also on rate at which the load is
applied).
▪ Modulus increases as strain rate increases.
▪ Most biologic tissues exhibit viscoelasticity e.g.: bone & ligaments.
▪ These materials exhibit two special modes of deformation:
1. Stress relaxation: internal stress decreases over time while deformation
remains constant.
2. Creep: increasing deformation over time while loads remains constant.
▪ These materials Exhibit Hysteresis:
• Proportional to the degree of viscosity of a material.
• Energy is lost or dissipated internally during loading & unloading.
• Loading & unloading curves differ.
◆ Hardness: ability of a material to resist wear or local indentation or penetration.
◆ Toughness: ability of a material to absorb energy before fracture.
◆ Strength: material resistance to deformation.
◆ Stiffness (rigidity): material resistance to deformation when it is under load.

Perfect orthopedic material:

1. Biocompatible: able to function in vivo without eliciting detrimental local or
systemic responses.
2. Stiff: resist deformation.
3. Hard: resist surface abrasion.
4. Tough: resist breakage.
5. Inert: resist corrosion or degradation.
6. Resist wear.
7. Adapt to loading.
8. Ductile: able to deform before breakage.
9. Regenerate (reduce failure): as composites.

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 ❖ Structure:
➢ Definition: material, shape& loading characteristics.
➢ Load deformation curve:(Force displacement curve):
▪ Constructed similarly to stress-strain curve.
▪ Slope in the elastic range is the structure’s
rigidity.
Bending of beams:
▪ Most bones & orthopedic implants are subjected to axial, bending & torsion
loading.
▪ Most failures occur secondary to bending & torsion.
Bending Theory Definitions:
▪ Neutral Axis: the location where a beam experiences zero stress (this is a
theoretical axis & can actually be located outside of the structure).
▪ Moment of Inertia: the geometric property of a beam/s cross section that
determines the beams stiffness.
Bending rigidity:
▪ Bending rigidity of a rectangular structure is proportional to the base multiplied
by the height cubed.
▪ Bending rigidity of a cylindrical structure as intramedullary nails & half-pins:
• Related to the fourth power of the radius.
• Closely related to area moment of inertia (I).
▪ Resistance to bending:
• Function of width, thickness & the polar moment of inertia (J).
▪ "J": resistance to torsion (twisting).

"I" & "J": functions of the distribution of material in cross section i.e. distance squared of
mass distribution from the center of mass.
Bending resistance:
▪ The resistance of a beam to bending is directly proportional to its moment of
inertia.
▪ The moment of inertia depends on its cross-sectional area & shape.
▪ When the diameter of a spinal instrumentation rod is increased from 4 mm to 5
mm, the rod's ability to resist a bending moment is increased by approximately
100%.
Deflection associated with bending is proportional to applied force "F" divided by elastic
modulus "E" and then multiplied by area moment of inertia "I ":
𝐹
(𝑑𝑒𝑓𝑙𝑒𝑐𝑡𝑖𝑜𝑛 = 𝐸 𝑥𝐼).

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N.B Tension band principle: a properly done tension band shifts the neutral axis to the
surface of the beam so that compression occurs across the entire cross section.

❖ Metals:
◆ Implant failure: it is a failure of an implant to satisfy the specific function for which
it is inserted.
Types:
Biological:
▪ Bone related: Osteomalacia or Osteoporosis.
▪ Implant related: Septic or Aseptic loosening.
Mechanical:
▪ Structural failure: Fatigue, Fracture or Buckling.
▪ Material failure: Corrosion, Wear, Creep & deformation.

Failure depends on:

➢ Implant material choice:
Implant material, design & biochemical activity (inert or not).
➢ Implant application:
Implant type, size, shape & application technique.

Problems with metals:

Fatigue failure:
➢ Definition: progressive material deterioration 2ry to
cyclic loading at stress below ultimate tensile strength
causing crack propagation.
➢ It depends on magnitude of stress & number of cycles.
➢ Crack usually starts at a Stress Riser: Scratch, Hole,
Corner, Change in cross section or Fretting.
Endurance limit:
➢ Maximum stress under which the material will not fail regardless of number of
loading cycles.
➢ If the stress is below this limit, the material may be loaded cyclically an infinite
number of times (more than 10 million cycles) without breaking.
➢ Above this limit, fatigue life is expressed by the (S-n) curve (Stress "S" versus the
number of cycles "n").

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Fatigue life:
➢ the number of cycles that a material can withstand at a given stress level.
Bone fatigue:
➢ if bone fails to heal when subjected to cyclic loads we get stress fractures.
➢ Reduction of fatigue failure can be achieved by:
1. Appropriate design of implants & avoiding sudden changes in geometry.
2. Surface treatments of implant e.g. peening & polishing.
3. Decrease fretting corrosion.
4. Correct insertion of implants e.g. avoiding distraction of fractures so that bone
heals and can share the loads with the implant.
5. Delay weight bearing until fracture healing.
Creep (cold flow):
➢ Definition: increasing deformation over time while loads remains constant.
➢ Sudden stress followed by constant loading causes continued deformation.
➢ It can produce permanent deformity & may affect mechanical function (e.g., TJA).
Corrosion:
➢ Definition: group of processes that produce compounds & free ions from bulk
metals i.e. chemical dissolving of metals (it may occur in the body’s high-saline
environment).
➢ Effects: corrosion can weaken implants, release products that can adversely
affect biocompatibility causing pain, swelling & destruction of nearby tissue.
➢ Classification: Chemical or Electrochemical.
➢ Forms, modes & Types:
1. Uniform attack: the most common which may not be noticed until or unless a
visible amount of metal is lost.
2. Galvanic: electrochemical destruction occurs in dissimilar metals as Stainless
steel (316 L) & Cobalt-Chromium-Molybdenum (Co-Cr-Mo) alloy.
3. Crevice: occurs in fatigue cracks with low O2 tension.
4. Stress: occurs in areas with high stress gradients.
5. Fretting: from small movements abrading the outside layer.
6. Inclusion.
7. Intergranular.
➢ Consequences:
1. Corrosion: high free ion concentration.
2. Passivation: reactions occur that coat the metal surface with a metal oxide
which prevents further release of metal ions into solution.
3. Immunity: rate of release of free ions into solution is very low.

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 ➢ Examples:
• Stainless steel (316L): is the most susceptible metal to both galvanic &
crevice corrosion.
• Galvanic corrosion is highest between (316L) Stainless steel & Cobalt-
Chromium (Co-Cr) alloy.
• Crevice corrosion occurs in the crack between screw head & plate.
• Modular components of THA:
➢ Direct contact between similar or dissimilar metals at the modular junctions
results in corrosion products (Crevice corrosion).
➢ Loose prosthesis or Malaligned stems: fretting & stress corrosion.
➢ Porous stems have 10-fold elevated corrosion rates than smooth surfaces (due to
increased surface area).
➢ Uniform attack corrosion operates in all prosthesis & at all sites.
• Examples: metal oxides & metal chlorides.
➢ Degradation is the form of corrosion affecting polymers & most common is
oxidation degradation of UHMWPE components of total joint arthroplasty.
➢ Corrosion can be decreased by:
1. Using similar metals.
2. Proper implant design.
3. Passivation by an adherent oxide layer:
▪ It is a process consists of dipping in nitric acid to generate oxide film on
implant.
▪ Effectively separates metal from solution.
▪ Example: stainless steel coated with chromium oxide.
Other problems:
➢ Wear: see later.
➢ Stress Shielding: increased in metals with a higher "E".
➢ Buckling: sudden material deterioration 2ry to compression of a thin walled tube
(diameter < 1/8 its length).
➢ Loosening.
➢ Ion release:
• (Co-Cr): macrophage proliferation & synovial degeneration.
• Ions excreted through the kidneys.

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❖ Porous Surface Metals:
➢ Importance: replacement of bone cements used in arthroplasty implant fixation by
direct biologic means (bone growth) using porous surface metals especially in
young patients (Cement-less Arthroplasty).

➢ Fabrication Techniques:
1. Sintering of cobalt-chrome powder or beads to cast or forged devices: most
popular technique.
2. Diffusion bonding of titanium wire mesh.
3. Direct (Spray) coating: porous coating.

❖ Types of metal alloys in orthopedic implants:

(Three types of alloys: Steel (iron-based), Cobalt-based & Titanium-based)
◆ Stainless steel (316 L):
➢ Strong material but can get stress, crevice or galvanic corrosion with time.
➢ Used for: fracture fixation & spinal implants.
➢ Composition & Properties: Fe-C, Cr, Ni, Mo, Mn.
• “L” = low Carbon (less than 2%): Carbon adds strength & greater corrosion
resistance but forms undesirable precipitate and fatigue fracture.
• 60% Iron.
• 20% Chromium: forms a passive surface oxide (Passivation) which improve
corrosion resistance (the Stainless quality).
• 15% Nickel: adds strength (stabilizes molecular structure) & increases
corrosion resistance.
• 3% Molybdenum: prevents pitting & crevice corrosions.
• traces of Manganese: improves crystalline stability.
◆ Cobalt alloy: (Cobalt-Chromium-Molybdenum "Co-Cr-Mo")
➢ Used for: joint replacements (bearing surfaces) & occasionally for fracture fixation
devices.
➢ Composition: 60% Cobalt & 30% Chromium & 7% Molybdenum & traces of other
metals.
➢ Properties:
• Highly resistant to corrosion due to Chromium which forms a passive surface
oxide.
• Highly resistant to fatigue fracture.
• HIPing or forging increases ductility & fatigue resistance.

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 • Special forging process in which Nickel may be added to improve ease of forging
& metal strength but has corrosion and compatibility problems.
◆ Co-Cr alloy:
➢ Generates less metal debris (in THA) than does titanium alloy.
➢ Problems with orthosis fabrication:
• Stainless steel: heavy.
• Aluminum: low endurance limit.
◆ Titanium alloy (Ti-6Al-4V):
➢ Composition: 90% Titanium & 6% Aluminum & 4% Vanadium.
➢ Pure Titanium "Ti" has a lower stiffness, strength & corrosion resistance than “Ti”
alloys.
➢ Advantages:
1. Polishing, passivation & ion implantation improve its fatigue properties.
2. Its modulus of elasticity is around half of that of stainless steel or "Co-Cr" so using
titanium implants may reduce the stress shielding.
3. Titanium is Extremely Biocompatible & lacks immunogenicity:
• Rapidly forms adherent oxide coating layer (self-passivation) which
decreases corrosion more than Stainless steel or "Co-Cr”.
• A nonreactive ceramic coating.
4. Other advantages:
• Relatively low "E".
• High yield strength.
• Most closely emulates axial & torsional stiffness of bone.
➢ Disadvantages:
1. Poor resistance to wear (notch sensitivity) leads to crack formation & decreased
fatigue life & particulate may stimulate histiocytic response.
2. Not a good bearing surface in joint arthroplasty as it gets rough with time.
3. The relationship between titanium & neoplasms is uncertain.
◆ New alloys: (Experimental)
 TRIP Steel "Transformation Induced Plasticity": steels with significantly
higher strengths while retaining greater ductility but have higher corrosion
rates than Stainless steel.
 Refractory metals:
• Called refractory metals due to their higher melting points as: Tungsten
& Tantalum.
• Highly corrosion resistant & excellent mechanical properties but they
are very hard so extremely difficult to machine.

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 Nickel-Titanium alloys: good yield strength with ductility but high Ni corrosion
release rate is high.
❖ Polymers:
◆ Polyethylene: "UHMWPE"
➢ Definition: ultra–high-molecular-weight polyethylene (UHMWPE) which is a
semi crystalline polymer of long carbon chains (Polymers are large molecules
made from combinations of smaller molecules as: Nylon, PMMA, Polyethylene).
➢ Used in: weight-bearing components of TJAs (Acetabular cups & tibial trays).
➢ Properties:
• Polyethylene is viscoelastic & highly susceptible to abrasion.
• Polyethylene is weaker than bone in tension & has a low "E".
• UHMWPE is thermoplastic i.e. its mechanical behavior has a very strong
dependence on temperature or high-dose radiation.
• Basic monomer of polyethylene is (CH)2 with a molecular weight of 28.
• Its mechanical & wear properties depend on its molecular weight, structure,
oxidation, cross linking, processing method & sterilization.
i.e. Not all polyethylene is the same.
➢ Polyethylene wear:
• Wear characteristics: superior to those of high-density polyethylene as it is
tough, ductile, resilient, resistant to wear & low friction.
• Wear damage to UHMWPE articulating surface is often caused by third-body
inclusions.
• Volumetric wear most affected by relative motion between the two surfaces in
contact.
• Polyethylene wear debris is the main factor affecting THA longevity:
• Fatigue wear more prevalent in TKA than in THA.
• Rate of polyethylene debris production in THR can be reduced by using a more
wettable materials (better able to maintain lubricant on the surface) for the
articular surface of the femoral component.
• Catastrophic wear of polyethylene tibial inserts associated with the following:
▪ Varus knee alignment.
▪ Thin inserts (less than 6mm).
▪ Flat & nonconforming inserts. = Heat treatments of the insert.
• Wear debris associated with a histiocytic osteolytic response:
▪ Particles with a size range of 0.1 to 1.0 μm are most reactive.
▪ This response is increased with thinner (less than 6mm) & flatter & carbon
fiber-reinforced polyethylene.

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➢ Role of creep in failure depends on the thickness i.e. Acetabular component wear.
➢ Oxidative polyethylene degradation after γ-irradiation in air:
• Degradation is due to free radical formation which increases susceptibility
to oxidation.
➢ γ-Irradiation increases polymer chain cross-links which greatly improves wear
characteristics but reduces resistance to fatigue & fracture as it decreases elastic
modulus, tensile strength, ductility & yield stress.
➢ Annealing:
• Definition: heating to below melting point to decreases free radicals.
• Conserve good mechanical properties of polyethylene & doesn't disrupt
crystalline areas.
➢ Cross Linking:
• It is done to create larger molecular polyethylene molecules that can
theoretically be more wear resistant.
• There are two common methods for crosslinking:
a. Irradiation.
b. Free radical generating chemical.
• The major problem with crosslinking is that usually higher doses of radiation
which produce the greatest amount of crosslinking also may cause degradation
in the materials mechanical properties specifically decrease in fracture
toughness & fatigue strength & life.
• Newer versions of highly cross-linked polyethylene are treated by a
combination of lower dose radiation & post irradiation melting and/or
annealing (these processes are showing low wear rates & small changes to the
mechanical properties).
➢ Metal backing may help minimize plastic deformation of high-density
polyethylene & loosening however it decreases effective thickness.

❖ PMMA (Bone Cement): "Poly-methyl-meth-acrylate"

➢ Function:
a. Mechanically interlocks with bone in TJA by acting as a grout no a glue (space
filling with no adhesive characters) leading to stabilization of implants so reduce
pain.
b. Distribute stresses induced by implants on bone in TJA so preventing local stress
concentration & bone necrosis.
c. Internal splint for patients with poor bone stock & Osteoporotic:
• PMMA can be used as a temporary internal splint until the bone heals.

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 • If the bone fails to heal: the PMMA will ultimately fail.
➢ Properties:
▪ Cold curing polymer.
▪ Viscoelastic material with modulus about 10% of cortical bone & compressive
strength about 50% of cortical bone.
▪ It is strongest in compression than in tension or shear but has low "E" (not as
strong as bone in compression) i.e. relatively brittle.
▪ Addition of antibiotics (Antibiotic Laden "Impregnated" Cement) decreases
strength while Carbon addition increase strength but intrusion properties are
decreased.
▪ Failure tends to occur at bone cement interface.
▪ Effects of its insertion:
 Local effects:
• Heat released on polymerization.
• Occlusion of nutrient metaphyseal arteries that can cause tissue necrosis.
• Wear particles initiate macrophage response leads to prosthesis loosening.
 Systemic effects:
• Hypotension due to peripheral vasodilatation, myocardial depression
(hypersensitivity reaction) & rarely induces anaphylactic responses.
• Insertion of cement plug as firmly as possible into the medullary cavity may
force fat or air or monomer into the circulatory system leading to
hypotension & may be cardiac arrest within minutes.
• It is metabolized to methacrylic acid which may diminish phagocytosis.
• Methyl methacrylate monomer before polymerization is toxic.
▪ It reaches ultimate strength within 24 hours.
▪ Cement failure often caused by micro-fracture & fragmentation.
➢ Composition & Preparation:
• Sterilized two-part kit: container of 40gm dry component & vial of 20ml
liquid component.
• Dry component: powder containing pre-polymerized
polymethylmethacrylate & barium sulphate & small quantity of free radical
source to be acted on by the initiator in the liquid component.
• Liquid component: methyl methacrylate monomer with an initiator & one
or more stabilizers to prevent premature polymerization by ultraviolet light
& an accelerator.
• Powder is sterilized by cobalt gamma irradiation while Liquid by
ultrafiltration.

18
 • Mix the components according to the manufacturer's recommendations to
initiate polymerization process (Curing) which is self-curing & cold-curing
i.e. all ingredients necessary for polymerization are present in the powder
and liquid & heat and pressure aren't needed.
• Some cements contain antibiotic in dry form (usually gentamycin).
• Some cements contain coloring agent e.g. chlorophyll to make
differentiation between cement & bone easier if the patient later requires
revision arthroplasty.
➢ Curing:
• It occurs without change in volume of cement so prosthetic stems is bedded in
them without subsequent loosening due to dimension changes.
• It has 3 characteristic times associations:
I. Dough time: it is the time point measured from the beginning of mixing at which
with moderate mixing the (BC) will not stick to un powdered surgical gloves (2-3
minutes under typical conditions).
II. Setting time: it is the time point measured from the beginning of mixing at which
the surface temperature of the dough mass reaches one-half of its maximum value
(8-10 minutes under typical conditions).
III. 3.Working time: the interval between setting & dough times (typically 5-
8minutes).
 Factors affecting dough & setting & working times:
1. Too rapid mixing: accelerate dough time & produce weaker more porous
cement due to inclusion of air.
2. Increased temperature reduces both dough and setting times & vice versa.
3. High humidity decreases setting &working times.
 Factors for optimizing cement strength:
I. Uncontrollable factors:
1. Aging: gradual loss of 10% of strength due to post-curing chemical changes.
2. Environmental temperature: cement is 10% weaker in body temperature than at
room temperature.
3. Fatigue: fatigue strength (106 cycles) is 25% of single cycle strength.
4. 4.Moisture content: loss of 10% strength due to water absorption.
5. Strain rate: significant increase in strength with increasing strain rate.
II. Partially controllable factors:
1. Cement thickness: intermediate thickness (typically < 5m) minimizes both fatigue
stresses & shrinkage effects.
2. Constraint: cement is stronger in compression than tension.
3. Inclusion of blood or tissue: up to 70% loss of strength depending on amount.

19
4. Stress risers (bony bed, prosthesis): significant.
III. Fully controllable by Surgeon:
1. Antibiotic inclusion: results in 10% loss of strength.
2. Centrifugation & Vacuum degassing: diminishes porosity (voids) which is due to
air inclusion & gives 20% increase in strength & decrease cracking but with
possible increase in fatigue strength.
3. Mixing speed: up to 20% loss of strength due to too slow or too rapid mixing.
4. Insertion: delay may produce up to 40% loss of strength while pressurization
increases strength by up to 20% by reduction of porosity.
5. Radiopaque fillers: 5% weaker than unfilled.

 Cementing techniques:
➢ 1st generation: finger filling with no femoral canal preparation or plug.
➢ 2nd generation: cement gun to allow retrograde filling after femoral canal
preparation & plug.
➢ 3rd generation: pressurization after insertion.
➢ 4th generation: cancellous suction using cannulated screw suction using triple
package cementation.
 Tissue reaction at bone-cement interface after implantation passes through 3
phases:
I. Initial phase:
• It lasts from the time of implantation to about 3 weeks after operation.
• There is always a zone of dead bone & bone marrow extending up to 5mm
from the cement surface.
• There may be death of larger areas of cancellous & cortical bone not in close
contact with the cement.
• Cause of death of bone at the bone-cement interface:
o Trauma & heat generated by cutting & reaming the bone.
o Heat generated by polymerization of the cement.
o Leakage of monomer from the cement before it polymerizes.
II. Reparative phase:
• Begins during about the 4th week & lasting for up to 2 years.
• Dead tissues are progressively invaded by living vascular granulation tissue.
• The dead bone is removed by the activity of osteoclasts.
• Active repair process proceeds until all of the dead tissues have been replaced
by living bone & living soft tissues.

20
III. Stabilization phase:
• Begins 6months to 2 years after operation.
• The permanent implant bed is composed of:
o Thin layer of Acellular fibrin-like tissue in immediate contact with cement.
o Outer layer of collagenized fibrous tissue up to 1.5 mm thick.

❖ Silicone rubber: (Silastic)

➢ Poor strength & wear capabilities.
➢ It induces frequent synovitis with extended use.
➢ Uses:
1. Spacer for non-weight bearing small joints or bones as replacement for the
carpal bones or head of radius or proximal IPJ or MCPJ.
2. Reconstructing the tendon sheath by insertion of an artificial (silastic)
tendon (spacer) for two months to promote the formation of smooth
fibrous tunnel through which a normal tendon graft will function
satisfactorily.
3. Silastic sheathing are wrapped around sites of nerve or tendon repair sites
to prevent adhesion formation.
4. Orthosis as that for flat foot.
5. Cosmetic & reconstructive plastic surgery as breast augmentation.

❖ Biodegradable & Fiber polymers:

Non-absorbable (Permanent) Fiber polymers:
➢ Forms: monofilaments or multistrand.
➢ Examples & Uses:
• Nylon & Dacron: used as suture materials or for ligament augmentation.
• Teflon (PTFE): "Poly-tetra-fluoro-ethylene"
▪ Used as braided fibers for ligament augmentation device for knee.
▪ Used as permanent implant for chronic instability of joints.
Biodegradable (Bioabsorbable) Polymers:
➢ Absorbable Fiber Polymers:
• Composition: Polylactic acid or Polyglycolic acid or both.
• Examples: Dexon & Vicryl & PDS.
• Uses:
1. Slowly absorbable suture materials.
2. Can be made relatively stiff so available as absorbable pins
for skull.

21
 ➢ Investigational Biodegradable Polymers:
• Induce foreign body reactions & inflammatory response in many
patients.
• Possibly in the future Bioabsorbable screws & pins can be used,
composed of a mix of:
1. Polylactic acid: has slow rate of resorption i.e. spread it over a long
period & reduce the level of inflammatory response.
2. Hydroxyapatite "HA": improving the stiffness of polylactic acid.
❖ Others:
❖ Ceramics:
➢ Definition & Composition:
• Metallic & nonmetallic elements bonded ionically in a highly oxidized state.
• Calcium phosphates (e.g. hydroxyapatite) may be useful as a coating
(plasma sprayed) to increase attachment strength & promote bone healing.
➢ Types:
I. Bioinert (Biostable) non resorbable crystalline (inorganic) Ceramics i.e.
unaffected by chemical effects of implantation as:
o Alumina: Al2O3 (Aluminum oxide).
o Zirconia: ZrO2 (Zirconium dioxide).
II. Bioactive resorbable (degradable) non-crystalline (organic) Ceramics i.e.
react with the local host environment to produce altered surface
properties & host response as:
o Silicon dioxide (SiO2) (Bioactive glass).
o Calcium phosphate compounds.
➢ Properties:
• Brittle (no elastic deformation).
• Difficult to machine.
• Poor crack resistance characteristics (low resistance to fracture).
• High modulus (E).
• Low yield strain.
• High compressive strength.
• Low tensile strength.
• Small grain size allows an ultra-smooth finish (less friction & wear).
• High surface wettability & high surface tension:
▪ Highly conducive to tissue bonding.
▪ Less friction & diminished wear (smooth surface).
• High resistance to wear & low oxidation rate.
• Inert so has excellent tissue biocompatibility.

22
 • Good insulators (poor conductors).
• High thermal & electrical resistance.
➢ Uses of Alumina or Zirconia:
I. Suitable than metals for fabrication of bearing surface of arthroplasty implants
(where significant tensile stresses are not encountered) due to:
1. Ceramics have a hard surface (the surface finish is finer than that of metal).
2. Chemical inertness makes them well tolerated by the body. N.B. Ceramics
didn't decompose to produce metal.
3. Coefficient of friction is low (lower than metal on polyethylene).
4. Ceramics wear rate is 3 to 16 times less than that of metal head in
polyethylene socket because Ceramics are abrasion resistant due to its
intrinsic hardness.
5. Protective passive oxide film on Chromium or Titanium surfaces can be
sheared off & adhering to the opposing polyethylene (transfer of the
passivated layer to the polymer) while Ceramics can maintain their
polished surface finish in the presence of PMMA or bone debris.
II. Unsuitable for fracture fixation hardware due to their mechanical
disadvantages.
III. Ceramics aren't widely used in the TKA due to high cost of manufacturing.
IV. In THA:
• Ceramic femoral heads may be articulated with Polyethylene or Ceramic cups
but never with metallic surfaces to avoid excessive wear of the metallic
component.
• Ceramic femoral head may be indicated if Titanium stem is used to avoid
creating galvanic cell by placing Chromium alloy head on Titanium prosthesis.
• The combination of Ceramic stem with Polyethylene cup is more favorable
than Ceramic on Ceramic due to:
a. It is difficult to manufacture concentric matching femoral head &
acetabular component.
b. Higher wear is demonstrated on using Ceramic on Ceramic.
c. Malposition of Ceramic acetabular component may produce fracture of
its rim with generation of debris.

23
 ➢ Uses of Calcium phosphate compounds:
I. Cement less THA: Hydroxyapatite (HA) coating of the implant surface to
enhance bony ingrowth around & into prosthetic device resulting in
osteointegration & direct bonding to bone to establish a mechanical
anchoring of the implant without any unmineralized tissue layer at HA-
bone interface.
II. Calcium phosphate ceramics: used as bone graft (bulk material or
granules) to fill gaps between bone and prosthesis & serve to fill bone
defects.

❖ Composites:

Plaster of Paris & its modern replacement (the main use of composites):
non-implantable composites used mainly as casting materials.
➢ Composition & Properties:
A. Reinforcing or Fabric component:
• Weak & flexible in compression but quite strong in tension.
• Old products: cotton gauze.
• Modern products: fiberglass or polyester mesh or fiberglass-polyester
interweave.
B. Matrix component:
• Weak & flexible in tension but quite strong in
compression.
• Plaster (calcium sulphate) or Thermoset polymer
(Resin) or polymer-plaster mixture (Plaster-
Resin).
• Matrix is hardened (set) by two different
processes:
a) For Plaster: it is a partially anhydrous calcium
sulphate ground to a fine powder which
recrystallizes & sets back into solid gypsum &
expands slightly & evolves heat after
recombination of water.
b) For Resin: harden by polymerization which is
initiated by water or heat or ultraviolet
illumination.
N.B. The composite combines the properties of both matrix & reinforcing
components to produce fairly strong & tough material.

24
Plaster of Paris:
Advantages Disadvantages
Low Coast Heavy weight & bulky.
Familiarity & easy revision Slow setting (4 - 8 min).
Its weight restricts patient activity 24h for
maximum strength.
Radiopaque

Resin:
Advantages Disadvantages
Light Weight. Adheres to skin & clothes.
Rapid setting. Flammable.
Radiolucent. Very hard edges.
Waterproof Tissue irritation (adjacent skin)

Investigational Composites:
➢ Polylactic acid-coated carbon.
➢ Polymer composites with carbon fiber reinforcement: piles of carbon fibers
impregnated with matrix polymer "poly-sulfone or poly-ether-ketone".

25
 Orthopedic Structures
❖ Bone:
Mechanical properties:
➢ Bone can be considered as a biphasic composite:
• Material & mineral as one phase.
• Collagen & ground substance as the other.
Composition: collagen & hydroxyapatite:
• Collagen: low "E" & poor compressive strength but good tensile strength.
• Calcium hydroxyapatite: stiff & brittle but good compressive strength.
• Mineral content is the main determinant of the elastic modulus of cortical
bone.
• Viscoelastic: exhibit both fluid (viscosity) & solid (elasticity) properties.
• Anisotropic: its failure depends on load direction & loading type:
o Strongest in compression.
o Weakest in shear.
o Intermediate in tension.
• Resists rapidly applied loads better than slowly applied loads.
• Cancellous bone is 25% as dense & 10% as stiff & 500% as ductile as cortical
bone.
• Cortical bone excellent at resisting torque.
• Cancellous bone good at resisting compression & shear.
• Cortical bone is weakest in directions that cause tensile stresses.
• In the transverse direction the bone is acting as a brittle material.
• Cortical bone is stiffer than cancellous bone and more brittle i.e.
withstanding less strain before failure than cancellous bone:
o Fracture occurs in cortical bone in vitro at strains of only 2%.
o Fracture occurs in cancellous bone in vitro at strains of > 75%.
• Bone is Dynamic:
o Able to self-repair.
o Changes with aging: gets stiffer & less ductile.
o Changes with immobilization: gets weaker.
• Bone Aging:
o To offset loss in material properties, bone remodels to increase inner
& outer cortical diameters.
o Area moment of inertia increases.
o Bending stresses decrease.

26
• Stress Riser "Stress concentration" effects:
o Occur at defect points (discontinuity as a hole or sudden change in cross
section) within bone or implant-bone interface.
o It reduces overall loading strength.
o The highest stress concentration occurs near a sharp point.
o A hole 25% of bone diameter reduces strength up to 50%, Regardless
whether it is filled with a screw.
o Area returns to normal 9 to 12 months after screw removal.
o Cortical defects can reduce strength 70% or more: oval defects less than
rectangular defects (due to smaller stress riser).
• Stress relaxation is the decrease of stress with time under constant strain.
• Stress Shielding by load-sharing implants:
o Occurs when an implant carries most of the stress and effectively
unloads the bone.
o Induces osteoporosis in adjacent bone (decreases normal physiologic
bone stresses).
o Loss of bone is common under plates and at the femoral calcar in high-
riding THAs. - A long bone is more than twice as strong in bending &
more than five times stronger in torsion than a solid tube of identical
mass.
• In load deformation curve of bone: the elastic portion of the graph has a
slight curve compared to other materials.
• Why are long bones hollow?
1. For the same total cross-sectional area, a hollow tube has higher bending
& torsional resistance than a solid tube.
2. Most bones are loaded in bending & torsion.
3. Bone responds to Wolfe’s law i.e. tries to maximize the bone density
where stress is highest & minimize it where stress is lowest within limit.
4. The thinner a bone is the easier for nutrients to reach the osteocytes.
5. Less energy is required to maintain the bone.
6. less bone weight for easier body movement.
• Bone remodeling:
o Wolff’s law: bone has the ability to adapt by changing its size & shape
& structure according to the mechanical demands placed on it (bone is
laid down where needed & resorbed where not needed).
o Thus, disuse leads to sup-periosteal & periosteal bone resorption so
reducing its stiffness & strength.

27
 o The remodeling may be either external (a change in the external shape
of the bone) or internal (a change in the porosity, mineral content, and
density of bone).
o Stress protection of bone: it is a phenomenon in which an implant
sharing the imposed load on bone can cause resorption of the
underlying/surrounding bone because this bone carries less load than
normal.
o Bone hypertrophy can also occur at implant attachment sites e.g. around
screws. * Laying down of bone can occur as a result of strenuous exercise
& resorption can occur in prolonged weightlessness or inactivity.

Other factors affecting bone strength:

I. Effects of use & disuse:
a. Disuse:
➢ 6 weeks without functional load decreased bone mineral content to
88% of normal.
➢ Bone is lost from the endosteal surface.
b. Use:
➢ Controlled cyclical loading (as low as 36 cycles per day) produced a
hypertrophic response with an increase of 150% of normal bone
mineral content.
➢ Bone is deposited on the periosteal surface.

II. Changes in bone associated with aging:

➢ Progressive loss of bone density occurs with age (senile Osteoporosis).
➢ Young bone is more ductile /less brittle than older bone so more strain before
breakage is allowed in young bone.
III. Effects of holes on bone strength:
➢ The strength of bone is affected by the size & shape of holes.
➢ Holes with sharp corners will reduce the torsional strength of bone to a greater
extent (due to the stress riser effect) than those with smooth edges.
➢ 4-point bending strength decreased to 80% of normal for a hole diameter of 10%
of the diameter of the bone.
➢ Torsional strength is reduced to 65% of normal when the hole size is greater than
20% of the diameter of the bone.

28
Fracture: (type is based on mechanism of injury)
- Bone behavior under various loading modes:
Tension:
➢ Due to muscle pull.
➢ Typically, transverse in pattern occurring perpendicular to load & bone axis.
➢ Occur in areas with large proportion of cancellous bone e.g. calcaneum & 5 th
metatarsal
Compression:
➢ Axial loading of the bone.
➢ Usually occur in cancellous bone because it is weaker.
➢ Oblique or Crush fracture patterns.
Shear:
➢ Commonly around joints (cancellous bone e.g. femoral condyles or tibial plateau).
➢ Load parallel to the bone surface.
➢ Fracture parallel to the load.
Bending:
➢ Due to eccentric loading or direct blows.
➢ In bending there is a combination of compression & tension:
 Tensile stresses & strains on one side of the neutral axis.
 Compressive stresses & strains on the other side.
➢ The compressive & tensile stresses may not be equal because bone is asymmetrical.
➢ Failure (fracture) begins on tension side of bone then continues
transversely/obliquely.
➢ Butterfly fragment is produced if there is combination of compressive & bending
forces:
 Bending causes a transverse crack on the tensile side of the bone.
 Compression causes an oblique crack on the other side.
 Where the 2 fractures meet a butterfly segment result.
➢ High-velocity bending: produces comminuted butterfly fracture.
➢ Three-point bending: produces transverse fracture because bone is weaker in
tension than in compression.
➢ Four-point bending: produces segmental fracture.
Torsion:
➢ Shear & tensile stresses around the longitudinal Axis of bone.
➢ Most likely to result in a spiral fracture pattern.
➢ Torsional stresses proportional to the distance from the neutral axis to the
periphery of a cylinder.

29
 ➢ Greatest stresses in a long bone under torsion are on the outer "periosteal" surface.
N.B. Comminution is a function of the amount of energy transmitted to bone.
Fatigue fracture of bone:
➢ Caused by repeated applications of a load below the ultimate strength/stress of
bone.
➢ the fatigue process in living bone is affected by:
• Amount of load.
• Number of repetitions & frequency of loading.
➢ Fatigue fracture only occurs when the rate of remodeling is outpaced by fatigue
process.
➢ Fatigue fractures tend to occur during continuous strenuous physical activity.

Strain theory of fracture healing:

➢ The type of tissue formed in a healing gap depends on the strain that it
experiences.
➢ If the strain is:
▪ 10%: granulation tissue will form.
▪ 2% - 10%: fibrocartilage will form.
▪ < 2%: bone will form.

❖ Bone Grafts & Substitutes:

➢ Definitions:
 Bone graft: it is an implanted bone material that alone or in combination with other
materials promote bone healing response by providing both osteoinductive and
osteoconductive activity to a local site.
 Bone graft substitutes: it is a material that can replace the use of autogenous bone
graft & achieve good results in fracture healing.
 Osteogenic: presence of active cells capable of bone production.
 Osteoinductive: presence of bio-active poly peptides that stimulate osteogenesis
(bone formation) through the differentiation of mesenchymal cells into
osteoprogenitor cells.
 Osteoconductive: provide linkage across defects and scaffold for attachment &
migration & distribution of cells responsible for bone-healing.

30
The three basic requirements for osteogenesis:
➔ Presence of osteoprogenitor cells.
➔ Bone matrix.
➔ Growth factors.

Indications of bone graft:

➔ Fill cavities or defects resulting from cysts or tumors.
➔ Bridge joints in extraarticular arthrodesis.
➔ Bridge major defects or establish the continuity of long bone.
➔ Provide bone blocks to limit joint motion (arthrodesis).
➔ Establish union in cases of nonunion & pseudo arthrosis.
➔ Promote union or fill defects in delayed union or malunion or fresh fractures or
osteotomies.

Contraindications of bone graft:

➔ Infections (wound infection or open fracture): calcium sulphate bone substitutes
can be used in this case.
➔ Non-viable surrounding bone.
➔ Bone disorders that hinders bone graft incorporation as:
• Inflammatory bone disease.
• Metabolic bone disease that alter calcium metabolism.
• Immunological abnormalities.
• Systemic disorders with poor wound healing.

Functions of bone grafts:

• Biological function: stimulate osteogenesis.
• Mechanical function: replace missing bone.

Preservation & transplantation:

 Fresh:
• Requires no preservation.
• No test for disease or sterility.
• There is high immune response.
• The application of fresh allograft is limited to joint resurfacing.
 Frozen (< - 60°C): inhibit enzyme degradation & decrease immunogenicity.

31
  Lyophilized (Freeze-Dried):
• Removing water + vacuum packing + freezing + storage up to 5y.
• Low antigenicity.
• Osteoconductive only.
 Irradiated:
• Powerful sterilizing method.
• Low antigenicity.
• Biomechanical alteration.

Stages of graft healing (incorporation):

I. Hemorrhage.
II. Inflammation: chemotaxis stimulated by necrotic debris.
III. Revascularization.
IV. Creeping Substitution: replacement of necrotic host tissue by donor new bone
formation along the invasive host blood vessels.
i. Osteoblast differentiation: from precursors.
ii. Osteoinduction: osteoblast and osteoclast function.
iii. Osteoconduction: new bone formation over a scaffold.
V. Remodeling: continues for years.

Classification of bone grafts:

I. According to source:
1. Human:
• Autograft.
• Isograft "twins".
• Allograft.
2. Different species: Xenograft as bovine or porcine.
3. Bone Substitutes:
• Osteoinductive.
• Osteoconductive.
• Osteogenic.
II. According to function:
A. Osteoinductive:
1. Bone Morphogenic Proteins (BMP.s).
2. Insulin-Like Growth Factor (IGF).
3. Platelet-Derived Growth Factor (PDGF).
4. Transforming Growth Factor-ß (TGF-ß).

32
 5. Fibroblast Growth Factors (FGF.s).
B. Osteoconductive:
1. Calcium Based Synthetic Substitutes.
2. Allograft Bone Matrices: although allograft bone lacks any viable cells that
might contribute to new bone formation but allograft matrix is highly
osteoconductive with some osteoinductive properties.
3. Collagen: conductive to bone formation &its surface contains sites for
deposition of mineral.
4. Hyaluronan: not osteoconductive but it is useful tissue engineering
substrate.
5. Polylactic & Polyglycolic Polymers: degradable polymers have little
osteoconductive potential.
6. Ceramic Matrices:
• Hydroxyapatite (HA).
• Calcium Sulfate Matrices.
• Tricalcium phosphate.
• Injectable Ceramic Cements.
• Ultra-porous β-tricalcium Phosphate.
C. Osteogenic:
1. Unfractionated Fresh Bone Marrow:
• Harvested from iliac crest & immediately transplanted to recipient site.
• Inexpensive simple procedure that can be done on an outpatient basis.
2. Connective Tissue Progenitors.
3. Differentiated Osteoblasts & Chondrocytes: difficult to obtain & has limited
capacity for proliferation.
4. Genetically Modified Cells: new technique in which gene therapy is used for
treatment of bone cells to transmit the genetic material coding for
osteoinductive stimuli.

III. According to structure:

1. Cortical.
2. Cancellous.
3. Cortico-cancellous: provide both structural stability & quick incorporation.
4. Osteo-chondral: for tumor surgery.
5. Bone marrow & BMP.
6. Calcium based synthetic substitutes.

33
❖ Autografts (Autogenous grafts):
➢ Definition: bone is transferred from one site to another in the same individual.
➢ Properties:
• No immunogenicity with highest Osteogenic & Osteoinductive capacity.
• Vascularized more quickly than allografts.
• Donor site morbidity is incidence is 20% in the form of: hematoma & pain &
fracture & infection.
• The graft segment heels as a fracture i.e. no resorption occurs at either ends of
the graft.
• It is the most commonly used graft & includes:

➔ Cancellous autografts:
➢ Obtained from: the thicker portions of the ilium, greater trochanter, proximal
metaphysis of the tibia, lower radius, olecranon, or from an excised femoral
head.
➢ Graft incorporation:
• Autografts undergo necrosis, but a few surface cells remain viable.
• The graft stimulates an inflammatory response with the formation of a
fibrovascular stroma; through this, blood vessels and osteoprogenitor
cells can pass from the recipient bone into the graft i.e. providing a
stimulus for bone growth (Osteoinduction).
• The graft also provides passive scaffold for new bone growth
(Osteoconduction).
• Cancellous graft becomes incorporated more rapidly and more
completely than cortical graft.
➔ Cortical autografts:
➢ Obtained from: any convenient long bone as proximal two thirds of fibula or from
the iliac crest.
➢ They have greater strength than cancellous grafts so it can provide structural
integrity.
➢ Technique:
• Usually need to be fixed with screws, sometimes reinforced by plate.
• They can be placed on the host bone or inlaid or slid along the long axis of bone.
➢ Graft incorporation: similar to that with cancellous autografts but slower & less
complete.

34
➔ Vascularized grafts:
➢ This is theoretically the ideal graft.
➢ Technique:
• Bone is transferred complete with its blood supply which is anastomosed to
vessels at the recipient site.
• The technique is difficult and time consuming and requires microsurgical skill.
➢ Available donor sites:
• The iliac crest (complete with one of the circumflex arteries).
• The fibula (with the peroneal artery).
• The radial shaft.
➢ Graft incorporation: they remain completely viable and become incorporated by
the same process of fracture healing.

➔ Bone marrow aspirates:

➢ Principle:
• Bone marrow contains stem cells and osteoprogenitor cells which are able to
transform into osteoblasts in the appropriate environment and with
stimulation.
• The number of these mesenchymal cells in aspirates from the iliac crest
decreases with age and also in females.
➢ Technique:
• The aspiration technique from the iliac crest can influence the number of
osteoblast progenitors obtained which account for the variable results
reported.
• The recommended procedure is to take multiple small volume aspirates
(four 1 mL aspirates from separate site punctures).
• Centrifugation of the aspirate in order to concentrate the cellular contents
has provided encouraging results.

➔ Platelet derived activators:

➢ They are derived from centrifugation of venous blood.
➢ These factors activate repair of tissues not just bone and augment healing
processes in vivo.

35
❖ Allografts (Homograft):
➢ Definition: bone transferred from one individual (alive or dead) to another of
the same species.
➢ Indication: reconstructive surgery where pieces are inserted for structural
support as for revision hip arthroplasty to replace bone loss from previous
prosthesis loosening.
➢ Advantages:
• They can be stored in a bone bank.
• Can be plentiful so useful for filling large defects.
➢ Disadvantages:
• Graft rejection:
▪ Allografts are immunologically unacceptable and induce inflammatory
response in the host and this may lead to rejection.
▪ Antigenicity can be reduced by freezing (at –70°C) or freeze-drying or
by ionizing radiation or demineralization.
▪ Transmission of diseases:
o Sterility must be ensured because potential for transfer of
infection is either from contamination at the time of harvesting or
from diseases present in the donor.
o Donor must be cleared for malignancy, syphilis, cytomegalovirus,
hepatitis, HIV.
➢ Sterilization of the graft done by ionizing radiation or exposure to ethylene
oxide.
➢ Graft incorporation:
• Similar to that with autografts but slower & less complete & not osteogenic.
• Higher rate of clinical failure.
➢ Available forms: putty or powder or granules.
➢ Properties:
• It can be combined with other types of bone substitutes.
➢ "Demineralized bone matrix" type of allografts doesn't have osteoinductive
capacity.

❖ Isografts: the same as allografts but between genetically identical twins i.e. not
immunogenic.
❖ Xenografts: the same as allografts but after freezing & irradiation.

36
❖ Bone Morphogenic Proteins (BMPs):
➢ Synthesis:
• They were originally extracted from allografts but were too difficult to
produce in large quantities.
• BMP-2 and BMP-7 are now manufactured by using recombinant techniques
and are available commercially but very expensive.
➢ Indication: treatment of non-union and open tibial fractures.
➢ Properties:
• They are osteoinductive.
• They are used with a carrier which may be: allograft or demineralized bone
matrix or collagen or bioactive bone cement.

❖ Calcium Based Synthetic Substitutes:

➢ Types: calcium phosphate, hydroxyapatite (crystalline calcium phosphate) &
calcium sulphate.
➢ Indications:
• Calcium phosphate and hydroxyapatite are used to fill metaphyseal defects
e.g. tibial plateau or distal radius or calcaneal fractures.
• Calcium sulphate is combination with gentamicin or tobramycin as a means
of local antibiotic delivery in the treatment of cavities or dead space after
surgery in chronic osteomyelitis.
➢ Available forms: granules or chips or paste.
➢ Properties:
• They are primarily osteoconductive.
• They don't possess sufficient compressive strength to withstand high loads so
should be used only in stabilized fractures and not as a means of contribution
to stability.
• Calcium phosphate materials are usually absorbed completely by 6 months but
hydroxyapatite substitutes are still visible on X-ray after several years.
• Calcium phosphate are mixed with autologous bone marrow and bovine
collagen to produce results equivalent to those of autogenous bone graft.

❖ Bone Wax:
➢ Definition: it is a waxy substance used to help mechanically control bleeding from
bone surfaces during surgical procedures.
➢ Composition:
• It is generally made of beeswax with a softening agent as paraffin or petroleum
jelly.

37
 • It is usually supplied in sterile sticks & requires softening before it can be
applied. * Action: it is smeared across the bleeding edge of the bone, blocking
the holes and cause immediate bone hemostasis through a tamponade effect
only (i.e. dose not activate blood clotting cascade).

❖ Gel foam: "Absorbable Gelatin"

➢ It is a sterile compressed sponge can be applied to bleeding surfaces as a
hemostatic.
➢ It is water insoluble, off-white, non-elastic, porous, and pliable product prepared
from purified porcine skin.
➢ Its hemostatic action is through physical effect only (i.e. doesn’t activate blood
clotting cascade).
➢ Gel foam is absorbed completely within 4 to 6 weeks with little tissue reaction.

❖ Ligaments & Tendons:

➢ These structures can sustain 5% to 10% tensile strain before failure:
• In contrast, bone can sustain only 1% to 4% tensile strain.
• Failure commonly results from tension rupture of fibers & shear failure among
fibers.
➢ Most ligaments can undergo plastic strain to the point that function is lost but
structure remains in continuity.
➢ Soft tissue implants have the following characteristics:
❖ Tendons:
➢ Strong in tension only.
➢ "E" is 10% that of bone & increases with slower loading.
➢ Parallel fiber orientation.
➢ Demonstrate stress relaxation & creep.
❖ Ligament Fibers:
➢ Oriented parallel if they resist major joint stress but oriented more randomly if
they resist forces from different directions.
𝑓𝑜𝑟𝑐𝑒
➢ 𝑠𝑡𝑖𝑓𝑛𝑒𝑠𝑠 = 𝑠𝑡𝑟𝑎𝑖𝑛.
➢ As depicted on a force deformation graph.
➢ Similar to "E" but does not account for cross-sectional area.
➢ The bone-ligament complex is softer: less stiff implies decreased "E".
➢ Prolonged immobilization lowers yield point and tensile strength.

38
❖ Stents:
➢ Internal splint devices:
• Proplast Tendon Transfer Stabilizer.
• Gore-Tex prosthetic ligaments.
• Xenotech (Bovine tendon).
• Polyester implants.
➢ Stents do not allow adequate collagen ingrowth (all eventually fail).
➢ Synthetic ligaments produce wear particles (increase proteinases, collagenase,
gelatinase, and chondrocyte activation factor).

❖ Ligament Augmentation Devices: "LADs"

➢ Kennedy LAD (polypropylene yarn) & Dacron LADs.
➢ LADs do allow some fibrous ingrowth; however, their use is limited.

❖ Biodegradable Tissue Scaffolding:

➢ Immediate stability.
➢ Long-term replacement with host tissue.
➢ Carbon fiber & polylactic acid-coated carbon fiber devices:
• Limited success.
• Slow ingrowth is improved with polylactic acid coating.

❖ Articular Cartilage:
• Ultimate tensile strength is only 5% that of bone:
• "E" is only 0.1% that of bone.
• However, because of its viscoelastic properties, it is well-suited for compressive
loading.
• Articular cartilage is Biphasic:
• Solid phase depends on the structural matrix.
• Fluid phase depends on deformation & shift of water within the solid matrix.
• Relatively soft & impermeable solid matrix requires high
hydrodynamic pressure to maintain fluid flow:
• Significant support provided by the fluid component.
• Stress-shielding effect on the matrix.

39
❖ Cartilage Substitutes:
• No reliable means to regenerate joint cartilage currently exists.
a) Growth factors:
1. Bone Morphogenic Proteins (BMP.s).
2. Insulin-Like Growth Factor (IGF).
3. Platelet-Derived Growth Factor (PDGF).
4. Transforming Growth Factor-ß (TGF-ß).
5. Fibroblast Growth Factors (FGF.s).
6. Hepatocytes Growth Factor (HGF).
b) Chondrocytes & undifferentiated mesenchymal cells:
• Produce a new cartilage matrix.
• Selective transfer of gene expression to chondrocytes or
chondroprogenitor cells are encouraging studies for the future use of
gene transfer to chondrocytes to treat cartilaginous defects.
c) Artificial matrices:
• Enhance ingrowth of new cells & matrix formation.
• Has protective function.
• Methods for holding matrices & cells in articular cartilage lesions are:
glues & flaps & pins.
• Intra-Articular Injection of Hyaluronan is an example of matrices in
cartilage tissue engineering.

40
 orthopedic Implants
Basic Information:
Types of Fixation:
❖ Internal fixation:
Indications:
1. Un-reducible Fractures that can't be reduced except by operation.
2. Unstable fractures which are prone to re-displace after reduction (e.g. mid-
shaft fractures of the forearm and some displaced ankle fractures).
3. Large avulsion fractures as they are liable to be pull by muscle action (e.g.
transverse fracture of the patella or olecranon.
4. Intra-articular fractures to obtain anatomical reduction.
5. Fractures that unite poorly & slowly as fractures of the femoral neck.
6. Pathological fractures in which bone disease may prevent healing.
7. Multiple fractures where early fixation (by either internal or external
fixation) reduces the risk of general complications and late multi organ
failure.
8. Fractures in patients with nursing difficulties:
• Paraplegics.
• Multiple injuries.
• Very elderly.
Complications:
➢ Most of them are due to poor technique, poor equipment or poor
operating conditions.
I. Infection:
• Iatrogenic infection is the most common cause of chronic
osteomyelitis.
• Quality of the patient ’s tissues also predispose to
infection.
II. Non-union:
• It is mainly due to presence of a gap between the ends even if the
fracture was fixed rigidly or excessive stripping of the soft tissues and
damage to the blood supply during operative fixation.
• This is more likely in the leg or the forearm if one bone is fractured
and the other remains intact.

41
 III. Implant failure:
• Metal is subject to fatigue and failure unless some union of the fracture
has occurred, so stress and weight bearing are avoided until radiological
signs of fracture healing is seen on x-ray "6 weeks".
• Pain at the fracture site is a danger signal and must be investigated.
IV. Refracture:
• A year is the minimum and 18 or 24 months safer before removing the
implants to avoid refracture.
• For several weeks after removal the bone is weak, so care or protection
is needed.
❖ External Fixation:
Indications:
1. Sever open fractures with severe soft tissue damage or contamination to
facilitate access to the wound for dressing or plastic surgery.
2. Infected fractures.
3. Sever comminuted diaphyseal or intra-articular fractures.
4. Closed fractures with soft tissues crushing or bad local condition of skin.
5. Fractures at site of burn or dermatological disorder.
6. Limb lengthening & correction of deformities.
7. Arthrodesis & osteotomies.
8. Fractures around joints with massive soft tissues swelling in which spanning
external fixator provides stability until soft-tissue conditions improve.
9. Patients with severe multiple injuries as bilateral femoral with severe
bleeding or associated chest or head injuries.
10. Certain pelvic fractures.
11. Fixation after radical tumor excision.
12. No-united fractures are excised & compressed when there are need for bone
lengthening to replace the excised segment.
13. Ligamentotaxis.
14. Fractures with nerve or vascular reconstruction.
15. For patients un fit for long duration of general or spinal anesthesia.
Complications:
1. Damage to soft-tissue structures:
• Transfixing pins or wires may injure nerves or vessels or may tether
ligaments or tendons and inhibit joint movement.
• The surgeon must be thoroughly familiar with the cross-sectional
anatomy & the regional safe zones before operating.

42
 • Muscle injury & Compartment syndrome.
2. Pin track infection: (the key problem)
Causes:
1. Thermo-necrosis due to high speed drill.
2. Lake of rigid fixation allows motion & leads to tissue irritation.
3. Increase stress at pin/bone interface leads to micro-fractures & loosening.
Prevention:
good operative technique & postoperative care.
Treatment:
meticulous pin-site care & antibiotics administration immediately.
3. Over distraction: if there is no contact between the fragments nonunion will
occur.
4. Delayed union.
5. Refracture after removal of frame.
Functions:
1. Alignment.
2. Compression.
3. Neutralization.
4. Distraction in limb lengthening (Callotasis or Chondrodyastasis).
5. Correction of deformities.
6. Fragment transport after corticotomy.
Types:
I. Unilateral (uni-planner) non-mobile: Hoffmann system.
II. Unilateral articulated.
III. Hybrid frame & tensioned wires.
IV. Ilizarov & tensioned wires.
Advantages:
1. Mechanically ideal for fracture management as it provides great rigidity &
stiffness.
2. Permit management of soft tissue injury in open fractures or burns.
3. Can be performed under local anesthesia in multiple trauma patients.
4. Doesn't disturb blood supply of the fractured area.
5. Technically easier in application.
6. Easy removal of the device.
7. Easy postoperative management.

43
 8. Early patient passive joint mobilization:
• Prevent joint stiffness.
• Prevent capsular fibrosis.
• Improve articular cartilage nutrition.
• Prevent muscle atrophy.
• Decrease edema.

Disadvantages:
1. Patient may reject it.
2. Non-compliant patient:
• Failure of the technique as in limb lengthening using Ilizarov device.
• Disturb the device.
• No care of pins leading to pin tract infection.
3. Difficult to inexperienced surgeon.
4. Iatrogenic fracture at pin tract may occur.
5. Refracture after frame removal may occur.
6. Joint stiffness in juxta-articular fractures.
7. Expensive.
Fixation Stability:

❖ Absolute Stability:
 Rigid fixation with primary bone healing.
➢ Performed by:
1. Lag screw.
2. Dynamic compression plates.
3. Over-bending of the plate.
4. Tension device.
➢ Static compression does not enhance bone resorption or necrosis.
➢ Inter-fragmentary compression provides stability through friction, but
has no direct influence on bone bridging or fracture healing.

❖ Relative Stability:
➢ Flexible reconstruction with external callus formation.
➢ Performed by:
1. External fixators.
2. Intra-medullary nailing.
3. Bridging plates.

44
Implant Fixation:

❖ Interference Fit:
➢ Mechanical or press-fit components: rely on formation of fibrous tissue interface.
➢ Loosening:
• Can occur if stability is not maintained.
• Use of high "E" substances.
➢ Increases bone resorption and remodeling.

❖ Interlocking Fit:
➢ PMMA allows gradual transfer of stress to bone:
• Micro-interlocking of cement within cancellous bone.
➢ May not be achieved with cemented revision of previously cemented TKA.
➢ Aseptic loosening can occur over time.
➢ Careful technique yields the best results:
o Limiting porosities and gaps.
o Use of 3 to 5 mm cement thickness.
➢ Other improvements are as follows:
o Low-viscosity cement.
o Better bone bed preparation.
o Plugging & pressurization.
o Better (vacuum) cement mixing.

❖ Biologic Fit:
➢ Tissue Ingrowth achieved by using:
• Fiber-metal composites.
• Void metal composites.
• Microbeads.
➢ Key: to create pore sizes of 100 to 400 μm (ideally 100 to 250 μm).
➢ Mechanical stability required.
➢ Ingrowth typically limited to 10% to 30% of the surface area.
➢ Problems:
• Fiber or bead loosening.
• Increased cost.
• Proximal bone resorption (monocyte/macrophage-mediated).
• Corrosion.
• Decreased implant fatigue strength.

45
 ➢ Uncemented TJA:
• Bone ingrowth in the tibial component of TKA occurs adjacent to fixation
pegs & screws.
• Bone ingrowth depends on the avoidance of micromotion at the bone-implant
interface (observed on radiographs as radio-dense reactive lines about the
prosthesis).
• Canal filling (maximal endosteal contact) of more fully coated femoral stems
is important for bone ingrowth.

Tribology:
➢ Definition: it is the study of Friction, Wear & Lubrication.
➢ The natural joint elements that influence the tribological function of a joint are:
1. The articular cartilage.
2. The synovial fluid.
3. To a lesser extent the subchondral bone, capsule, soft tissues & ligaments.

❖ Friction (f):
➢ Definition: resistance to motion between two solid objects as one slide over the
other (i.e. it is the shear force needed to allow 2 surfaces to slide on each other).
➢ The 2 lows of friction:
1. Friction is independent to area of the surface.
2. Friction is proportional to load between surfaces.
➢ Friction varies according to:
1. Material used.
2. Finishing.
3. Temperature.
4. Lubricants.
5. Load.
6. Length of lever arm.
➢ Properties:
• It isn't a function of contact area.
• Independent of contact area & surface shape.
• Produced at points of contact.
• Body motion begins when applied force exceeds friction.
• Oriented opposite to the applied force.
• Proportional to coefficient of friction & applied normal (perpendicular) load.

46
Coefficient of friction:
➢ It is the ratio of friction between any pair surfaces.
➢ It is constant for this pair.
➢ Coefficient of friction (u) = 0 "means no friction", (u) for human joints: 0.002 to
0.04, (u) for metal on metal: 0.8, (u) for metal on UHMWPE joint arthroplasty: 0.05
to 0.15.
➢ Coulomb's low of friction:
shear stress = compressive stress X (u).
❖ Wear: (Erosion)
➢ Definition: removal of material from solid surface by forces exerted during
use(sliding).
➢ Fretting: wear produced by small inter-part motions.
➢ Types (Mechanisms) of wear:

I. Interfacial wear: between 2 surfaces in contact & in relative motion to each

other, types:
i. Abrasive: when rough hard surface glides across relatively softer one
leading to its grooving & wear.
ii. Adhesive: phenomenon occurs when 2 metals rub together with
sufficient force to cause removal of fragments from the less wear
resistant (softer) surface & adhere to the harder surface (called transfer
film wear).
iii. 3rd body: form of abrasive wear occurs when hard particles become
embedded in a soft surface (as metallic or bone particles entrapped in
polyethylene bearing surface). Back side wear: between polyethylene &
the metal backing
II. Fatigue wear: deformation of contacting surfaces due to repeated cyclic
loading.

➢ Factors determine wear:

1. Coefficient of friction of materials: increased (u) leads to increased wear.
2. Hardness of materials.
3. Applied load.
4. Sliding distance of each cycle.
5. Number of cycles that occur over time.

47
❖ Lubrication:
➢ Definition: materials applied to the interface reducing friction resistance between
surfaces which reduces wear (these materials also prevent corrosion).
➢ Lubrication modes (Mechanisms):
a) Boundary:
• No pressure is belt up in the lubricant (absent hydrodynamic
pressure).
• The contact area is protected by absorbed molecules of the
lubricant & a thin oxide layer.

b) Fluid film:
i. Hydrostatic:
• thick film of lubricant is maintained under external pressure source.
ii. Hydrodynamic:
• Relative motion between surfaces creating a sufficient hydrodynamic
pressure that force a thin film of lubricant to wedge between bearing
surfaces.
• Pressure builds as speed increases.
• The load & hydrodynamic pressures are in equilibrium.
iii. Elasto-hydrodynamic:
• when bearing surfaces are elastic enough to deform.
iv. Squeeze film.

c) Mixed lubrication.

❖ Lubrication of articular cartilage:

➢ Articular surfaces have a coefficient of friction 10 times better than the best
synthetic systems because it is lubricated with synovial fluid.
➢ Elasto-hydrodynamic lubrication is the primary lubrication mechanism for
articular cartilage during dynamic function.

❖ Artificial joint surfaces:

➢ Metal / Ceramic bearing on UHMWPE do not benefit from fluid film lubrication
they operate in a mixed fluid film regime.
➢ Unavoidable wear results at a rate of approximately 200μm of linear penetration
per year giving a life expectancy of a 4mm thick cup about 20 years.

48
 ➢ Metal-on-Metal and Ceramic on Ceramic perform in a fluid film regime
therefore the resultant wear rate is significantly reduced.

Implant-Host reactions & Biocompatibility:

➢ Biocompatibility: it is the tolerance of host organism for an implant.
➢ Biocompatible Implant: when implantation doesn't compromise the patient's health by
inducing adverse local or systemic reactions or jeopardize success of the implant.

A. Local host response:

➢ Cellular & extracellular events consistent with early stages of wound healing:
macrophages & lymphocytes & Plasma cells multinucleated giant cells (foreign
body giant cells) are seen near the implant.
N.B. plasma cells & lymphocytes are present in allergic reactions.
➢ Foreign body response:
• Metallosis: tissue discoloration (mainly blackening) & fibrous
capsule formed around implants & heads of screws due to focal
corrosion & significant wear of metallic implants with increased
number of phagocytic cells in the area.
• Paniculate transport: transport of particulates by macrophages to
regional lymph nodes & to the lungs.
➢ Sterile abscess phenomenon:
• Highly localized pain sensation due to local inflammatory response (Kinin-
induced pain) which is due to elevated local concentration of corrosion products.
• More common with multipart fracture fixation devices & less recognized in TJAs.
• On exploration: tissue discoloration is found & cultures are negative.
• Curettage & device removal or exchange produces prompt remission of pain.
➢ Osteolysis:
• Pathogenesis: implant micromotion & wear debris excite phagocytic
macrophage response which attack bone directly & excrete osteoclast
activating factor (Prostaglandin E2) which attracts & stimulates osteoclasts.
• Result: quick "dissecting" osteolysis that moves into bone-implant interface
leaving broad (1-5 mm wide) lucent zone of bone absorption & leading to
implant loosening & rapid clinical failure.
➢ Infection: (most serious)
• Early: due to the introduction of skin or air borne pathogens during surgery.
• Late: due to hematogenous source.

49
 • Implant may encourage or maintain infection by:
a. Implant act as mechanical barrier to easy revascularization of damaged tissues.
b. Increased metal product concentration inhibits chemotaxis & phagocytosis.
c. Residence of bacteria in glycocalyx which is formed on any implant.
d. Metal sensitization: leading to loss of macrophage chemotactic ability.

➢ Neoplasia: Extremely rare & occur by foreign body neoplasia or chemical

transformation.

❖ Mechanism of local host response:

➢ Chemical: by products of corrosion & degradation & wear debris released from the
implant material.
➢ Mechanical: remodeling responses to initial changes in stress distribution.
➢ Electrical: minimal except in using of implanted electrodes to stimulate
osteogenesis.
➢
B. Systemic host response:
➔ Acute effects: as systemic effects of PMMA cement.
➔ Physiological effects: large elevation of serum levels of metals as chromium, nickel
& other trace elements.
N.B.: Normal trace elements in blood: iron, iodine, copper, zinc, manganese, cobalt,
molybdenum, selenium, chromium, nickel, tin, silicon, fluorine, vanadium.
➔ Allergy: type IV delayed hypersensitivity (Hapten-protein complex) may occur to
Ni or other metals or PMMA.

C. Implant response:
“Changes in the properties of the materials"
➔ Corrosion: group of processes that produce compounds & free ions from bulk
metals.
➔ Degradation: Polymers & Ceramics don't corrode but they degraded chemically by
their environment,
 Permanent & partially degradable polymers are degraded by:
1. Depolymerization of polymers i.e. inverse process of polymerization.
2. Absorption of water & lipids.
 Biodegradable polymers: degrade by resorption.
 Ceramics: the material loses strength.

50
Bone-Implant Unit:
➢ The composite structure of this unit has shared properties.
➢ More accurate bone cross-section reconstruction with metallic support improves
loading characteristics.
➢ Plates should act as tension bands.
➢ Materials with increased "E" may result in bone resorption while materials with
decreased "E" may result in implant failure.
➢ Placement of the implant initiates a race between bone healing & implant failure.

51
❖ Wires & Pins:
◆ Kirschner Wires: (K – wires)
➢ Length: 7 to 30 cm.
➢ Diameter: 0.6 to 3 mm.
➢ Types:
1. Smooth.
2. Threaded.
3. Pointed at one end.
4. Pointed at both ends.
5. Trocar pointed.
6. Diamond pointed.
➢ Indications:
1. Traction: may be stiffened by tensioned with traction bow.
2. Provisional fixation: temporary fixation after reduction of comminuted
fractures.
3. Definitive fixation:
• Unstable supracondylar fractures in children.
• Distal radius fractures.
• Bennett fracture.
• Metacarpal, Phalanges, metatarsals & toes fractures.
➢ Special types of wires:
1. Guide wire: have distal serration used for insertion of cannulated screws.
2. Olive wire: used with Ilizarov.

◆ Cerclage Wiring:
➢ Diameter: 0.4 to 1.5 mm.
➢ Made of: Stainless steel or Vitallium.
➢ Better 2 wires are twisted to form double strand which:
• Have greater flexibility than single wire.
• Less slip-on bone.
➢ Indications:
1. Provisional (temporary) fixation: hold butterfly fragment until lag screw
insertion then wire is removed.
2. Definitive fixation:
o Along the shaft of long bone in IMN fixation.
o When fracture (Shuttering) occurs during insertion of femoral prosthesis in
THA.

52
 ➢ Disadvantage: it interferes with periosteal circulation leading to bone necrosis.

◆ Tension Band Wires:

➢ Principle: the wire absorbs the fracture distraction force & convert it to
compressive force.
➢ Types of compression:
1. Static: by tightening on tension band wire.
2. Dynamic: by active joint movement.
➢ Sites of use:
• Patella.
• Malleoli.
• Olecranon.
• Distal end clavicle.
• Greater trochanter.
➢ Techniques:
a. Wire alone: as in transverse fracture of patella & repair of avulsed
tendoachilles.
b. Wires with two parallel longitudinally placed K-wires: to provide axial
rotational stability & provide anchorage points around which tension band
wire will be placed.

◆ Steinmann Pins:
➢ Length: 15 to 30 cm.
➢ Diameter: 3 to 6 mm.
➢ They have pointed end which may be: trocar or diamond or cove in shape.
➢ Types:
1. Smooth.
2. Fully threaded.
3. Centrally threaded.
➢ N.B. thread diameter is 0.5 mm larger than pin so threaded segment is stronger.
➢ Indications:
• Traction: in Bohler.
• Pins & Plaster technique: used in the past before the use of external fixators.

53
◆ Screws:
➢ Uses:
1. Attach implant to bone (plats or prosthesis).
2. Fix bone to bone (Intra-fragmentary compression).
3. Fix ligament to bone (using Cancellous screw with washer).
➢ Parts:
1. Head: hexagonal, cruciate, slotted, Philips.
2. Shaft (Shank): smooth part between head & threaded part.
3. Thread: wrapped around the "Core" of the screw.
4. Tip:
▪ Non-self-tapping: rounded & blunt in cortical screws.
▪ Self-tapping: flutes or trocar in cortical screws & cork in cancellous screws.
➢ Characteristics:
• Pitch: distance between threads.
• Lead: distance of screw advanced into bone in each complete turn.
• Root (Core) diameter: minimal/inner diameter is proportional to tensile
strength.
• Outer (Thread) diameter: determines holding power (pullout strength).
➢ Biomechanics of screw:
• Compression clamping force: basic rule of screw.
• Holding power of screw: depends on depth of thread in bone.
• Tensile strength (resistance to breakage & deformation): depends on core
diameter.
• Pullout strength: depends on thread diameter.
o To maximize pullout strength of screw:
1. Large outer diameter.
2. Small root diameter.
3. Fine pitch.
4. Pedicle screw pullout strength most affected by the degree of
osteoporosis.
◆ Cortical: (full threaded)
➢ Types:
a. Non-self-tapping: made of Stainless steel & need tapping.
b. Self-tapping: made of Titanium so stronger.
➢ Size: 3.5 mm (2.5 drill) & 4.5 mm (3.2 drill).
➢ N.B.Tap size is the same size of the screw.
➢ Other sizes: 1.5 mm (1.1 drill) & 2 mm (1.5 drill) & 2.7 mm (2 drill).

54
 ◆ Cancellous: (self-tapping)
➢ Characteristics:
• Larger and wide thread with higher pitch & thin core.
• To obtain best hold in cancellous bone don't tap.
• If cancellous screw inserted in cortical bone it can't be removed.
➢ Types:
a. Full threaded.
b. Partial threaded: available in variable thread lengths to allow for optimizing
purchase in the far fragment for maximum compression & stability.
➢ Size: 4 mm (2.5 drill) & 6.5 mm (3.2 drill).
➢ N.B.: Malleolar screw: partially threaded 4.5 mm used in fixation of malleolar
fractures.
c. Other types:
i Cannulated screw:
➢ Fully or partially threaded & have hollow core to be inserted
percutaneously over pre-placed guide wire.
➢ Uses: percutaneous fixation of femoral neck or calcaneus or tibial plateau
fractures.
➢ Disadvantages: weaker & expensive. = Size: 4.5 & 7.3 mm.
ii Herbert (headless) screw:
➢ Inserted in the articular surfaces.
➢ Uses: fixation of scaphoid or osteochondral or radial head fractures.
➢ Size: 1.5 & 2.4 & 3 mm = Disadvantage: difficult to remove.
iii Cross lock screw: self-tapping 5 mm in size & used in locked IMN.
iv Pedicle screw: used for spine fixation (uniaxial or biaxial).
v Locked screw: used in locked plate.
vi Interference screw: used in ACL reconstruction.

Instruments for screw fixation:

a. Power source.
b. Drill bits.
c. Measuring depth.
d. Tapping.
e. Screw driver.

55
◆ Lag screw:
➢ Lag screw mechanics is the best example of static intra-fragmentary compression
which gives very efficient "absolute" stability.
➢ Mechanics:
• Any screw can function as lag screw when its threads have purchase in far
cortex only.
• This can be made by:
▪ The screw has upper smooth shank (partially serrated cancellous
screw).
➢ Lag effect:
• Over drilling of the near cortex (cortical or cancellous screws).
• Techniques:
1. Gliding hole (near cortex hole) first: the larger drill point used first.
2. Threaded hole (far cortex hole) first: the smaller drill point used first.
3. Positioning: best positioned at optimum inclination which may be:
a. Perpendicular to the fracture plane: ideal in absence of forces along the
bone axis.
b. Halfway between perpendicular to the fracture & perpendicular to the long
axis of the bone: ideal in presence of forces (load) along the bone axis.
➢ Lag screw generates forces up to 3000 N which can't bought by any of the other
methods.
➢ Combination of lag screw with neutralization plate can protect screws from
shearing force.
➢ Lag screws can be used alone without plate in fixation of long oblique
diaphyseal fractures when the length of the fracture is at least 3 time the
diameter of the shaft of the bone.

56
 ❖ Plates:
➢ Plates are Load-Bearing devices (most effective on a fracture’s tension side).
➢ Strength varies with material & moment of inertia.
➢ Bending stiffness is proportional to the third power of the thickness (T3) so,
doubling thickness increases bending stiffness by eight folds.
➢ Local problems of rigid internal fixation by plates:
1. Bone loss under plate due to:
i. Stress Shielding (protection): localized osteoporosis under the plate
occurs because the plate decreases load on the bone leading to
increased osteoclastic activity.
N.B. Using LC-DCP solves this problem.
ii. Hypo-vascularity of bone due to plate contact.
2. Stress concentration at open screw holes can lead to implant failure.
3. Screw holes in bone that remain after removal of plate represent stress
riser (at risk of re-fracture).
➢ Indications: fixation of metaphyseal fractures of long bones, diaphyseal fractures
of the radius & ulna.
➢ Functions:
 Compression:
I. Static Compression:
➢ Often used in metaphyseal fractures where healing across the cancellous fracture
gap may occur directly without periosteal callus.
➢ Best in the upper extremity.
➢ Types:
a. Original AO round hole plates: compression done by using
tension device.
b. Pre-bent plate:
▪ The plate is stressed by bending for compression.
▪ Applying tension over-bent plate leads to straightening of
the plate & subsequent compression of the opposite
cortex.
▪ Compression force greater underneath the over-bent plate
& less at opposite side so small gap & distraction will be
created on the opposite side.
▪ The inner screws are placed before the outer.
▪ Amount of bending:
• If small amount of bending: compression on near
cortex only.

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 • If large amount of bending: compression on far
cortex only.
• If proper bending: good compression of both
cortices.
II. Dynamic Compression:
Compression by DCP plate:
➢ Screw hole described as inclined & angled cylinder.
➢ Head of screw slides down the inclined shoulder of the cylinder.
➢ Technique:
• Place the most proximal 2 screws to the fracture site (one on each side).
• The first of them is central while the other is eccentric.
• With tightening the eccentric screw, the bone fragment moves relative to
the plate (about 1 mm) leads to compression.
• For compression more than 2 mm use an articulated tension device.
• Additional eccentric before first is locked.

Compression with the Tension device:

➢ Effective in gaps exceeds 1-2 mm in transverse or short oblique fractures.
➢ In osteoporotic bone or excess forces needed bi-cortical screw fixation is used.
➢ In oblique fracture the device should be used in the side of acute angle of the
fracture to make the compression in the direction of Axilla formed by the plate &
bone on the other side.

Tension band plate:

➢ Conversion of the distraction force to compression force.
➢ Criteria should be fulfilled for plate to act as tension band:
1. Bone is eccentrically loaded so it has tension side & compression side.
2. Plate is placed on the tension side which allows compression to be applied to
the biomechanically more advantageous side of fracture e.g.:
• Femur: anterolateral surface.
• Tibia: lateral surface.
• Humerus: lateral or posterior surface.
• Radius: posterolateral surface.
3. Plate withstands the tensile forces.
4. Bony buttress opposite to the plate to prevent its cyclic bending & fatigue.

58
Compression by using inter-fragmentary lag screw:
➢ Can be inserted through or outside the plate.
➢ Combination of lag screw through the plate after axial compression is greatly
increase the bending & rotational stability of the fracture.
➢ The hole of DCP allow for 25 degrees inclination in longitudinal axes (proximal
to distal) & only 7 degrees in transverse (anterior to posterior).

 Neutralization (Protection):
➢ When plates used to supplement the effect of inter-fragmentary lag screws to resist
shortening & torsion in comminuted fractures or in presence of butterfly fragment.
➢ It transmits the forces from proximal to distal fragment & prevent forces from
acting direct on comminuted fragments.

 Buttress (Supporting):
➢ Its major function is to support rather than rigid fixation.
➢ Used to support metaphyseal split fractures of long bone in which lag screws
aren't sufficient as tibial platue or pilon or distal humerus or Smith’s fractures.
➢ It protects bone graft & combined with lag screws.

 Anti-glide:
➢ Fixing a plate over the tip of a spiral or oblique fracture line to prevent shortening
(glide) of the fracture by the muscle pull.
➢ Lag screws are combined with neutralization or buttress or anti-glide.

 Bridge plate principle:

➢ Mini-invasive Biological fixation: plate is placed sub-muscular with minimal
incisions called Minimally Invasive Plate Osteosynthesis "MIPO".
➢ Used in multi-fragmentary complex (severely comminuted) fractures.
➢ Fixed to the main fragments only with bridging of the comminuted area.
➢ No touch of the fracture site so preserves bone fragments vascularity & fracture
hematoma & decrease chance of fracture site infection.
➢ Correct alignment & length & rotation.
➢ It is considered relative flexible reconstruction.

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Types:
◆ Tubular Plates:
➢ Subtypes:
• 1/4 (one-quarter): 2.7 mm size for metacarpals.
• 1/3 (one-third): 3.5 mm size for fibula.
• 1/2 (semi-tubular): 4.5 mm size for larger bones.
➢ Thickness: 1 mm.
➢ Have oval holes which gives the plate mechanism of self-compression.
➢ Indication: used in subcutaneous lesions in which rigidity isn't required.
➢ Advantage: it gives rotational stability because its edges digging into underling
bone.
➢ Disadvantage: screw heads protrude under skin.

◆ Dynamic Compression Plate"DCP":

I. Broad DCP:
➢ Size is 4.5 mm in which holes are aligned in 2 rows so considered double plate
so, gives more stability (2 parallel planes) than small or narrow DCP.
➢ Used for shafts of broad single long bones (femur & humerus).
➢ Not indicated in tibia or radius as presence of fibula & ulna gives additional
stability.
II. Small DCP:
➢ Size is 4.5 mm in which holes are aligned in one row.
➢ Used for tibia.
III. Narrow DCP:
➢ Size is 3.5 mm in which holes are aligned in one row.
➢ Used for forearm bones.
IV. mm DCP:
➢ Used for mandible.
V. Limited contact (LC-DCP):
➢ Size 3.5 or 4.5 mm.
➢ Less rigid (more flexible) made of Titanium.
➢ Designed to limit contact between the plate & underling bone to interfere less with
bone biology (periosteal blood supply) so preserve better cortical perfusion.
➢ Reduce the stress shielding.
➢ Distribution of the stiffness makes contouring easier without stress concentration
at holes but the plate generally weaker than simple DCP.
➢ Self-tensioning principle is possible in each direction.

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➢ Allow for compression at several levels (segmental fracture).

VI. Reconstruction "Recon." Plates:

➢ Easily contoured according to bone shape.
➢ Used for distal humerus, pelvi&calcaneus.

VII. Locked plates:

➢ Equals combined internal & external fixation so gives more stability.
➢ The holes of the plate & the heads of the locked screws are serrated to fit with each
other so working as external fixator.
➢ It absorbs axial forces transmitted from screws.
➢ Doesn't require compression to bone so preserve periosteal blood supply.
➢ Biomechanical advantages for osteoporotic fractures without cortical contact.

VIII. Hybrid locking plates:

➢ Both conventional (non-locked) & locked screws are used:
• Non-locked screws assist in reduction.
• Locked screws create fixed-angle device.
➢ Technique:
• Fix at least 6 cortices (3 screws passing both cortices or 6 screws passing one
cortex) proximal & the same distal to the fracture site.
• If more screws are needed they should be conventional screws to decrease
the stress on the plate.

IX. Special Shape Plates:

➢ Hooked plates: olecranon & distal ulna & AC joint plates.
➢ Clavicle plate & Mini-plates (metacarpals & metatarsals).
➢ Proximal & distal plates of Humerus & Femur & Tibia.
➢ T & L & Y plates (buttress function): as distal humerus & distal radius & proximal
tibia.
➢ Blade plate & Dynamic Hip Screw "DHS" & Dynamic Compression Screw "DCS".
N.B.: Blade plates: have increased resistance to torsional deformation.
X. Compression Hip Screws:
➢ Loading characteristics superior to those of blade plates: higher angled plates
subjected to lower bending loads however, may be more difficult to insert.
➢ Sliding of the lag screw proportional to two aspects:
• Angle of screw to side plate.
• Length of the screw in the barrel.

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 ❖ Intramedullary Nails: "IMN"
Functions (Biomechanics) of IMNs:
1. Load-Sharing devices: i.e. sharing of compressive, bending, torsional loads with
the surrounding osseous structures so weight bearing is preferable in cases of stable
IMN fixation (unlike plates or external fixators which are load bearing).
2. Internal splint & require high polar moment of inertia to maximize torsional
rigidity & strength.

Mechanical Characteristics:
1. Torsional Rigidity:
➢ Amount of torque required to produce a unit angle of torsional
deformation. - Depends on both material properties (shear modulus) &
structural properties (polar moment of inertia).
2. Bending Rigidity:
➢ Amount of force required to produce a unit amount of deflection.
➢ Depends on both material properties (elastic modulus) & structural
properties (area, moment of inertia, length).
➢ Related to the fourth power of the nail’s radius (increasing nail diameter by
10% increases bending rigidity by 50%).
➢ Better at resisting bending forces than rotational forces.

Nailing principle:
➢ stabilization is dependent on contact between elastic nail & stiff bone.
A. Intrinsic factors:
1. Material properties.
2. Cross-sectional shape.
3. Anterior bow.
4. Nail diameter: bending & torsional rigidity are directly proportional to nail
diameter.
5. Working Length:
• It is the distance between proximal & distal locking screws.
• It influences nail stiffness in bending & torsion.
B. Extrinsic factors:
1. Reaming of the medullary canal.
2. Fracture stability (comminution).
3. The use and location of locking bolts.

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Types of IMNs:
 Flexible nails:
➢ Nailing without reaming or locking.
➢ Examples: Rush pins & Ender nails & Nancy nails.
➢ Mechanics:
• Act by stabilizing fracture with three-point compression (pressure, fixation,
contact).
• Equilibrium between the tensioned pin & the bone with its soft attached
tissues will hold the alignment.
• Bending movements are neutralized but telescoping & torsion aren't
prevented.
➢ Disadvantages:
• Additional immobilization is often required.
• Secondary loss of reduction (not rigid fixation).
• Shortening with loading so better used in transverse than long oblique
fractures.
➢ Applications:
▪ Children: mainly for forearm or femur fractures.
▪ Adults:
• Clavicle fracture.
• Forearm fracture.
• Shaft or Proximal humerus fracture.

 Conventional (Tight fitting, Unlocked nails):

◆ Femur:
➢ Reamed: classical kuntscher nail.
➢ Non-reamed: Schneider, Hansen.
◆ Tibia:
➢ Lotte’s nail.

 Mechanics:
➢ Principle of fixation based on compression between bone & implant.
➢ Elastic deformation is principle of nail stability.
➢ Nail insertion cause radially oriented force which is proportional to the contact
area between the bone & nail.
➢ Produced friction stops the nail from pulling out “Elastic Locking”.

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  Indications:
➢ Transverse fracture of middle 3/5 of shafts of femur or tibia.
➢ Delayed union.
➢ Pseudo-arthrosis (nonunion).

 Complications of closed insertion of kuntscher nail:

1. Failure of reduction.
2. Nail impaction.
3. Bone shuttering.
4. Failure to pass guide wire into proximal medullary canal.
5. Breaking of reamers.

 Complications of open insertion of kuntscher nail:

1. False passage if anterolateral normal bow of femur is high.
2. Refracture.
3. Gluteal bursitis when nail protrude under gluteal region.
4. Infection.
5. Migration of nail.
6. Bent or broken nail.
7. Excessive formation of sub-periosteal callus.
8. Mal or delayed or non-union.

 Interlocking Nails "ILNs" (Universal, Tight fitting, Locked nails):

 Examples:
◆ Femur ILNs:
➢ Anti-grade: piriformis fossa or greater trochanter entry point.
➢ Retro-grade.
◆ Tibia.
◆ Humerus.
◆ Ulna.
◆ Radius.
◆ Clavicle ILNs.
◆ Gamma nail.
◆ Trigen nail.
 Mechanics:
➢ It has proximal & distal locking (antirotational) screws.

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 ➢ Types of fixation:
◆ Dynamic:
➢ Using locking screws at one end only or insertion of proximal screw
in dynamic hole only (Dynamization).
➢ It allows full axial load so used in axially stable (as transvers or
isthmic) fractures or non-unions.
◆ Static:
➢ Using locking screws at both ends to control length & rotation.
➢ Used in comminuted fractures & non-isthmal fractures.
➢ Can be dynamized later by removal of locking screws from the longest segment of
the bone.
➢ Resistance to axial & torsional forces at the fracture site is mainly dependent on
interlocking screws bone interphase.
➢ Minor movements occur between nail & screws allowing toggling of the bone.

➢ Indication: diaphyseal fractures of long bones even if segmental or comminuted.

Techniques of nailing:
I. Closed: reduction, reaming & insertion of the nail done with opening the fracture
site (closed under image intensifier "C-arm").
II. Open:
➢ Opening the fracture site so:
• Increase risk of infection.
• Increase blood loss.
• Skin & muscle scar.
• Delayed & nonunion due to disturbance of fracture hematoma.
• Need less experience.
• No traction required.
• No need for image intensifier.
• To be Sure that there is no soft tissue interposition.
• Accurate reduction.

Reaming:
➢ Medullary canal is hour glass shape & reaming make it more cylindrical so adapt
it for larger nail insertion & increase contact between bone & nail so increase
stability.
➢ Reaming allows increased torsional resistance by: Increased contact area between
nail & bone.

65
 ➢ Using larger nail: increase rigidity, strength & mechanical properties of implant
bone interface.
➢ Temperature with sharp reamer is 39.5 C while with blunt reamer is 44 C.

Nailing with solid un-reamed (locking without reaming):

➢ Smaller diameter will be used.
➢ The material strength of the nail should be reinforced to decrease risk of implant
failure.
➢ Use titanium nails.
➢ Lower infection rate as hollow one with dead space infection so used in cases of
open shaft fractures.

Comparison between Reamed & Unreamed IMNs:

Reamed IMNs Unreamed IMNs

Larger diameter & stiff nail. Suitable for contaminated fractures (Gust. 1 & 2).

Increase area of bone nail contact (stability). motion at fracture site.

Initial bone endosteal devascularization. vessels. Doesn't disturb the endosteal blood

Thermal necrosis. No thermal effect

Increase local intra-medullary pressure. Less pressure

Microthrombi may lead to pulmonary embolism. Less microthrombi

Increase operative time & blood loss. Low cost & simple to insert

May increase fracture comminution. Risk of shuttering (explosion fracture).

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  Unslotted Nails:
➢ Smaller diameter.
➢ Stronger fixation.
➢ At the expense of flexibility.
➢ Increased torsional stiffness: greatest advantage of closed-section nails over
slotted nails.
➢ Intramedullary nail insertion for femoral shaft fracture:
• Hoop stresses are lowest for a slotted titanium alloy nail with a thin wall.
• Posterior starting point decrease hoop stresses & iatrogenic comminution
of fracture.
➢ Implant failure is more frequent with smaller diameter un-reamed nails.

Contraindications of IMN:
1. Children to avoid injury of growth plate.
2. Sever open fractures Gust. 3
3. Neglected open fractures (more than 12 hours) whatever its degree.
4. Disrupted site of nail insertion as pyriformis fossa in anti-grade nail femur.

Comparison between IMNs & Plates:

IMNs Plates
Load sharing. Load bearing.
Decrease endosteal circulation. Decrease periosteal circulation.
P Preserves soft tissue. Perform direct reduction.
perform indirect reduction. Destroys soft tissue.
Allows fracture motion. Rigid fixation.
Early union with callus. Slow union with no callus.
Rare to obtain anatomical reduction. Frequent anatomical reduction is obtained.
Failure occurs at cross bolts. Failure at plate.
Indicated for segmental fractures. Indicated for intraarticular fractures.
Indicated for diaphyseal (shaft) fractures. Indicated for metaphyseal (juxta-articular)
fractures.

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❖ External Fixators:
 Conventional (Pin) External Fixators:
➢ Types: simple or clamp.
➢ Technique "Principle":
• The bone is transfixed above and below the fracture with pins then connected to
each other by rigid bars after fracture reduction.
• In segmental fracture: each segment should be held securely with a half-pin.
• Knowledge of ‘safe corridors’ is essential to avoid injuring nerves or vessels.
• The entry sites should be irrigated to prevent burning of the bone (only 50o Celsius
can cause bone death).
• The fracture is then reduced by connecting the various pins.
• Weight bearing is started as early as possible to stimulate fracture healing.
➢ Some fixators incorporate a telescopic unit that allows ‘dynamization’; this will
convert the forces of weight bearing into axial micro movement at fracture site,
thus promoting callus formation & accelerating bone union.
➢ Factors to enhance Stability (Rigidity) include:
1. Allowing fracture ends to come into contact is the most important factor for
stability of fixation with external fixation.
2. Use larger-diameter pins (second most important factor).
3. Place additional pins.
4. Place pins in different planes (pins separated by more than 45 degrees).
5. Increased spacing between pins:
a. Place central pins closer to fracture site.
b. Place peripheral pins farther from fracture site (near-near, far-far).
6. Decreased bone-rod distance
7. Increased mass of the rods or stacked rods (a second rod in the same plane
increases resistance to bending).
8. Place rods in different planes.
➢ Tibial shaft fractures: additional lag screws with external fixation are associated
with a higher refracture rate than is external fixation alone.

 Ilizarov (Circular or Ring) External Fixators:

➢ Composition:
• Circular rings connected by vertical rods.
• Thin wires (usually 1.8 mm in diameter) fixed under tension (usually between
90 & 130 kg): wires may be simple or olive wires.

68
 • Half-pins may also be used (offer better purchase in diaphyseal "not
metaphyseal" bone).
➢ Optimum orientation of implants (wires or pins) on the ring:
• At a 90-degree angle to each other will maximizes stability.
• A 90-degree angle not always possible due to anatomic constraints, such as
neurovascular structures.
➢ Bending stiffness of frame is independent of the loading direction because frame
is circular.
➢ Each ring should have at least two implants:
• Wires or half-pins may be used.
• The construct is most stable when an olive wire and a half-pin are at a 90-degree
angle to each other on a ring.
• When two wires are used on a ring:
o One wire should be superior to the ring and one inferior.
o Tensioned wires on the same side can cause the ring to deform.
➢ Factors that enhance Stability of circular external fixators:
1. Using larger diameter wires & half-pins.
2. Use of olive wires.
3. Increased wire tension (up to 130 kg).
4. Place additional wires or half-pins, or both.
5. Wires or half-pins or both crossing at a 90-degree angle.
6. Decreased ring diameter.
7. Increased number of rings.
8. Placement of the two central rings close to the fracture site.
9. Decreased spacing between adjacent rings.

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 ❖ Total Hip Arthroplasty: "THA"
➢ Biomechanics of TJA differs from that of plates &
screws which is adapted for partial support until
bone union while arthroplasty components
should withstand many years of cyclic loading.
➢ Forces acting on hip joint:
▪ In the Coronal plane:
1. Body weight: load applied to lever arm extending from COG to center of
femoral head.
2. Abductor musculature:
o Acting on lever arm extending from lateral aspect of greater
trochanter to center of femoral head.
o It should exert equal moment to body weight during standing on
single limb to hold pelvis level.
o It should exert moment greater than body weight during walking
or running to tilt the pelvis to the same side.
▪ Sagittal plane:
➢ Forces tend to bend stem posteriorly & increase when the loaded hip is flexed due
to: COG of body lies anterior to S2 & posterior to joint axis.
➢ N.B.: Moment (lever) arms:
o Femoral component design must account for rotational forces.
o Rotational torque in retroversion:
▪ Most responsible for initiating loosening in cemented femoral stems.
▪ Increased in femoral stems with a higher offset.
 Acetabular component (Cup):
➢ Design:
1. Cemented UMWHPE: with wire marker to assess the position & wear rate.
2. Cemented metal packed & polyethylene.
3. Cement-less:
• Porous coated: press fit or fixed by screws.
• Hydroxy-Appetite coated.
• Double coating.
4. Custom shaped: for acetabular deficiency.

▪ Materials used in acetabular component:

1. UHMWPE
2. UHMWPE with Carbon fibers.

70
3. Ceramics.

▪ Acetabular component fixation:

➔ Cemented cups have:
• Flanges: compress the cement.
• Ridges: increase surface area.
• Pods: prevent bottoming out.
➔ Cement-less cups:
➢ Depends on press fit or screw fixation before bone growth.

▪ Types of acetabular ring:

1 Screws & hook.
2 Screws on both ilium & ischium.
▪ Cemented versus Cement-less:
➢ Cemented cups:
• Suitable for elder low demanding patients.
• Low cost.
• Simple application & easier detection of loosening.
• More suitable for some tumor management.
➢ Cement-less (uncemented) cups:
• Suitable for young active individuals.
• The most secure position for screw fixation is the postero-superior.
• Long term cup survivorship is limited which make surgeons use cement-less cups.

 Femoral component:
➢ Design:
➔ Cemented:
• Polished.
• Textured (Matte).
• PMMA coated.
➔ Cement-less:
• Press fit.
• Porous coated.
• (HA) Coated: bone ingrowth enhances to the double.
• HA-TCP coated: for osteo-induction & osteo-conduction as well.

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 STEM types:
➔ Modular stems:
FOR calcar replacement, in tumor & limb salvage hips.
➔ Dysplastic stems:
• Small.
• straight with 22mm head.

▪ Materials used in femoral component & bearing surfaces (head):

1. Stainless steel: cheap & easily to be machined.
2. Cobalt alloys: tough & high wear resistance.
3. Titanium:
• Prevent stress shielding because of its closer elastic modulus to bone.
• Passivated layer is inert & easily reformed if damaged.
• Nitrogen ion implanted Titanium has very high wear resistance.
4. Combines:
• Cobalt alloys with Ceramic head OR Titanium with Ceramic head.
5. Ceramic (Alumina & Zirconium):
• High wear resistance (the hardest bearing surface).
• Brittle.
• Difficult to be manufactured.

▪ Femoral component fixation:

1. Cemented: all interfaces are fixed.
2. Cemented: bone interface fixed.
3. Cement-less fixation: depends on press fit.

▪ Cemented versus Cement-less:

Femoral components designed for use with or without cement.
➢ Cement-less:
• Proximal porous coating: should be circumferential.
• Seals the diaphysis from wear debris.
➢ Cemented:
• mantle less than 2 mm thick increases incidence of crack formation.

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▪ Femoral Head Size:
I. Small (22 mm) components:
➢ Disadvantages:
• Decrease ROM & stability.
• Increase creep, linear wear & dislocation.
➢ Advantages:
• Decrease friction torque, polyethylene volumetric wear & stress on
acetabulum.

II. Large (36 mm) components:

➢ Disadvantages:
• Increase friction torque & polyethylene volumetric wear.
➢ Advantages:
• Increase ROM & stability.

▪ Effects of head size:

1. Stress distribution is more in small head.
2. Thickness of cup increased with small head.
3. Wear:
• Volumetric wear directly proportional to sliding distance which is directly
proportional radius of head.
• Linear wear is inversely proportional to sliding distance & radius of head.
4. Friction torque force is more with large head.
5. Impingement of neck on edge of cup & decreased ROM with small head.
6. Dislocation is more with small head.

▪ Charnley concept in THR:

➢ Centralize the head by deepening of acetabulum so result in short lever arm of
body weight.
➢ Lengthening of abductor lever arm by reattachment of greater trochanter (now
THR are done without trochanteric osteotomy).
➢ "Heterotopic ossification" & minimal reaming i.e. preserve the anatomy).
➢ Arthritic hip ratio of lever arms (B.W.: Abd. = 4:1) can be adjusted to (1:1)
surgically.
➢ Abductor Lever Arm can be increased by: Charnley concept & increasing
medial offset.

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 ➢ Ideal femoral reconstruction reproduces normal center of rotation of femoral
head which determined by the 3 Offsets of the stem:
1. Medial offset (head stem offset):
▪ Transverse distance between center of the head to a line pass through
axis of the stem.
• Increasing medial offset leads to:
1. Increasing abductor lever (moment) arm so decreasing abductor force & JRF.
2. Reduces abductor force required in normal gait.
3. Increasing stress of medial cement mantle leading to loosening.
4. Increasing stress & bending moment at neck-stem junction (Broken Prosthesis).
5. Increasing stress at stem tip lead to calcar pivot “Wind Shield” effect &
loosening.
6. Increasing rotational micromotion leading to decreasing bone in-growth in
Cement-less stems & loosening.
• Decreasing medial offset leads to:
1. Decreasing abductor moment arm so abductors do more power to perform.
2. Increasing JRF so Increasing acetabular loosening & polyethylene wear.
3. Increasing incidence of limp.
4. Increasing Laxity in the abductor musculature leading to instability.
5. Increasing impingement.
2. Vertical offset (height):
▪ Distance between base of collar (lesser trochanter) & center of head.
▪ It corrects leg length.
3. Anterior offset (version angle of neck):

• Durability:
➢ Survival of surface replacement hip arthroplasty is poor as a result of volumetric
wear of polyethylene (this wear is 4 to 10 times that of a THA when a 28mm head
is used).
➢ Metal-backing acetabular components are used (decrease stress in cement &
cancellous bone).
➢ Polyethylene on titanium makes a poor bearing surface (excessive volumetric
wear).
➢ Titanium on weight-bearing surfaces is not recommended as it may lead to fretting
& wear Debris & blackening of soft tissues).
➢ Wear synovitis can occur in TJA & associated with histiocyte injection of
submicron polyethylene debris.

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➢ UHMWPE serves as a “shock absorber” & should be at least 6 mm thick to prevent
creep.
➢ Ceramic femoral head on ceramic acetabulum has the lowest coefficient of friction.

• Wear rates:
➢ UHMWPE in the acetabulum: 0.1 mm (100 μm) per year.
➢ Metal-on-metal bearings for THA: 0.002 to 0.005 mm (2 to 5 μm) per year (smaller
particles than UHMWPE but more numerous).
➢ Ceramic bearing surfaces: 0.0005 to 0.0025 mm (0.5 to 2.5 μm) per year.

• Newer concepts:
➢ Computer design of THA stems.
➢ Modularity: increased corrosion at modular metallic junction sites such as junction
of the head & stem.
➢ Custom designs.
➢ More flexible stems.
➢ Forging of components appears to be superior to casting.

❖ Bipolar hip arthroplasty:

➢ It is a type of Hemi-arthroplasty considered as an intermediate step between Hemi
& THA.
➢ It consists of: stem with metal head & plastic insert & metal cup.
➢ Advantages:
1. Better longevity of the prosthesis because motion is distributed on 2 surfaces:
• Inner bearing: between head & plastic insert.
• Outer bearing: between metal cup & acetabulum.
2. Better longevity for the bony acetabulum.
3. Can be converted to THA.
➢ Disadvantage: the motion is mainly out bearing.

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 ❖ Total Knee Arthroplasty: "TKA"
➢ Kinematics:
• Knee motion is tri-axial (occur 3 different planes):
1. Flexion-Extension.
2. Adduction-Abduction.
3. Internal-External rotation bout the long axis of the limb.

Knee flexion:
▪ It is a function of both the articular geometry of knee & the ligamentous restraints.
▪ It occurs about varying transverse axes due to what is called femoral rollback.
▪ Normal gait requires knee flexion of about:
o 65° during swing phase.
o 85°for stairs climbing.
o 90° for descending stairs.
o 95° to rise from a chair.

Types of prostheses available:

❖ PCL retaining:
1. Greater ROM with effective femoral rollback & relatively flat tibial articular surface.
2. Ligaments function as a restraint to translational displacement of the knee.
3. More symmetrical gait especially during stair climbing.
4. Less bone resection on femoral side.
5. Improved function of patella-femoral joint.

❖ PCL substituting:
1. PCL is diseased with arthritis.
2. Significant deformity can be corrected.
3. Deleterious effect of excessive femoral rollback on component fixation with knee
motion.
4. Less polyethylene wears.

❖ PCL sacrificing.
➢ Design has evolved significantly.
• Original designs didn't account for human knee kinematics.
• Appropriate compromise is sought between the following designs:
o Total-contact designs: excess stability (less motion) & less wear.

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 o Low-contact designs: less stability (better motion) & increased wear.
• Metal alloys are typically used.

N.B Cemented, cruciate ligament-substituting TKA designs are available:

• Associated with low polyethylene wear rates.
• Minimal osteolysis.
• High Tibio-Femoral conformity.

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