Biomechanical analysis of titanium-alloy and biodegradable implants in dual plate osteosynthesis for AO/ASIF type 33-C2 fractures

Background and objective: Treating geriatric osteoporotic distal femur fractures has always presented challenges, but developing biodegradable materials has brought new opportunities for therapeutic intervention. Despite this progress, there currently needs to be more evidence-based biomechanical guidelines for using dual plate fixation and biodegradable materials in treating osteoporotic comminuted distal femoral fractures. In this study, finite element analysis was conducted to evaluate the mechanical effectiveness of different implant materials (titanium alloys, biodegradable materials, and combinations of both) in the fixation of physiological and osteoporotic distal femoral fractures. Methods: We constructed finite element models of 33-C2 fractures and three types of plates: the Lateral Less Invasive Stabilization System (LISS) plate, the titanium-alloy medial plate (TAP), and the biodegradable plate (BP). To evaluate the biomechanical advantages in both physiological femur (PF) and osteoporotic femur (OF) conditions, three scenarios were developed: LISS + TAP, LISS + BP, and double biodegradable plates (DBPs). Five loading conditions were applied to measure structural stiffness, fracture micromotion, and implant stress: medio-lateral four-point bending, antero-posterior four-point bending, axial loading, torsional loading, and sideways falling. Several parameters were examined, including peak Von Mises Stress (VMS) of the femur and lateral plate, maximum displacement, bending angle, torsional angle of fracture, and risk of fracture. Results: In four-point bending tests, the lateral plate of the DBPs group exhibited a slightly lower peak VMS compared to the LISS + TAP and LISS + BP groups. When subjected to axial loading, the stiffness values of the LISS + TAP (OF) were 1.42 times and 1.86 times higher than LISS + BP (OF) and DBPs (OF) groups, and the peak VMS of lateral plate of DBPs (OF) construct was approximately 2% and 16% lower than that of the LISS + TAP (OF) and LISS + BP (OF) constructs. Under torsional loading, DBPs (OF) demonstrated rotational stiffness that was respectively 2% and 52% greater than that of LISS + TAP (OF) and LISS + BP (OF). Regarding the peak VMS of femur, the values of DBPs (OF) were almost 8% and 15% lower than those of LISS + TAP (OF) and LISS + BP (OF). Conclusions: The use of DBPs at 11.33 GPa facilitated early mobilization of load-bearing joints but exhibited limited ability to support full weightbearing activities. Though LISS + TAP met practical strength requirements, one should consider the potential biological irritation and stress shielding. Thus, employing a combination of biodegradable and metal internal fixation is a valid approach to effectively treat weight-bearing joint fractures in clinical practice.