vii TABLE OF CONTENTS
CHAPTER
1
2
TITLE
PAGE
DECLARATION
ii
DEDICATION
iii
ACKNOWLENGEMENTS
iv
ABSTRACT
v
ABSTRAK
vi
TABLE OF CONTENTS
vii
LIST OF TABLES
x
LIST OF FIGURES
xi
LIST OF ABBREVIATIONS
xiv
LIST OF SYMBOLS
xvi
LIST OF APPENDICES
xvii
INTRODUCTION
1
1.1
Project Background
1
1.2
Problem Statement
3
1.3
Aims and Objectives
4
1.4
Scope and the Importance of Research
5
LITERATURE REVIEW
8
2.1
Anatomy
8
2.2
Bone Fracture
13
2.2.1
Fracture Classification
14
2.2.1.1
16
OTA Fracture Classification
viii 2.2.2
3
Biomechanics of Fracture Bone
21
2.3
Bone Deformity
23
2.4
Fracture Fixation
25
2.4.1
AO Principles
26
2.4.2
Fixation Device
28
2.4.2.1
External Fixator
29
2.4.2.2
Internal Fixator
31
2.5
Bone Healing
43
2.6
Finite Element Analysis (FEA)
45
2.7
CT Scan Image Dataset
45
FINITE ELEMENT ANALYSIS OF PUDDU AND
46
TOMOFIX PLATE FIXATION FOR OPEN WEDGE
HIGH TIBIAL OSTEOTOMY
4
3.1
Case Background
46
3.2
Methods
47
3.2.1
Three Dimensional Model Design
47
3.2.2
Material Properties
49
3.2.3
Analysis
50
3.3
Results
51
3.4
Discussion
57
3.5
Conclusion
59
BIOMECHANICAL
ANALYSIS
OF
LOCKING
61
COMPRESSION PLATE (LCP) FOR OBLIQUE
TIBIAL FRACTURE FIXATION
4.1
Case Background
61
4.2
Methods
62
4.3
Results
66
4.4
Discussion
69
4.5
Conclusion
72
ix 5
COMPARISON
LOCKING
BETWEEN
PLATES
FRACTURE
ON
FIXATION:
TWO
DIFFERENT
DISTAL
FINITE
73
TIBIAL
ELEMENT
STUDY
6
5.1
Case Background
73
5.2
Methods
74
5.3
Results
79
5.4
Discussion
85
5.5
Conclusion
87
LIMITATIONS OF STUDY AND FUTURE
88
RECOMMENDATION, CONTRIBUTIONS &
CONCLUSION
6.1
Limitation of Study and Future Recommendation
88
6.2
Contributions
90
6.3
Conclusion
91
REFERENCES
93
Appendices A - E
103 - 144
x LIST OF TABLES
TABLE NO.
TITLE
PAGE
2.1
AIS rated injury for pelvis and lower extremities
14
2.2
Tibia and fibula fracture classification by OTA
19
3.1
Material properties of reconstructed 3D model
50
3.2
Difference between Puddu and Tomofix for different
biomechanical properties
57
4.1
Magnitude for muscle and joint contact forces also the
summation of joint forces of knee and ankle
65
4.2
Numbers of screws and their placement on LCP
66
4.3
Difference for each configuration using ANOVA
69
5.1
Comparison between fixation with ATL and MDT plate
fixation
83
xii LIST OF FIGURES
FIGURE NO.
TITLE
PAGE
1.1
Number of cases from 2007 till 2009 based on NTrD
reports
2
2.1
Anatomy of bone showing three bone tissues
9
2.2
Anatomy of femur bone with anterior and posterior view
10
2.3
Detail anatomies of tibia and fibula on anterior and
posterior view
12
2.4
Fracture according to loading
16
2.5
OTA classification by anatomy location
18
2.6
Bone fracture classification code based on OTA
19
2.7
Fracture around lower limb. First three right picture is
the tibia fracture and the next for picture is the femur
fracture
21
2.8
Different condition of the lower limb with weight
bearing line. Normal bone alignment with normal WBL
(line ABC) (i), varus alignment with the WBL (line
AED) shift medially (ii), valgus alignment with the
WBL (line AED) shift laterally
24
2.9
Types of external fixators used at lower limb. Pin and
rod external fixator (a, b, e). Circular external fixator
(c, d)
31
2.10
Lambotte Plate
33
2.11
Coapteur by Danis
34
2.12
Tensioner by Müller that anchor to the bone will
compress the bone fragment before the plate be fixed
34
2.13
Limited Contact Dynamic Compression Plate (LC-DCP)
36
xii 2.14
The undersurface of the LC-DCP allow the formation of
small callus under the plate, while the undersurface of
the DCP compress on the fracture site and disturb the
callus formation under the plate
37
2.15
Point Contact Fixator (PC-Fix)
38
2.16
Locking Head Screws (LHS), (a), and Conventional
screws (b)
39
2.17
Locking Head Screw, (a), and conventional screw, (b),
on plate. Threaded screw hole on plate to house the
LHS, (c), and screw hole to house the conventional
screw, (d). Large fragment LCP screw holes
configuration, (e)
40
2.18
Shear effect of the LHS (b), (c) and the conventional
screw (d), (e)
41
2.19
Screws pullout testing with conventional screws (a) and
the LHS
41
2.20
Bone Healing Process: (A) Fracture inflammatory stage
where blood clotting occurred. (B) Granulation tissue
formation. (C) Reparative phase where callus and
lamellar bone develops. (D) Remodeling phase
44
3.1
Puddu plate positioning on 3D model of simulated open
wedge high tibia osteotomy
48
3.2
Tomofix plate positioning on 3D model of simulated
open wedge high tibia osteotomy bone
49
3.3
Displacement direction of the Puddu system (lateral
view of the tibia). The pink colour mesh is the original
position and colour contour object is the model after full
load being applied
51
3.4
Displacement result acquire from finite element for each
model that being analyse
52
3.5
Equivalent von Mises stress (EVMS) distribution along
the model. Bottom view of plates (a), (e). Plates side
view (b), (f). Anterior view of fixation models (c), (d),
(g), (h)
54
3.6
Micromotion result for the Tomofix plate (a), (b) and
Puddu plate (c), (d)
56
xii 4.1
The position of the locking compression plate in 3D
model of simulated tibial oblique fracture
63
4.2
Locking compression plate and locking screw design
64
4.3
Equivalent Von Mises Stress (EVMS) for all
configurations
67
4.4
Displacement for the fracture bone and implant model
68
5.1
X-ray image and preoperative sketch for pilon fracture
using 1/3 tubular plate
75
5.2
The position of the Anterolateral (ATL) plate and
Medial Distal Tibia (MDT) plate on simulated
comminuted fracture of distal tibia
76
5.3
Anterolateral (ATL) plate, Medial Distal Tibia (MDT)
plate and locking screw design using CAD software
77
5.4
Equivalent Von Mises Stress (EVMS) distribution on
anterolateral, ATL implant (a, b, c, d, and e) and medial
distal tibia, MDT implant (f, g, h, i, and j) on different
view
80
5.5
Displacement on the bone fracture constructs on a) ATL
and b) MDT
81
5.6
Displacement direction for both bone construct
82
5.7
Comparison between mean value for each bone
fragment in ATL and MDT
84
xiv LIST OF ABBREVIATIONS
3D
-
Three dimension
AIS
-
Abbreviated injury scale
ANOVA
-
Analysis of variance
AO
-
Arbeitsgemeinschaft für Osteosynthesefragen
ATL
-
Anterolateral
BMD
-
Bone mineral density
CAD
-
Computer-aided design
CT
-
Computed Tomography
CWHTO
-
Closed-wedge high tibial osteotomy
DCP
-
Dynamic Compression Plate
DISP
-
Displacement
EVMS
-
Equivalent von Mises stress
FEA
-
Finite element analysis
HTO
-
High tibial osteotomy
JOT
-
Journal of Orthopaedic Trauma
LC-DCP
-
Limited Contact Dynamic Compression Plate
LCP
-
Locking Compression Plate
LHS
-
Locking head screws
LISS
-
Less invasive stabilize system
MDT
-
Medial distal tibia
MIPO
-
Minimal invasive plate osteosynthesis
mm
-
Millimeter
MPa
-
Mega Pascal
N
-
Newton
NA
-
Neutral axis
xv No.
-
Number
NTrD
-
National Trauma Database
OTA
-
Orthopaedic Trauma Association
OWHTO
-
Open-wedge high tibial osteotomy
PC-Fix
-
Point Contact fixator
PC-Fix2
-
Point Contact fixator 2
USA
-
United State of America
WBL
-
Weight bearing line
xvi LIST OF SYMBOLS
%
-
Percentage
E
-
Elastic Modulus
o
-
Degree
υ
-
Poisson ratio
x, y, z
-
Rectangular coordinates
σ
-
Stress
xvii LIST OF APPENDICES
APPENDIX
TITLE
PAGE
A
Contact table for contact modeling used in case 3
for ATL
103
B
Contact table for contact modeling used in case 3
for MDT
105
C
Manuscript published in INJURY
107
D
Manuscript submitted to Journal of Orthopaedic
Trauma (JOT)
112
E
Manuscript submitted to Journal of Bone and
Joint Surgery (JBJS)
126