Introduction
Patellar fractures, constituting approximately 1% of Orthopedic injuries, present unique challenges due to their intricate role in knee mechanics and joint function [
1,
2]. While direct trauma and indirect forces can result in various patella fracture types, transverse fractures are the most prevalent [
3,
4]. Initially considered a vestige, the patella is a mechanical pulley that enhances extensor forces by up to 30% [
5]. This function is especially vital in the final 30 degrees of knee extension. Thus, the patella’s integrity is paramount for normal knee kinematics, underscoring the significance of optimal treatment.
Effective management of transverse patella fractures aligns with AO (Arbeit gemeinschaft für Osteosyntheses fragment) principles and aims to minimize hardware-related complications. Neglecting these fractures can result in a misalignment of the patellofemoral joint, potentially leading to early-onset patellofemoral osteoarthritis, restricted motion, and ongoing knee discomfort [
6,
7].
Traditional methods such as using K-wires, screws, and cerclage wiring have been commonly employed among the treatment options for displaced patella fractures. While these conventional techniques have demonstrated effectiveness in many cases, they exhibit limitations when confronted with the distinctive biomechanical challenges observed in specific patient populations. Notably, older patients with osteoporosis or significant muscle atrophy present a unique set of circumstances that can compromise the outcomes of these standard approaches.
Treatment of transverse patella fractures in older patients or those with less muscle mass introduces additional complexities [
8,
9]. The advanced age and potential for decreased bone density may lead to challenges in achieving stable fracture fixation and optimal healing. Complications such as implant failure, delayed union, or nonunion become concerns in these cases. Moreover, the increased load-bearing demands on the patellofemoral joint in elderly or osteoporotic patients with less muscle mass can place additional stress on the fixation hardware.
In specific patient populations, particularly those among the elderly with less muscle mass, the effectiveness of conventional methods comes under increased scrutiny. Notably, these cases often present factors such as variations in implant quality and anatomical considerations that can potentially impact treatment outcomes [
10]. In response to these challenges, there is a growing interest in reinforcing fracture implants by adopting advanced techniques. One method that has gained attention is the anterior variable angle locking neutralization plate (VA LNP or construct). This approach is considered promising solutions to enhance implant stability, particularly in the complex scenarios posed by such patient groups. However, it is essential to highlight that a comprehensive biomechanical analysis of implants fortified with traditional TBW or an anterior VA LNP, mainly when used in conjunction with vertically oriented cannulated screws for transverse fracture fixation, is currently lacking in the existing body of literature.
The VA LNP, emerging as a promising treatment option, offers superior biomechanical support for patella fractures compared to tension band wiring. Bilateral VA LNP plating has demonstrated reduced interfragmentary displacement and higher failure loads compared to other methods under cyclic loading conditions [
11,
12]. Moreover, VA LNP provides increased adjustability and stability of screw heads, offering improved outcomes compared to TBW [
13,
14].
However, despite these advancements, the optimal treatment approach for transverse patella fractures remains a subject of ongoing investigation. This study explores the biomechanical advantage of an implant combining cannulated screws and VA LNP compared to TBW. We hypothesize that the hybrid VA LNP will exhibit higher load-to-failure properties and better fracture reduction maintenance under cyclic loading, presenting a promising alternative for treating transverse patella fractures.
Finite Element Analysis (FEA) has emerged as a valuable tool in investigating patellofemoral pressure dynamics. These studies aim to understand the intricate interplay between anatomical factors, loading conditions, and surgical interventions concerning patellofemoral pressure levels. While some research has focused on contact pressure distribution and cartilage stresses, validating FEA models against empirical measurements remains crucial [
15,
16]. Few studies have explored parametric variations associated with symptomatic knees and treatment methods [
17,
18]. Within the scope of our investigation, our study introduces a specialized FEA modeling technique. This technique is meticulously designed to evaluate the stress and deformation dynamics, particularly within the context of implant performance, explicitly emphasizing the maximum failure loading of the patellar tendon.
This study assesses the biomechanical superiority of a composite approach involving VA LNP compared to TBW. By comprehensively evaluating these two implant options' durability and tensile strength, we aim to validate our findings using FEA. Previous biomechanical inquiries into transverse patella fractures treated with a plate and tension band wire (TBW) have primarily involved experimental studies utilizing polyurethane forms. These studies predominantly focused on evaluating the behavior of the two principal fracture gaps while lacking the capacity for real-time sensing and monitoring [
19]. Our research integrates FEA, primarily emphasizing early gap formation at the fracture level followed by load-to-failure testing and a comparative analysis with results obtained from cadaver experiments. Notably, cyclic testing was exclusively conducted within the cadaveric experiment and was not included in the FEA simulation.
Discussion
The challenges associated with fixing patella fractures are often tied to issues with hardware causing discomfort. Moreover, achieving satisfactory functional results remains challenging, even when patients avoid additional surgeries. Using VA LNP could offer a new approach to improving desired outcomes.
This study aims to determine whether VA LNP could be a viable treatment option for transverse patella fractures, surpassing the current gold standard approach involving the TBW technique [
26,
27]. DePuy Synthes developed the three holes and six holes VA LNP options to accommodate the various morphology of the patella. VA LNP plate has arms and body. There is also an option of three legs, which gives the surgeon more options to fix the various types of patella fractures.
The advantageous mechanical properties of VA LNPs for patella fractures have been consistently demonstrated [
12,
19,
28]. Fixed-angle plates, in particular, have been proven to provide better biomechanical support and reduce the widening of fractures during movement compared to using cannulated screws with the VA LNP technique [
29]. Recent designs of VA LNP are believed to offer enhanced adjustability and stability [
13,
14,
30]. Stoffel et al. studied the effectiveness of using TBW versus using VA LNP in cadaver tests, and the VA LNP approach showed significantly less displacement after cycling compared to the tension band wiring method [
14]. Similar findings were reported by Kfuri et al. [
30] However, there is a lack of data on the effectiveness of these VA LNPs for simple transverse patella fractures.
The study demonstrates that the VA LNP and TBW implant achieve displacement rates within the acceptable range for non-operative management in a controlled environment. Nevertheless, after 500 cycles, a significant difference emerges between the two methods. The VA LNP has an average displacement of 0.09 ± 0.13 mm, while the TBW has an average displacement of 0.78 ± 0.13 mm. Despite this divergence, both groups fall within the range of less than 2 mm for proper healing [
31], with the VA LNP showing static superiority. However, the marginal clinical significance of this difference might not justify the added expense [
31].
The observation that there was no significant difference in deformation within each implant group (VA LNP and TBW) across the cycles ranging from 100 to 500 suggests that both implants demonstrate stable mechanical behavior under the tested conditions, indicating their resilience and reliability under up to 500 cycles of load. This stability, however, also implies that the testing parameters, specifically the number of cycles, may not be extensive enough to fully delineate the mechanical endurance or fatigue limits of these implants. It raises the possibility that conducting tests over a larger number of cycles could reveal more pronounced differences and provide deeper insights into each implant's long-term performance and durability.
Previous studies revealed that the most force the patella tendon could withstand was around 300 N [
32]. This value is notably lower than the minimum measurement recorded for either group in our study and significantly below the average load to failure observed for the VA LNP (1359 N) and the TBW (780 N). Notably, a tensile force 780N, achieved through TBW and cannulated screw fixation, is clinically sufficient. However, the VA LNP plate exhibits an almost doubled tensile force capacity at approximately 1359N. We recommend reserving the VA LNP plate for patients with higher body mass or musculature or in instances where the quality of the implant material is debatable and there is a desire for enhanced fixation stability.
Both fixation methods provide increased stability, facilitating the commencement of active quadriceps range of motion at an earlier stage after surgery [
33]. However, balancing implementing aggressive postoperative protocols and the potential risk of compromising fixation integrity is crucial. The fixation technique investigated in this study might alleviate this concern, thereby rendering the adoption of more assertive postoperative approaches more viable.
The implant profile becomes a significant consideration when assessing implants, particularly given the prevalence of symptomatic hardware. A meta-analysis by Dy et al. revealed a reoperation rate of 33.6%, primarily due to symptomatic hardware [
34]. Lower profile implants, such as the VA LNP, could potentially reduce the incidence of symptomatic hardware and associated complications, even though the higher cost might not justify the marginal decrease in implant removal rates.
Furthermore, delving into our study's Finite Element Analysis (FEA) aspect is essential, as it adds a significant layer of understanding. FEA has emerged as a crucial tool in biomechanical studies, enabling us to gain profound insights into the intricate mechanical behaviors of complex structures. Within this context, it is important to recognize the distinctive mechanical implications associated with the VA LNP configuration. This method typically involves direct attachment to the bone, exerting a unique mechanical influence on the surrounding tissue. In contrast, TBW fixation often rests atop the tendon. This disparity in mechanical behavior led to minor tearing in the tendon with the VA LNP model, a phenomenon that aligns with clinical observations and underscores the importance of accurately representing the mechanics of each fixation method in our simulations.
The stress concentration points vary: the VA LNP exhibits higher stress levels concentrated toward its middle distal end, while the TBW fixation concentrates stress on its lateral side. These variations suggest diverse load-bearing capacities and potential complication zones. Deformation patterns also differ, with VA LNP showing distal-end deformation and the TBW fixation revealing proximal-end deformation. However, it is essential to acknowledge that the FEA tensile test may not fully reflect the loosening and deformation changes experienced during cyclic tests, which could account for the observed discrepancies in deformation between the two methods. These discrepancies may also stem from various factors, including differences in different anatomy models, material properties, and the simplifications inherent in our computational model.
Acknowledging these discrepancies in our FEA model, particularly concerning the deformation patterns and stress concentrations between the VA LNP and TBW methods, we were compelled to initiate a validation process. This process was pivotal in ensuring that our model's outputs closely mirrored real-world tendon behaviors. To this end, we performed a comparative analysis, aligning our model's outputs with experimental biomechanical data. A key part of this analysis involved conducting a sensitivity analysis, wherein we carefully adjusted and examined the impact of various parameters, including material properties and boundary conditions. Furthermore, we aligned our model's predictions with clinical observations and existing biomechanical literature [
17,
35,
36].
The study's limitations are associated with its reliance on in vitro examination of fixation techniques, which excludes clinical aspects such as biological healing response, soft tissue contributions, and individual patient factors. Furthermore, the exclusion of a sample, specifically one that exhibited a distinct pattern of displacement during cyclic testing and experienced catastrophic failure below 400 N, raises concerns about tissue quality owing to the absence of bone mineral density measurements. Additionally, using isolated patellae in our study, tested by placing each patella over standard sawbones and a customized rig, is another limitation. Without the context of a knee joint, the patellae may not have entirely replicated the exact physiologic conditions, further affecting the generalizability of our findings. Moreover, incorporating diverse methodologies from existing literature examining patella fracture fixation methods hinders direct comparisons.
Introducing a range of material properties into FEA can significantly refine and potentially alter the result. When analyzing the VA LNP and TBW fixation, these failure criteria can unveil more intricate and realistic stress distribution and deformation patterns. The inclusion of plasticity, for example, can indicate areas of material yielding under high stress not just limited to the middle distal end of the VA LNP and lateral side of the TBW fixation. Moreover, crack initiation and propagation can reveal potential zones of structural weakness that were not previously evident. Additionally, using a diverse range of material properties in the model can lead to a more accurate representation of each structure’s biomechanical behavior and offer new perspectives on their load-bearing capacities and failure mechanisms.
Using a diverse range of material properties in the model can lead to a more accurate representation of each structure’s biomechanical behavior. This offers new perspectives on their load-bearing capacities and failure mechanisms. However, our current approach involves using a homogeneous model to represent bone mechanical properties, which simplifies the modeling process. This approach may not adequately capture the distinct mechanical characteristics of different bone types, such as cortical versus cancellous bone. The homogeneous model's potential limitation lies in its oversimplifying these nuanced differences, which are crucial for a precise depiction of biomechanical behavior.
It is also important to highlight that our FEA model used a customized tendon and ligament based on average values from measured cadaveric specimens, rather than individualized models for each specimen. This approach, while necessary due to limitations in segmenting these structures using available imaging techniques and to ensure a manageable scope for the study, may not fully capture the intricate biomechanical behavior of each specific specimen. Additionally, the limited number of samples used for creating the FEA model is a constraint that could affect the robustness and variability of our findings.
In light of these study results, it is essential to conduct extensive multicenter randomized controlled trials that compare VA LNP fixation with the widely established treatment for patella fractures. Evaluating real patient outcomes is crucial to determine whether the innovative VA LNP reduces rates of symptomatic implants or improves functional outcomes. Additionally, these trials can aid in assessing the cost-effectiveness of adopting the new VA LNP. Furthermore, both fixation techniques observed in the study demonstrated the ability to minimize fracture displacement during cyclic loading, suggesting the feasibility of considering more proactive postoperative management. Future research directions should focus on developing evidence-based guidelines for standardizing postoperative protocols, which have the potential to enhance outcomes by reducing muscle atrophy and reported pain.
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