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Joint Diseases and
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Original Article · Open access

Bicortical screw placement and microdamage in medial buttress plates in the management of Pauwels Type III femoral neck fractures: A scanning electron microscopy-based analysis

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Osman Gorkem Muratoglu

Department of Orthopedics and Traumatology, Cam and Sakura City Hospital, İstanbul, Türkiye

ORCID: 0000-0003-0049-7937

Cem Yildirim

Department of Orthopedics and Traumatology, Cam and Sakura City Hospital, İstanbul, Türkiye

ORCID: 0000-0003-4540-1927

Hasan Ceylan

Department of Orthopedics and Traumatology, Cam and Sakura City Hospital, İstanbul, Türkiye

ORCID: 0000-0001-5941-0600

Yinal Neşes Huvaj

Department of Geological Engineer, Turkish Petroleum Corporation, Ankara, Türkiye

ORCID: 0000-0002-5366-4762

Mehmet Demirel

Department of Orthopedics and Traumatology, İstanbul University Faculty of Medicine, İstanbul, Türkiye

ORCID: 0000-0003-1131-7719

Süreyya Ergün Bozdağ

Department of Mechanical Engineer, İstanbul Technical University, Mechanical Engineering Faculty, İstanbul, Türkiye

ORCID: 0000-0001-7412-1129

Abstract

Objectives: This study aims to investigate the microstructural effects of distal bicortical screw placement in medial buttress plate (MBP) constructs using scanning electron microscopy (SEM).

Materials and methods: Ten synthetic femur models with standardized Pauwels type III fractures were divided into two groups. All specimens received fixation with three cannulated screws in an inverted triangle configuration. Group A received a MBP fixed with four unicortical screws. Group B received the same construct, except for the most distal screw was inserted bicortically. All specimens underwent combined axial and torsional cyclic loading, followed by load-to-failure testing. Plates were, then, analyzed under SEM to assess deformation and microdamage. A semi-quantitative scoring system was used to compare the severity of microstructural changes between groups.

Results: The SEM analysis revealed significantly more microdamage in Group B compared to Group A (median deformation scores: 4 vs. 2; p=0.0181). Plates with bicortical screw placement showed localized plastic deformation, microcracks, and in some cases, complete fractures, particularly at the bent midsection of the plate. In contrast, unicortical plates showed only mild surface irregularities without structural failure.

Conclusion: Although distal bicortical screw placement may enhance initial mechanical stability, it also increases the risk of microstructural damage in MBPs, potentially compromising long-term durability. These findings underscore the importance of optimizing screw configuration to balance stability with implant longevity in the treatment of vertically unstable femoral neck fractures.

Declarations

Author Contributions

Idea/concept, references and fundings: C.Y., O.G.M.; Design, literature review: C.Y., O.G.M., Y.N.H.; Control/supervision: C.Y., O.G.M., S.E.B.; Data collection and/or processing: C.Y., O.G.M., H.C., S.E.B.; Analysis and/or interpretation: C.Y., H.C.; Writing the article: C.Y., O.G.M., H.C., M.D.; Critical review: C.Y., M.D.; Materials: C.Y., Y.N.H., H.C., S.E.B.

Conflict of Interest

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Financial Disclosure

The authors received no financial support for the research and/or authorship of this article.

Data Sharing Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

  1. Augat P, Bliven E, Hackl S. Biomechanics of femoral neck fractures and implications for fixation. J Orthop Trauma 2019;33 Suppl 1:S27-S32. DOI: 10.1097/BOT.0000000000001365.
  2. Yildirim C, Demirel M, Karahan G, Cetinkaya E, Misir A, Yamak F, et al. Biomechanical comparison of four different fixation methods in the management of Pauwels type III femoral neck fractures: Is there a clear winner? Injury 2022;53:3124-3129. DOI: 10.1016/j.injury.2022.06.029.
  3. Levack AE, Gausden EB, Dvorzhinskiy A, Lorich DG, Helfet DL. Novel treatment options for the surgical management of young femoral neck fractures. J Orthop Trauma 2019;33 Suppl 1:S33-37. DOI: 10.1097/BOT.0000000000001368.
  4. Slobogean GP, Sprague SA, Scott T, McKee M, Bhandari M. Management of young femoral neck fractures: Is there a consensus? Injury 2015;46:435-40. DOI: 10.1016/j.injury.2014.11.028.
  5. Tahak F, Yaka H, Kırılmaz A, Kekeç AF, Çolak TS, Özer M. Relationship between mortality and HALP score in femoral neck fractures treated with hemiarthroplasty. Jt Dis Relat Surg 2025;36:589-95. DOI: 10.52312/jdrs.2025.2093.
  6. Yang JJ, Lin LC, Chao KH, Chuang SY, Wu CC, Yeh TT, et al. Risk factors for nonunion in patients with intracapsular femoral neck fractures treated with three cannulated screws placed in either a triangle or an inverted triangle configuration. J Bone Joint Surg Am 2013;95:61-9. DOI: 10.2106/JBJS.K.01081.
  7. Bout CA, Cannegieter DM, Juttmann JW. Percutaneous cannulated screw fixation of femoral neck fractures: The three point principle. Injury 1997;28:135-9. DOI: 10.1016/s0020-1383(96)00161-1.
  8. Aminian A, Gao F, Fedoriw WW, Zhang LQ, Kalainov DM, Merk BR. Vertically oriented femoral neck fractures: mechanical analysis of four fixation techniques. J Orthop Trauma 2007;21:544-8. DOI: 10.1097/BOT.0b013e31814b822e.
  9. Mir H, Collinge C. Application of a medial buttress plate may prevent many treatment failures seen after fixation of vertical femoral neck fractures in young adults. Med Hypotheses 2015;84:429-33. DOI: 10.1016/j.mehy.2015.01.029.
  10. Chan YS, Yuan LJ, Hung SS, Wang CJ, Yu SW, Chen CY, et al. Arthroscopic-assisted reduction with bilateral buttress plate fixation of complex tibial plateau fractures. Arthroscopy 2003;19:974-84. DOI: 10.1016/j.arthro.2003.09.038.
  11. Chen NC, Jupiter JB. Management of distal radial fractures. J Bone Joint Surg Am 2007;89:2051-62. DOI: 10.2106/JBJS.G.00020.
  12. Li J, Yin P, Zhang L, Chen H, Tang P. Medial anatomical buttress plate in treating displaced femoral neck fracture a finite element analysis. Injury 2019;50:1895-900. DOI: 10.1016/j.injury.2019.08.024.
  13. Liu J, Li Z, Ding J, Huang B, Piao C. Biomechanical analysis of two medial buttress plate fixation methods to treat Pauwels type III femoral neck fractures. BMC Musculoskelet Disord 2022;23:49. DOI: 10.1186/s12891-022-05014-4.
  14. Ye Y, Chen K, Tian K, Li W, Mauffrey C, Hak DJ. Medial buttress plate augmentation of cannulated screw fixation in vertically unstable femoral neck fractures: Surgical technique and preliminary results. Injury 2017;48:2189-93. DOI: 10.1016/j.injury.2017.08.017.
  15. Huang ZY, Su YH, Huang ZP, Wang YB, Du GC, Huang YP, et al. Medial buttress plate and allograft bone-assisted cannulated screw fixation for unstable femoral neck fracture with posteromedial comminution: A retrospective controlled study. Orthop Surg 2022;14:911-8. DOI: 10.1111/os.13273.
  16. Mughrabi H. Microstructural mechanisms of cyclic deformation, fatigue crack initiation and early crack growth. Philos Trans A Math Phys Eng Sci 2015;373:20140132. DOI: 10.1098/rsta.2014.0132.
  17. Giordano V, Alves DD, Paes RP, Amaral AB, Giordano M, Belangero W, et al. The role of the medial plate for Pauwels type III femoral neck fracture: A comparative mechanical study using two fixations with cannulated screws. J Exp Orthop 2019;6:18. DOI: 10.1186/s40634-019-0187-3.
  18. Rho JY, Tsui TY, Pharr GM. Elastic properties of human cortical and trabecular lamellar bone measured by nanoindentation. Biomaterials 1997;18:1325-30. DOI: 10.1016/s0142-9612(97)00073-2.
  19. Türkmen F, Kaçıra BK, Özkaya M, Erkoçak ÖF, Acar MA, Özer M, et al. Comparison of monoplanar versus biplanar medial opening-wedge high tibial osteotomy techniques for preventing lateral cortex fracture. Knee Surg Sports Traumatol Arthrosc 2017;25:2914-20. DOI: 10.1007/s00167-016-4049-6.
  20. Lee KB, Jeong SY, Kim SH, Shim DG. Complete reduction for pilon fracture can make complete failure. J Am Podiatr Med Assoc 2018;108:257-61. DOI: 10.7547/17-001.
  21. von Rüden C, Augat P. Failure of fracture fixation in osteoporotic bone. Injury 2016;47 Suppl 2:S3-10. DOI: 10.1016/S0020-1383(16)47002-6.
  22. Leuders S, Thöne M, Riemer A, Niendorf T, Tröster T, Richard HA, et al. On the mechan-ical behaviour of titanium alloy TiAl6V4 manufactured by selective laser melting: Fatigue re-sistance and crack growth performance. Int J Fatigue 2013;48:300-7.
  23. Slobogean GP, Sprague SA, Scott T, Bhandari M. Complications following young femoral neck fractures. Injury 2015;46:484-91. DOI: 10.1016/j.injury.2014.10.010.