Application of a combined cancellous lag screw enhances the stability of locking plate fixation of osteoporotic lateral tibial plateau fracture by providing interfragmentary compression force

Application of a combined cancellous lag screw enhances the stability of locking plate fixation of osteoporotic lateral tibial plateau fracture by providing interfragmentary compression force | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Application of a combined cancellous lag screw enhances the stability of locking plate fixation of osteoporotic lateral tibial plateau fracture by providing interfragmentary compression force Jiang Jiang, Daqiang Xu, Fei Wang, Rui Jia, Jun Wang, Hong Hong, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3316671/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Feb, 2024 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted 8 You are reading this latest preprint version Abstract Background Insufficient interfragmentary compression force (IFCF) frequently leads to unstable fixation of osteoporotic lateral tibial plateau fractures (OLTPFs). A combined cancellous lag screw (CCLS) enhances IFCF; however, its effect on OLTPF fixation stability remains unclear. Therefore, we investigated the effect of CCLS on OLTPF stability using locking plate fixation (LPF). Methods Twelve synthetic osteoporotic tibial bones were used to simulate OLTPFs, which were fixed using LPF, LPF-AO cancellous lag screws (LPF-AOCLS), and LPF-CCLS. Subsequently, 10,000 cyclic loadings from 30 to 400 N were performed. The initial axial stiffness (IAS), maximal axial micromotion of the lateral fragment (MAM-LF) measured every 1,000 cycles, and failure load after 10,000 cycles were tested. The same three fixations for OLTPF were simulated using finite element analysis (FEA). IFCFs of 0, 225, and 300 N were applied to the LPF, LPF-AOCLS, and LPF-CCLS, respectively, with a 1,000-N axial compressive force. The MAM-LF, peak von Mises Stress (VMS), peak equivalent elastic strain of the lateral fragment (EES-LF), and nodes of EES-LF > 2% (considered bone destruction) were calculated. Results Biomechanical tests revealed the LPF-AOCLS and LPF-CCLS groups to be superior to the LPF group in terms of the IAS, MAM-LF, and failure load (all p 2% in the LPF were higher than those in the LPF-AOCLS and LPF-CCLS. Conclusions IFCF was shown to enhance the stability of OLTPFs using LPF. Although there were no significant differences between the CCLS and AOCLS, CCLS is preferably recommended due to considerations regarding overscrewing. combined cancellous lag screw locking plate osteoporotic lateral tibial plateau fracture stable fixation interfragmentary compression force Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Osteoporotic tibial plateau fracture (TPF) is a prevalent fracture type among older populations [ 1 ]. Due to specific knee geometry and tibiofemoral joint force, over 60% of osteoporotic TPFs occur in the lateral column [ 2 ]. The prevalence of osteoporotic lateral TPF (OLTPF) gradually increases with age [ 3 ], and this injury can have a catastrophic effect on the health of older adults. Stable fixation for OLTPF is critical for accelerating recovery in older patients and avoiding complications related to long-term bed rest [ 4 , 5 ]. Among the various available fixation methods, locking plate (LP) fixation is the most widely used for OLTPF [ 6 , 7 ]. However, 11% of patients with LP-fixed lateral TPF experience lateral platform collapse [ 8 , 9 ]. Gardner et al. found that locking screw-cutting in the cancellous epiphyseal area was an important contributing factor, possibly due to the increasing shear stresses at the locking screw-bone interface [ 10 ]. Therefore, additional lag screws were applied to increase the interfragmentary compression force (IFCF), thereby reducing the shear stresses at the locking screw-bone interface and ultimately enhancing the stability of the LPF of the lateral TPF [ 11 , 12 ]. However, due to severe bone mass reduction in the osteoporotic tibia, the commonly used cancellous lag screws are prone to overscrewing, resulting in a decrease in IFCF and a high risk of lateral platform collapse [ 13 , 14 ]. The combined cancellous lag screw (CCLS) previously developed by our research team may offer promise for solving this issue [ 13 ]. The major improvement in this device is that the screw rod of the CCLS is divided into two parts and connected by fine threads. This allows the screwing angle range to be expanded through fine threads, enabling surgeons to accurately determine the stop time of screw insertion to obtain a greater IFCF and avoid the risk of overscrewing. Moreover, this device facilitates the avoidance of further cutting damage to the osteoporotic cancellous bone by screw threads, as it fastens fragments by shortening the screw length through fine threads. With these characteristics, CCLS obtained a 25% higher IFCF than AO cancellous lag screws (AOCLS) in osteoporotic bones [ 15 ]. However, no studies have yet investigated the effect of CCLS on the stability of OLTPF using LPF. Consequently, this study aimed to investigate the effect of CCLS on the stability of OLTPF using biomechanical testing and finite element analysis (FEA). We hypothesized that the CCLS would effectively enhance the stability of the LPF of OLTPFs by providing IFCF. Materials and Methods Biomechanical testing Materials Twelve large fourth-generation osteoporotic synthetic left tibial bones (No. #3402 Sawbones, 0.16 g/cc, Pacific Research Laboratories, Vashon, WA, USA) were used in this study [ 16 ]. The synthetic tibial bones were transversely truncated 200 mm from the lateral plateau and fixed using a dental tray powder (polymethyl methacrylate, Shanghai New Century Dental Materials Co., Ltd, Shanghai, China). Fracture models and test groups A reproducible cut was mechanically created by the same surgeon who used a thin blade saw based on a single template to create a lateral tibial plateau fracture (Schatzker type I). Following anatomical reduction under direct vision, the synthetic tibial bones were randomly instrumented into three groups of four samples each: LP Fixation (LPF): A single lateral proximal tibia LP (left; thickness, 4.0 mm; length, 106 mm; Jiangsu Jinlu Medical Device, Inc., Zhangjiagang, China) was fixed with seven locking screws (4.0 mm diameter, Jiangsu Jinlu Medical Device, Inc., Zhangjiagang, China). All locking screws were tightened with a torque of 4 Nm, and no IFCF was applied. LPF with AOCLS (LPF-AOCLS): An AOCLS (6.5S*65 mm; thread length, 18 mm; Changzhou Geasure Medical Apparatus and Instruments Co., Ltd., China) with a washer was used to fix the lateral fragment to the maximum IFCF perceived by the surgeon. An LP was then implanted with seven locking screws, and all locking screws were tightened with a torque of 4 Nm. LPF with CCLS (LPF-CCLS): A CCLS (6.5S*65 mm; thread length, 18 mm; Changzhou Geasure Medical Apparatus and Instruments Co., Ltd., China) with a washer was used to fix the lateral fragment. Rod length was reduced using a custom-designed locked screwdriver to obtain the maximum IFCF. Finally, the LP was implanted with seven locking screws, and all locking screws were tightened with a torque of 4 Nm. Test procedure All samples were subjected to compression loading to replicate the shearing forces on the tibial plateau during complete knee extension using a specially designed loading applicator. A hard gasket was attached to the upper surface of the lateral fragment, and a four-camera marker-based motion capture system (120 Hz, Qualysis AB, Gothenburg, Sweden) was used to obtain interfragmentary displacements. The mechanical properties of the samples were measured using a BOSE3510-AT testing machine (Bose Corporation, Force Systems Group, Eden Prairie, MN, USA) (Fig. 1 ). After the models were created, the bones were subjected to 10,000 cyclic loadings with forces ranging from 30 to 400 N with a loading frequency of 3 Hz. Fixation failure was defined as either synthetic bone fracture, implant fracture, or disengagement of the bone–implant relationship. If the samples did not exhibit failure within 10,000 cycles, a load-to-failure test was performed at a loading speed of 5 mm/min until a displacement of 3 mm could be achieved. The initial axial stiffness (IAS), maximal axial micromotion of the lateral fragment (MAM-LF) during cyclic loading, failure loads, and number of failure cycles (for structures that failed within 10,000 cycles) were assessed. The IAS was defined as the force-displacement ratio at the third loading [ 17 , 18 ]. The load that caused a 2-mm displacement was identified as the failure load. FEA Experimental models Experimental models including the AOCLS, CCLS, and LP systems were constructed based on the specifications provided by their manufacturers. The left proximal tibia model was generated using Mimics v19.0 software (Materialize Mimics, Leuven, Belgium) to create a three-dimensional reconstruction of computed tomography scan data obtained from a healthy volunteer (male; height, 174 cm; weight, 70 kg), from whom informed consent was obtained prior to data collection. Ethical approval was granted by the Institutional Ethics Committee of our institution (Ethical Clearance Certificate No. 2022-01). Subsequently, the model was imported into SolidWorks (version 2017; Dassault Systèmes, Waltham, MA, USA) to create the lateral TPF (Schatzker I) and to virtually implant all devices into the fractured proximal tibia to simulate the three fixations: LPF, LPF-AOCLS, and LPF-CCLS (Fig. 2 ). The assembled models were then submitted to ANSYS (version 17.0, ANSYS, Inc., Canonsburg, PA, USA) to mesh. Tetrahedral elements were utilized as unit types [ 19 , 20 ]. The material properties were defined as homogeneous, isotropic, and linearly elastic; these are summarized in Table 1 [ 21 , 22 ]. Table 1 Material properties of the FE models used in this study. Material Young’s modulus, MPa Poisson’s ratio Material type Cancellous bone 34 0.2 Osteoporotic cancellous bone Cortical bone 8,040 0.3 Osteoporotic cortical bone Screws 110,000 0.3 Titanium alloy Locking Plate 110,000 0.3 Titanium alloy Boundary and loading conditions The threads of the AOCLS and CCLS were fully tied to the cancellous bone, and all locking screws were fully tied to the LP. The friction coefficients were assigned as 0.3 between the fragment and the tibia. IFCFs of 0, 225, and 300 N were then applied to the LPF, LPF-AOCLS, and LPF-CCLS, respectively [ 15 ]. An axial compressive force of 1,000 N was applied to simulate the walking load in an adult patient. Sixty percent of the selected force was attributed to the medial tibial plateau and 40% to the lateral tibial plateau (Fig. 3 ). Convergence analysis, model validation, and analysis Convergence analysis of the meshes was performed to determine the appropriate mesh quality (convergence change rate < 2%) [ 23 ]. The MAM-LF, peak von Mises Stress (VMS), and peak equivalent elastic strain of the lateral fragment (EES-LF) were then assessed. The MAM-LF was evaluated to validate the finite element (FE) model, which was compared using biomechanical tests. MAM-LF > 2 mm and EES-LF > 2% were considered indicative of failure displacement and bone destruction, respectively [ 24 ]. Statistical analysis Statistical analyses were performed using IBM SPSS (version 27.0; IBM Corp., Armonk, NY, USA). The Shapiro–Wilk normality test was performed to check for data normality. An analysis of variance was used to compare differences among the three groups, and the Fisher’s Least Significant Difference test was used as a post-hoc test. Results Biomechanical testing The IAS test revealed a significant difference among the LPF (754.54 ± 134.43 N/mm), LPF-AOCLS (1,305.40 ± 386.71 N/mm), and LPF-CCLS (1,336.893 ± 176.921 N/mm) groups ( p < 0.05). Specifically, the LPF group showed statistically significant differences compared to the LPF-AOCLS and LPF-AOCLS groups ( p < 0.05) (Fig. 4 ). No fixation failure was observed in any of the samples during the loading cycles. The MAM-LF of the LPF group showed statistically significant differences compared to both the LPF-AOCLS and LPF-CCLS groups when measured after every 1,000 cycles ( p < 0.05) (Fig. 5 ). The load-to-failure test revealed statistically significant differences in failure load in the LPF group (794.848 ± 24.99 N), which were compared to those in the LPF-AOCLS (1,057.122 ± 216.84 N) and LPF-CCLS (1,101.470 ± 160.09 N) groups ( p < 0.05) (Fig. 6 ). The detailed biomechanical test results and p -values are listed in Table 2 . Table 2 The MAM-LF at every 1,000-cycle loading phase, IAS and failure load at 2-mm displacement. Number of cycles LPF (mm) LPF-AOCLS (mm) LPF-CCLS (mm) p value Initial 0.5446±0.1092 ac 0.3341±0.1268 a 0.3030±0.0387 c 0.015 * 1,000 0.6251±0.1106 ac 0.4020±0.1060 a 0.3727±0.0733 c 0.01 * 2,000 0.6423±0.1107 ac 0.4106±0.1068 a 0.3937±0.0728 c 0.01 * 3,000 0.6464±0.1118 ac 0.4157±0.1062 a 0.4021±0.0756 c 0.011 * 4,000 0.6499±0.1120 ac 0.4201±0.1074 a 0.4047±0.0745 c 0.011 * 5,000 0.6540±0.1130 ac 0.4233±0.1068 a 0.4119±0.0786 c 0.013 * 6,000 0.6564±0.1126 ac 0.4260±0.1077 a 0.4153±0.0793 c 0.013 * 7,000 0.6594±0.1132 ac 0.4283±0.1069 a 0.4209±0.0820 c 0.014 * 8,000 0.6617±0.1133 ac 0.4302±0.1063 a 0.4249±0.0844 c 0.015 * 9,000 0.6633±0.1143 ac 0.4308±0.1081 a 0.4279±0.0865 c 0.016 * 10,000 0.6661±0.1142 ac 0.4335±0.1067 a 0.4313±0.0889 c 0.016 * IAS (N/mm) 754.543±134.432 ac 1,305.401±386.713 a 1,336.893±176.921 c 0.018 * Failure load (N) 794.848±24.994 ac 1,057.122±216.844 a 1,101.470±160.086 c 0.044 * *, p -value < 0.05. Values are expressed as the mean ± SD; MAM-LF, Maximal axial micromovement of the lateral fragment; IAS, Initial axial stiffness; LPF, Locking Plate Fixation; AOCLS, AO cancellous lag screw; CCLS, combined cancellous lag screw; LPF-AOCLS, LPF with AOCLS; LPF-CCLS, LPF with CCLS. a indicates a significant difference between LPF and LPF-AOCLS groups; b indicates a significant difference between LPF-AOCLS and LPF-CCLS groups; c indicates a significant difference between LPF and LPF-CCLS groups. FEA Convergence analysis and FE model validation Mesh sizes of 2.0 mm for bones and 0.5 mm for implants were applied in this study according to the results of the mesh convergence analysis (Table 3 ). The MAM-LF in the FE model was 0.596 mm, similar to the results of the biomechanical test (0.5446±0.1092 mm). The FEA model was therefore deemed valid. Table 3 Mesh convergence analysis of finite element models. Meshing schemes of the FE model Scheme 1 Scheme 2 Scheme 3 Scheme 4 Scheme 5 Scheme 6 Bone mesh size (mm) 1.8 2 2.2 2.4 2.6 2.8 Implant mesh size (mm) 0.4 0.5 0.6 0.7 0.8 0.9 Number of elements (bone) 394,567 283,144 211,575 162,570 130,294 105,606 Number of elements (implants) 927,049 476,396 279,679 176,629 118,313 83,809 Analysis time (min) 113min 90min 42min 44min 29min 15min Maximum stress of the bone (MPa) 13.521 12.314 12.47 12.154 12.585 13.44 Stress change rate (bone) -9.80% 1.25% -2.60% 3.42% 6.36% - Maximum stress of the implants (MPa) 99.186 102.14 101.33 96.872 100.58 95.029 Stress change rate (implants) 2.89% -0.80% -4.60% 3.69% -5.84% - MAM-LF No failed displacements of the lateral fragments were observed in any model. The MAM-LFs were 0.5909, 0.4255, and 0.4192 mm for the LPF, LPF-AOCLS, and LPF-CCLS models, respectively (Fig. 4 a). Peak VMS of implants The peak VMS of the implants in the three fixation models occurred at the bending of the locking plate. In the LPF model, the peak VMS of the implant (246.17 MPa) was higher than those in the LPF-AOCLS (232.47 MPa) and LPF-CCLS (231.85 MPa) models (Fig. 4 b). EES-LF In the three fixation models, the peak EES-LF was observed at the posterior screw tunnel close to the fracture plane. The peak EES-LF and nodes with EES-LF > 2% in the LPF model (6.93%, 4,660) were higher than those in the LPF-AOCLS (3.97%, 656) and LPF-CCLS (3.74%, 649) models (Fig. 4 c). Discussion This study investigated the effect of a CCLS on OLTPF stability using an LPF through biomechanical testing and FEA. Biomechanical tests showed that the stability of the OLTPF was enhanced through the IFCF provided by the lag screw. Furthermore, the FEA showed that adding a lag screw reduced the peak VMS of the LP and EES-LF. Previous studies have shown that the IFCF produced by the lag screws improves the stability of distal femoral fractures in non-osteoporotic bones [ 25 – 27 ]. However, the role of IFCF in OLTPFs remains unclear. In our study, the effect of IFCF on OLTPF was investigated using biomechanical testing and FEA. The results of the biomechanical tests showed that the LPF-AOCLS and LPF-CCLS groups exhibited significantly higher IAS than that of the LPF group. This was similar to the results of the study by Plecko et al. [ 28 ] and is significant for patients to bear weight early, restore knee function, and avoid complications related to long-term bed rest. Additionally, we performed a fatigue test consisting of 10,000 loading cycles from 30 to 400 N to simulate a 70-kg adult walking during the 6-week fracture-healing process [ 29 ]. No failure in which the MAM-LF was greater than 2 mm was observed in any of the samples during the loading cycles. However, there were significant differences in MAM-LF in the LPF group compared with those in the LPF-AOCLS and LPF-CCLS groups, indicating that the stability of LPF-AOCLS and LPF-CCLS was superior to that of LPF during the fracture-healing process. In addition, the load-to-failure test demonstrated a significant increase in the failure load in both the LPF-AOCLS and LPF-CCLS groups compared to the LPF group. This finding is aligned with existing research on non-osteoporotic bones [ 27 ] and supports the hypothesis that the IFCF provided by the lag screw plays a crucial role in enhancing the stability of the LPF in OLTPF. The FEA showed findings similar to those of the biomechanical tests. The results of the MAM-LF in the LPF model were greater than those in the LPF-AOCLS and LPF-CCLS models. This was also reflected in the VMS results. The LPF model exhibited a higher peak VMS for the LP compared to the LPF-AOCLS and LPF-CCLS models. Thus, the IFCF provided by the lag screw was shown to effectively reduce the MAM-LF and load on the LP to protect it from damage. This finding agrees with the results of the study by Zhang et al. [ 26 ] in which FEA of distal femoral fractures was performed. Moreover, the LPF model exhibited a higher peak EES-LF and a greater number of nodes with EES-LF > 2% compared to the LPF-AOCLS and LPF-CCLS models. This finding implies that the lateral fragment suffered more severe bone damage when fixed using LPF, thereby suggesting that the IFCF provided by the lag screw could decrease the cutting effect caused by locking screws in practical applications. These results suggest that the LP combined with lag screws is a feasible fixation strategy for OLTPFs. However, the present analysis revealed no significant differences between the LPF-CCLS and LPF-AOCLS groups in the IAS, fatigue test, or load-to-failure test, although the LPF-CCLS group exhibited numerically superior performance compared to the LPF-AOCLS group. Two possible explanations for this exist. First, although patients with osteoporosis have a low bone density and the trabecular bone structure is too weak to maintain the holding force of the lag screw [ 30 ], both AOCLS and CCLS have sufficient holding force in synthetic tibial bones; hence, it was difficult for the AOCLS and CCLS to produce significant differences in the holding force. Second, the limited sample size of the study and slight disparity in IFCF provided by the CCLS and AOCLS may have resulted in a lack of significant differences in the stability of LPF of OLTPFs. Based on the biomechanical testing and FEA findings, it can be inferred that both CCLS and AOCLS may enhance the stability of the LPF of OLTPFs by providing an IFCF. Limitations This study has several limitations. First, only synthetic tibia bones were used, and no experiments were conducted on actual bones. Although this model may not accurately reproduce clinical osteoporotic fracture fixation, it nevertheless allows for the use of homogeneous material and highly reproducible testing. Second, the force exerted by body weight on the tibia is subject to variation based on the degree of flexion and extension in real life. Accurately replicating these intricate dynamics in the laboratory setting has proven challenging. However, according to published methods, the single test setting used in this study was sufficient to examine fixation stability [ 29 ]. Conclusion Overall, the results of this analysis showed that both CCLS and AOCLS are effective at enhancing the stability of OLTPFs using LPF by providing IFCF. Although no significant differences were observed between the CCLS and AOCLS groups, CCLS is preferably recommended for improving the stability of LPF in patients with OLTPF, considering the risk of overscrewing in osteoporotic bones. Abbreviations TPF, tibial plateau fracture; OLTPF, osteoporotic lateral tibial plateau fracture; LP, locking plate; IFCF, interfragmentary compression force; CCLS, combined cancellous lag screw; AOCLS, AO cancellous lag screws; FEA, finite element analysis; LPF, locking plate fixation; LPF-AOCLS, locking plate fixation with AO cancellous lag screws; LPF-CCLS, locking plate fixation with combined cancellous lag screw; IAS, initial axial stiffness; MAM-LF, maximal axial micromotion of the lateral fragment; VMS, von Mises Stress; EES-LF, equivalent elastic strain of the lateral fragment; FE, finite element. Declarations Ethics approval and consent to participate The ethical approval was granted by the Institutional Ethics Committee of Zhongshan Torch Development Zone People’s Hospital (Ethical Clearance Certificate No. 2022-01). Consent for publication Not applicable. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the National Key R&D Program of China (No. 2022YFF1202600), National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation and Jiangsu China-Israel Industrial Technical Research Institute Foundation (2021-NCRC-CXJJ-ZH-19), Natural Science Foundation of Guangdong Province, China (No. 2022A1515011604) and Special Project of Clinical Medicine of Nantong University (YXY-Z 2023015). Authors’ contributions All authors contributed to the study conception and design. JL, HZ, JJ and DX conceived and designed the experiments. JJ and DX performed the experiments. FW, RJ, HH, JW and HZ analysed the data. JJ, DX, JL and FW wrote the paper. All authors commented on previous versions of the manuscript and approved the final manuscript. Acknowledgements We would like to thank Editage (www.editage.com) for English language editing. References Kosters C, Schliemann B, Raschke MJ. Tibial head fractures in the elderly. Unfallchirurg. 2011;114:251–60. Shen QJ, Zhang JL, Xing GS, Liu ZY, Li EQ, Zhao BC, et al. Surgical treatment of lateral tibial plateau fractures involving the posterolateral column. Orthop Surg. 2019;11:1029–38. Parratte S, Ollivier M, Argenson JN. Primary total knee arthroplasty for acute fracture around the knee. Orthop Traumatol Surg Res. 2018;104(1S): S71-S80. Honkonen SE. Indications for surgical treatment of tibial condyle fractures. Clin Orthop Relat Res. 1994;(302):199–205. Lansinger O, Bergman B, Körner L, Andersson GB. Tibial condylar fractures. A twenty-year follow-up. J Bone Joint Surg Am. 1986;68:13–9. Carrera I, Gelber PE, Chary G, Gonzalez-Ballester MA, Monllau JC, Noailly J. Fixation of a split fracture of the lateral tibial plateau with a locking screw plate instead of cannulated screws would allow early weight bearing: a computational exploration. Int Orthop. 2016;40:2163–9. Matsunobu T, Maekawa A, Nomoto S, Iwamoto Y. Successful management of radiation-associated insufficiency fracture of the tibial plateau with low-intensity pulsed ultrasound. Am J Case Rep. 2022;23:e934372. Urruela AM, Davidovitch R, Karia R, Khurana S, Egol KA. Results following operative treatment of tibial plateau fractures. J Knee Surg. 2013;26:161–5. Ali AM, El-Shafie M, Willett KM. Failure of fixation of tibial plateau fractures. J Orthop Trauma. 2002;16:323–9. Gardner MJ, Nork SE, Huber P, Krieg JC. Less rigid stable fracture fixation in osteoporotic bone using locked plates with near cortical slots. Injury. 2010;41:652–6. Wang Z, Zheng Z, Wang Y, Zhu Y, Tan Z, Chen W, et al. Unilateral locking plate versus unilateral locking plate combined with compression bolt for Schatzker I-IV tibial plateau fractures: a comparative study. Int Orthop. 2022;46:1133–43. Gao W, Qi X, Zhao K, Feng X, Yang Y, Liu P, et al. Lateral locking plate plus antero-posterior lag screws techniques for the management of posterolateral tibial plateau fracture: preliminary clinical results and biomechanical study. Arch Orthop Trauma Surg. 2023;143:3163–72. Bel JC. Pitfalls and limits of locking plates. Orthop Traumatol Surg Res. 2019;105(1S):S103-S109. Barlow JD, Logli AL, Steinmann SP, Sems SA, Cross WW, Yuan BJ, et al. Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate. J Shoulder Elbow Surg. 2020;29:1689–94. Xu DQ, Sun PD, Wang J, Yang HL, Liu XJ, Zhao WD. The new shank construct of lag screw improves the maximum compression force for internal fixations: preliminary results. Eur Rev Med Pharmacol Sci. 2015;19:2195–201. O'Neill F, Condon F, McGloughlin T, Lenehan B, Coffey C, Walsh M. Validity of synthetic bone as a substitute for osteoporotic cadaveric femoral heads in mechanical testing: a biomechanical study. Bone Joint Res. 2012;1:50–5. Newell N, Rivera TD, Rahman T, Lim S, O'Connell GD, Holsgrove TP. Influence of testing environment and loading rate on intervertebral disc compressive mechanics: an assessment of repeatability at three different laboratories. Jor Spine. 2020;3:e21110. Wilke HJ, Wenger K, Claes L. Testing criteria for spinal implants: recommendations for the standardization of in vitro stability testing of spinal implants. Eur Spine J. 1998;7:148–54. Lewis GS, Mischler D, Wee H, Reid JS, Varga P. Finite element analysis of fracture fixation. Curr Osteoporos Rep. 2021;19:403–16. MacLeod AR, Simpson AHRW, Pankaj P. Reasons why dynamic compression plates are inferior to locking plates in osteoporotic bone: a finite element explanation. Comput Method Biomec. 2015;18:1818–25. Iniguez-Macedo S, Lostado-Lorza R, Escribano-Garcia R, Martinez-Calvo MA. Finite element model updating combined with multi-response optimization for hyper-elastic materials characterization. Materials (Basel). 2019;12:1019. Zhang L, Yang G, Wu L, Yu B. The biomechanical effects of osteoporosis vertebral augmentation with cancellous bone granules or bone cement on treated and adjacent non-treated vertebral bodies: a finite element evaluation. Clin Biomech (Bristol, Avon). 2010;25:166–72. Bonivtch AR, Bonewald LF, Nicolella DP. Tissue strain amplification at the osteocyte lacuna: a microstructural finite element analysis. J Biomech. 2007;40:2199–206. Chen AC, Lin YH, Kuo HN, Yu TC, Sun MT, Lin CL. Design optimisation and experimental evaluation of dorsal double plating fixation for distal radius fracture. Injury. 2013;44:527–34. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002;84:1093–110. Mardian S, Schmolz W, Schaser KD, Duda GN, Heyland M. Interfragmentary lag screw fixation in locking plate constructs increases stiffness in simple fracture patterns. Clin Biomech (Bristol, Avon). 2015;30:814–9. Zhang J, Wei Y, Li G, Wang J, Xu Y. Interfragmentary lag screw and locking plate combination in simple distal femoral fractures: a finite element analysis. Acta Orthop Traumatol Turc. 2021;55:9–15. Mardian S, Schmolz W, Schaser KD, Duda GN, Heyland M. Locking plate constructs benefit from interfragmentary lag screw fixation with decreased shear movements and more predictable fracture gap motion in simple fracture patterns. Clin Biomech (Bristol, Avon). 2019;70:89–96. Plecko M, Lagerpusch N, Pegel B, Andermatt D, Frigg R, Koch R, et al. The influence of different osteosynthesis configurations with locking compression plates (LCP) on stability and fracture healing after an oblique 45 degrees angle osteotomy. Injury. 2012;43:1041–51. Salduz A, Birisik F, Polat G, Bekler B, Bozdag E, Kilicoglu O. The effect of screw thread length on initial stability of Schatzker type 1 tibial plateau fracture fixation: a biomechanical study. J Orthop Surg Res. 2016;11:146. Rexiti P, Aierken G, Wang S, Abudurexiti T, Abuduwali N, Deng Q, et al. Anatomical research on strength of screw track fixation in novel cortical bone trajectory for osteoporosis lumbar spine. Am J Transl Res. 2019;11:6850–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Feb, 2024 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted Editorial decision: Major revision 20 Oct, 2023 Reviews received at journal 03 Oct, 2023 Reviewers agreed at journal 23 Sep, 2023 Reviewers agreed at journal 22 Sep, 2023 Reviewers invited by journal 07 Sep, 2023 Editor assigned by journal 04 Sep, 2023 Submission checks completed at journal 04 Sep, 2023 First submitted to journal 01 Sep, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3316671","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":230765964,"identity":"b665c225-c8de-4f09-99b1-a2fc37e328a4","order_by":0,"name":"Jiang Jiang","email":"","orcid":"","institution":"Department of Anatomy, Guangdong Provincial Key Laboratory of Digital Medicine and Biomechanics, School of Basic Medical Sciences, Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jiang","middleName":"","lastName":"Jiang","suffix":""},{"id":230765965,"identity":"5b1ac061-faf2-4e64-97ec-3e33f739a9e7","order_by":1,"name":"Daqiang Xu","email":"","orcid":"","institution":"Affiliated Hospital Sixth of Nantong University, Yancheng Third People’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Daqiang","middleName":"","lastName":"Xu","suffix":""},{"id":230765966,"identity":"2ed7fda7-58b1-4784-a0cd-e6560cf89ccb","order_by":2,"name":"Fei Wang","email":"","orcid":"","institution":"Department of Anatomy, Guangdong Provincial Key Laboratory of Digital Medicine and Biomechanics, School of Basic Medical Sciences, Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fei","middleName":"","lastName":"Wang","suffix":""},{"id":230765967,"identity":"b77b4cea-98ca-44f8-9fb0-a27b98376724","order_by":3,"name":"Rui Jia","email":"","orcid":"","institution":"Department of Rehabilitation Medicine, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rui","middleName":"","lastName":"Jia","suffix":""},{"id":230765968,"identity":"ffa37b1b-9486-4651-aac2-002b09fdfd20","order_by":4,"name":"Jun Wang","email":"","orcid":"","institution":"Department of Anatomy, Guangdong Provincial Key Laboratory of Digital Medicine and Biomechanics, School of Basic Medical Sciences, Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Wang","suffix":""},{"id":230765969,"identity":"5ff08a3e-258c-4f3b-809f-dcf552587e7c","order_by":5,"name":"Hong Hong","email":"","orcid":"","institution":"Department of Anatomy, Guangdong Provincial Key Laboratory of Digital Medicine and Biomechanics, School of Basic Medical Sciences, Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Hong","suffix":""},{"id":230765970,"identity":"ade28f8b-44ca-4e70-af45-fd457bdeb972","order_by":6,"name":"Hongtao Zhang","email":"","orcid":"","institution":"Zhongshan Torch Development Zone People’s Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hongtao","middleName":"","lastName":"Zhang","suffix":""},{"id":230765971,"identity":"7e6b2b81-17d8-49dd-98c3-61532d9e0ea1","order_by":7,"name":"Jianyi Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYBACPmaGhANAmocfxHvAwGBAUAsbTItkAwNjQwJRWmAMgwNEa2FneHjg547DMsbHe8wfJFTYGDOwHz66gZDDDvaeOcxjduaMYUPCmTQzBp60tBsE/cLbBtRyI8ewIbHtsA2DBJBN0Ja/QC3GM0jRchhki4EERIsZcVpk29J5JM4cK5wB9IsxGyG/8POfSf74ts3anr+9ecOHDxU2hv3sh4/h1QKMxAQg0YxkL37lIMB+AEjUEVY3CkbBKBgFIxcAAJwiSJZwrxqSAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Anatomy, Guangdong Provincial Key Laboratory of Digital Medicine and Biomechanics, School of Basic Medical Sciences, Southern Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jianyi","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2023-09-01 10:29:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3316671/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3316671/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13018-024-04564-8","type":"published","date":"2024-02-14T15:01:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":42775198,"identity":"fdce3352-b698-43bf-be1f-bb0c2e8b9b05","added_by":"auto","created_at":"2023-09-07 14:26:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":6315373,"visible":true,"origin":"","legend":"\u003cp\u003ePreparation of samples and accessories\u003c/p\u003e\n\u003cp\u003ea) Views of constructs mounted for testing; b) Two different lag screws for osteoporotic lateral tibial plateau fracture (OLTPF) reduction; c) A hard gasket was matched between the upper surface of the lateral fragment and the loading applicator\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-3316671/v1/16bc4425f3efe51ef6f1a3f3.png"},{"id":42776762,"identity":"c151d699-3ec8-4097-a648-c2f8a373b50c","added_by":"auto","created_at":"2023-09-07 14:34:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4173626,"visible":true,"origin":"","legend":"\u003cp\u003eThree fixations of the finite element models\u003c/p\u003e\n\u003cp\u003ea) Locking plate fixation (LPF); b) LPF with AO cancellous lag screw (LPF-AOCLS) and LPF with combined cancellous lag screw (LPF-CCLS)\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-3316671/v1/1dbeb977f184f7d50b95eea4.png"},{"id":42776761,"identity":"97886ae6-be8c-4697-b3b7-80e21a048932","added_by":"auto","created_at":"2023-09-07 14:34:56","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1536480,"visible":true,"origin":"","legend":"\u003cp\u003eDepictions of the loads applied in the finite element models\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-3316671/v1/0f1c88d01bf0c4f5e819bedf.png"},{"id":42775203,"identity":"c23cc7f2-a59e-4e93-94a6-a32eb3d95ce4","added_by":"auto","created_at":"2023-09-07 14:26:56","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1337010,"visible":true,"origin":"","legend":"\u003cp\u003eResults of biomechanical testing\u003c/p\u003e\n\u003cp\u003ea) Initial axial stiffness (IAS): The locking plate fixation (LPF) group showed statistical differences compared to both the LPF-AO cancellous lag screw (AOCLS) group and the LPF-combined cancellous lag screw (CCLS) group (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05); b) Maximal axial micromotion of the lateral fragment (MAM-LF)in cyclic compression loading in every 1,000 cycles: The MAM-LF in the LPF group showed statistical differences compared to that of both the LPF-AOCLS and LPF-CCLS groups measured at every 1,000 cycles (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05); c) Failure load in the load-to-failure test: There was a statistical difference in failure load when the LPF group was compared to the LPF-AOCLS and LPF-CCLS groups (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05). *, \u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.05\u003c/p\u003e","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-3316671/v1/e8627b8faa6755637ea78fd2.png"},{"id":42775205,"identity":"2a54319a-5d2d-4c1f-a7b1-ceba2b22ffde","added_by":"auto","created_at":"2023-09-07 14:26:56","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":3832553,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of three fixation models of MAM-LF in finite element analysis\u003c/p\u003e","description":"","filename":"Fig5.png","url":"https://assets-eu.researchsquare.com/files/rs-3316671/v1/0eda0fbd99f3f902e76a3643.png"},{"id":42775200,"identity":"1c5cf864-be72-440f-9d4d-925cbe975053","added_by":"auto","created_at":"2023-09-07 14:26:56","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":3747436,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of implants of peak von Mises Stress (VMS) of three fixation models; the red label indicates the location where peak VMS occurred\u003c/p\u003e","description":"","filename":"Fig6.png","url":"https://assets-eu.researchsquare.com/files/rs-3316671/v1/5e6e77c7a1f8d1e75a8778d1.png"},{"id":42775201,"identity":"b19754f4-a304-4955-81c5-5957bca86907","added_by":"auto","created_at":"2023-09-07 14:26:56","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":3864498,"visible":true,"origin":"","legend":"\u003cp\u003eComparison ofpeak equivalent elastic strain of the lateral fragment (EES-LF) and nodes with EES-LF \u0026gt;2%; the numerical indicators depicted in the figure correspond to the screw tunnels in the lateral fragment\u003c/p\u003e","description":"","filename":"Fig7.png","url":"https://assets-eu.researchsquare.com/files/rs-3316671/v1/1b92eea3f91d5dfd39614a47.png"},{"id":51323099,"identity":"49c68a9f-40fe-4e50-a41a-15ea286a8139","added_by":"auto","created_at":"2024-02-19 15:15:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5581690,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3316671/v1/ff147d34-970d-4b2d-a720-33286ee1492e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Application of a combined cancellous lag screw enhances the stability of locking plate fixation of osteoporotic lateral tibial plateau fracture by providing interfragmentary compression force","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOsteoporotic tibial plateau fracture (TPF) is a prevalent fracture type among older populations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Due to specific knee geometry and tibiofemoral joint force, over 60% of osteoporotic TPFs occur in the lateral column [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The prevalence of osteoporotic lateral TPF (OLTPF) gradually increases with age [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and this injury can have a catastrophic effect on the health of older adults.\u003c/p\u003e \u003cp\u003eStable fixation for OLTPF is critical for accelerating recovery in older patients and avoiding complications related to long-term bed rest [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Among the various available fixation methods, locking plate (LP) fixation is the most widely used for OLTPF [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, 11% of patients with LP-fixed lateral TPF experience lateral platform collapse [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Gardner et al. found that locking screw-cutting in the cancellous epiphyseal area was an important contributing factor, possibly due to the increasing shear stresses at the locking screw-bone interface [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Therefore, additional lag screws were applied to increase the interfragmentary compression force (IFCF), thereby reducing the shear stresses at the locking screw-bone interface and ultimately enhancing the stability of the LPF of the lateral TPF [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, due to severe bone mass reduction in the osteoporotic tibia, the commonly used cancellous lag screws are prone to overscrewing, resulting in a decrease in IFCF and a high risk of lateral platform collapse [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe combined cancellous lag screw (CCLS) previously developed by our research team may offer promise for solving this issue [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The major improvement in this device is that the screw rod of the CCLS is divided into two parts and connected by fine threads. This allows the screwing angle range to be expanded through fine threads, enabling surgeons to accurately determine the stop time of screw insertion to obtain a greater IFCF and avoid the risk of overscrewing. Moreover, this device facilitates the avoidance of further cutting damage to the osteoporotic cancellous bone by screw threads, as it fastens fragments by shortening the screw length through fine threads. With these characteristics, CCLS obtained a 25% higher IFCF than AO cancellous lag screws (AOCLS) in osteoporotic bones [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, no studies have yet investigated the effect of CCLS on the stability of OLTPF using LPF.\u003c/p\u003e \u003cp\u003eConsequently, this study aimed to investigate the effect of CCLS on the stability of OLTPF using biomechanical testing and finite element analysis (FEA). We hypothesized that the CCLS would effectively enhance the stability of the LPF of OLTPFs by providing IFCF.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eBiomechanical testing\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eMaterials\u003c/h2\u003e \u003cp\u003eTwelve large fourth-generation osteoporotic synthetic left tibial bones (No. #3402 Sawbones, 0.16 g/cc, Pacific Research Laboratories, Vashon, WA, USA) were used in this study [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The synthetic tibial bones were transversely truncated 200 mm from the lateral plateau and fixed using a dental tray powder (polymethyl methacrylate, Shanghai New Century Dental Materials Co., Ltd, Shanghai, China).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eFracture models and test groups\u003c/h2\u003e \u003cp\u003eA reproducible cut was mechanically created by the same surgeon who used a thin blade saw based on a single template to create a lateral tibial plateau fracture (Schatzker type I). Following anatomical reduction under direct vision, the synthetic tibial bones were randomly instrumented into three groups of four samples each:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLP Fixation (LPF): A single lateral proximal tibia LP (left; thickness, 4.0 mm; length, 106 mm; Jiangsu Jinlu Medical Device, Inc., Zhangjiagang, China) was fixed with seven locking screws (4.0 mm diameter, Jiangsu Jinlu Medical Device, Inc., Zhangjiagang, China). All locking screws were tightened with a torque of 4 Nm, and no IFCF was applied.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLPF with AOCLS (LPF-AOCLS): An AOCLS (6.5S*65 mm; thread length, 18 mm; Changzhou Geasure Medical Apparatus and Instruments Co., Ltd., China) with a washer was used to fix the lateral fragment to the maximum IFCF perceived by the surgeon. An LP was then implanted with seven locking screws, and all locking screws were tightened with a torque of 4 Nm.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLPF with CCLS (LPF-CCLS): A CCLS (6.5S*65 mm; thread length, 18 mm; Changzhou Geasure Medical Apparatus and Instruments Co., Ltd., China) with a washer was used to fix the lateral fragment. Rod length was reduced using a custom-designed locked screwdriver to obtain the maximum IFCF. Finally, the LP was implanted with seven locking screws, and all locking screws were tightened with a torque of 4 Nm.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eTest procedure\u003c/h2\u003e \u003cp\u003eAll samples were subjected to compression loading to replicate the shearing forces on the tibial plateau during complete knee extension using a specially designed loading applicator. A hard gasket was attached to the upper surface of the lateral fragment, and a four-camera marker-based motion capture system (120 Hz, Qualysis AB, Gothenburg, Sweden) was used to obtain interfragmentary displacements. The mechanical properties of the samples were measured using a BOSE3510-AT testing machine (Bose Corporation, Force Systems Group, Eden Prairie, MN, USA) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter the models were created, the bones were subjected to 10,000 cyclic loadings with forces ranging from 30 to 400 N with a loading frequency of 3 Hz. Fixation failure was defined as either synthetic bone fracture, implant fracture, or disengagement of the bone\u0026ndash;implant relationship. If the samples did not exhibit failure within 10,000 cycles, a load-to-failure test was performed at a loading speed of 5 mm/min until a displacement of 3 mm could be achieved.\u003c/p\u003e \u003cp\u003eThe initial axial stiffness (IAS), maximal axial micromotion of the lateral fragment (MAM-LF) during cyclic loading, failure loads, and number of failure cycles (for structures that failed within 10,000 cycles) were assessed. The IAS was defined as the force-displacement ratio at the third loading [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The load that caused a 2-mm displacement was identified as the failure load.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFEA\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eExperimental models\u003c/h2\u003e \u003cp\u003eExperimental models including the AOCLS, CCLS, and LP systems were constructed based on the specifications provided by their manufacturers. The left proximal tibia model was generated using Mimics v19.0 software (Materialize Mimics, Leuven, Belgium) to create a three-dimensional reconstruction of computed tomography scan data obtained from a healthy volunteer (male; height, 174 cm; weight, 70 kg), from whom informed consent was obtained prior to data collection. Ethical approval was granted by the Institutional Ethics Committee of our institution (Ethical Clearance Certificate No. 2022-01). Subsequently, the model was imported into SolidWorks (version 2017; Dassault Syst\u0026egrave;mes, Waltham, MA, USA) to create the lateral TPF (Schatzker I) and to virtually implant all devices into the fractured proximal tibia to simulate the three fixations: LPF, LPF-AOCLS, and LPF-CCLS (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe assembled models were then submitted to ANSYS (version 17.0, ANSYS, Inc., Canonsburg, PA, USA) to mesh. Tetrahedral elements were utilized as unit types [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The material properties were defined as homogeneous, isotropic, and linearly elastic; these are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMaterial properties of the FE models used in this study.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaterial\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYoung\u0026rsquo;s modulus, MPa\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePoisson\u0026rsquo;s ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaterial type\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancellous bone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOsteoporotic cancellous bone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCortical bone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8,040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOsteoporotic cortical bone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScrews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e110,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTitanium alloy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocking Plate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e110,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTitanium alloy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eBoundary and loading conditions\u003c/h2\u003e \u003cp\u003eThe threads of the AOCLS and CCLS were fully tied to the cancellous bone, and all locking screws were fully tied to the LP. The friction coefficients were assigned as 0.3 between the fragment and the tibia. IFCFs of 0, 225, and 300 N were then applied to the LPF, LPF-AOCLS, and LPF-CCLS, respectively [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. An axial compressive force of 1,000 N was applied to simulate the walking load in an adult patient. Sixty percent of the selected force was attributed to the medial tibial plateau and 40% to the lateral tibial plateau (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eConvergence analysis, model validation, and analysis\u003c/h2\u003e \u003cp\u003eConvergence analysis of the meshes was performed to determine the appropriate mesh quality (convergence change rate\u0026thinsp;\u0026lt;\u0026thinsp;2%) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The MAM-LF, peak von Mises Stress (VMS), and peak equivalent elastic strain of the lateral fragment (EES-LF) were then assessed. The MAM-LF was evaluated to validate the finite element (FE) model, which was compared using biomechanical tests. MAM-LF\u0026thinsp;\u0026gt;\u0026thinsp;2 mm and EES-LF\u0026thinsp;\u0026gt;\u0026thinsp;2% were considered indicative of failure displacement and bone destruction, respectively [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS (version 27.0; IBM Corp., Armonk, NY, USA). The Shapiro\u0026ndash;Wilk normality test was performed to check for data normality. An analysis of variance was used to compare differences among the three groups, and the Fisher\u0026rsquo;s Least Significant Difference test was used as a post-hoc test.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eBiomechanical testing\u003c/h2\u003e \u003cp\u003eThe IAS test revealed a significant difference among the LPF (754.54\u0026thinsp;\u0026plusmn;\u0026thinsp;134.43 N/mm), LPF-AOCLS (1,305.40\u0026thinsp;\u0026plusmn;\u0026thinsp;386.71 N/mm), and LPF-CCLS (1,336.893\u0026thinsp;\u0026plusmn;\u0026thinsp;176.921 N/mm) groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Specifically, the LPF group showed statistically significant differences compared to the LPF-AOCLS and LPF-AOCLS groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNo fixation failure was observed in any of the samples during the loading cycles. The MAM-LF of the LPF group showed statistically significant differences compared to both the LPF-AOCLS and LPF-CCLS groups when measured after every 1,000 cycles (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe load-to-failure test revealed statistically significant differences in failure load in the LPF group (794.848\u0026thinsp;\u0026plusmn;\u0026thinsp;24.99 N), which were compared to those in the LPF-AOCLS (1,057.122\u0026thinsp;\u0026plusmn;\u0026thinsp;216.84 N) and LPF-CCLS (1,101.470\u0026thinsp;\u0026plusmn;\u0026thinsp;160.09 N) groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The detailed biomechanical test results and \u003cem\u003ep\u003c/em\u003e-values are listed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe MAM-LF at every 1,000-cycle loading phase, IAS and failure load at 2-mm displacement.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNumber of cycles\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLPF (mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLPF-AOCLS (mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLPF-CCLS (mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eInitial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5446\u0026plusmn;0.1092\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.3341\u0026plusmn;0.1268\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.3030\u0026plusmn;0.0387\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003e0.015\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e1,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6251\u0026plusmn;0.1106\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4020\u0026plusmn;0.1060\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.3727\u0026plusmn;0.0733\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003e0.01\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e2,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6423\u0026plusmn;0.1107\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4106\u0026plusmn;0.1068\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.3937\u0026plusmn;0.0728\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003e0.01\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e3,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6464\u0026plusmn;0.1118\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4157\u0026plusmn;0.1062\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.4021\u0026plusmn;0.0756\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003e0.011\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e4,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6499\u0026plusmn;0.1120\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4201\u0026plusmn;0.1074\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e0.4047\u0026plusmn;0.0745\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.011\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e5,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6540\u0026plusmn;0.1130\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4233\u0026plusmn;0.1068\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.4119\u0026plusmn;0.0786\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003e0.013\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e6,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6564\u0026plusmn;0.1126\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4260\u0026plusmn;0.1077\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.4153\u0026plusmn;0.0793\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003e0.013\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e7,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6594\u0026plusmn;0.1132\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4283\u0026plusmn;0.1069\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.4209\u0026plusmn;0.0820\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003e0.014\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e8,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6617\u0026plusmn;0.1133\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4302\u0026plusmn;0.1063\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.4249\u0026plusmn;0.0844\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003e0.015\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e9,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6633\u0026plusmn;0.1143\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4308\u0026plusmn;0.1081\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.4279\u0026plusmn;0.0865\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003e0.016\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e10,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6661\u0026plusmn;0.1142\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4335\u0026plusmn;0.1067\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.4313\u0026plusmn;0.0889\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003e0.016\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIAS (N/mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e754.543\u0026plusmn;134.432\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,305.401\u0026plusmn;386.713\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1,336.893\u0026plusmn;176.921\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003e0.018\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFailure load (N)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e794.848\u0026plusmn;24.994\u003csup\u003eac\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,057.122\u0026plusmn;216.844\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1,101.470\u0026plusmn;160.086\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003e0.044\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003csup\u003e*,\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eValues are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eMAM-LF, Maximal axial micromovement of the lateral fragment; IAS, Initial axial stiffness; LPF, Locking Plate Fixation; AOCLS, AO cancellous lag screw; CCLS, combined cancellous lag screw; LPF-AOCLS, LPF with AOCLS; LPF-CCLS, LPF with CCLS.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003csup\u003ea\u003c/sup\u003e indicates a significant difference between LPF and LPF-AOCLS groups;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003csup\u003eb\u003c/sup\u003e indicates a significant difference between LPF-AOCLS and LPF-CCLS groups;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003csup\u003ec\u003c/sup\u003e indicates a significant difference between LPF and LPF-CCLS groups.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFEA\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eConvergence analysis and FE model validation\u003c/h2\u003e \u003cp\u003eMesh sizes of 2.0 mm for bones and 0.5 mm for implants were applied in this study according to the results of the mesh convergence analysis (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The MAM-LF in the FE model was 0.596 mm, similar to the results of the biomechanical test (0.5446\u0026plusmn;0.1092 mm). The FEA model was therefore deemed valid.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMesh convergence analysis of finite element models.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeshing schemes of the FE model\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScheme 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScheme 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eScheme 3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eScheme 4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eScheme 5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eScheme 6\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone mesh size (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant mesh size (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of elements (bone)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e394,567\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e283,144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e211,575\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e162,570\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e130,294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e105,606\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of elements (implants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e927,049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e476,396\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e279,679\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e176,629\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e118,313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e83,809\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalysis time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum stress of the bone (MPa)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.521\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.585\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress change rate (bone)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-9.80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.42%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.36%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum stress of the implants (MPa)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99.186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e101.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96.872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress change rate (implants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.89%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-4.60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.69%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-5.84%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMAM-LF\u003c/h2\u003e \u003cp\u003eNo failed displacements of the lateral fragments were observed in any model. The MAM-LFs were 0.5909, 0.4255, and 0.4192 mm for the LPF, LPF-AOCLS, and LPF-CCLS models, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ea).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePeak VMS of implants\u003c/h2\u003e \u003cp\u003eThe peak VMS of the implants in the three fixation models occurred at the bending of the locking plate. In the LPF model, the peak VMS of the implant (246.17 MPa) was higher than those in the LPF-AOCLS (232.47 MPa) and LPF-CCLS (231.85 MPa) models (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eb).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eEES-LF\u003c/h2\u003e \u003cp\u003eIn the three fixation models, the peak EES-LF was observed at the posterior screw tunnel close to the fracture plane. The peak EES-LF and nodes with EES-LF\u0026thinsp;\u0026gt;\u0026thinsp;2% in the LPF model (6.93%, 4,660) were higher than those in the LPF-AOCLS (3.97%, 656) and LPF-CCLS (3.74%, 649) models (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ec).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the effect of a CCLS on OLTPF stability using an LPF through biomechanical testing and FEA. Biomechanical tests showed that the stability of the OLTPF was enhanced through the IFCF provided by the lag screw. Furthermore, the FEA showed that adding a lag screw reduced the peak VMS of the LP and EES-LF.\u003c/p\u003e \u003cp\u003ePrevious studies have shown that the IFCF produced by the lag screws improves the stability of distal femoral fractures in non-osteoporotic bones [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e–\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, the role of IFCF in OLTPFs remains unclear. In our study, the effect of IFCF on OLTPF was investigated using biomechanical testing and FEA. The results of the biomechanical tests showed that the LPF-AOCLS and LPF-CCLS groups exhibited significantly higher IAS than that of the LPF group. This was similar to the results of the study by Plecko et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and is significant for patients to bear weight early, restore knee function, and avoid complications related to long-term bed rest. Additionally, we performed a fatigue test consisting of 10,000 loading cycles from 30 to 400 N to simulate a 70-kg adult walking during the 6-week fracture-healing process [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. No failure in which the MAM-LF was greater than 2 mm was observed in any of the samples during the loading cycles. However, there were significant differences in MAM-LF in the LPF group compared with those in the LPF-AOCLS and LPF-CCLS groups, indicating that the stability of LPF-AOCLS and LPF-CCLS was superior to that of LPF during the fracture-healing process. In addition, the load-to-failure test demonstrated a significant increase in the failure load in both the LPF-AOCLS and LPF-CCLS groups compared to the LPF group. This finding is aligned with existing research on non-osteoporotic bones [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and supports the hypothesis that the IFCF provided by the lag screw plays a crucial role in enhancing the stability of the LPF in OLTPF.\u003c/p\u003e \u003cp\u003eThe FEA showed findings similar to those of the biomechanical tests. The results of the MAM-LF in the LPF model were greater than those in the LPF-AOCLS and LPF-CCLS models. This was also reflected in the VMS results. The LPF model exhibited a higher peak VMS for the LP compared to the LPF-AOCLS and LPF-CCLS models. Thus, the IFCF provided by the lag screw was shown to effectively reduce the MAM-LF and load on the LP to protect it from damage. This finding agrees with the results of the study by Zhang et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] in which FEA of distal femoral fractures was performed. Moreover, the LPF model exhibited a higher peak EES-LF and a greater number of nodes with EES-LF \u0026gt; 2% compared to the LPF-AOCLS and LPF-CCLS models. This finding implies that the lateral fragment suffered more severe bone damage when fixed using LPF, thereby suggesting that the IFCF provided by the lag screw could decrease the cutting effect caused by locking screws in practical applications. These results suggest that the LP combined with lag screws is a feasible fixation strategy for OLTPFs.\u003c/p\u003e \u003cp\u003eHowever, the present analysis revealed no significant differences between the LPF-CCLS and LPF-AOCLS groups in the IAS, fatigue test, or load-to-failure test, although the LPF-CCLS group exhibited numerically superior performance compared to the LPF-AOCLS group. Two possible explanations for this exist. First, although patients with osteoporosis have a low bone density and the trabecular bone structure is too weak to maintain the holding force of the lag screw [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], both AOCLS and CCLS have sufficient holding force in synthetic tibial bones; hence, it was difficult for the AOCLS and CCLS to produce significant differences in the holding force. Second, the limited sample size of the study and slight disparity in IFCF provided by the CCLS and AOCLS may have resulted in a lack of significant differences in the stability of LPF of OLTPFs. Based on the biomechanical testing and FEA findings, it can be inferred that both CCLS and AOCLS may enhance the stability of the LPF of OLTPFs by providing an IFCF.\u003c/p\u003e "},{"header":"Limitations","content":"\u003cp\u003eThis study has several limitations. First, only synthetic tibia bones were used, and no experiments were conducted on actual bones. Although this model may not accurately reproduce clinical osteoporotic fracture fixation, it nevertheless allows for the use of homogeneous material and highly reproducible testing. Second, the force exerted by body weight on the tibia is subject to variation based on the degree of flexion and extension in real life. Accurately replicating these intricate dynamics in the laboratory setting has proven challenging. However, according to published methods, the single test setting used in this study was sufficient to examine fixation stability [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOverall, the results of this analysis showed that both CCLS and AOCLS are effective at enhancing the stability of OLTPFs using LPF by providing IFCF. Although no significant differences were observed between the CCLS and AOCLS groups, CCLS is preferably recommended for improving the stability of LPF in patients with OLTPF, considering the risk of overscrewing in osteoporotic bones.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTPF, tibial plateau fracture; OLTPF, osteoporotic lateral tibial plateau fracture; LP, locking plate; IFCF, interfragmentary compression force; CCLS, combined cancellous lag screw; AOCLS, AO cancellous lag screws; FEA, finite element analysis; LPF, locking plate fixation; LPF-AOCLS, locking plate fixation with AO cancellous lag screws; LPF-CCLS, locking plate fixation with combined cancellous lag screw; IAS, initial axial stiffness; MAM-LF, maximal axial micromotion of the lateral fragment; VMS, von Mises Stress; EES-LF, equivalent elastic strain of the lateral fragment; FE, finite element.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ethical approval was granted by the Institutional Ethics Committee of Zhongshan Torch Development Zone People’s Hospital (Ethical Clearance Certificate No. 2022-01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Key R\u0026amp;D Program of China (No. 2022YFF1202600), National Clinical Research Center for Orthopedics, Sports Medicine \u0026amp; Rehabilitation and Jiangsu China-Israel Industrial Technical Research Institute Foundation (2021-NCRC-CXJJ-ZH-19), Natural Science Foundation of Guangdong Province, China (No. 2022A1515011604) and Special Project of Clinical Medicine of Nantong University (YXY-Z 2023015).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. JL, HZ, JJ and DX conceived and designed the experiments. JJ and DX performed the experiments. FW, RJ, HH, JW and HZ analysed the data. JJ, DX, JL and FW wrote the paper. All authors commented on previous versions of the manuscript and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Editage (www.editage.com) for English language editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKosters C, Schliemann B, Raschke MJ. Tibial head fractures in the elderly. Unfallchirurg. 2011;114:251\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShen QJ, Zhang JL, Xing GS, Liu ZY, Li EQ, Zhao BC, et al. Surgical treatment of lateral tibial plateau fractures involving the posterolateral column. Orthop Surg. 2019;11:1029\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParratte S, Ollivier M, Argenson JN. Primary total knee arthroplasty for acute fracture around the knee. Orthop Traumatol Surg Res. 2018;104(1S): S71-S80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHonkonen SE. Indications for surgical treatment of tibial condyle fractures. Clin Orthop Relat Res. 1994;(302):199\u0026ndash;205.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLansinger O, Bergman B, K\u0026ouml;rner L, Andersson GB. Tibial condylar fractures. A twenty-year follow-up. J Bone Joint Surg Am. 1986;68:13\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarrera I, Gelber PE, Chary G, Gonzalez-Ballester MA, Monllau JC, Noailly J. Fixation of a split fracture of the lateral tibial plateau with a locking screw plate instead of cannulated screws would allow early weight bearing: a computational exploration. Int Orthop. 2016;40:2163\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsunobu T, Maekawa A, Nomoto S, Iwamoto Y. Successful management of radiation-associated insufficiency fracture of the tibial plateau with low-intensity pulsed ultrasound. Am J Case Rep. 2022;23:e934372.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUrruela AM, Davidovitch R, Karia R, Khurana S, Egol KA. Results following operative treatment of tibial plateau fractures. J Knee Surg. 2013;26:161\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAli AM, El-Shafie M, Willett KM. Failure of fixation of tibial plateau fractures. J Orthop Trauma. 2002;16:323\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGardner MJ, Nork SE, Huber P, Krieg JC. Less rigid stable fracture fixation in osteoporotic bone using locked plates with near cortical slots. Injury. 2010;41:652\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Z, Zheng Z, Wang Y, Zhu Y, Tan Z, Chen W, et al. Unilateral locking plate versus unilateral locking plate combined with compression bolt for Schatzker I-IV tibial plateau fractures: a comparative study. Int Orthop. 2022;46:1133\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao W, Qi X, Zhao K, Feng X, Yang Y, Liu P, et al. Lateral locking plate plus antero-posterior lag screws techniques for the management of posterolateral tibial plateau fracture: preliminary clinical results and biomechanical study. Arch Orthop Trauma Surg. 2023;143:3163\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBel JC. Pitfalls and limits of locking plates. Orthop Traumatol Surg Res. 2019;105(1S):S103-S109.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarlow JD, Logli AL, Steinmann SP, Sems SA, Cross WW, Yuan BJ, et al. Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate. J Shoulder Elbow Surg. 2020;29:1689\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu DQ, Sun PD, Wang J, Yang HL, Liu XJ, Zhao WD. The new shank construct of lag screw improves the maximum compression force for internal fixations: preliminary results. Eur Rev Med Pharmacol Sci. 2015;19:2195\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Neill F, Condon F, McGloughlin T, Lenehan B, Coffey C, Walsh M. Validity of synthetic bone as a substitute for osteoporotic cadaveric femoral heads in mechanical testing: a biomechanical study. Bone Joint Res. 2012;1:50\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNewell N, Rivera TD, Rahman T, Lim S, O'Connell GD, Holsgrove TP. Influence of testing environment and loading rate on intervertebral disc compressive mechanics: an assessment of repeatability at three different laboratories. Jor Spine. 2020;3:e21110.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilke HJ, Wenger K, Claes L. Testing criteria for spinal implants: recommendations for the standardization of in vitro stability testing of spinal implants. Eur Spine J. 1998;7:148\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis GS, Mischler D, Wee H, Reid JS, Varga P. Finite element analysis of fracture fixation. Curr Osteoporos Rep. 2021;19:403\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacLeod AR, Simpson AHRW, Pankaj P. Reasons why dynamic compression plates are inferior to locking plates in osteoporotic bone: a finite element explanation. Comput Method Biomec. 2015;18:1818\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIniguez-Macedo S, Lostado-Lorza R, Escribano-Garcia R, Martinez-Calvo MA. Finite element model updating combined with multi-response optimization for hyper-elastic materials characterization. Materials (Basel). 2019;12:1019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang L, Yang G, Wu L, Yu B. The biomechanical effects of osteoporosis vertebral augmentation with cancellous bone granules or bone cement on treated and adjacent non-treated vertebral bodies: a finite element evaluation. Clin Biomech (Bristol, Avon). 2010;25:166\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonivtch AR, Bonewald LF, Nicolella DP. Tissue strain amplification at the osteocyte lacuna: a microstructural finite element analysis. J Biomech. 2007;40:2199\u0026ndash;206.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen AC, Lin YH, Kuo HN, Yu TC, Sun MT, Lin CL. Design optimisation and experimental evaluation of dorsal double plating fixation for distal radius fracture. Injury. 2013;44:527\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002;84:1093\u0026ndash;110.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMardian S, Schmolz W, Schaser KD, Duda GN, Heyland M. Interfragmentary lag screw fixation in locking plate constructs increases stiffness in simple fracture patterns. Clin Biomech (Bristol, Avon). 2015;30:814\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang J, Wei Y, Li G, Wang J, Xu Y. Interfragmentary lag screw and locking plate combination in simple distal femoral fractures: a finite element analysis. Acta Orthop Traumatol Turc. 2021;55:9\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMardian S, Schmolz W, Schaser KD, Duda GN, Heyland M. Locking plate constructs benefit from interfragmentary lag screw fixation with decreased shear movements and more predictable fracture gap motion in simple fracture patterns. Clin Biomech (Bristol, Avon). 2019;70:89\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlecko M, Lagerpusch N, Pegel B, Andermatt D, Frigg R, Koch R, et al. The influence of different osteosynthesis configurations with locking compression plates (LCP) on stability and fracture healing after an oblique 45 degrees angle osteotomy. Injury. 2012;43:1041\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalduz A, Birisik F, Polat G, Bekler B, Bozdag E, Kilicoglu O. The effect of screw thread length on initial stability of Schatzker type 1 tibial plateau fracture fixation: a biomechanical study. J Orthop Surg Res. 2016;11:146.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRexiti P, Aierken G, Wang S, Abudurexiti T, Abuduwali N, Deng Q, et al. Anatomical research on strength of screw track fixation in novel cortical bone trajectory for osteoporosis lumbar spine. Am J Transl Res. 2019;11:6850\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"combined cancellous lag screw, locking plate, osteoporotic lateral tibial plateau fracture, stable fixation, interfragmentary compression force","lastPublishedDoi":"10.21203/rs.3.rs-3316671/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3316671/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInsufficient interfragmentary compression force (IFCF) frequently leads to unstable fixation of osteoporotic lateral tibial plateau fractures (OLTPFs). A combined cancellous lag screw (CCLS) enhances IFCF; however, its effect on OLTPF fixation stability remains unclear. Therefore, we investigated the effect of CCLS on OLTPF stability using locking plate fixation (LPF).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTwelve synthetic osteoporotic tibial bones were used to simulate OLTPFs, which were fixed using LPF, LPF-AO cancellous lag screws (LPF-AOCLS), and LPF-CCLS. Subsequently, 10,000 cyclic loadings from 30 to 400 N were performed. The initial axial stiffness (IAS), maximal axial micromotion of the lateral fragment (MAM-LF) measured every 1,000 cycles, and failure load after 10,000 cycles were tested. The same three fixations for OLTPF were simulated using finite element analysis (FEA). IFCFs of 0, 225, and 300 N were applied to the LPF, LPF-AOCLS, and LPF-CCLS, respectively, with a 1,000-N axial compressive force. The MAM-LF, peak von Mises Stress (VMS), peak equivalent elastic strain of the lateral fragment (EES-LF), and nodes of EES-LF\u0026thinsp;\u0026gt;\u0026thinsp;2% (considered bone destruction) were calculated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBiomechanical tests revealed the LPF-AOCLS and LPF-CCLS groups to be superior to the LPF group in terms of the IAS, MAM-LF, and failure load (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). FEA revealed that the MAM-LF, peak VMS, peak EES-LF, and nodes with EES-LF\u0026thinsp;\u0026gt;\u0026thinsp;2% in the LPF were higher than those in the LPF-AOCLS and LPF-CCLS.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIFCF was shown to enhance the stability of OLTPFs using LPF. Although there were no significant differences between the CCLS and AOCLS, CCLS is preferably recommended due to considerations regarding overscrewing.\u003c/p\u003e","manuscriptTitle":"Application of a combined cancellous lag screw enhances the stability of locking plate fixation of osteoporotic lateral tibial plateau fracture by providing interfragmentary compression force","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-09-07 14:26:51","doi":"10.21203/rs.3.rs-3316671/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-10-20T09:52:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-10-03T19:35:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6498ca40-7eba-44a2-b3b5-33f917af9567","date":"2023-09-23T20:46:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54c79ed2-b364-41f4-ae48-311f07f16ed4","date":"2023-09-22T14:44:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-09-07T12:50:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-09-04T14:31:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-09-04T09:27:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2023-09-01T10:27:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e95fb25b-1dca-48a3-8a2b-4fc6e234d18d","owner":[],"postedDate":"September 7th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-02-19T15:09:52+00:00","versionOfRecord":{"articleIdentity":"rs-3316671","link":"https://doi.org/10.1186/s13018-024-04564-8","journal":{"identity":"journal-of-orthopaedic-surgery-and-research","isVorOnly":false,"title":"Journal of Orthopaedic Surgery and Research"},"publishedOn":"2024-02-14 15:01:06","publishedOnDateReadable":"February 14th, 2024"},"versionCreatedAt":"2023-09-07 14:26:51","video":"","vorDoi":"10.1186/s13018-024-04564-8","vorDoiUrl":"https://doi.org/10.1186/s13018-024-04564-8","workflowStages":[]},"version":"v1","identity":"rs-3316671","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3316671","identity":"rs-3316671","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}