Finite Element Analysis of Lateral Plate, Intramedullary Nail, and Nail-Plate Combination Techniques in Osteoporotic Distal Femur Fractures

Finite Element Analysis of Lateral Plate, Intramedullary Nail, and Nail-Plate Combination Techniques in Osteoporotic Distal Femur Fractures | 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 Finite Element Analysis of Lateral Plate, Intramedullary Nail, and Nail-Plate Combination Techniques in Osteoporotic Distal Femur Fractures Tahsin Olgun Bayraktar, Mustafa Bugra Ayaz, Ihsan Ahmet Güneren, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6920941/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Osteoporotic distal femur fractures are known for their high mechanical complication rates. In our study, using finite element analysis in the osteoporotic distal femur fracture model; under two different loads; It was aimed to investigate the fracture reduction displacement amount and directions, the amount of stress on the implant and implant fatigue analysis of lateral plate, intramedullary nail and nail plate combination fixation models. Method: The 3D femur model was drawn by us with the Materialize Mimics Medical 21.0® (Materialise, Leuven, Belgium) program. 3D drawings of intramedullary nails, lateral plates and implant screws were made by us with the Dassault Systèmes Solidworks 2021 SP4.1® program. Three different groups were created by combining the planned fracture model, modeled lateral plate, intramedullary nail and nail plate combination methods. Then, the deformation amounts, stress analyzes and fatigue analysis of the models were examined under 2 different loading conditions. Total deformation; defined as the sum of displacement amounts experienced by a model under loading. Stress on implants was examined, and breaking in the implant under cyclic loading was defined as failure. Results: In the compression analysis, the total deformation amount of the nail model was max: 101.1 mm; lateral plate max:110.4 mm; the maximum in nail and plate combination was 50.3 mm. After loading, the maximum stress on the implants was 1132 MPa in the nail fixation model, 1278 MPa in the lateral plate model, 671 MPa in the nail system and 595 MPa in the plate system in the nail-plate combination model. In the fatigue analysis, failure was observed after 7725 cycles in the model created with the nail, while failure was observed after 2473 cycles in the lateral plate and 1023200 cycles in the nail-plate combination. Discussion: Nail-plate combinations seem promising in terms of mechanical complications in osteoporotic fractures of the distal femur. Finite element analysis is a widely accepted tool that is increasingly used in many industries. Among the tested models, the nail-plate combination showed higher cyclic strength and less displacement in fracture fragments under loading compared to the nail-only or plate-only model, which seems to support other clinical studies. Conclusion: The nail-plate combination for osteoporotic fractures of the distal femur may reduce mechanical complications through longer cycle strength, reduced stress on the implant, and less movement between fracture fragments. Randomized controlled clinical studies will better evaluate these hypotheses. finite element analysis distal femur nail plate combination osteoporotic fracture Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Introduction With increasing life expectancy, osteoporotic fractures are becoming more prevalent (1). The treatment of these complex fractures remains controversial, with locked plates and intramedullary nails demonstrating similar clinical outcomes in terms of union rates and prevention of varus collapse (2). Nail-plate construction, which has emerged as an alternative in recent years, reports fewer mechanical complications and higher union rates. However, this technique is still questionable because the studies include a limited number of cases and there is no randomized controlled study (3,4,5). There is limited biomechanical study in the literature regarding the nail-plate combination technique in distal femur fractures (6). In this study, 3 different fixation methods used in distal femur fractures under two different loads were examined. Lateral anatomical locking plate, retrograde intramedullary nail and nail-plate combination methods were examined with finite element analysis to reveal the fracture model created and the fracture reduction displacement amount and directions under loading, stress areas on the implant and implant fatigue analysis. Our hypothesis is that the nail-plate combination technique creates less stress areas on the implants compared to nail and plate fixation alone in osteoporotic fractures of the distal femur and shows less displacement during fracture reduction under loading. In the study, we aimed to evaluate this hypothesis with finite element analysis. Methods Our study has obtained ethical approval from the ethics committee. The entire methodology has been checked by the study of "Oefner at all" (7). Obtaining the bone model For our study, DICOM (Digital Imaging and Communications in Medicine) data from a 65-year-old female patient who presented to our hospital's imaging system, ExtremePACS 2017- Çankaya/Ankara®, with suspected peripheral arterial disease of the lower extremities, without any history of prior femur injury, and who underwent lower extremity CT angiography for suspected acute embolism, was utilized to obtain the femur model. The DICOM images were imported into Materialise Mimics Medical 21.0® and Materialise 3-matic Medical 13.0® (Materialise, Leuven, Belgium) software, where the left femur bone was isolated, and the boundaries of cortical bone, cancellous bone, and medulla were defined in three dimensions within appropriate Hounsfield Unit ranges. Bone is an unhomogeneous and anisotropic material. In this study, the inhomogeneity of bone was taken into account. However, as in other studies, it was accepted as an isotropic, linear, elastic material (8). The thickness of the cortex, which reaches up to 7 mm in the diaphysis, decreases to 1 mm in the metaphyseal region. The bone marrow present in the diaphysis was ignored and considered a cavity. The metaphyseal bone was assumed to be present in the first 10 cm from the distal femoral joint line. Subsequently, STEP file outputs were obtained. These STEP files were then imported into SolidWorks Premium 2021 SP4.1® (Dassault Systèmes SolidWorks Corp., Waltham, MA) software. Following this, cortical and cancellous components were merged (Figure 1). Creation of Fracture and Fixation Models In many finite element analyses, when interfragmentary compression is not performed, there are studies where the gap between fragments is assumed to be between 1 and 10 mm (9,10,11). However, determining the gap range is related to the methodology of the study. There are studies where the gap is assumed to be 10 mm when implant strength is investigated under poor reduction conditions (9,10). It is recommended to assume a 1mm gap to allow movement between fragments (11). In our study, in order to emphasize that the need for rigid fixation was due to osteoporosis, models with a distance between fragments of 1 mm were designed. 38.6% of distal femur fractures are AO type A fractures (12). This rate increases as age increases. (13). In our study, we used the AO 33A3.1 fracture type as a basis to simulate the osteoporotic population. Then, a 5 mm thick and 34 cm long distal femur anatomical lateral plate (TST ® (Türk Spinal Travma, İstanbul) LW-30 MISS Distal Femur Plates®) and a 38 cm long and 10 mm diameter retrograde femur nail (Tasarımmed Medical Devices Corporate® FN- 3 Retrograde Femoral Nail®) and 5 mm diameter screws of appropriate length were designed and drawn in 3D with Dassault Systèmes Solidworks 2021®. Three models to be examined were obtained with fracture models fixed with nail, plate and nail-plate combination on Dassault Systèmes Solidworks 2021 SP4.1®. Fixation methods applied with these implants in clinical studies were examined and simulation groups were created (6,14,15). Fracture femur in model 1; The created intramedullary nail was fixed distally with two 5 mm diameter screws, passing the double cortex, and proximally, it was fixed statically with a double cortex 5 mm screw in the anterior-posterior direction. Fracture femur in model 2; With the created distal femur plate, the double cortex in the distal was fixed with 6 locking screws, and the double cortex in the proximal was fixed with three 5mm locking screws, skipping one hole each. Fracture femur in model 3; It was fixed with the previously created intramedullary nail and its screws. Then, the created plate was fixed distally with 4 double-cortex 5.0mm locking screws, and proximally with one single-cortex locking and 1 eccentrically placed double-cortex non-locking 5mm screw. The three created and stabilized fracture models were saved as STEP files (Figure 2). Material Properties Determination: Material properties were defined using the Workbench module in Ansys 2022 R2® for static structural analysis. Mechanical properties were determined for a lightweight osteoporotic bone model, with the following values specified: ● Young's Modulus: 12 GPa for cortical bone ● Poisson's Ratio: 0.30 for cortical bone ● Young's Modulus: 250 MPa for cancellous bone ● Poisson's Ratio: 0.30 for cancellous bone (16) The mechanical properties of Ti6Al4V alloy for the implant material were defined as follows in the Ansys Workbench module, with reference to "ASTM F136-12 standards" (10): ● Young's Modulus: 117 GPa ● Poisson's Ratio: 0.33 ● Tensile yield strength: 880 MPa ● Compressive yield strength: 970 MPa ● Tensile ultimate strength: 950 MPa (17) Subsequently, model parts were arranged using the Discovery module and transferred to the Mechanical module. Simulation of Fixation Techniques: Contact features on Ansys Mechanical module; It was defined as frictional between bone fragments. In the intramedullary nail system; It was defined as frictional between bone and nail, between bone and screws, and between nail and screws. Since it is assumed that the plate used is a locked plate and all screws used are locked; The relationship between the plate and the screws was defined as bonded (18). The relationship between the screws of the plate and the bone was defined as frictional. Assuming that all screws were used locked, it was assumed that the plate worked as an internal fixator and there was no contact between the bone and the plate (19). Then, mesh properties were determined and meshing was performed on the models to be worked on. The network structure is created in a tetrahedral 4-node element structure. Accordingly, 163860 elements with 271822 nodes were formed in the nail model, 165848 elements with 276229 nodes in the plate model, and 184727 elements with 311985 nodes in the nail-plate model (Figure-3) In similar studies, there are simulations in which the femur model is fixed from the distal or proximal and loading is applied (10,20). In our study, the area to which force was applied was considered the femoral head, and a natural loading pattern was tried to be simulated by supporting both condyles separately with fixed support at different levels in the axial plane. In this study, quasi-static analysis methods were used. Evaluated Parameters: The unloaded state of a model was defined as the "initial state". All parameters evaluated in our study are the results in the first second of loading. A) Compression Analyses: 1. Total Deformation: The total deformation definition was obtained via Ansys software. Total deformation; It is the total amount of displacement a system undergoes at the end of loading compared to its "initial state" under load. Maximum deformation indicates the amount of deviation of the point that moves the most on the system relative to its initial position. Average deformation refers to the average amount of deviation of points in the entire system relative to their initial states. Taking into account the biomechanical and kinematic properties of the hip joint, a load equivalent to the load exerted by a person standing on one limb was simulated. Accordingly, the joint reaction force applied to the femoral head is approximately 4 times the body weight, equivalent to 3255 N, as compression in the axial plane (21,22,23,24,25). Joint reaction force, femur anatomy and mechanical axes are simulated, at the femoral head approximately 11-13 degrees in the inferolateral axis in the AP plane and 3-5 degrees in the postero-inferior axis in the lateral plane, 110 N according to the -X axis, 420 N according to the Y axis and -Z axis With 3125 N, a resulting force of 3255 N was applied (Figure 4a, 4b, 4c). 2. X Axis Directional Deformation: Deformation in the coronal plane was evaluated as deviation in the "x" direction in a three-dimensional plane (varus collapse). 3. Y Axis Directional Deformation: Deformation in the sagittal plane was evaluated as deviation in the "y" direction in a three-dimensional plane. B) Distraction-Rotation Combined Analysis: By simulating the iliopsoas anatomy, the iliopsoas strength was determined at 9 degrees in the superomedial axis in the AP plane and 47 degrees in the anterosuperior axis in the lateral plane, over the minor trochanter. The iliopsoas pulling force was applied over the minor trochanter - 160 N in the X axis, 480 N in the Y axis and 720 N in the Z axis, resulting in a net force of 885 N (21). The total deformation of the system under the effect of the force in the direction of the iliopsoas tendon was examined (Figure 4d, 4e, 4f). C) Equivalent (von-Mises) Stress on the Model: The stresses on the models were calculated via Ansys software. Von mises stress includes the vector sum of normal and shear stresses on a material. Equivalent stress analyses applied to the implants were evaluated in two categories for the first two test setups, comprising bone and implants, and in three categories for the last test setup, comprising bone and both implants. The maximum stress resulting from the compression force applied to the fixation systems was considered as the maximum stress, while the average stress resulting from all stresses was evaluated as the average stress. D) Fatigue Analysis on the Models: Fatigue analysis was conducted based on the joint reaction forces applied along the mechanical axis of the extremity on the femur. Accordingly, fatigue tool properties added via the Ansys Mechanical module were determined to be applied for 10⁷ cycles, and the results of the 'life' analysis were examined. For this purpose, the fatigue-stress properties of Ti6Al4V were referenced from the MMPDS-01 (2003) report (26) (Table 1). Failure at any location in the analyzed system (including the system's screws) was defined as fixation system failure, while failure within the implant itself was defined as implant failure. Results A) Compression Analyses: 1. Total Deformation In the compression analysis, the total deformation in the intramedullary nail simulation after loading was max: 101.1 mm and average: 30.2 mm; In the distal femur anatomical plate simulation, total deformation max: 110.4 mm and average: 40.5 mm; In the nail and plate combination simulation, total deformation was observed as max: 50.3 mm and average: 10.8 mm (Figure 5)(Table 2). 2. Directional Deformation in the X Axis: In the intramedullary nail simulation, directional deviation in the x-axis according to the fracture line was observed as 4 mm in the varus direction, 15 mm in the valgus direction, and the ultimate effect was 5 mm in the valgus direction. In the anatomical lateral plate simulation of the distal femur, directional deviation in the x-axis was observed as 84 mm to the varus direction. There was no direction towards valgus direction. The ultimate effect was 21 mm to the varus direction. In the nail-plate combination simulation, directional deviation in the x-axis according to the fracture line was observed as 12 mm in the varus direction. There was no direction towards valgus direction. The final effect was 3 mm in the varus direction (Figure 5)(Figure 6). 3. Directional Deformation In the Y Axis: In the intramedullary nail simulation, the deviation from the fracture line was observed as 6 mm towards the recurvatum direction, 98 mm towards the antecurvatum direction, and the ultimate effect was 32 mm towards the antecurvatum direction. In the anatomical lateral plate simulation of the distal femur, the deviation was observed as 1 mm to the recurvatum direction, 78 mm to the antecurvatum direction, and the ultimate effect was 25 mm to the antecurvatum direction. In the nail plate combination simulation, the deviation according to the fracture line was observed as 5 mm towards the recurvatum direction, 46 mm towards the antecurvatum direction and the final effect was 12 mm towards the antecurvatum direction (Figure 5) (Figure 7). B) Distraction-Rotation Combined Analysis: In the distraction-rotation combined analysis, total deformation max: 130.2 mm and average: 40.2 mm in the intramedullary nail simulation after loading, total deformation max: 100.8 cm and average: 30.9 cm in the distal femur anatomical lateral plate simulation, max: 50.5 mm in the nail plate combination simulation. and the average was observed as 10.1 mm (Figure 8) (Table 2). C) Equivalent (von-Mises) Stress Applied to the Implants: In the intramedullary nail simulation, it was observed that the maximum stress on the bone was 585 MPa, the maximum stress on the nail was 1132 MPa, and the maximum stress on the screws was 1254 MPa. In the distal femur anatomical lateral plate simulation, it was observed that the maximum stress on the bone was 645 MPa, the maximum stress on the plate was 324 MPa, and the maximum stress on the screws was 1786 MPa. In the nail-plate combination simulation, the maximum stress on the bone was 782 MPa, the maximum stress on the nail was 671 MPa, the maximum stress on the plate was 595 MPa, and the maximum stress on the screws was 1548 MPa (Figure 9)(Figure 10)(Table 2). In the intramedullary nail simulation, it was observed that the average stress on the bone was 11 MPa, the average stress on the nail was 237 MPa, and the average stress on the screws was 295 MPa. In the distal femur anatomical lateral plate simulation, it was observed that the average stress on the bone was 14 MPa, the average stress on the nail was 324 MPa, and the average stress on the screws was 154 MPa. In the nail-plate combination simulation, the average stress on the bone was 12 MPa, the average stress on the nail was 123 MPa, the average stress on the plate was 324 MPa, and the average stress on the screws was 155 MPa (Table 2). D) Fatigue Analysis on the Implant: In the fatigue analysis of the implants, in the model created with intramedullary nails, inadequacy was observed in the entire system after 1685 cycles. The first failure occurred at the proximal end of the two locking screws in the distal region. The intramedullary nail showed failure after 4110 cycles at the fracture level. In the model created with the distal femur lateral plate, inadequacy was observed in the entire system after 188 cycles. The first failure occurred at the most proximal of the distal screws, similar to the nail system. The plate showed failure after 2523 cycles at the fracture level. In the nail-plate combination model, the first inadequacy was observed in the entire fixation system after 1111 cycles, with the first broken screw being the distal screw proximal to the fracture line. When screw fractures were neglected and only fixation implants were evaluated, inadequacy starting from the intramedullary nail at the fracture level was observed after 1692900 cycles (Table 2). Discussion Although there is no data proven by randomized controlled studies today, many studies claim that nail-plate combination techniques in osteoporotic complicated fractures of the distal femur have low mechanical complication rates and provide the patient with the opportunity to bear weight early ( 6 , 14 , 15 ). Most articles on this topic are in the form of case series, and it is the subject of research with increasing frequency. Biomechanical studies of these implant combination are also very limited ( 3 ). Finite element analysis is a widely accepted tool that is increasingly used in many industries ( 27 ). It has an important place in medical device design and development ( 27 ). Finite element analysis can be used for the same purposes as biomechanical studies. It evaluates the research object in discrete elements and obtains a numerical simulation ( 27 ). It can also visually reflect many biomechanical properties of the system being studied and has advantages such as low cost, short cycle and high efficiency compared to experimental biomechanical tests ( 28 ). Finite element analysis may give us very useful ideas in evaluating the biomechanical properties of such new implant designs and implant combinations. It is known that micromotion between bone fragments induces callus formation ( 29 , 30 ). According to the tension theory put forward by ‘’Perren at all.’’ ( 31 ), strain can be calculated by comparing the original length of the fracture gap with the size of the gap under tension (Strain = ΔL/L). Absolute stability conditions occur if the fracture stress is 2% or less, and relative stability conditions occur if the fracture stress is between 2% and 10%. If the fracture stress is > 10%, fibrous tissue formation is induced and a possible nonunion may occur ( 32 , 33 ). In addition, although it is known that this micromotion has a callus-increasing effect in the axial direction, the same information is not available for displacements in other directions ( 29 , 34 , 35 ). Of course, the mechanical state alone does not guarantee biological healing. Additionally, the integration of implants into the bone may be affected by osteoporosis or defects in the bone. Recent meta-analysis reveals that the main goal in fracture fixation should be high initial stability ( 36 ). In osteoporotic fractures, the least possible movement between bone fragments is recommended ( 37 ). As a mechanical complication in osteoporotic distal femur fractures, varus deformity in the x-axis and antecurvation deformity in the y-axis are generally observed ( 38 , 39 , 40 ). In our study, the deviation in both the x and y axis in the nail-plate combination was extremely low compared to other implants, which may indicate that this combination is mechanically successful. This may support the reported high union rates of nail-plate combination therapy in osteoporotic distal femur fractures in clinical studies ( 3 , 4 , 5 , 15 ) In long bone shaft fractures, the intramedullary nail is biomechanically more resistant to compression, while the plate is more resistant to rotational forces ( 41 ). Similar results were observed in the rotation analysis in our study. The nail-plate combination showed significantly higher stability against rotational forces compared to the other two simulations. The nail-plate combination appears to be significantly more resistant to both compressive and rotational forces in distal femur fractures, and the lower mechanical complications in clinical studies seem to support this information ( 6 , 15 ). The lower extremity mechanical axis passes medially to the midline of the knee joint ( 42 ). After an AO 33A3.1 fracture occurring in the distal femur, there is generally a varus effect on the fracture because the lower extremity mechanical axis passes medial to the fracture line ( 38 ). Lateral anatomical locking plate treatment, which is the most commonly used treatment for these fractures today, provides advantages such as ease of application, allowing minimally invasive approaches, and easier reduction due to less fragmentation on the lateral side in general ( 43 ). However, the deforming forces acting on the fracture are applied in the opposite direction, resulting in excessive load on the implant ( 44 ). Implant fracture may occur in areas where the load is concentrated. The implant must be able to bear the load until bone union. From the simulations in our study, significantly less implant stress and significant long-cycle strength were observed in the nail-plate combination. This may increase implant strength in osteoporotic distal femur fractures and support union rates by maintaining fixation for a longer period of time. In our study, the stress loads of bones were examined under upper limit load values ​​in order to highlight the risk of microfracture that may cause screw and implant failure ( 45 ). Maximum stresses occurring in fixation models are monitored at a single point on the implants or bone. A true biomechanical test may also produce local microfractures in that area at these loading values ( 45 ). Loading of the nail and plate is done through both the screws and the implant body. Since the stress on nail and plate implants is concentrated in the part of the implant at the fracture level, failure is expected in this area. because the stresses are observed above 950 MPa, which is the tensile strength of titanium. In this study, it was observed that under the same loads, the failure seen in only nail and only plate fixation did not occur in combined fixation. Additionally, higher maximum stress on the nail-only and plate-only system may increase the risk of implant failure. However, without normal data that determine the threshold that will cause implant failure or refracture, these concerns may be unfounded ( 46 ). This and similar finite element studies have many limitations. In the analysis used in this study, the forces acting on the femur were simplified and the main force axes were evaluated ( 47 ). Again, it is extremely difficult to fully simulate the deforming physiological forces that occur after a distal femur fracture. There are still debates about the number and direction of the forces acting on the hip joint in situations such as walking and climbing stairs ( 48 ). In addition, since the investigation of implant strength was prioritized in our study, the loading values ​​were determined from the upper limit. Finite element analysis provides us with some mechanistic information, but biological simulations are extremely limited. Conclusion High mechanical complication rates are reported in the literature for osteoporotic fractures of the distal femur. Although there is no clear consensus on it, in cases such as old age, osteoporosis, and significant medial cortex fragmentation, the nail-plate combination may significantly reduce mechanical complications with its more medialized load transfer compared to the lateral plate and its higher rigidity compared to the intramedullary nail. Even if these hypotheses are proven by clinical studies, problems such as cost-effectiveness will continue to be discussed. It is clear that randomized controlled clinical studies are needed to prove these hypotheses. Declarations Ethics approval and consent to participate: Ethical approval was obtained for our study from the Istanbul Prof. Dr. Cemil Taşcıoğlu City Hospital Ethics Committee with decision number 117 dated 23.09.2024. For the human participant informed consent to participate in the study was obtained from the participant. Consent was obtained for all forms of personally identifiable data. Consent for publication : Each author has submitted for publication. (TOB,MBA,İAG,AY,MY,NE,MSS) Availability of data and materials The datasets used and/or 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. (TOB,MBA,İAG,AY,MY,NE,MSS) Funding: The authors declare that they did not receive any funding for this study. (TOB,MBA,İAG,AY,MY,NE,MSS) Authors' contributions T.O.B designed the protocol, reviewed the literature, analyzed the data, and critically reviewed and wrote the manuscript. A.Y and MBA analyzed the data, reviewed the literature, and critically reviewed and wrote the manuscript. T.O.B and M.Y. designed the protocol, collected and analyzed the data, and reviewed the literature. N.E, M.S.S. and IAG collected and analyzed the data and wrote the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable. 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Injury. 2007;38 Suppl 1:S3-10. 10.1016/j.injury.2007.02.005 . PMID: 17383483. Hollensteiner M, Sandriesser S, Bliven E, von Rüden C, Augat P. Biomechanics of Osteoporotic Fracture Fixation. Curr Osteoporos Rep. 2019;17(6):363–74. 10.1007/s11914-019-00535-9 . PMID: 31755030; PMCID: PMC6944651. Liporace FA, Aneja A, Carroll EA, Yoon RS. Maintaining the Neutral Axis in the Treatment of Distal Femur Fractures Via Dual Plate or Nail Plate Combination Technique: When and How? J Orthop Trauma. 2021;35(Suppl 5):S38-S40. 10.1097/BOT.0000000000002235 . PMID: 34533501. Kerr MS, Young EG, Shaath MK, Avilucea FR, Adigweme OO, Haidukewych GJ. Periprosthetic distal femur fractures treated by retrograde intramedullary nails with a 10-degree distal bend achieve significantly better post-operative radiographic alignment when compared to conventional retrograde nails. Injury. 2023;54(2):694–7. Epub 2022 Nov 12. PMID: 36428147. Bong MR, Kummer FJ, Koval KJ, Egol KA. Intramedullary nailing of the lower extremity: biomechanics and biology. J Am Acad Orthop Surg. 2007;15(2):97–106. 10.5435/00124635-200702000-00004 . PMID: 17277256. Wähnert D, Hoffmeier K, Fröber R, Hofmann GO, Mückley T. Distal femur fractures of the elderly–different treatment options in a biomechanical comparison. Injury. 2011;42(7):655–9. 10.1016/j.injury.2010.09.009 . Epub 2010 Oct 15. PMID: 20951378. Liu X, Chen Z, Gao Y, Zhang J, Jin Z. High Tibial Osteotomy: Review of Techniques and Biomechanics. J Healthc Eng. 2019;2019:8363128. 10.1155/2019/8363128 . PMID: 31191853; PMCID: PMC6525872. Ebraheim NA, Buchanan GS, Liu X, Cooper ME, Peters N, Hessey JA, Liu J. Treatment of Distal Femur Nonunion Following Initial Fixation with a Lateral Locking Plate. Orthop Surg. 2016;8(3):323–30. 10.1111/os.12257 . PMID:27627715; PMCID: PMC6584123. Fontenot PB, Diaz M, Stoops K, Barrick B, Santoni B, Mir H. Supplementation of Lateral Locked Plating for Distal Femur Fractures: A Biomechanical Study. J Orthop Trauma. 2019;33(12):642–648. 10.1097/BOT.0000000000001591 . PMID: 31335505. Zhang BB, Wang BH, Mei J, Luo CF, Zhu Y. Biomechanical study of a new rim plate fixation strategy for two kinds of posterolateral depression patterns of tibial plateau fractures: a finite element analysis. J Orthop Surg Res. 2023;18(1):840. 10.1186/s13018-023-04315-1 . PMID: 37932801; PMCID: PMC10629018. Huang X, Zhi Z, Yu B, Chen F. Stress and stability of plate-screw fixation and screw fixation in the treatment of Schatzker type IV medial tibial plateau fracture: a comparative finite element study. J Orthop Surg Res. 2015;10:182. 10.1186/s13018-015-0325-2 . PMID: 26608217; PMCID: PMC4658795. Polgár K, Gill HS, Viceconti M, Murray DW, O'Connor JJ. Strain distribution within the human femur due to physiological and simplified loading: finite element analysis using the muscle standardized femur model. Proc Inst Mech Eng H. 2003;217(3):173 – 89. 10.1243/095441103765212677 . PMID: 12807158. Noda M, Nakamura Y, Adachi K, Saegusa Y, Takahashi M. Dynamic finite element analysis of implants for femoral neck fractures simulating walking. J Orthop Surg (Hong Kong). 2018 May-Aug;26(2):2309499018777899. 10.1177/2309499018777899 . PMID: 29860916. Tables Table-1: Fatigue-Stress Values of Ti-6Al-4V Obtained Using MMPDS-01 Guide Stress [Mpa] Fatigue Life [Cycle] 2.948.155 1E+00 2304.6 1E+01 1801.6 1E+02 1408.3 1E+03 1100.9 1E+04 860.5 1E+05 672.8 1E+06 525.9 1E+07 411.1 1E+08 321.36 1E+09 251.2 1E+10 Table 2: Some of the finite element analysis results Compression analysis Distraction rotation analysis Stress (Von-mises) (mPa) Stress (Von-mises) (mPa) Fatigue analysis (cycle) max average max average max average Total deformation (mm) bone implant bone implant fixation system implants Nail 101.1 30.2 130.2 40.2 585 1132 11 237 2953.3 7725.6 Plate 110.4 40.5 100.8 30.9 645 1278 14 324 108.7 2473.2 Nail-plate 50.3 10.8 50.5 10.1 782 nail plate 12 nail plate 413.35 1023200 671 595 123 324 Additional Declarations No competing interests reported. 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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-6920941","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":491894674,"identity":"02a3f2a9-d237-4451-b255-bb953d32059d","order_by":0,"name":"Tahsin Olgun 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08:38:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6920941/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6920941/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87924014,"identity":"ad9a7015-20dd-4a80-b40f-1fa8777035eb","added_by":"auto","created_at":"2025-07-30 12:17:16","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":82711,"visible":true,"origin":"","legend":"\u003cp\u003eObtaining the bone model in ''Materialize Mimics Medical 21.0®''\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6920941/v1/5cb0f00cf7aee24504f53f77.jpg"},{"id":87924019,"identity":"9f2a5b69-226c-4a87-8fa8-8596a1cfda1e","added_by":"auto","created_at":"2025-07-30 12:17:18","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":61416,"visible":true,"origin":"","legend":"\u003cp\u003eImplant Fixation of Bone Models with Fracture Lines Created in SolidWorks:\u003c/p\u003e\n\u003cp\u003ea) Model where the fracture is fixed with a nail using one AP screw from the proximal side and two oblique screws from the distal side.\u003c/p\u003e\n\u003cp\u003eb) Model where the fracture is fixed with a distal femur anatomical LISS plate using three screws proximally and six screws distally.\u003c/p\u003e\n\u003cp\u003ec) Model where the fracture is fixed using both implants.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6920941/v1/58d7ef4b80cf1427b4484847.jpg"},{"id":87923636,"identity":"552e29f9-6390-4e3d-b6ac-94e64fdf75c1","added_by":"auto","created_at":"2025-07-30 12:09:19","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":99281,"visible":true,"origin":"","legend":"\u003cp\u003eModels with fixation techniques applied.\u003c/p\u003e\n\u003cp\u003ea) intramedullary nail fixation\u003c/p\u003e\n\u003cp\u003eb)lateral plate fixation\u003c/p\u003e\n\u003cp\u003ec) nail-plate combination fixation\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6920941/v1/03e8a4bc56b98ebe071c1895.jpg"},{"id":87924021,"identity":"1b0ee4c3-ca40-4b73-875d-8993a4b01333","added_by":"auto","created_at":"2025-07-30 12:17:19","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":42700,"visible":true,"origin":"","legend":"\u003cp\u003eForce vectors applied to the implant models.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6920941/v1/fcded1951735fb95fed050ad.jpg"},{"id":87923632,"identity":"0bf169d1-7d1e-486b-a746-1e11ec2389d2","added_by":"auto","created_at":"2025-07-30 12:09:19","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":56068,"visible":true,"origin":"","legend":"\u003cp\u003eDeformation after Compression Analysis\u003c/p\u003e\n\u003cp\u003ea) Unloaded undeformed bone AP view\u003c/p\u003e\n\u003cp\u003eb) Intramedullary nail model with applied joint reaction force AP view\u003c/p\u003e\n\u003cp\u003ec) Anatomical plate model with applied joint reaction force AP view\u003c/p\u003e\n\u003cp\u003ed) Nail-plate combination model with applied joint reaction force AP view\u003c/p\u003e\n\u003cp\u003ee) Unloaded undeformed bone lateral view\u003c/p\u003e\n\u003cp\u003ef) Intramedullary nail model with applied joint reaction force lateral view\u003c/p\u003e\n\u003cp\u003eg) Anatomical plate model with applied joint reaction force lateral view\u003c/p\u003e\n\u003cp\u003eh) Nail-plate combination model with applied joint reaction force lateral view\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6920941/v1/c6d12a522f675f7f1051941d.jpg"},{"id":87923629,"identity":"d09d9afd-3bd5-439a-a69a-9ea56e08d0b4","added_by":"auto","created_at":"2025-07-30 12:09:19","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":19068,"visible":true,"origin":"","legend":"\u003cp\u003eGraph of Directional Deformation Data in the X Axis in Compression Analysis\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6920941/v1/26175a30e7298e92b97486f1.jpg"},{"id":87923600,"identity":"f9b4222d-6a1a-477a-be32-0a67b4433450","added_by":"auto","created_at":"2025-07-30 12:09:16","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":37462,"visible":true,"origin":"","legend":"\u003cp\u003eGraph of Directional Deformation Data in the Y Axis in Compression Analysis\u003c/p\u003e","description":"","filename":"7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6920941/v1/158e68e0c3448362c0fa92e2.jpg"},{"id":87923611,"identity":"8f41a46e-154c-451e-965f-b3419b113d4a","added_by":"auto","created_at":"2025-07-30 12:09:18","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":51650,"visible":true,"origin":"","legend":"\u003cp\u003eDeformation after Distraction-Rotation Analysis\u003c/p\u003e\n\u003cp\u003ea) Unloaded undeformed bone AP view\u003c/p\u003e\n\u003cp\u003eb) Intramedullary nail model with applied iliopsoas force AP view\u003c/p\u003e\n\u003cp\u003ec) Anatomical plate model with applied iliopsoas force AP view\u003c/p\u003e\n\u003cp\u003ed) Nail-plate combination model with applied iliopsoas force AP view\u003c/p\u003e\n\u003cp\u003ee) Unloaded undeformed bone lateral view\u003c/p\u003e\n\u003cp\u003ef) Intramedullary nail model with applied iliopsoas force lateral view\u003c/p\u003e\n\u003cp\u003eg) Anatomical plate model with applied iliopsoas force lateral view\u003c/p\u003e\n\u003cp\u003eh) Nail-plate combination model with applied iliopsoas force AP view\u003c/p\u003e","description":"","filename":"8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6920941/v1/24630bf0e1d5287dacce34e5.jpg"},{"id":87923638,"identity":"7f77beb5-72d0-4f33-9cce-dcf14a46fe1f","added_by":"auto","created_at":"2025-07-30 12:09:19","extension":"jpg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":68954,"visible":true,"origin":"","legend":"\u003cp\u003eMaximum stress points in the bone in stress analysis\u003c/p\u003e\n\u003cp\u003ea) nail model\u003c/p\u003e\n\u003cp\u003eb) plate model\u003c/p\u003e\n\u003cp\u003ec) nail-plate model\u003c/p\u003e","description":"","filename":"9.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6920941/v1/ab14adf6efe6aa51c05df3ae.jpg"},{"id":87924015,"identity":"00b8c141-1e6f-4c1c-832d-a99f574382d8","added_by":"auto","created_at":"2025-07-30 12:17:16","extension":"jpg","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":81443,"visible":true,"origin":"","legend":"\u003cp\u003eMaximum stress points on implants in stress analysis\u003c/p\u003e\n\u003cp\u003ea) nail model\u003c/p\u003e\n\u003cp\u003eb) plate model\u003c/p\u003e\n\u003cp\u003ec) nail-plate model\u003c/p\u003e","description":"","filename":"10.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6920941/v1/eae43e07181cf2e571da7172.jpg"},{"id":93621227,"identity":"44dbcbf1-461b-438e-82de-cf5b7030dd37","added_by":"auto","created_at":"2025-10-15 18:01:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1526876,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6920941/v1/f2d04ebc-709f-4aed-bf61-52de5a130d58.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Finite Element Analysis of Lateral Plate, Intramedullary Nail, and Nail-Plate Combination Techniques in Osteoporotic Distal Femur Fractures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith increasing life expectancy, osteoporotic fractures are becoming more prevalent (1). The treatment of these complex fractures remains controversial, with locked plates and intramedullary nails demonstrating similar clinical outcomes in terms of union rates and prevention of varus collapse (2). Nail-plate construction, which has emerged as an alternative in recent years, reports fewer mechanical complications and higher union rates. However, this technique is still questionable because the studies include a limited number of cases and there is no randomized controlled study (3,4,5). There is limited biomechanical study in the literature regarding the nail-plate combination technique in distal femur fractures (6).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study, 3 different fixation methods used in distal femur fractures under two different loads were examined. Lateral anatomical locking plate, retrograde intramedullary nail and nail-plate combination methods were examined with finite element analysis to reveal the fracture model created and the fracture reduction displacement amount and directions under loading, stress areas on the implant and implant fatigue analysis. Our hypothesis is that the nail-plate combination technique creates less stress areas on the implants compared to nail and plate fixation alone in osteoporotic fractures of the distal femur and shows less displacement during fracture reduction under loading. In the study, we aimed to evaluate this hypothesis with finite element analysis.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eOur study has obtained ethical approval from the ethics committee.\u0026nbsp;The entire methodology has been checked by the study of \"Oefner at all\" (7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObtaining the bone model\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor our study, DICOM (Digital Imaging and Communications in Medicine) data from a 65-year-old female patient who presented to our hospital's imaging system, ExtremePACS 2017- Çankaya/Ankara®, with suspected peripheral arterial disease of the lower extremities, without any history of prior femur injury, and who underwent lower extremity CT angiography for suspected acute embolism, was utilized to obtain the femur model.\u003c/p\u003e\n\u003cp\u003eThe DICOM images were imported into Materialise Mimics Medical 21.0® and Materialise 3-matic Medical 13.0® (Materialise, Leuven, Belgium) software, where the left femur bone was isolated, and the boundaries of cortical bone, cancellous bone, and medulla were defined in three dimensions within appropriate Hounsfield Unit ranges. Bone is an unhomogeneous and anisotropic material. In this study, the inhomogeneity of bone was taken into account. However, as in other studies, it was accepted as an isotropic, linear, elastic material (8). The thickness of the cortex, which reaches up to 7 mm in the diaphysis, decreases to 1 mm in the metaphyseal region. The bone marrow present in the diaphysis was ignored and considered a cavity. The metaphyseal bone was assumed to be present in the first 10 cm from the distal femoral joint line.\u0026nbsp;Subsequently, STEP file outputs were obtained. These STEP files were then imported into SolidWorks Premium 2021 SP4.1® (Dassault Systèmes SolidWorks Corp., Waltham, MA) software. Following this, cortical and cancellous components were merged (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCreation of Fracture and Fixation Models\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn many finite element analyses, when interfragmentary compression is not performed, there are studies where the gap between fragments is assumed to be between 1 and 10 mm (9,10,11). However, determining the gap range is related to the methodology of the study. There are studies where the gap is assumed to be 10 mm when implant strength is investigated under poor reduction conditions (9,10). It is recommended to assume a 1mm gap to allow movement between fragments (11). In our study, in order to emphasize that the need for rigid fixation was due to osteoporosis, models with a distance between fragments of 1 mm \u0026nbsp;were designed.\u003c/p\u003e\n\u003cp\u003e38.6% of distal femur fractures are AO type A fractures (12). This rate increases as age increases. (13). In our study, we used the AO 33A3.1 fracture type as a basis to simulate the osteoporotic population.\u003c/p\u003e\n\u003cp\u003eThen, a 5 mm thick and 34 cm long distal femur anatomical lateral plate (TST ® (Türk Spinal Travma, İstanbul) LW-30 MISS Distal Femur Plates®) and a 38 cm long and 10 mm diameter retrograde femur nail (Tasarımmed Medical Devices Corporate® FN- 3 Retrograde Femoral Nail®) and 5 mm diameter screws of appropriate length were designed and drawn in 3D with Dassault Systèmes Solidworks 2021®. Three models to be examined were obtained with fracture models fixed with nail, plate and nail-plate combination on Dassault Systèmes Solidworks 2021 SP4.1®.\u003c/p\u003e\n\u003cp\u003eFixation methods applied with these implants in clinical studies were examined and simulation groups were created (6,14,15).\u003c/p\u003e\n\u003cp\u003eFracture femur in model 1; The created intramedullary nail was fixed distally with two 5 mm diameter screws, passing the double cortex, and proximally, it was fixed statically with a double cortex 5 mm screw in the anterior-posterior direction.\u003c/p\u003e\n\u003cp\u003eFracture femur in model 2; With the created distal femur plate, the double cortex in the distal was fixed with 6 locking screws, and the double cortex in the proximal was fixed with three 5mm locking screws, skipping one hole each.\u003c/p\u003e\n\u003cp\u003eFracture femur in model 3; It was fixed with the previously created intramedullary nail and its screws. Then, the created plate was fixed distally with 4 double-cortex 5.0mm locking screws, and proximally with one single-cortex locking and 1 eccentrically placed double-cortex non-locking 5mm screw.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe three created and stabilized fracture models were saved as STEP files (Figure 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterial Properties Determination:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMaterial properties were defined using the Workbench module in Ansys 2022 R2® for static structural analysis. Mechanical properties were determined for a lightweight osteoporotic bone model, with the following values specified:\u003c/p\u003e\n\u003cp\u003e● Young's Modulus: 12 GPa for cortical bone\u003c/p\u003e\n\u003cp\u003e● Poisson's Ratio: 0.30 for cortical bone\u003c/p\u003e\n\u003cp\u003e● Young's Modulus: 250 MPa for cancellous bone\u003c/p\u003e\n\u003cp\u003e● Poisson's Ratio: 0.30 for cancellous bone (16)\u003c/p\u003e\n\u003cp\u003eThe mechanical properties of Ti6Al4V alloy for the implant material were defined as follows in the Ansys Workbench module, with reference to \"ASTM F136-12 standards\" (10):\u003c/p\u003e\n\u003cp\u003e● Young's Modulus: 117 GPa\u003c/p\u003e\n\u003cp\u003e● Poisson's Ratio: 0.33\u003c/p\u003e\n\u003cp\u003e● Tensile yield strength: 880 MPa\u003c/p\u003e\n\u003cp\u003e● Compressive yield strength: 970 MPa\u003c/p\u003e\n\u003cp\u003e● Tensile ultimate strength: 950 MPa (17)\u003c/p\u003e\n\u003cp\u003eSubsequently, model parts were arranged using the Discovery module and transferred to the Mechanical module.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSimulation of Fixation Techniques:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContact features on Ansys Mechanical module; It was defined as frictional between bone fragments.\u003c/p\u003e\n\u003cp\u003eIn the intramedullary nail system; It was defined as frictional between bone and nail, between bone and screws, and between nail and screws.\u003c/p\u003e\n\u003cp\u003eSince it is assumed that the plate used is a locked plate and all screws used are locked; The relationship between the plate and the screws was defined as bonded (18). The relationship between the screws of the plate and the bone was defined as frictional. Assuming that all screws were used locked, it was assumed that the plate worked as an internal fixator and there was no contact between the bone and the plate (19).\u003c/p\u003e\n\u003cp\u003eThen, mesh properties were determined and meshing was performed on the models to be worked on. The network structure is created in a tetrahedral 4-node element structure. \u0026nbsp;Accordingly, 163860 elements with 271822 nodes were formed in the nail model, 165848 elements with 276229 nodes in the plate model, and 184727 elements with 311985 nodes in the nail-plate model (Figure-3)\u003c/p\u003e\n\u003cp\u003eIn similar studies, there are simulations in which the femur model is fixed from the distal or proximal and loading is applied (10,20). In our study, the area to which force was applied was considered the femoral head, and a natural loading pattern was tried to be simulated by supporting both condyles separately with fixed support at different levels in the axial plane.\u003c/p\u003e\n\u003cp\u003eIn this study, quasi-static analysis methods were used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluated Parameters:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe unloaded state of a model was defined as the \"initial state\". All parameters evaluated in our study are the results in the first second of loading.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA) Compression Analyses:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.\u0026nbsp; \u0026nbsp;\u0026nbsp;Total Deformation:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe total deformation definition was obtained via Ansys software. Total deformation; It is the total amount of displacement a system undergoes at the end of loading compared to its \"initial state\" under load. Maximum deformation indicates the amount of deviation of the point that moves the most on the system relative to its initial position. Average deformation refers to the average amount of deviation of points in the entire system relative to their initial states.\u003c/p\u003e\n\u003cp\u003eTaking into account the biomechanical and kinematic properties of the hip joint, a load equivalent to the load exerted by a person standing on one limb was simulated. Accordingly, the joint reaction force applied to the femoral head is approximately 4 times the body weight, equivalent to 3255 N, as compression in the axial plane (21,22,23,24,25).\u003c/p\u003e\n\u003cp\u003eJoint reaction force, femur anatomy and mechanical axes are simulated, at the femoral head approximately 11-13 degrees in the inferolateral axis in the AP plane and 3-5 degrees in the postero-inferior axis in the lateral plane, 110 N according to the -X axis, 420 N according to the Y axis and -Z axis With 3125 N, a resulting force of 3255 N was applied (Figure 4a, 4b, 4c).\u003c/p\u003e\n\u003cp\u003e2. \u003cstrong\u003eX Axis Directional Deformation:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeformation in the coronal plane was evaluated as deviation in the \"x\" direction in a three-dimensional plane (varus collapse).\u003c/p\u003e\n\u003cp\u003e3. \u003cstrong\u003eY Axis Directional Deformation:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeformation in the sagittal plane was evaluated as deviation in the \"y\" direction in a three-dimensional plane.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB) Distraction-Rotation Combined Analysis:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBy simulating the iliopsoas anatomy, the iliopsoas strength was determined at 9 degrees in the superomedial axis in the AP plane and 47 degrees in the anterosuperior axis in the lateral plane, over the minor trochanter. The iliopsoas pulling force was applied over the minor trochanter - 160 N in the X axis, 480 N in the Y axis and 720 N in the Z axis, resulting in a net force of 885 N (21). The total deformation of the system under the effect of the force in the direction of the iliopsoas tendon was examined (Figure 4d, 4e, 4f).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC) Equivalent (von-Mises) Stress on the Model:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe stresses on the models were calculated via Ansys software. Von mises stress includes the vector sum of normal and shear stresses on a material.\u0026nbsp;Equivalent stress analyses applied to the implants were evaluated in two categories for the first two test setups, comprising bone and implants, and in three categories for the last test setup, comprising bone and both implants. The maximum stress resulting from the compression force applied to the fixation systems was considered as the maximum stress, while the average stress resulting from all stresses was evaluated as the average stress.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eD) Fatigue Analysis on the Models:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFatigue analysis was conducted based on the joint reaction forces applied along the mechanical axis of the extremity on the femur. Accordingly, fatigue tool properties added via the Ansys Mechanical module were determined to be applied for 10⁷ cycles, and the results of the 'life' analysis were examined. For this purpose, the fatigue-stress properties of Ti6Al4V were referenced from the MMPDS-01 (2003) report (26) (Table 1). Failure at any location in the analyzed system (including the system's screws) was defined as fixation system failure, while failure within the implant itself was defined as implant failure.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eA) Compression Analyses:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Total Deformation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the compression analysis, the total deformation in the intramedullary nail simulation after loading was max: 101.1 mm and average: 30.2 mm; In the distal femur anatomical plate simulation, total deformation max: 110.4 mm and average: 40.5 mm; In the nail and plate combination simulation, total deformation was observed as max: 50.3 mm and average: 10.8 mm (Figure 5)(Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Directional Deformation in the X Axis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the intramedullary nail simulation, directional deviation in the x-axis according to the fracture line was observed as 4 mm in the varus direction, 15 mm in the valgus direction, and the ultimate effect was 5 mm in the valgus direction.\u003c/p\u003e\n\u003cp\u003eIn the anatomical lateral plate simulation of the distal femur, directional deviation in the x-axis was observed as 84 mm to the varus direction. There was no direction towards valgus direction. The ultimate effect was 21 mm to the varus direction.\u003c/p\u003e\n\u003cp\u003eIn the nail-plate combination simulation, directional deviation in the x-axis according to the fracture line was observed as 12 mm in the varus direction. There was no direction towards valgus direction. The final effect was 3 mm in the varus direction (Figure 5)(Figure 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Directional Deformation\u003c/strong\u003e \u003cstrong\u003eIn the Y Axis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the intramedullary nail simulation, the deviation from the fracture line was observed as 6 mm towards the recurvatum direction, 98 mm towards the antecurvatum direction, and the ultimate effect was 32 mm towards the antecurvatum direction.\u003c/p\u003e\n\u003cp\u003eIn the anatomical lateral plate simulation of the distal femur, the deviation was observed as 1 mm to the recurvatum direction, 78 mm to the antecurvatum direction, and the ultimate effect was 25 mm to the antecurvatum direction.\u003c/p\u003e\n\u003cp\u003eIn the nail plate combination simulation, the deviation according to the fracture line was observed as 5 mm towards the recurvatum direction, 46 mm towards the antecurvatum direction and the final effect was 12 mm towards the antecurvatum direction (Figure 5) (Figure 7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB) Distraction-Rotation Combined Analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the distraction-rotation combined analysis, total deformation max: 130.2 mm and average: 40.2 mm in the intramedullary nail simulation after loading, total deformation max: 100.8 cm and average: 30.9 cm in the distal femur anatomical lateral plate simulation, max: 50.5 mm in the nail plate combination simulation. and the average was observed as 10.1 mm (Figure 8) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC) Equivalent (von-Mises) Stress Applied to the Implants:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the intramedullary nail simulation, it was observed that the maximum stress on the bone was 585 MPa, the maximum stress on the nail was 1132 MPa, and the maximum stress on the screws was 1254 MPa.\u003c/p\u003e\n\u003cp\u003eIn the distal femur anatomical lateral plate simulation, it was observed that the maximum stress on the bone was 645 MPa, the maximum stress on the plate was 324 MPa, and the maximum stress on the screws was 1786 MPa.\u003c/p\u003e\n\u003cp\u003eIn the nail-plate combination simulation, the maximum stress on the bone was 782 MPa, the maximum stress on the nail was 671 MPa, the maximum stress on the plate was 595 MPa, and the maximum stress on the screws was 1548 MPa (Figure 9)(Figure 10)(Table 2).\u003c/p\u003e\n\u003cp\u003eIn the intramedullary nail simulation, it was observed that the average stress on the bone was 11 MPa, the average stress on the nail was 237 MPa, and the average stress on the screws was 295 MPa.\u003c/p\u003e\n\u003cp\u003eIn the distal femur anatomical lateral plate simulation, it was observed that the average stress on the bone was 14 MPa, the average stress on the nail was 324 MPa, and the average stress on the screws was 154 MPa.\u003c/p\u003e\n\u003cp\u003eIn the nail-plate combination simulation, the average stress on the bone was 12 MPa, the average stress on the nail was 123 MPa, the average stress on the plate was 324 MPa, and the average stress on the screws was 155 MPa (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eD) Fatigue Analysis on the Implant:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the fatigue analysis of the implants, in the model created with intramedullary nails, inadequacy was observed in the entire system after 1685 cycles. The first failure occurred at the proximal end of the two locking screws in the distal region. The intramedullary nail showed failure after 4110 cycles at the fracture level.\u003c/p\u003e\n\u003cp\u003eIn the model created with the distal femur lateral plate, inadequacy was observed in the entire system after 188 cycles. The first failure occurred at the most proximal of the distal screws, similar to the nail system. The plate showed failure after 2523 cycles at the fracture level.\u003c/p\u003e\n\u003cp\u003eIn the nail-plate combination model, the first inadequacy was observed in the entire fixation system after 1111 cycles, with the first broken screw being the distal screw proximal to the fracture line. When screw fractures were neglected and only fixation implants were evaluated, inadequacy starting from the intramedullary nail at the fracture level was observed after 1692900 cycles (Table 2).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough there is no data proven by randomized controlled studies today, many studies claim that nail-plate combination techniques in osteoporotic complicated fractures of the distal femur have low mechanical complication rates and provide the patient with the opportunity to bear weight early (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Most articles on this topic are in the form of case series, and it is the subject of research with increasing frequency. Biomechanical studies of these implant combination are also very limited (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFinite element analysis is a widely accepted tool that is increasingly used in many industries (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). It has an important place in medical device design and development (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Finite element analysis can be used for the same purposes as biomechanical studies. It evaluates the research object in discrete elements and obtains a numerical simulation (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). It can also visually reflect many biomechanical properties of the system being studied and has advantages such as low cost, short cycle and high efficiency compared to experimental biomechanical tests (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Finite element analysis may give us very useful ideas in evaluating the biomechanical properties of such new implant designs and implant combinations.\u003c/p\u003e\u003cp\u003eIt is known that micromotion between bone fragments induces callus formation (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). According to the tension theory put forward by \u0026lsquo;\u0026rsquo;Perren at all.\u0026rsquo;\u0026rsquo; (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), strain can be calculated by comparing the original length of the fracture gap with the size of the gap under tension (Strain\u0026thinsp;=\u0026thinsp;ΔL/L). Absolute stability conditions occur if the fracture stress is 2% or less, and relative stability conditions occur if the fracture stress is between 2% and 10%. If the fracture stress is \u0026gt;\u0026thinsp;10%, fibrous tissue formation is induced and a possible nonunion may occur (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In addition, although it is known that this micromotion has a callus-increasing effect in the axial direction, the same information is not available for displacements in other directions (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Of course, the mechanical state alone does not guarantee biological healing. Additionally, the integration of implants into the bone may be affected by osteoporosis or defects in the bone. Recent meta-analysis reveals that the main goal in fracture fixation should be high initial stability (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). In osteoporotic fractures, the least possible movement between bone fragments is recommended (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). As a mechanical complication in osteoporotic distal femur fractures, varus deformity in the x-axis and antecurvation deformity in the y-axis are generally observed (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). In our study, the deviation in both the x and y axis in the nail-plate combination was extremely low compared to other implants, which may indicate that this combination is mechanically successful. This may support the reported high union rates of nail-plate combination therapy in osteoporotic distal femur fractures in clinical studies (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eIn long bone shaft fractures, the intramedullary nail is biomechanically more resistant to compression, while the plate is more resistant to rotational forces (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Similar results were observed in the rotation analysis in our study. The nail-plate combination showed significantly higher stability against rotational forces compared to the other two simulations. The nail-plate combination appears to be significantly more resistant to both compressive and rotational forces in distal femur fractures, and the lower mechanical complications in clinical studies seem to support this information (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe lower extremity mechanical axis passes medially to the midline of the knee joint (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). After an AO 33A3.1 fracture occurring in the distal femur, there is generally a varus effect on the fracture because the lower extremity mechanical axis passes medial to the fracture line (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Lateral anatomical locking plate treatment, which is the most commonly used treatment for these fractures today, provides advantages such as ease of application, allowing minimally invasive approaches, and easier reduction due to less fragmentation on the lateral side in general (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). However, the deforming forces acting on the fracture are applied in the opposite direction, resulting in excessive load on the implant (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Implant fracture may occur in areas where the load is concentrated. The implant must be able to bear the load until bone union. From the simulations in our study, significantly less implant stress and significant long-cycle strength were observed in the nail-plate combination. This may increase implant strength in osteoporotic distal femur fractures and support union rates by maintaining fixation for a longer period of time.\u003c/p\u003e\u003cp\u003eIn our study, the stress loads of bones were examined under upper limit load values ​​in order to highlight the risk of microfracture that may cause screw and implant failure (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Maximum stresses occurring in fixation models are monitored at a single point on the implants or bone. A true biomechanical test may also produce local microfractures in that area at these loading values (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Loading of the nail and plate is done through both the screws and the implant body. Since the stress on nail and plate implants is concentrated in the part of the implant at the fracture level, failure is expected in this area. because the stresses are observed above 950 MPa, which is the tensile strength of titanium. In this study, it was observed that under the same loads, the failure seen in only nail and only plate fixation did not occur in combined fixation. Additionally, higher maximum stress on the nail-only and plate-only system may increase the risk of implant failure. However, without normal data that determine the threshold that will cause implant failure or refracture, these concerns may be unfounded (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis and similar finite element studies have many limitations. In the analysis used in this study, the forces acting on the femur were simplified and the main force axes were evaluated (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Again, it is extremely difficult to fully simulate the deforming physiological forces that occur after a distal femur fracture. There are still debates about the number and direction of the forces acting on the hip joint in situations such as walking and climbing stairs (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). In addition, since the investigation of implant strength was prioritized in our study, the loading values ​​were determined from the upper limit. Finite element analysis provides us with some mechanistic information, but biological simulations are extremely limited.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eHigh mechanical complication rates are reported in the literature for osteoporotic fractures of the distal femur. Although there is no clear consensus on it, in cases such as old age, osteoporosis, and significant medial cortex fragmentation, the nail-plate combination may significantly reduce mechanical complications with its more medialized load transfer compared to the lateral plate and its higher rigidity compared to the intramedullary nail. Even if these hypotheses are proven by clinical studies, problems such as cost-effectiveness will continue to be discussed. It is clear that randomized controlled clinical studies are needed to prove these hypotheses.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained for our study from the Istanbul Prof. Dr. Cemil Taşcıoğlu City Hospital Ethics Committee with decision number 117 dated 23.09.2024. For the human participant informed consent to participate in the study was obtained from the participant. Consent was obtained for all forms of personally identifiable data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eEach author has submitted for publication.\u0026nbsp;\u003cem\u003e(TOB,MBA,İAG,AY,MY,NE,MSS)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eThe authors declare that they have no competing interests. (TOB,MBA,İAG,AY,MY,NE,MSS)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare that they did not receive any funding for this study. (TOB,MBA,İAG,AY,MY,NE,MSS)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT.O.B designed the protocol, reviewed the literature, analyzed the data, and critically reviewed and wrote the manuscript. A.Y and MBA analyzed the data, reviewed the literature, and critically reviewed and wrote the manuscript. T.O.B and M.Y. designed the protocol, collected and analyzed the data, and reviewed the literature. N.E, M.S.S. and IAG collected and analyzed the data and wrote the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKhan AM, Tang QO, Spicer D. The Epidemiology of Adult Distal Femoral Shaft Fractures in a Central London Major Trauma Centre Over Five Years. Open Orthop J. 2017;11:1277\u0026ndash;91. PMID: 29290866; PMCID: PMC5721335.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGangavalli AK, Nwachuku CO. Management of Distal Femur Fractures in Adults: An Overview of Options. Orthop Clin North Am. 2016;47(1):85\u0026ndash;96. doi: 10.1016/j.ocl.2015.08.011. PMID: 26614924.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaşcı O, Karakaşlı A, Kumtepe E, G\u0026uuml;ran O, Havıt\u0026ccedil;ıoğlu H. 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J Orthop Surg Res. 2023;18(1):840. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13018-023-04315-1\u003c/span\u003e\u003cspan address=\"10.1186/s13018-023-04315-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 37932801; PMCID: PMC10629018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHuang X, Zhi Z, Yu B, Chen F. Stress and stability of plate-screw fixation and screw fixation in the treatment of Schatzker type IV medial tibial plateau fracture: a comparative finite element study. J Orthop Surg Res. 2015;10:182. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13018-015-0325-2\u003c/span\u003e\u003cspan address=\"10.1186/s13018-015-0325-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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J Orthop Surg (Hong Kong). 2018 May-Aug;26(2):2309499018777899. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2309499018777899\u003c/span\u003e\u003cspan address=\"10.1177/2309499018777899\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 29860916.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable-1: Fatigue-Stress Values of Ti-6Al-4V Obtained Using MMPDS-01 Guide\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"290\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eStress [Mpa]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003eFatigue Life [Cycle]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e2.948.155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e1E+00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e2304.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e1E+01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1801.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e1E+02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1408.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e1E+03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1100.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e1E+04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e860.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e1E+05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e672.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e1E+06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e525.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e1E+07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e411.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e1E+08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e321.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e1E+09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e251.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e1E+10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2: Some of the finite element analysis results\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"766\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompression analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistraction rotation analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStress\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Von-mises)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(mPa)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStress\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Von-mises)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(mPa)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFatigue analysis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(cycle)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;max\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eaverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003emax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003eaverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003emax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003eaverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003eTotal deformation (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003ebone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eimplant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003ebone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eimplant\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003efixation system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eimplants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNail\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e101.1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e30.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e130.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e40.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;585\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;1132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;2953.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;7725.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e110.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e40.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e100.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e30.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e645\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e1278\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e324\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e108.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;2473.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNail-plate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e50.3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e10.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e50.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e10.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;782\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003enail\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003enail\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eplate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;413.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1023200\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e671\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e595\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e324\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"finite element analysis, distal femur, nail plate combination, osteoporotic fracture","lastPublishedDoi":"10.21203/rs.3.rs-6920941/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6920941/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e\u003cp\u003eOsteoporotic distal femur fractures are known for their high mechanical complication rates. In our study, using finite element analysis in the osteoporotic distal femur fracture model; under two different loads; It was aimed to investigate the fracture reduction displacement amount and directions, the amount of stress on the implant and implant fatigue analysis of lateral plate, intramedullary nail and nail plate combination fixation models.\u003c/p\u003e\u003ch2\u003eMethod:\u003c/h2\u003e\u003cp\u003eThe 3D femur model was drawn by us with the Materialize Mimics Medical 21.0\u0026reg; (Materialise, Leuven, Belgium) program. 3D drawings of intramedullary nails, lateral plates and implant screws were made by us with the Dassault Syst\u0026egrave;mes Solidworks 2021 SP4.1\u0026reg; program. Three different groups were created by combining the planned fracture model, modeled lateral plate, intramedullary nail and nail plate combination methods. Then, the deformation amounts, stress analyzes and fatigue analysis of the models were examined under 2 different loading conditions. Total deformation; defined as the sum of displacement amounts experienced by a model under loading. Stress on implants was examined, and breaking in the implant under cyclic loading was defined as failure.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eIn the compression analysis, the total deformation amount of the nail model was max: 101.1 mm; lateral plate max:110.4 mm; the maximum in nail and plate combination was 50.3 mm. After loading, the maximum stress on the implants was 1132 MPa in the nail fixation model, 1278 MPa in the lateral plate model, 671 MPa in the nail system and 595 MPa in the plate system in the nail-plate combination model. In the fatigue analysis, failure was observed after 7725 cycles in the model created with the nail, while failure was observed after 2473 cycles in the lateral plate and 1023200 cycles in the nail-plate combination.\u003c/p\u003e\u003ch2\u003eDiscussion:\u003c/h2\u003e\u003cp\u003eNail-plate combinations seem promising in terms of mechanical complications in osteoporotic fractures of the distal femur. Finite element analysis is a widely accepted tool that is increasingly used in many industries. Among the tested models, the nail-plate combination showed higher cyclic strength and less displacement in fracture fragments under loading compared to the nail-only or plate-only model, which seems to support other clinical studies.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eThe nail-plate combination for osteoporotic fractures of the distal femur may reduce mechanical complications through longer cycle strength, reduced stress on the implant, and less movement between fracture fragments. Randomized controlled clinical studies will better evaluate these hypotheses.\u003c/p\u003e","manuscriptTitle":"Finite Element Analysis of Lateral Plate, Intramedullary Nail, and Nail-Plate Combination Techniques in Osteoporotic Distal Femur Fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-30 12:08:54","doi":"10.21203/rs.3.rs-6920941/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3c4a166a-fa63-44aa-a2b6-c75dd90899b2","owner":[],"postedDate":"July 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T07:23:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-30 12:08:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6920941","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6920941","identity":"rs-6920941","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}