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Objective: The purpose of this study was to compare the biomechanical behavior of using two versus three locking screws per bone segment in a cadaveric humerus fracture gap model., Methods: Six matched pairs of elderly osteoporotic fresh-frozen human cadaveric humerii were used. An eight-hole locking compression plate was placed posteriorly on the humeral shaft and secured with either four or six bicortical locking screws. A 5-mm middiaphyseal gap osteotomy was created to simulate a comminuted fracture without bony contact. Specimens were tested in offset axial compression, four-point anteroposterior bending, four-point medial-lateral bending, and torsion. After the initial testing in each of these modalities, the constructs were cyclically loaded in torsion and again tested in the four loading modalities. Lastly, the fixation constructs were then tested to failure in torsion., Results: There were no significant differences in stiffness between the group fixed with two screws per segment and the group fixed with three screws per segment. The peak torque to failure was higher in the four-screw construct compared with the six-screw construct. The mean torque to failure was 23.5 +/- 3.7 Nm in the construct with two locking screws per segment compared with 20.4 +/- 2.8 Nm in the construct with three locking screws per segment (P = 0.030)., Conclusions: The addition of a third screw in the locked plate construct did not add to the mechanical stability in axial loading, bending, or torsion. In testing to failure, the addition of a third screw resulted in lower load to failure.

The ability of an interlocking screw fixation technique to minimize bone loss related to stress shielding in the tibia was investigated and compared to the abilities of cement and press-fit fixation. Full bony ingrowth has been associated with greater stress shielding than partial ingrowth; therefore, the effect of intimate bonding of the stem to bone on subsequent bone loss was also studied. A damage- and disuse-based remodeling theory was coupled with a two-dimensional finite element model of the tibia to predict changes in bone remodeling following long stemmed total knee arthroplasty (TKA) for four different fixation techniques (cement, press-fit, interlock with bony ingrowth, and interlock without bony ingrowth). Remodeling changes commenced with the model state variables--bone area fraction, mechanical stimulus, damage, and remodeling activity--at steady-state values predicted by the intact tibia simulation. After TKA and irrespective of fixation technique, the model predicted elevated remodeling due to disuse, in which more bone was removed than replenished. In regions below the tibial tray and along the cortices, the interlocking stem with full bony ingrowth and the cemented stem caused the least amount of bone loss. An interlocking stem with a smooth, matted finish did not reduce the bone loss associated with interlocking fixation.

Revision total knee replacements or primary total knee replacements with large amounts of bone loss frequently require long-stemmed prostheses to stabilize the components. The hypothesis of the current study was that long-stemmed prostheses can be fixed with interlocking screws, provide a successful outcome, avoid extensive stress-shielding, and allow easy revision in the future. Ten patients with a minimum 2-year followup were studied. Outcomes were studied preoperatively and postoperatively using the Short Form-12 questionnaires, physical examinations, and radiographs. Complications were recorded. Ability to do activities of daily living, strenuous work, and sedentary work were recorded on a 10-point analog scale. Results indicated that 80% of stems well-fixed as shown on serial radiographs, functional outcome scores postoperatively improved significantly from preoperatively, pain was improved significantly, and positive bone remodeling without stress-shielding was seen in 80% of patients, but 20% had significant stress-shielding in the metaphysis. Complications included two periprosthetic fractures for which the patients did not require revision surgery, and one infection. Long-stemmed total knee components with interlocking fixation seem to be a reasonable alternative when large bone defects exist in the femur or tibia.