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ORIGINAL ARTICLE
Year : 2019  |  Volume : 12  |  Issue : 3  |  Page : 256-261  

Comparative study of stainless steel and titanium limited contact-dynamic compression plate application in the fractures of radius and ulna


1 Department of Orthopaedics, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
2 Department of Orthopaedics, Base Hospital, Lucknow Cantt, Uttar Pradesh, India

Date of Submission27-Aug-2018
Date of Acceptance04-Feb-2019
Date of Web Publication15-May-2019

Correspondence Address:
B M Naveen
Base Hospital, Lucknow Cantt - 226 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_140_18

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  Abstract 


Background: Stainless steel and titanium are two different metals with different mechanical and metallurgical properties. Stainless steel is twice more stiffer than titanium. Internal fixation of fractures with stainless steel plates is likely to produce more rigid fixation than titanium plates. Hence, stainless steel plate fixation is likely to produce healing of fracture site with minimum callus/primary healing. This study analyzes whether these properties of the metals influence the healing of the fractures and their outcomes. Materials and Methods: Thirty-five cases of fractures of radius and ulna were treated by internal fixation using stainless steel limited contact-dynamic compression plate (LC-DCP) (Group I) in 17 patients and titanium LC-DCP (Group II) in 18 patients. Follow-up was done at 6 weeks, 12 weeks, 6 months, and 1 year for clinical and radiological healing and complications. Results: All the fractures united in time. 10 (62.5%) patients in Group I and 9 (56.2%) patients in Group II showed primary union and 6 (37.5%) patients in Group I and 7 (43.2%) patients in Group II showed union with callus formation. No complications were observed. Conclusion: Stainless steel and titanium are two different metals with different mechanical and metallurgical properties. However, fixation of fractures with these metals failed to show the difference in the patterns of fracture healing.

Keywords: Fracture healing, limited contact-dynamic compression plate, stainless steel, titanium


How to cite this article:
Joshi G R, Naveen B M. Comparative study of stainless steel and titanium limited contact-dynamic compression plate application in the fractures of radius and ulna. Med J DY Patil Vidyapeeth 2019;12:256-61

How to cite this URL:
Joshi G R, Naveen B M. Comparative study of stainless steel and titanium limited contact-dynamic compression plate application in the fractures of radius and ulna. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Jul 19];12:256-61. Available from: http://www.mjdrdypv.org/text.asp?2019/12/3/256/258200




  Introduction Top


Fractures of radius and ulna are common and are treated by open reduction and internal fixation by plating and occasionally by intramedullary nails. Plate osteosynthesis has been found to be superior because of excellent stability provided by the plate to axial, rotational, and bending forces and producing more than 98% union rates.[1] The small dynamic compression plates (DCPs) have been commonly used for internal fixation since 1970s. Although the results of DCPs are excellent, they have many biological and mechanical disadvantages. All the biological and mechanical shortcomings of the DCP were overcome by new design of the plate called limited contact-DCP (LC-DCP) by AO/ASIF in 1990.

The LC-DCP is available in both in stainless steel and pure titanium. Both these metals have different metallurgical and mechanical properties. Steel contains chromium (17%–20%), nickel (12%–14%), molybdenum (2%–4%), manganese (2%), and rest is Iron. Stainless steel is cheap, has good ductility, can be well machined, and contoured easily. It has good tensile strength, but in terms of corrosion resistance, biocompatibility, and fatigue strength, stainless steel is inferior to titanium. Stainless steel has modulus of elasticity eight times greater than the bone. The internal fixation provided by stainless steel plate is said to produce more rigid fixation than titanium plate of same size and dimension.[2] The other disadvantage is the allergic reaction to nickel content of steel in 1%–2% of the patients.[3] Stainless steel is known to produce more inflammatory reaction than titanium.[4] The stainless implants are associated with higher rate of infection compared to that of titanium implants. It was attributed to better biocompatibility of titanium which may enhance the tissue adhesion to the implant surface with improved surface vascularization, whereas the stainless steel implants form fibrous capsule enclosing dead space with liquid film. The bacteria grow in this space and are inaccessible to defense mechanism.[5]

Stainless steel LC-DCP is said to produce primary healing of fractures by rigid fixation, thus hardly any external callus is formed and the radiological assessment of completion of healing is difficult, also making timing of removal of plate difficult clinically and radiologically. Due to the rigid fixation and unloading, bone underlying the plate fails to remodel.[6] The experimental study by Uhthoff and Finnegan[7] shows distinct advantage of titanium over stainless steel plates for internal fixation of fractures. The advantages are as follows:

  1. Presence of radiologically visible callus in healing phase of fracture
  2. Scope for physiological remodeling of the cortices and return to normal bone structure
  3. Better tissue compatibility, no corrosion
  4. Accurate assessment of radiological union, ideal timing of plate removal, and reduced incidence of refracture.


The differences in biochemical and mechanical properties between the metals are bound to influence the healing of the fracture, remodeling process, implant failure, and other complications. The hypothesis proposed was that “The Stainless steel and Titanium are two different metals with different biomechanical and metallurgical properties and hence in spite of this difference it should not influence the healing of the fractures.” Multitude of experimental studies[6],[7],[8],[9],[10] compare stainless steel and titanium plate fixation with different aspects of fracture healing, but very few studies[9] compare their clinical results of fracture fixation. The purpose of the study is to compare the clinical and radiological healing of fractures of radius and ulna in patients treated with internal fixation using stainless steel and titanium LC-DCP and their complications.


  Materials and Methods Top


Between January 2003 and December 2004, 35 patients with fractures of radius and ulna were selected for this prospective comparative study. Simple transverse/oblique fractures of radius and ulna within 2 weeks of fracture were selected. All the patients with comminuted fractures, open fractures, pathological fractures, and patients aged more than 55 years were excluded from the study. The baseline characteristics of patients in both groups were similar. Patients were divided into two groups as follows: patients in Group I received stainless steel LC-DCP [Figure 1] and Group II received titanium LC-DCP [Figure 2]. Stainless steel LC-DCP were manufactured by Synthes (Mathy's Medical Ltd., Switzerland) and Titanium LC-DCP were manufactured by Mishra Dhatu Nigam (MIDHANI), Hyderabad, India. All ulnar fractures were treated by posterior approach, and all radial fractures were treated by Thompson's approach. Prophylactic antibiotics were given for 2 days postoperatively, and sutures were removed after 2 weeks. Active and passive motions were started after 4 weeks of immobilization. Patients were followed up for 1 year following surgical intervention at 6 weeks, 3 months, 6 months, and 1 year for evidence of clinical and radiological healing and any infection, allergy, delayed union/nonunion, and implant failure. The amount of callus formed at the fracture site was compared in both groups. Statistical analysis was done using the Chi-square test, and the P value was set at <0.05 to be statistically significant.
Figure 1: Fracture radius and ulna with internal fixation by stainless steel limited contact-dynamic compression plate

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Figure 2: Fracture radius ulna with internal fixation using titanium limited contact-dynamic compression plate

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  Results Top


A total of 35 patients (27 males and 8 females) were treated. Twelve had radial bone fractures, five had ulnar bone fractures, and 18 had both bones fractures. 17 patients were treated with stainless steel LC-DCP (Group I) and 18 patients were treated with titanium LC-DCP (Group II) [Table 1]. The demographics of the patients included in the study were comparable in both the groups [Table 2]. The time interval from trauma to operation was <1 week in all the cases. Three patients (2 from Group I and 1 from Group II) were lost to follow-up after 3 months and all of them were with both bones fractures. These three patients were excluded from the study and the rest of all patients were included as they were followed up serially at regular intervals for 1 year from the date of surgery.
Table 1: Flowchart representation of patient recruitment and the follow-up rates

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Table 2: Patient demographics and P value between the two groups

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All the fractures showed bridging callus at 6 weeks and all fractures were clinically and radiologically united by 3 months. Ten patients (62.5%) from Group I showed primary healing and 6 (37.5%) showed healing by callus formation [Figure 3]. Nine patients (56.2%) from Group II showed healing by primary union [Figure 4] and 7 (43.2%) showed union by callus formation. The details of radiological healing either by primary union or by callus formation in each group at the end of the 3 months are shown in [Table 3]. P value of the results was calculated to be 0.72; hence, the difference was statistically not significant.
Figure 3: Fracture radius showing union by callus formation at 3 months

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Figure 4: Fracture showing primary union at 3 months

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Table 3: Radiological type of healing (n=32)

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There were no cases of delayed union/nonunion and infection. Two patients in Group I with both bones fractures had maculopapular patch near the scar associated with itching which appeared 4–6 weeks after the surgery and were symptomatic intermittently and disappeared after 6 months without any specific treatment. As the lesions were minimal, focal, associated with itching, intermittently symptomatic, and disappeared by 3 months, it was presumed to be allergic reaction to metal implanted. No further confirmation was carried out.


  Discussion Top


Plating is a common method of treating forearm bone fractures. Stainless Steel DCP has been traditionally used for fracture fixation of radius and ulna with excellent results. The arrival of LC-DCP in 1990 overcame the numerous shortcomings of the DCPs. This new plating system had only 50% of the plate under surface contact with bone and hence did not interfere with cortical blood supply, thereby reducing the subcortical necrosis and porosis of the bone caused by plate contact.[2],[5],[11],[12],[13] The titanium is an excellent implant material and is in use since 1966 as DCP by AO.

Stainless steel though cheap has modulus of elasticity eight times greater than bone. When used for internal fixation, it produces rigid fixation leading to primary fracture union with no callus formation; hence, radiological assessment of fracture healing is difficult. The rigid fixation by stainless steel plate unloads the protected segment leading to osteoporosis and reduction in the bone mass.[14] Titanium has half of the modulus of elasticity as that of stainless steel, and its stiffness is more close to the bone than stainless steel. The lower modulus of elasticity of Ti provides an advantage by reducing the stress protection. Thus, it reduces the osteoporosis and allows the fracture to heal with callus formation.

The ideal implant material is one which has biomechanical properties close to the bone and is biocompatible. Titanium meets these requirements partially. Commercially, pure titanium (CTi) implants are available, it is twice as flexible as steel (Half modulus of elasticity than steel) and is two-thirds as strong as steel. Titanium has excellent corrosion resistance in chloride environment. Its oxide surface is highly inert, biocompatible, and reforms very easily after damage. Titanium has better fatigue strength but is more brittle than steel. It has poor ductility, contouring, and machining. Cracks occur in notches and tend to spread faster. Allergic response is rare, but it is expensive.

The present study compared fracture healing in stainless steel and titanium LC-DCP. Ten patients (62.5%) treated with stainless steel LC-DCP showed primary healing and six patients (37.5%) showed demonstrable callus. Similarly, nine patients (56.2%) treated with titanium LC-DCP showed primary bone healing and seven patients (43.8%) showed callus formation. The healing of fractures in both categories did not go by the patterns predicted by mechanical properties of the metals. The reason may be explained by a study by Jain et al.[13] who investigated the stiffness and strength of bone plate constructs using stainless steel and titanium LC-DCP in canine osteotomies with and without bone gap. Before creating bone gap, bending stiffness for stainless steel and titanium LC-DCP was not significantly different in anteroposterior (AP) and mediolateral directions. Similarly, the torsion stiffness was also similar for both constructs. However, in the presence of gap, stainless steel LC-DCP was 20% and 10% stiffer than titanium LC-DCP in AP and mediolateral directions, but torsional stiffness in the presence of gap remained the same. In terms of stability of fixation, the application of titanium LC-DCP to fractures without interfragmentary gap will result in a bone-plate construct with stiffness similar to that with stainless steel LC-DCP.

This study had patients with oblique and transverse fractures which were fixed with good bone contact, thus the construct acted like fracture without gap and the stiffness of stainless steel and titanium LC-DCP were similar. Thus, it may have resulted in producing primary fracture union in majority of titanium LC-DCP cases (56.2%). Callus in other group may be due to the presence of minimal bone gap. In a study by Holzach and Matter,[9] they compared steel and titanium DCP used for internal fixation of 256 fractures of tibia. Clinically, 91% patients in titanium group and 93% in stainless steel group had achieved complete union. Radiologically, 65% of the patients in titanium group had primary healing and 68% of those in stainless steel group had primary union. Rest of the patients in both groups showed healing with visible callus formation. This was probably not because of instability but because of fracture comminution. Our study has also demonstrated similar almost results and the P value in our study is 0.72; hence, the difference is statistically not significant. Hence, the authors conclude that no difference between the two groups in the pattern of fracture healing.

In a study by Souer et al.,[15] functional outcome of titanium and steel plates for extra-articular fractures of distal radius was compared. The results were similar among both the groups, and no significant difference was noted in the functional outcome whether treated by stainless steel or titanium plates. Another recent study was undertaken by Marshall et al.[16] to compare the biomechanical properties of the fixed-angle volar plates of titanium and steel plates in AO C3 types of distal radius fractures. Although the fixed-angle compression locking stainless steel volar plates resulted in less displacement and rotation of fracture fragments in some patients as compared to fixed-angle locking volar titanium plate, there were no differences between the plates in mechanical load to failure and stiffness. Both of these metals were also compared for their elastic nails for fixation of pediatric femoral fractures by Wall et al.[17] Their purpose was to compare the complications associated with the use of similarly designed titanium and stainless steel elastic nails for the fixation of pediatric femoral fractures. They found higher rates of malunion in titanium group and concluded that the less expensive stainless steel elastic nails are clinically superior to titanium nails for pediatric femoral fixation primarily because of a much lower rate of malunion.

There were no delayed/nonunions and infections in this study. Holzach and Matter[9] achieved union in 91% of titanium DCP group and 93% of stainless steel group. They did not have infection in either group. Matter and Burch[18] reported the clinical outcome of 271 titanium LC-DCP and did not observe any nonunion, delayed union, or implant failures. However, some isolated case reports of implant failure[19] and stress fractures[20] with titanium implants have been reported. We noticed local skin reaction with itching in two patients with stainless steel implant which was noticed intermittently after 6 weeks and disappeared by 6 months spontaneously. It was presumed to be due to allergy to the metal inside the body. Some authors have noted skin reaction associated with sensitization to metals. Halpin[21] reports a case of hypersensitivity to cobalt alloy plate in a 40-year-old woman who presented with periprosthetic fibrosis, patchy muscle necrosis, and chronic inflammatory reactions following implantation of cobalt alloy screws and plate in radius and ulna after 7 years of fixation. After the removal of the implant, the swelling disappeared and the patient became asymptomatic. Later, patch test showed hypersensitivity to cobalt. All metals in contact with biological system, corrode[22],[23] and the released ions, while not sensitizers on their own, can activate the immune system by forming complexes with native proteins.[24],[25] Nickel is the most common sensitizer in humans, followed by cobalt and chromium.[26],[27],[28] The prevalence of metal sensitivity in human population is approximately 10%–15%. In general, there are more case reports of hypersensitivity reactions to stainless steel and cobalt alloy implants than to titanium alloy components.[29],[30] As the plates could not be removed in any of the patients, the local tissue reaction of the plate and corrosion of the metal could not be ascertained. Despite these variations, stainless steel has been recommended by few authors as an alternative to titanium because of its cost and easier availability.[31]


  Conclusion Top


The present study was carried out to evaluate the effects of mechanical and metallurgical properties of the stainless steel and titanium LC-DCP on fracture healing of forearm bones. Although it was carried out a decade before, it was not published due to organizational constraints till date. As the literature on the index subject is scarce, this study still carries its own significance. It reveals that, despite having significant difference in their properties, the two metallic plates did not show any difference in the pattern of fracture healing in both groups; both groups produced excellent union rate with no complications. However, allergic reaction was observed in two patients in stainless steel group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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