Cannulated Screws and Braided Polyester Tension Band as an Alternative for Fixation of Transverse Patella Fracture: A Finite Element Analysis Study
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Published:
Sep 20, 2017
Keywords:
patella fracture, tension band fixation, cannulated screw, braided polyester, finite element
Main Article Content
Abstract
BACKGROUND: Modified tension band wiring is a common surgical technique forfixation of patella fractures; however, various complications have been associated withmetal implants in this configuration. Modification of techniques and non-metallicimplants have been proposed in order to reduce hardware associated complications whileoptimizing fixation strength. Our study investigated the biomechanical strengthprovided by various modifications of figure-of-eight tension band constructs.
MATERIALS AND METHODS: A finite element (FE) model of normal patella wasreconstructed based on CT images of a 46-year old man. Mathematical variations fromconversion of actual DICOM images into 3D geometric mesh were recorded. Simpletransverse fracture at the midpole was established with a 0.5 mm fracture gap. Twointerfragmentary fixations were made by using: 1) 2.0 mm K-Wires or 2) 4.0 mm. cannulatedcancellous screws. Figure-of-eight loop with 1.25 mm stainless-steel wire or FiberWireno.5 were allocated to each group. Figure of-eight loops in the K-wire group were invertical orientation while figure-of-eight loops in the cannulated screw group were inhorizontal orientation. These combinations constituted four different FE models. Analysiswas done on each model under the same environment, which was a 400N load on eachfragment at 45o flexion. Implant stress/strain and material deformation were determined.
RESULTS: The models with cannulated screws have von Mises stress on implant thatis three times less than those with K-wires. The least von Mises stress occurred on thecombined cannulated screws and horizontal FiberWire loop model (471.2 MPa). Thiscombination also provided least deformation to loading condition (0.1267 mm).Traditional construct with K-wires and metal wire loop was found to have maximalstress (1422.9 MPa) and maximal deformation (0.3856 mm).
CONCLUSION: Cannulated screws combined with FiberWire figure-of-eight loopoffers favorably low implant stress. Our findings demonstrate superior stability andresistance to implant failure of the construct. This low-profile tension band fixation couldbe a good alternative for transverse patella fracture.
MATERIALS AND METHODS: A finite element (FE) model of normal patella wasreconstructed based on CT images of a 46-year old man. Mathematical variations fromconversion of actual DICOM images into 3D geometric mesh were recorded. Simpletransverse fracture at the midpole was established with a 0.5 mm fracture gap. Twointerfragmentary fixations were made by using: 1) 2.0 mm K-Wires or 2) 4.0 mm. cannulatedcancellous screws. Figure-of-eight loop with 1.25 mm stainless-steel wire or FiberWireno.5 were allocated to each group. Figure of-eight loops in the K-wire group were invertical orientation while figure-of-eight loops in the cannulated screw group were inhorizontal orientation. These combinations constituted four different FE models. Analysiswas done on each model under the same environment, which was a 400N load on eachfragment at 45o flexion. Implant stress/strain and material deformation were determined.
RESULTS: The models with cannulated screws have von Mises stress on implant thatis three times less than those with K-wires. The least von Mises stress occurred on thecombined cannulated screws and horizontal FiberWire loop model (471.2 MPa). Thiscombination also provided least deformation to loading condition (0.1267 mm).Traditional construct with K-wires and metal wire loop was found to have maximalstress (1422.9 MPa) and maximal deformation (0.3856 mm).
CONCLUSION: Cannulated screws combined with FiberWire figure-of-eight loopoffers favorably low implant stress. Our findings demonstrate superior stability andresistance to implant failure of the construct. This low-profile tension band fixation couldbe a good alternative for transverse patella fracture.
Article Details
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1.
Mayurasakorn C, Phiphobmongkol V, Kosuwon W, Nabudda K, Bavonratanavech S. Cannulated Screws and Braided Polyester Tension Band as an Alternative for Fixation of Transverse Patella Fracture: A Finite Element Analysis Study. BKK Med J [Internet]. 2017 Sep. 20 [cited 2024 Dec. 22];13(2):11. Available from: https://he02.tci-thaijo.org/index.php/bkkmedj/article/view/221900
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This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
1. Mehling I, Mehling A, Rommens PM. Comminuted patellar fractures. Curr Orthop 2006;20(6):397-404.
2. Chiang CC, Huang CK, Chen WM, et al. Arthroscopically assisted percutaneous osteosynthesis of displaced transverse patellar fractures with figure-eight wiring through paired cannulated screws. Arch Orthop Trauma Surg 2011;131(7): 949-54.
3. Melvin JS, Mehta S. Patellar Fractures in Adults. J Am Acad Orthop Surg 2011;19(4):198-207.
4. Rudloff MI. Fractures of the Lower Extremity. In: Canale ST, Beaty JH, editors. Campbell’s Operative Orthopaedics. Philadelphia: Elsevier Health Sciences; 2012:2681-88.
5. Melvin JS, Karunakar MA. Patella Fractures and Extensor Mechanism Injuries. In: Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta P, McKee MD, editors. Rockwood and Green’s Fractures in Adults. 8th ed. Philadelphia: Wolters Kluwer Health; 2015:2269-302.
6. Hungerford DS, Barry M. Biomechanics of the patellofemoral joint. Clin Orthop Relat Res 1979(144):9-15.
7. Weber MJ, Janecki CJ, McLeod P, Nelson CL, Thompson JA. Efficacy of various forms of fixation of transverse fractures of the patella. J Bone Joint Surg Am 1980;62(2):215-20.
8. Benjamin J, Bried J, Dohm M, et al. Biomechanical evaluation of various forms of fixation of transverse patellar fractures. J Orthop Trauma 1987;1(3):219-22.
9. Carpenter JE, Kasman RA, Patel N, et al. Biomechanical evaluation of current patella fracture fixation techniques. J Orthop Trauma 1997;11(5):351-6.
10. Patel VR, Parks BG, Wang Y, et al. Fixation of patella fractures with braided polyester suture: a biomechanical study. Injury Injury 2000;31(1):1-6.
11. John J, Wagner WW, Kuiper JH. Tension-band wiring of transverse fractures of patella. The effect of site of wire twists and orientation of stainless steel wire loop: a biomechanical investigation. Int Orthop 2007;31(5):703-7.
12. Petrie J, Sassoon A, Langford J. Complications of patellar fracture repair: treatment and results. J Knee Surg 2013;26(5):309-12.
13. Schuett DJ, Hake ME, Mauffrey C, et al. Current Treatment Strategies for Patella Fractures. Orthopedics 2015;38(6):377-84.
14. Kakazu R, Archdeacon MT. Surgical Management of Patellar Fractures. Orthop Clin North Am 2016;47(1):77-83.
15. Finkemeier CG, Nerlich M. Patella. In: Ruedi TP, editor. AO Principles of Fracture Management. New York: Thieme; 2007:801-14.
16. Hung LK, Chan KM, Chow YN, et al. Fractured patella: operative treatment using the tension band principle. Injury 1985;16(5):343-7.
17. Smith ST, Cramer KE, Karges DE, et al. Early complications in the operative treatment of patella fractures. J Orthop Trauma 1997;11(3):183-7.
18. Gosal HS, Singh P, Field RE. Clinical experience of patellar fracture fixation using metal wire or non-absorbable polyester- -a study of 37 cases. Injury 2001;32(2):129-35.
19. Dy CJ, Little MT, Berkes MB, et al. Meta-analysis of reoperation, nonunion, and infection after open reduction and internal fixation of patella fractures. J Trauma Acute Care Surg 2012;73(4):928-32.
20. Lin T, Liu J, Xiao B, et al. Comparison of the outcomes of cannulated screws vs. modified tension band wiring fixation techniques in the management of mildly displaced patellar fractures. BMC Musculoskelet Disord 2015;16:282.
21. Biddau F, Fioriti M, Benelli G. Migration of a Broken Cerclage Wire from the Patella into the Heart. J Bone Joint Surg Am 2006;88(9):2057.
22. Choi HR, Min KD, Choi SW, et al. Migration to the popliteal fossa of broken wires from a fixed patellar fracture. Knee 2008;15(6):491-3.
23. Konda SR, Dayan A, Egol KA. Progressive migration of broken Kirschner wire into the proximal tibia following tension-band wiring technique of a patellar fracture--case report. Bull NYU Hosp Jt Dis 2012;70(4):279-82.
24. Mak N-TS. Breakage and Migration of Metal Wires in Operated Patella Fractures: Does it Correlate with Time? J Orthop Trauma Rehab 2013;17(1):13-6.
25. Hoshino CM, Tran W, Tiberi JV, et al. Complications following tension-band fixation of patellar fractures with cannulated screws compared with Kirschner wires. J Bone Joint Surg Am 2013;95(7):653-9.
26. Lazaro LE, Wellman DS, Sauro G, et al. Outcomes after operative fixation of complete articular patellar fractures: assessment of functional impairment. J Bone Joint Surg Am 2013;95(14):e96 1-8.
27. Chen A, Hou C, Bao J, et al. Comparison of biodegradable and metallic tension-band fixation for patella fractures. 38 patients followed for 2 years. Acta Orthop Scand 1998;69(1): 39-42.
28. McGreal G, Reidy D, Joy A, et al. The biomechanical evaluation of polyester as a tension band for the internal fixation of patellar fractures. J Med Eng Technol 1999;23(2):53-6.
29. Hughes SC, Stott PM, Hearnden AJ, et al. A new and effective tension-band braided polyester suture technique for transverse patellar fracture fixation. Injury 2007;38(2):212-22.
30. Qi L, Chang C, Xin T, et al. Double fixation of displaced patella fractures using bioabsorbable cannulated lag screws and braided polyester suture tension bands. Injury 2011;42(10):1116-20.
31. Chen CH, Huang HY, Wu T, et al. Transosseous suturing of patellar fractures with braided polyester - a prospective cohort with a matched historical control study. Injury 2013;44(10):1309-13.
32. Camarda L, La Gattuta A, Butera M, et al. FiberWire tension band for patellar fractures. J Orthop Traumatol 2016;17(1):75-80.
33. Yotsumoto T, Nishikawa U, Ryoke K, et al. Tension band fixation for treatment of patellar fracture: novel technique using a braided polyblend sutures and ring pins. Injury 2009;40(7):713-7.
34. Chatakondu SC, Abhaykumar S, Elliott DS. The use of nonabsorbable suture in the fixation of patellar fractures: a preliminary report. Injury 1998;29(1):23-7.
35. Juutilainen T, Patiälä H, Rokkanen P, et al. Biodegradable wire fixation in olecranon and patella fractures combined with biodegradable screws or plugs and compared with metallic fixation. Arch Orthop Trauma Surg 1995;114(6):319-23.
36. Egol K, Howard D, Monroy A, et al. Patella Fracture Fixation with Suture and Wire: you Reap what you Sew. Iowa Orthop J 2014;34:63-7.
37. Tian Y, Zhou F, Ji H, et al. Cannulated screw and cable are superior to modified tension band in the treatment of transverse patella fractures. Clin Orthop Relat Res 2011;469(12): 3429-35.
38. Cho JH. Percutaneous cannulated screws with tension band wiring technique in patella fractures. Knee Surg Relat Res 2013;25(4):215-9.
39. Dargel J, Gick S, Mader K, et al. Biomechanical comparison of tension band- and interfragmentary screw fixation with a new implant in transverse patella fractures. Injury 2010;41(2):156-60.
40. Burvant JG, Thomas KA, Alexander R, et al. Evaluation of methods of internal fixation of transverse patella fractures: a biomechanical study. J Orthop Trauma 1994;8(2):147-53.
41. Berg EE. Open reduction internal fixation of displaced transverse patella fractures with figure-eight wiring through parallel cannulated compression screws. J Orthop Trauma 1997;11(8):573-6.
42. Tan H, Dai P, Yuan Y. Clinical results of treatment using a modified K-wire tension band versus a cannulated screw tension band in transverse patella fractures: A strobe-compliant retrospective observational study. Medicine (Baltimore) 2016;95(40):e4992.
43. Bryant TL, Anderson CL, Stevens CG, et al. Comparison of cannulated screws with FiberWire or stainless steel wire for patella fracture fixation: A pilot study. J Orthop 2015;12(2):92-6.
44. Ali M, Kuiper J, John J. Biomechanical analysis of tension band wiring (TBW) of transverse fractures of patella. Chin J Traumatol 2016;19(5):255-8.
45. Baran O, Manisali M, Cecen B. Anatomical and biomechanical evaluation of the tension band technique in patellar fractures. Int Orthop 2009;33(4):1113-7.
46. Lee SK, Hwang YS, Choy WS. Horizontal versus vertical orientation of the loop for tension band wiring of transverse patella fractures. Orthopedics 2014;37(3):e265-71.
47. Gargiulo P, Helgason T, Reynisson PJ, et al. Monitoring of muscle and bone recovery in spinal cord injury patients treated with electrical stimulation using three-dimensional imaging and segmentation techniques: methodological assessment. Artif Organs 2011;35(3):275-81.
48. Pal S. Mechanical Properties of Biological Materials. Design of Artificial Human Joints & Organs. New York: Springer; 2014:23-40.
49. Disegi J. Implant Materials. 3 ed: Synthes; 2009 2009.
50. Najibi S, Banglmeier R, Matta JM, et al. Material properties of common suture materials in orthopaedic surgery. Iowa Orthop J 2010;30:84-8.
51. Reilly DT, Burstein AH. The elastic and ultimate properties of compact bone tissue. J Biomech 1975;8(6):393-405.
52. Turker M, Kilicoglu O, Salduz A, et al. Loop security and tensile properties of polyblend and traditional suture materials. Knee Surg Sports Traumatol Arthrosc 2011;19(2):296-302.
53. Roberts GL, Pallister I. Finite element analysis in trauma & orthopaedics - an introduction to clinically relevant simulation & its limitations. Orthop Trauma 2012;26(6):410-6.
54. Gerber C, Schneeberger AG, Beck M, et al. Mechanical strength of repairs of the rotator cuff. J Bone Joint Surg Br 1994;76(3):371-80.
55. Scilaris TA, Grantham JL, Prayson MJ, et al. Biomechanical comparison of fixation methods in transverse patella fractures. J Orthop Trauma 1998;12(5):356-9.
56. Nakamura N, Ellis M, Seedhom BB. Advancement of the tibial tuberosity. A biomechanical study. J Bone Joint Surg Br 1985;67(2):255-60.
57. Masouros SD, Bull AMJ, Amis AA. (i) Biomechanics of the knee joint. Orthop Trauma 2010;24(2):84-91.
58. Wright PB, Kosmopoulos V, Cote RE, et al. FiberWire is superior in strength to stainless steel wire for tension band fi x a t i o n o f t r a n s v e r s e p a t e l l a r f r a c t u r e s . Injury 2009;40(11):1200-3.
59. Catalano JB, Iannacone WM, Marczyk S, et al. Open fractures of the patella: long-term functional outcome. J Trauma 1995;39(3):439-44.
60. Torchia ME, Lewallen DG. Open fractures of the patella. J Orthop Trauma 1996;10(6):403-9.
61. Jo MJ, Tencer AF, Gardner MJ. Biomechanics of Fractures and Fracture Fixation. In: Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta P, McKee MD, editors. Rockwood and Green’s Fractures in Adults. 8th ed. Philadelphia: Wolters Kluwer Health; 2015:1-42.
62. Carpenter JE, Kasman R, Matthews LS. Fractures of the Patella. J Bone Joint Surg Am 1993;75(10):1550.
63. Camarda L, Morello S, Balistreri F, et al. Non-metallic implant for patellar fracture fixation: A systematic review. Injury 2016;47(8):1613-7.
2. Chiang CC, Huang CK, Chen WM, et al. Arthroscopically assisted percutaneous osteosynthesis of displaced transverse patellar fractures with figure-eight wiring through paired cannulated screws. Arch Orthop Trauma Surg 2011;131(7): 949-54.
3. Melvin JS, Mehta S. Patellar Fractures in Adults. J Am Acad Orthop Surg 2011;19(4):198-207.
4. Rudloff MI. Fractures of the Lower Extremity. In: Canale ST, Beaty JH, editors. Campbell’s Operative Orthopaedics. Philadelphia: Elsevier Health Sciences; 2012:2681-88.
5. Melvin JS, Karunakar MA. Patella Fractures and Extensor Mechanism Injuries. In: Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta P, McKee MD, editors. Rockwood and Green’s Fractures in Adults. 8th ed. Philadelphia: Wolters Kluwer Health; 2015:2269-302.
6. Hungerford DS, Barry M. Biomechanics of the patellofemoral joint. Clin Orthop Relat Res 1979(144):9-15.
7. Weber MJ, Janecki CJ, McLeod P, Nelson CL, Thompson JA. Efficacy of various forms of fixation of transverse fractures of the patella. J Bone Joint Surg Am 1980;62(2):215-20.
8. Benjamin J, Bried J, Dohm M, et al. Biomechanical evaluation of various forms of fixation of transverse patellar fractures. J Orthop Trauma 1987;1(3):219-22.
9. Carpenter JE, Kasman RA, Patel N, et al. Biomechanical evaluation of current patella fracture fixation techniques. J Orthop Trauma 1997;11(5):351-6.
10. Patel VR, Parks BG, Wang Y, et al. Fixation of patella fractures with braided polyester suture: a biomechanical study. Injury Injury 2000;31(1):1-6.
11. John J, Wagner WW, Kuiper JH. Tension-band wiring of transverse fractures of patella. The effect of site of wire twists and orientation of stainless steel wire loop: a biomechanical investigation. Int Orthop 2007;31(5):703-7.
12. Petrie J, Sassoon A, Langford J. Complications of patellar fracture repair: treatment and results. J Knee Surg 2013;26(5):309-12.
13. Schuett DJ, Hake ME, Mauffrey C, et al. Current Treatment Strategies for Patella Fractures. Orthopedics 2015;38(6):377-84.
14. Kakazu R, Archdeacon MT. Surgical Management of Patellar Fractures. Orthop Clin North Am 2016;47(1):77-83.
15. Finkemeier CG, Nerlich M. Patella. In: Ruedi TP, editor. AO Principles of Fracture Management. New York: Thieme; 2007:801-14.
16. Hung LK, Chan KM, Chow YN, et al. Fractured patella: operative treatment using the tension band principle. Injury 1985;16(5):343-7.
17. Smith ST, Cramer KE, Karges DE, et al. Early complications in the operative treatment of patella fractures. J Orthop Trauma 1997;11(3):183-7.
18. Gosal HS, Singh P, Field RE. Clinical experience of patellar fracture fixation using metal wire or non-absorbable polyester- -a study of 37 cases. Injury 2001;32(2):129-35.
19. Dy CJ, Little MT, Berkes MB, et al. Meta-analysis of reoperation, nonunion, and infection after open reduction and internal fixation of patella fractures. J Trauma Acute Care Surg 2012;73(4):928-32.
20. Lin T, Liu J, Xiao B, et al. Comparison of the outcomes of cannulated screws vs. modified tension band wiring fixation techniques in the management of mildly displaced patellar fractures. BMC Musculoskelet Disord 2015;16:282.
21. Biddau F, Fioriti M, Benelli G. Migration of a Broken Cerclage Wire from the Patella into the Heart. J Bone Joint Surg Am 2006;88(9):2057.
22. Choi HR, Min KD, Choi SW, et al. Migration to the popliteal fossa of broken wires from a fixed patellar fracture. Knee 2008;15(6):491-3.
23. Konda SR, Dayan A, Egol KA. Progressive migration of broken Kirschner wire into the proximal tibia following tension-band wiring technique of a patellar fracture--case report. Bull NYU Hosp Jt Dis 2012;70(4):279-82.
24. Mak N-TS. Breakage and Migration of Metal Wires in Operated Patella Fractures: Does it Correlate with Time? J Orthop Trauma Rehab 2013;17(1):13-6.
25. Hoshino CM, Tran W, Tiberi JV, et al. Complications following tension-band fixation of patellar fractures with cannulated screws compared with Kirschner wires. J Bone Joint Surg Am 2013;95(7):653-9.
26. Lazaro LE, Wellman DS, Sauro G, et al. Outcomes after operative fixation of complete articular patellar fractures: assessment of functional impairment. J Bone Joint Surg Am 2013;95(14):e96 1-8.
27. Chen A, Hou C, Bao J, et al. Comparison of biodegradable and metallic tension-band fixation for patella fractures. 38 patients followed for 2 years. Acta Orthop Scand 1998;69(1): 39-42.
28. McGreal G, Reidy D, Joy A, et al. The biomechanical evaluation of polyester as a tension band for the internal fixation of patellar fractures. J Med Eng Technol 1999;23(2):53-6.
29. Hughes SC, Stott PM, Hearnden AJ, et al. A new and effective tension-band braided polyester suture technique for transverse patellar fracture fixation. Injury 2007;38(2):212-22.
30. Qi L, Chang C, Xin T, et al. Double fixation of displaced patella fractures using bioabsorbable cannulated lag screws and braided polyester suture tension bands. Injury 2011;42(10):1116-20.
31. Chen CH, Huang HY, Wu T, et al. Transosseous suturing of patellar fractures with braided polyester - a prospective cohort with a matched historical control study. Injury 2013;44(10):1309-13.
32. Camarda L, La Gattuta A, Butera M, et al. FiberWire tension band for patellar fractures. J Orthop Traumatol 2016;17(1):75-80.
33. Yotsumoto T, Nishikawa U, Ryoke K, et al. Tension band fixation for treatment of patellar fracture: novel technique using a braided polyblend sutures and ring pins. Injury 2009;40(7):713-7.
34. Chatakondu SC, Abhaykumar S, Elliott DS. The use of nonabsorbable suture in the fixation of patellar fractures: a preliminary report. Injury 1998;29(1):23-7.
35. Juutilainen T, Patiälä H, Rokkanen P, et al. Biodegradable wire fixation in olecranon and patella fractures combined with biodegradable screws or plugs and compared with metallic fixation. Arch Orthop Trauma Surg 1995;114(6):319-23.
36. Egol K, Howard D, Monroy A, et al. Patella Fracture Fixation with Suture and Wire: you Reap what you Sew. Iowa Orthop J 2014;34:63-7.
37. Tian Y, Zhou F, Ji H, et al. Cannulated screw and cable are superior to modified tension band in the treatment of transverse patella fractures. Clin Orthop Relat Res 2011;469(12): 3429-35.
38. Cho JH. Percutaneous cannulated screws with tension band wiring technique in patella fractures. Knee Surg Relat Res 2013;25(4):215-9.
39. Dargel J, Gick S, Mader K, et al. Biomechanical comparison of tension band- and interfragmentary screw fixation with a new implant in transverse patella fractures. Injury 2010;41(2):156-60.
40. Burvant JG, Thomas KA, Alexander R, et al. Evaluation of methods of internal fixation of transverse patella fractures: a biomechanical study. J Orthop Trauma 1994;8(2):147-53.
41. Berg EE. Open reduction internal fixation of displaced transverse patella fractures with figure-eight wiring through parallel cannulated compression screws. J Orthop Trauma 1997;11(8):573-6.
42. Tan H, Dai P, Yuan Y. Clinical results of treatment using a modified K-wire tension band versus a cannulated screw tension band in transverse patella fractures: A strobe-compliant retrospective observational study. Medicine (Baltimore) 2016;95(40):e4992.
43. Bryant TL, Anderson CL, Stevens CG, et al. Comparison of cannulated screws with FiberWire or stainless steel wire for patella fracture fixation: A pilot study. J Orthop 2015;12(2):92-6.
44. Ali M, Kuiper J, John J. Biomechanical analysis of tension band wiring (TBW) of transverse fractures of patella. Chin J Traumatol 2016;19(5):255-8.
45. Baran O, Manisali M, Cecen B. Anatomical and biomechanical evaluation of the tension band technique in patellar fractures. Int Orthop 2009;33(4):1113-7.
46. Lee SK, Hwang YS, Choy WS. Horizontal versus vertical orientation of the loop for tension band wiring of transverse patella fractures. Orthopedics 2014;37(3):e265-71.
47. Gargiulo P, Helgason T, Reynisson PJ, et al. Monitoring of muscle and bone recovery in spinal cord injury patients treated with electrical stimulation using three-dimensional imaging and segmentation techniques: methodological assessment. Artif Organs 2011;35(3):275-81.
48. Pal S. Mechanical Properties of Biological Materials. Design of Artificial Human Joints & Organs. New York: Springer; 2014:23-40.
49. Disegi J. Implant Materials. 3 ed: Synthes; 2009 2009.
50. Najibi S, Banglmeier R, Matta JM, et al. Material properties of common suture materials in orthopaedic surgery. Iowa Orthop J 2010;30:84-8.
51. Reilly DT, Burstein AH. The elastic and ultimate properties of compact bone tissue. J Biomech 1975;8(6):393-405.
52. Turker M, Kilicoglu O, Salduz A, et al. Loop security and tensile properties of polyblend and traditional suture materials. Knee Surg Sports Traumatol Arthrosc 2011;19(2):296-302.
53. Roberts GL, Pallister I. Finite element analysis in trauma & orthopaedics - an introduction to clinically relevant simulation & its limitations. Orthop Trauma 2012;26(6):410-6.
54. Gerber C, Schneeberger AG, Beck M, et al. Mechanical strength of repairs of the rotator cuff. J Bone Joint Surg Br 1994;76(3):371-80.
55. Scilaris TA, Grantham JL, Prayson MJ, et al. Biomechanical comparison of fixation methods in transverse patella fractures. J Orthop Trauma 1998;12(5):356-9.
56. Nakamura N, Ellis M, Seedhom BB. Advancement of the tibial tuberosity. A biomechanical study. J Bone Joint Surg Br 1985;67(2):255-60.
57. Masouros SD, Bull AMJ, Amis AA. (i) Biomechanics of the knee joint. Orthop Trauma 2010;24(2):84-91.
58. Wright PB, Kosmopoulos V, Cote RE, et al. FiberWire is superior in strength to stainless steel wire for tension band fi x a t i o n o f t r a n s v e r s e p a t e l l a r f r a c t u r e s . Injury 2009;40(11):1200-3.
59. Catalano JB, Iannacone WM, Marczyk S, et al. Open fractures of the patella: long-term functional outcome. J Trauma 1995;39(3):439-44.
60. Torchia ME, Lewallen DG. Open fractures of the patella. J Orthop Trauma 1996;10(6):403-9.
61. Jo MJ, Tencer AF, Gardner MJ. Biomechanics of Fractures and Fracture Fixation. In: Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta P, McKee MD, editors. Rockwood and Green’s Fractures in Adults. 8th ed. Philadelphia: Wolters Kluwer Health; 2015:1-42.
62. Carpenter JE, Kasman R, Matthews LS. Fractures of the Patella. J Bone Joint Surg Am 1993;75(10):1550.
63. Camarda L, Morello S, Balistreri F, et al. Non-metallic implant for patellar fracture fixation: A systematic review. Injury 2016;47(8):1613-7.