Fracture fixation in extremity trauma with carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates: evidence today

Integrating Virtual Planning and three-dimensional Printing for Craniofacial Trauma Management

Virtual surgical planning (VSP) in craniofacial trauma features unique challenges due to the complexity of fracture patterns and anatomic considerations. Among the most challenging tasks are segmenting trauma models, performing complex virtual reductions to restore anatomic integrity and functional occlusion, and utilizing technology to enhance surgical accuracy. The authors propose a classification model categorizing craniofacial trauma into 2 main classes: occlusion-impairing (eg, mandibular and Le Fort fractures) and occlusion-nonimpairing (eg, zygomaticomaxillary complex and orbital fractures). A general workflow for VSP, including advanced imaging and 3 dimensional printing, is outlined to address these challenges, particularly in panfacial trauma.

Surgeons' perspective on the use of carbon fibre plates for extremity fracture fixation

INTRODUCTION/PURPOSE

Carbon fibre plating (CFR-PEEK) became available to orthopaedic surgeons in 1998 as a competitor to the traditional metal implants. Despite this, the use of such implants has been limited globally. The aim of this study was therefore to explore the barriers to more widespread use of CFR-PEEK, specifically by examining orthopaedic surgeons' perceptions and opinions of its use through a cross-sectional survey.

METHODS

An online questionnaire with basic information attached regarding similarities and differences between CFR-PEEK and metal implants was sent out internationally, with 106 responses gained from 26 countries. Specific questions were asked to ascertain orthopaedic surgeons' current knowledge of advantages and disadvantages of CFR-PEEK, the barriers they perceive to its more widespread use, and own personal preferences. Free-text responses were analysed and the results discussed.

RESULTS

A minority of orthopaedic surgeons surveyed would choose CFR-PEEK over traditional metal implants (10.38%). The most common disadvantage of CFR-PEEK reported was increased cost, with 46.23% respondents identifying this. Concerns regarding structural integrity of the implant were second most commonly perceived disadvantage, with 34% of surgeons citing one or more of 'stiffness/breakage/durability/contourability' as a disadvantage. A small number of surgeons (3.8%) listed unfamiliarity as a potential disadvantage to the use of carbon fibre plates. The main barrier identified to their use was poor knowledge (education) in relation to the properties and existing evidence of their performance.

CONCLUSIONS

More work is needed to make CFR-PEEK more acceptable to surgeons including examination of perceived increased cost and increasing education of these implants. Further high-level evidence confirming carbon fibre non-inferiority may increase the usage of CFR-PEEK for extremity fracture fixation in the future.

Comparison of the use of biocompatible materials and titanium in the treatment of midshaft clavicle fractures with a patient-specific plate: a finite element analysis study

BACKGROUND

Clavicular midshaft fractures treated with titanium plates may encounter complications like implant failure. We assess if alternative biocompatible materials suchs as PLA, PLA/HA, PEEK offer comparable stability. Our study evaluates the biomechanical performance of these materials in surgical management of midshaft clavicle fractures.

METHODS

We simulated a personalized fixation implant with four different materials and conducted finite element analysis in ANSYS to assess maximum von Mises stress (MvMs).

RESULTS

The MvMs occurring on the plates, screws, clavicle, and fracture site were recorded. MvMs on titanium material at the 6th hole level (764.79 MPa) and the 6th screw level (503.38 MPa), with the highest stresses observed at 48.52 MPa on the lateral clavicle at the 1st hole level and 182.27 MPa on the medial clavicle at the 6th hole level. In PLA material analyses, the highest MvMs were observed at the 3rd hole level (340.6 MPa) and the 3rd screw level (157.83 MPa), with peak stresses at 379.63 MPa on the lateral clavicle fracture line and 505.44 MPa on the medial clavicle fracture line. In PLA/HA material analyses, the highest MvMs were at the 3rd hole (295.99 MPa) and 3rd screw (128.27 MPa), with peak stresses at 220.33 MPa on the lateral clavicle and 229.63 MPa on the medial clavicle fracture line. In PEEK material analyses, the highest MvMs were at the 3rd hole (234.74 MPa) and 6th screw (114.48 MPa), with peak stresses at 184.36 MPa on the lateral clavicle and 180.1 MPa on the medial clavicle.

CONCLUSION

Our findings indicate that titanium material shows significantly higher stresses on plates and screws compared to those on the clavicle, suggesting a risk of implant failure. PLA and PLA/HA were inadequate for fixation. Although stress on the plate with PEEK material is higher than on the clavicle, it remains lower than titanium, indicating potential stability at fracture site. Further research is needed to confirm these findings.

Low-Temperature Plasmas Improving Chemical and Cellular Properties of Poly (Ether Ether Ketone) Biomaterial for Biomineralization

Osteoblastic and chemical responses to Poly (ether ether ketone) (PEEK) material have been improved using a variety of low-temperature plasmas (LTPs). Surface chemical properties are modified, and can be used, using low-temperature plasma (LTP) treatments which change surface functional groups. These functional groups increase biomineralization, in simulated body fluid conditions, and cellular viability. PEEK scaffolds were treated, with a variety of LTPs, incubated in simulated body fluids, and then analyzed using multiple techniques. First, scanning electron microscopy (SEM) showed morphological changes in the biomineralization for all samples. Calcein staining, Fourier transform infrared spectroscopy (FTIR), and X-ray photoelectron spectroscopy (XPS) confirmed that all low-temperature plasma-treated groups showed higher levels of biomineralization than the control group. MTT cell viability assays showed LTP-treated groups had increased cell viability in comparison to non-LTP-treated controls. PEEK treated with triethyl phosphate plasma (TEP) showed higher levels of cellular viability at 82.91% ± 5.00 (n = 6) and mineralization. These were significantly different to both the methyl methacrylate (MMA) 77.38% ± 1.27, ethylene diamine (EDA) 64.75% ± 6.43 plasma-treated PEEK groups, and the control, non-plasma-treated group 58.80 ± 2.84. FTIR showed higher levels of carbonate and phosphate formation on the TEP-treated PEEK than the other samples; however, calcein staining fluorescence of MMA and TEP-treated PEEK had the highest levels of biomineralization measured by pixel intensity quantification of 101.17 ± 4.63 and 96.35 ± 3.58, respectively, while EDA and control PEEK samples were 89.53 ± 1.74 and 90.49 ± 2.33, respectively. Comparing different LTPs, we showed that modified surface chemistry has quantitatively measurable effects that are favorable to the cellular, biomineralization, and chemical properties of PEEK.

A PEEK into carbon fiber: A practical guide for high performance composite polymeric implants for orthopaedic oncology

Introduction

The use of carbon fiber implants in orthopaedic oncology has increased within recent years. The most widely used type of polymer is carbon fiber polyether ether ketone (CF-PEEK). Its radiolucency enables targeted radiotherapy and artifact-free tumor surveillance, which provides major advantages over metallic hardware. We aim to summarize the unique benefits within orthopaedic oncology, clinical pitfalls, and recent advancements.

Methods

Four representative patient cases from a single tertiary academic medical center were treated with carbon fiber implants (n = 2 nails, n = 2 plates) from 2021 to 2022.

Results

There were no adverse events noted during intraoperative implantation or postoperative follow up. All patients reported improvements in pain and no difficulties in ambulation. There were no instances of catastrophic failure or implant loosening.

Conclusion

CF implants offer a diverse array of advantages regarding its radiolucency, low scatter density, and bioinert profile. Nonetheless, further research is required to understand the long-term surgical outcomes and robustness of CF implants. Multi institutional trials could address important aspects of durability and stability over extended periods, feasibility and ease-of-use for different anatomical sites and bone quality, as well as cost-effectiveness in post-operative imaging, healthcare resource utilization, and revision rates. Providing orthopaedic surgeons with valuable insight will enable thorough clinically supported, informed decision making regarding optimal use of implants.

Taguchi optimization of 3D printed short carbon fiber polyetherketoneketone (CFR PEKK)

In this study, the Taguchi method was utilized to optimize fused filament fabrication (FFF) additive manufacturing with the goal of maximizing the flexural strength of 3D printed polyaryletherketone specimens. We analyzed 3D printed (3DP) carbon fiber reinforced poly-etherketoneketone (CFR PEKK), 3D printed and pressed (3DP + P) CFR PEKK, and injection molded medical grade polyetheretherketone (PEEK) as a control. Fracture surfaces were analyzed via scanning electron microscopy (SEM). The parameters that were varied in the optimization included nozzle diameter, layer height, print speed, raster angle, and nozzle temperature. We analyzed the flexural strength and flexural modulus determined from 3-point bending (ASTM D790). Using Taguchi optimization, the signal to noise ratio (SNR) was calculated to determine the relationship between the input parameters and flexural strength and to determine optimal print settings. Results were confirmed with analysis of variance (ANOVA). The raster angle and layer height were determined to have the greatest impact on the flexural strength of specimens printed in the FFF process for 3DP CFR PEKK. The optimized printing parameters were found to be 0/90 Raster Angle, 0.25 mm layer height, 0.8 mm Nozzle Diameter, 375 °C nozzle temperature, and 1100 mm/min print speed. The optimized 3DP CFR PEKK test samples had a flexural strength of 111.3 ± 5.3 MPa and a flexural modulus of 3.5 GPa. 3DP + P CFR PEKK samples had a flexural strength of 257.2 ± 17.8 MPa and a flexural modulus of 8.2 GPa. Statistical comparisons between means demonstrated that pressing significantly improves both flexural strength and flexural modulus of 3DP CFR PEKK. The results of this study support the hypothesis that post consolidation of 3DP specimens improves mechanical properties. Post-processing composites via pressing may allow greater design freedom within the 3DP process while improving mechanical properties.

Carbon-fibre plates for traumatic and (impending) pathological fracture fixation: Where do we stand? A systematic review

BACKGROUND

Carbon-fibre (CF) plates are increasingly used for fracture fixation. This systematic review evaluated complications associated with CF plate fixation. It also compared outcomes of patients treated with CF plates versus metal plates, aiming to determine if CF plates offered comparable results. The study hypothesized that CF plates display similar complication rates and clinical outcomes as metal plates for fracture fixation.

METHODS

The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following databases were searched from database inception until June 2023: PubMed, MEDLINE, Embase, Web of Science, Cochrane Library, Emcare, Academic Search Premier and Google Scholar. Studies reporting on clinical and radiological outcomes of patients treated with CF plates for traumatic fractures and (impending) pathological fractures were included. Study quality was assessed, and complications were documented as number and percentage per anatomic region.

RESULTS

A total of 27 studies of moderate to very low quality of evidence were included. Of these, 22 studies (800 patients, median follow-up 12 months) focused on traumatic fractures, and 5 studies (102 patients, median follow-up 12 months) on (impending) pathological fractures. A total of 11 studies (497 patients, median follow-up 16 months) compared CF plates with metal plates. Regarding traumatic fractures, the following complications were mostly reported: soft tissue complications (52 out of 391; 13%) for the humerus, structural complications (6 out of 291; 2%) for the distal radius, nonunion and structural complication (1 out of 34; 3%) for the femur, and infection (4 out of 104; 4%) for the ankle. For (impending) pathological fractures, the most frequently reported complications were infections (2 out of 14; 14%) for the humerus and structural complication (6 out of 86; 7%) for the femur/tibia. Comparative studies reported mixed results, although the majority (7 out of 11; 64%) reported no significant differences in clinical or radiological outcomes between patients treated with CF or metal plates.

CONCLUSION

This systematic review did not reveal a concerning number of complications related to CF plate fixation. Comparative studies showed no significant differences between CF plates and metal plates for traumatic fracture fixation. Therefore, CF plates appear to be a viable alternative to metal plates. However, high-quality randomized controlled trials (RCTs) with long-term follow-up are strongly recommended to provide additional evidence supporting the use of CF plates.

LEVEL OF EVIDENCE

III, systematic review.

Polyetheretherketone development in bone tissue engineering and orthopedic surgery

Polyetheretherketone (PEEK) has been widely used in the medical field as an implant material, especially in bone tissue engineering and orthopedic surgery, in recent years. This material exhibits superior stability at high temperatures and is biosecured without harmful reactions. However, the chemical and biological inertness of PEEK still limits its applications. Recently, many approaches have been applied to improve its performance, including the modulation of physical morphology, chemical composition and antimicrobial agents, which advanced the osteointegration as well as antibacterial properties of PEEK materials. Based on the evolution of PEEK biomedical devices, many studies on the use of PEEK implants in spine surgery, joint surgery and trauma repair have been performed in the past few years, in most of which PEEK implants show better outcomes than traditional metal implants. This paper summarizes recent studies on the modification and application of biomedical PEEK materials, which provides further research directions for PEEK implants.

Patient perspective on the use of carbon fibre plates for extremity fracture fixation

INTRODUCTION

Carbon fibre-reinforced polyetheretherketone (CFR-PEEK) plates represent an exciting development within trauma and orthopaedic surgery, offering advantages including radiolucency, material properties similar to bone, and lack of localised tissue reaction. As more call for trials examining their use, there is no data available as to the acceptability of these implants to patients. This study aimed to therefore examine the acceptability of CFR-PEEK plates to patients undergoing fracture surgery.

METHODS

This was a prospective cross-sectional survey of patients undergoing surgery for a fracture of the ankle, distal femur, distal radius, or proximal humerus. Once a decision had been made to pursue operative fixation with a plate, patients were provided with descriptions of both CFR-PEEK and stainless steel and titanium metal implants alongside the current clinical evidence. All patients undertook a questionnaire examining their views as to the advantages and disadvantages of CFR-PEEK plates, and whether they would be happy to participate in a trial comparing both.

RESULTS

Ninety-nine patients were happy to participate (64 females, mean age 50). Eighty-seven patients reported that they would want a CFR-PEEK implant for their fracture, and 76 reported that they would be willing to participate in an RCT comparing their use. Commonly reported advantages included radiolucency, low weight and biocompatibility. Disadvantages reported included cost and concerns regarding durability.

CONCLUSIONS

This study demonstrates that CFR-PEEK implants would be acceptable to patients undergoing fracture surgery, with high numbers of patients stating that they would be willing to participate in a randomised study examining their use.

Investigation of the biomechanical stability of Cfr-PEEK in the treatment of mandibular angulus fractures by finite element analysis

The purpose of this study is to explore the effectiveness of Cfr-PEEK, in the fixation of unfavorable fractures of mandibular angulus by comparing it with the titanium and resorbable biomaterials. 8 different fixation models were created. In the first 4 groups, a single mini plate was applied to the upper edge of the fracture line by the Champy method. In the other 4 groups, an additional plate was placed on the lower edge of the fracture line. In these models, titanium, resorbable and Cfr-PEEK plate/screw systems were investigated by the finite element analysis method. The highest Von Mises stress was observed on the upper plate in the group 5 while the lowest was seen in the lower plate in the group 7. The highest stress values on the screws were observed on the screws placed closer to the fracture line. Considering the stresses on the bone around the screws, the highest Pmax and Pmin values were seen in group 5, and the lowest values were seen in the group 7. The highest displacement was observed in the group 3, while the lowest was observed in the group 5. According to the results it can be said that Cfr-PEEK plate/screw systems may provide advantages by decreasing the stresses on the fixation systems over the titanium plates and providing more stable fixation over the resorbable systems. Cfr-PEEK plates of 2 mm thickness seems to be a potential alternative to 1 mm thick titanium plates.