AN EXPERIMENTAL ANALVSIS OF THE

MECHANICAL PERFORMANCES
RELATIVE TO AN ORTHOPEDIC
EXTERNAL FIXATION APPARATUS
by P. Cappa, M. Berardi and R. Spinelli
External fixation is a method of
immobilization that uses percutaneous pins and wires placed
in bone and linked with external connectors. The pins and
wires are nserted under generai anesthesia through skin
and facial incisions (see Fig. 1). In clinica! situations the
bone to which the fixator is attached may be subjected to
forces and moments which may produce virtually any com-
bination of axial loading, bending and torsion. lt is im-
portant, obviously, that the fixator provides adequate
stiffness to ensure an acceptable standard of fracture align-
ment and stability under ali conditions.
The concep of external fixation appears in works of
Malgaigne from the middle of the 19th century and the first
readily available external fixator was designed at the end of
the 19th century. However, results of early applications
were discouraging due to the high incidence of complica-
tions, e.g., pin-tract infection, inadequate stability, difficulties
in bone realignment, and fracture non-unions.
The recent increase in reliability is partially caused by
severa! biomechanical analysesl-1 that focused the static
mechanical performances and the fatigue limits of skeletal
fixators of different designs. There has also been an
awareness that the optimum conditions of support and
movement at the fracture site can significantly affect the
type and quality of fracture healing. Wu et a/.,
10
for example,
observed that the time required to achieve mature bone-
healing with a more rigid external fixator would be longer
than with a less rigid fixator of similar design. However, if
the fixator's rigidity becomes insufficient, delayed union or
non-union may result.
Skeletal fixators are currently utilized in the treatment of
infected fracture, stabilization of joint arthrodesis, osteotomy,
P. Cappa (SEM Member) is Assistant Professar. University of Rome,
Rome, ltaly. M. Berardi is Senior Engineer, HOWMEDICA, Rome,
ltaly. R. Spine/li is Professar, University of Bologna, Institute of
Orthopedics, Bologna, Italy.
Paper was presented at the 1990 SEM Spring Conference on
Experimental Mechanics, fune 3-6, 1990 in Albuquerque, NM.
and limb lengthening. Moreover, because of its versatility,
the external fixator can be used at any body level.
The purpose of this paper is to provide preliminary
quantitative information concerning the static axial stiffness
Fig. 1-Circular external fixator: (1) full or three-quarter rlng;
(2) connecting bar; (3) transfixing pin or w/re
Experimental Technlqueo 31
of a recent externai fixator (HOWMEDICA externai fixator
system). This work is a preliminary study of a global
anaiysis of the mechanicai performances of the examined
fixator that will evaiuate the effects caused by axiailoading
aiong the axis of the hone, bending about the bone's long
axis, and torsion about the long axis of the hone.
EXPERIMENTALPROCEDURE
ANDRESULTS
The examined circular externai fixator can be reduced to
essentials as an extemai structure, made up of two externai
full or three-quarter rings, connected by longitudinai bars
that are attached to the fractured hone by transfixing pins
(diameter of 4 mm) and wires (diameter of l mm), (see
Fig. 1). The pins are threaded in the middle to firmly
grasp both cortices of hone and to reduce pin-tract loosening.
The wires are placed under tension before locking in piace
on the ring by means of a torque wrench equipped with a
scale for indicating the tensile load applied and to assure
a chosen constant tension in each wire used in the device.
The pins and wires fixation clamps can be placed inside
or outside the ring frame. Moreover, the externai fixator
can be assembled, depending on clinical constraints, using
various parameters such as number and relative positions
of longitudinai bars; pins and wires; the chosen preload
applied to the wires; and, finally, the utilization of full or
three-quarter externai rings.
Because the effective load applied to the wires is one of
the hypothesized key parameters for the control of fracture
deflection, the necessity to measure the load with the
intervais of uncertainty less than those associated to the
torque wrench appeared. Then some pretests were carried
out by applying an electricai resistance strain gage on one
wire to evaiuate the tensile load/longitudinai strain relation-
ship. It utilized a rigid base frame and a straining frame
basicaily designed for photoelastic anaiysis. This structure
incorporates a screw-operated loading system that has a
load capacity of 1000 daN. The load applied, monitored by
a commercialload cell placed in series with the wire, was
measured with an intervai of uncertainty aiways less than
0.3 percent. The static strain indicator assured a maximum
intervai of uncertainty of l l'm/m. The wire caiibration
tests were organized so that ten measurements were taken
in the range of 0-150 daN.
The tests were repeated ten times. It was decided to
report the results of the caiibration test as mean standard
deviation. The vaiue of the standard deviation was caiculated
in accordance with the more conservative, i.e., larger,
definition. The measurements relative to the wire caiibra-
tion tests showed small uncertainties. In fact, the standard
deviation vaiues were aiways less than 0.6 percent. Every
wire utilized in this project was equipped with an electricai
strain gage. The effective load applied by the torque wrench
during the locking in place on the ring frame was monitored
by the strain measuring system.
The geometry and physicai property of the hone model
play a relevant role in determining the performance of
externai fixators. However, fresh cadaver bones are charac-
terized by a high variability
11
that can greatly affect the test
32 November/December 1991
results. In fact, when pins and wires are interfaced to hone,
non-uniform models may introduce additional variables and
multiple drill holes could damage the hone quality and
distort the test results. As a consequence, Lexan poly-
carbonate was adopted in experimentai anaiysis to simulate
hone behavior aithough Hein et al.
12
showed that a Lexan
model is about 20 percent stronger than a cadaver hone in
axial compression. The previous observation does not
appear to be a limiting factor because the main objective of
the study was the relative comparison of different fixator
configurations. Moreover, a simple geometry for the
models was chosen; in fact the models of the distai site
have an internai diameter of 13 mm and an externai diameter
of 25 mm. The models of the proximai site have a diameter
equai to 100 mm. The distai and proximai site are defined
in orthopedics as the leg area situated far and dose to the
knee. Although the chosen solid model did not resemble the
structure of the corticai hone, Briggs et al.l obtained similar
mechanicai performances to the actuai hone with cylindricai
models.
For the measurement of fracture deflection as a function
of the applied compressive load, two linear voltage displace-
ment transformers (L VDT) were located diametrically
opposite to the models of the hone. The metrological
characteristics of the displacement system are linearity
error of the transducers equai to 2 percent of full range;
stability of constant voltage power supply unit equal to
(0.01 percent + l m V); and, finaily, accuracy of the DVM
of (0.01 percent + 3 digits).
This experimentai study was carried out examining two
different extemai ring frames that are selected by the
clinicians according to the limb diameter and the objectives
to be achieved. The full rings are made up of a three-quarter
ring and a quarter ring held together by nuts and bolts.
Each examined fixator configuration was assembled in
accordance with the manufacturer's recommendation. New
pins were used whenever redrilling was required, and were
verticaily loaded by means of the same device utilized for
wire caiibration. The compressive loading cycle, measured
by the same load cell utilized in wire calibration and
previously described, was equai to 30-90 daN. The two
displacement readings were done at each increment of
20 daN and averaged. Ten tests were carried out for each
examined model-fixator configuration. The measured dis-
placements showed standard deviation values aiways in the
ranges of 1.1-9.8 percent. The maximum dispersion of the
results was observed for the fixator configurations that do
not utilize transfixing pins but only wires, i.e., for those
configurations that assure less certain interactions in
fixator-synthetic hone.
First, by utilizing 'small' extemai full rings, the verticai
displacement of the distai model was tested. Two wires,
placed orthogonaily, were used and the sliding clamps were
anchored to the internai circumference of the ring frames
with a diameter of 147 mm. The effect in the system stiff-
ness determined by variations of the wire pre-load value
(120 daN or 150 daN) and by the addition of a transfixing
pin was anaiyzed. The results, summarized in Fig. 2, show
the relevance in the overail rigidity of the examined
parameters. The presence of a pin seems to be the most
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Comoressive load [daNJ
Fig. 2-Distal mode/, 'sma/1' external full rlngs, sliding
clamps anchored to the interna/ rim-circumference of the
rings and orthogonal wires. Variation of the fracture
deflection with axia/loads for the examined fixator
configurations. Parameters: tensile load app/ied to the wires
(120 or 150 daN); and a/so utilizatlon of a transfixing pin
00
effective parameter and, in fact, determines a reduction of
the axial motion of the fracture bone site equai to 32 and
36 percent for a wire preload of 120 daN and 150 daN,
respectively.
The vertical displacement of the distai model, when fixed
utilizing 'mediurn' externai full rings, was investigated. A
group of geometrie variables was aitered: the pre-load
applied to the wires (120 daN or 150 daN); the utilization,
or not, of a transfixing pin anchored to the internai rim-
circurnference; and, finally, the mounting of the clamps,
utilized for locking the wire in piace along the external or
the internai rim-circurnference. Figure 3 shows the varia-
tions of the displacements as a function of the applied
compressive loads. The results confirmed the noticeable
effects caused by the wire pre-load vaiues and the presence,
or not, of a transfixing pin, but indicated lso that the most
effective parameter was the position of the sliding clamps.
Moreover, from a comparative examination of similar
model-fixator geometry, with the exception of the externai
ring dimensions (see Figs. 2 and 3) significantly different
behavior emerges. These differences appear to be caused
by the bone's model-clamp separations.
In order to evaluate the performances of a proximal
mode) fixed by a 'medium' external ring, a finai series of
tests was carried out. The chosen parameters were: the
preload applied to the wires (120 daN or 150 daN); the
external ring geometry (full ring or three-quarter ring); and,
the angle between the wires (60 deg or 90 deg). Moreover,
two other configurations were tested including two parailel
transfixing pins anchored to the ring, placing the clamps
aiong the externai or the internai rim circurnference. From
a comparative examination of Fig. 4 which summarizes the
axiai displacements, the irrelevance of the geometry of the
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120 daN)t1 pln
l 6 2 w i resCE:120 ddll)t1 p in
o
50 m oo
Comoressive load [daNJ
Fig. 3-Dista/ mode/, 'medium' external full rings. Variation of
the fracture deflection with axia/loads for the examined
fixator configuration. Parameters: sliding c/amps anchored to
the interna/ (l) or external (E) rim c/rcumference of the ring;
tensile load app/ied to the wires (120 or 150 da N); and a/so
utilization of a transfixing p/n


c
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6 2 porollel pins(J) full ring
9
1::1 2 w i rese I :120 doN:60 ) three-qLCrter ring
8 2 wirssCI:I20 doN:60) full ring
7
2 wiresCI:120 doN:OO ) full rlng
6
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+ 2 w i resCE:150 daN:OO ) j
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Comoressive load [daNJ
Fig. 4-Proxima/ mode/, 'medium' external rings. Variation of
the fracture deflectlon wlth axialloads for the examined
fixator configurations. Parameters: full or three-quarter ring;
sliding clamps anchored to the internai(/) or externa/ (E) rim
circumference of the ring; tenslle load appl/ed to the wlres
(120 or 150 da N); and angle between the wires (60 deg or
90 deg)
externai ring, as well as the angle between the wires,
appeared. Moreover the choice of an internai or externai
anchorage, i.e., the distance variation between the clamps
and the model, seems to be the most effective parameter.
In fact the choice of an internai anchorage determines a
displacement reduction of 71 and 79 percent for a fixator
configuration that utilizes two parailel pins and two ortho-
Experimental Teehniquea 33
gonal wires, respectively. The variation value of the preload
applied to the wires appears to cause no relevant effects on
the fixator behavior. In fact, an increase of the preload of
35 percent determines a decrease in the axial motion equal
to 7 percent.
CONCLUSIONS
The experimental results of this investigation, carried out
for the evaluation of axial motions of the hone fracture site
offered by an extemal fixation apparatus, appear to support
the following conclusions.
(l) The use of a transfixing pin determines more repetitive
results and, as a consequence, more predictive hone healing
and an increase of apparatus stiffness, at least in the range
of the compressive loads tested.
(2) The distance between the clamps and the bone's
model appear to be the key parameter for the improvement
of fracture fixation stiffness.
This information should help clinicians who apply the
tested apparatus to achieve more predictable results.
REFERENCES
l. Briggs, B. T. and Chao, E. YS., "The Mechanical Performance of
the Standard Hoffmann- Vidal External Fi:xation Apparatus, " ]. of
Bone and ]oint Surgery, 64A (4), 566-573 (1982).
2. McCoy, M T., Chao, E. Y.S. and Kasman, R.A., "Comparison of
Mechanical Performance in Four Types of External Fi:xators,"
Clinica/ Orthopedics and Related Research, (l 08), ].B. Lippincott
Company, Philadelphia (1983).
3. Churches, A.E., Tanner, K.E. and Harris, ].D., "The Oxford
External Fi:xator: Fi:xator Stiffness and the Effects of Bone Pin
Loosening, "Engineen'ng in Medicine, 14 (1), 3-11 (1985).
4. Churches, A.E., Tanner, K.E., Evans, M. and Gwillim, ].,
"Fracture Healing Assessment with External Fi:xation," Engineering
in Medicine, 14 (1), 13-20 (1985).
5. Churches, A.E., Tanner, K.E. and Harris, ].D., "An Engineen'ng
Evaluation of the Oxford External Fi:xator with Sliding Clamps:
Fi:xator Stiffness and Fracture Healing Assessment, " Engineering in
Medicine, 14 (1), 21-29 (1985).
6. Hein, T.]. and Chao, E. Y.S., "Biomechanical Analysis of the
Orthofix Axial Externa/ Fi:xator, " Proc. XXIV Rocky Mountain Bio-
engineering Symposium, 23-22 (Apri/27-28, 1987).
7. Fleming, B., Paley, D., Kristiensen, T. and Pope, M, "A Bio-
mechanical Ana/ysis of the flizarov External Fixator," Clinica/
Orthopedics, 95-105 (Aprii 1989).
8. ]ohnson, W.D. and Fisher, D.A., "Skeletal Stabilization with a
Multiplane External Fi:xation Device. Biomechanical Evaluation and
Finite Element Mode/, " Proc. XXIV Rocky Mountain Bioengineering
Symposium, 34-43 (Aprii 27-28, 1987).
9. Demelio, G., Pappalettere, C. and Quaglia, L., "Metodolagia di
analisi strutturale di fissatori esterni" (A Methodology far a Structural
Analysis of External Fi:xator), XIV Conv. A./.A.S., L 'Aquilia, 20-24
(Sept. 1988), (in Italian).
10. Wu, ].]., Shyr, H.S.S., Chao, E. Y.S. and Kelly, P.]., "Com
parison of Osteotomy Healing under External Fi:xation Devices with
Different Stiffness Characteristics," ]ournal of Bone and ]oint Sur-
gery, 66A (8), 1258-1264 (1984).
11. Currey, ].D., "Effect of Differences in Mineralization on the
Mechanical Properties of Bone, " Philosophical Trans. Royal Society
London Bio/ogy, 304, 509-518 (1984).
12. Hein, T.]., Perissinotto, A., Hotchkiss, R. and Chao, E. Y.S.,
"Analysis of Bone Mode/ Materials for External Fracture Fi:xation
Experiments, " Proc. XXIV Rocky Mountain Bioengineering Sym-
posium, 23-33 (Apri/27-28, 1987).
34 November/December 1991
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