G Model

JJBE-2506; No. of Pages 9 ARTICLE IN PRESS

Medical Engineering & Physics xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Medical Engineering & Physics

journal homepage: www.elsevier.com/locate/medengphy

Technical note

Finite element analysis of three commonly used external fixation

devices for treating Type III pilon fractures
Muhammad Hanif Ramlee a , Mohammed Rafiq Abdul Kadir a,∗ ,
Malliga Raman Murali b , Tunku Kamarul b
a
Medical Devices and Technology Group (MEDITEG), Faculty of Biosciences and Medical Engineering, Universiti Teknologi Malaysia, 81310 Johor Bahru,
Johor, Malaysia
b
Tissue Engineering Group (TEG), National Orthopaedic Centre of Excellence in Research and Learning (NOCERAL), Department of Orthopaedic Surgery,
Faculty ofMedicine, University of Malaya, 50603 Lembah Pantai, Kuala Lumpur, Malaysia

a r t i c l e i n f o a b s t r a c t

Article history: Pilon fractures are commonly caused by high energy trauma and can result in long-term immobilization
Received 28 October 2013 of patients. The use of an external fixator i.e. the (1) Delta, (2) Mitkovic or (3) Unilateral frame for treating
Received in revised form 19 May 2014 type III pilon fractures is generally recommended by many experts owing to the stability provided by
Accepted 24 May 2014
these constructs. This allows this type of fracture to heal quickly whilst permitting early mobilization.
However, the stability of one fixator over the other has not been previously demonstrated. This study was
Keywords:
conducted to determine the biomechanical stability of these external fixators in type III pilon fractures
Finite element
using finite element modelling. Three-dimensional models of the tibia, fibula, talus, calcaneus, navicu-
External fixator
Pilon fractures
lar, cuboid, three cuneiforms and five metatarsal bones were reconstructed from previously obtained
Stability CT datasets. Bones were assigned with isotropic material properties, while the cartilage was assigned as
Biomechanics hyperelastic springs with Mooney–Rivlin properties. Axial loads of 350 N and 70 N were applied at the
Micromovement tibia to simulate the stance and the swing phase of a gait cycle. To prevent rigid body motion, the calca-
neus and metatarsals were fixed distally in all degrees of freedom. The results indicate that the model
with the Delta frame produced the lowest relative micromovement (0.03 mm) compared to the Mitkovic
(0.05 mm) and Unilateral (0.42 mm) fixators during the stance phase. The highest stress concentrations
were found at the pin of the Unilateral external fixator (509.2 MPa) compared to the Mitkovic (286.0 MPa)
and the Delta (266.7 MPa) frames. In conclusion, the Delta external fixator was found to be the most stable
external fixator for treating type III pilon fractures.
© 2014 IPEM. Published by Elsevier Ltd. All rights reserved.

1. Introduction
A pilon fracture is a general description of a comminuted frac-
ture at the distal tibia involving the ankle joint that occurs as the
result of high-energy vertical axial loading. This can occur as the
result of a fall from a substantial height, road traffic accidents,
industrial mishaps or sporting injuries, especially those involving
contact sports [1–6]. These fractures are uncommon and represent
up to 7–10% of tibia fractures and less than 1% of all lower extrem-
ity fractures [4,7]. The mechanism of injury varies from simple
rotational fractures to high energy axial compression injuries com-
plicated by shearing, rotation and bending forces [4,8,9]. In 1969,
∗ Corresponding author. Tel.: +6 07 5535961; fax: +6 07 5536222.
E-mail addresses: mhanif008@gmail.com (M.H. Ramlee),
rafiq@biomedical.utm.my (M.R. Abdul Kadir), mrmurali08@gmail.com
(M.R. Murali), tkzrea@um.edu.my (T. Kamarul).
Ruedi and Allgower [10–16] classified the pilon fractures into three
types: type I is an intra-articular fracture of the distal tibia with or
without minimal displacement; type II is a displaced intra-articular
fracture with or without minimal comminution; and type III has sig-
nificant comminution and impaction of the intra-articular surface
with displacement.
Treatment of pilon fractures is targeted to reduce the frac-
ture, align the ankle position, provide fast soft tissue healing,
be minimally invasive, allow the recreation of the joint surfaces
and provide early ankle function [17–19]. Type I and type II frac-
tures can be almost effortlessly restored using internal fixation,
and the results are promising without any major complications
[4,17,20,21]. However, the treatment of a type III fracture is still
controversial since it involves an intra-articular fracture with dis-
placement, significant comminution and is associated with high
rate of complications [1,22]. Immediate treatment is reported to
produce complications such as infection, loss of reduction, non-
union, malunion and deformity [23–26]. A systemic step-wise

http://dx.doi.org/10.1016/j.medengphy.2014.05.015
1350-4533/© 2014 IPEM. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Ramlee MH, et al. Finite element analysis of three commonly used external fixation devices for treating
Type III pilon fractures. Med Eng Phys (2014), http://dx.doi.org/10.1016/j.medengphy.2014.05.015
G Model
JJBE-2506; No. of Pages 9 ARTICLE IN PRESS
2 M.H. Ramlee et al. / Medical Engineering & Physics xxx (2014) xxx–xxx
approach, consisting of fibular plating and temporary bridging
external fixation, later substituted by a definitive external fixation,
was reported to be favourable for type III fracture treatment [2,3,5].
The range of external fixators used for the treatment of type
III pilon fractures includes spanning fixator with rods and clamps,
dynamic or articulated devices, and ring frames [1–3,5,27–30]. The
clinical outcome of using external fixators has been reported to be
superior over those treated with internal plates and screws [28,29].
The three most popular spanning external fixators in the litera-
ture include the Delta, Mitkovic and Unilateral devices [7,27,30].
Although the mid-term clinical outcomes have been shown to be
good in terms of successful healing process, the biomechanical sta-
bility of these devices has not been well investigated. Furthermore,
there is no clear evidence in the present literature with regard to
these types of implants and whether one of these will produce
the best stability in treating type III pilon fractures. Therefore, the
overall aim of this study was to understand the underlying biome-
chanics of the three most commonly used external fixators for type
III pilon fractures. Finite element method was used to (1) assess the
stability of the aforementioned three external fixators (2) investi-
gate the stress distribution in the fixator and bone to highlight the
likelihood of the particular areas of the implant and bone that may
be subjected to excessive mechanical stress.
2. Materials and methods
2.1. Three-dimensional modelling
CT images of the right lower limb used in this study were
acquired with the approval of the medical ethical committee of
the Hospital Tengku Ampuan Afzan, Kuantan, Malaysia [65]. The
slice thickness of the CT images was 1.5 mm in a 512 × 512 matrix.
The DICOM data sets, which consist of 225 CT images, were then
imported into Mimics 15.1 software (Materialise, Leuven, Belgium)
to reconstruct the surface geometry of the tibia, fibula, talus, calca-
neus, cuboid, navicular, cuneiforms and metatarsals. The tibial bone
Fig. 1. Finite element model; (a) Delta frame, (b) Mitkovic fixation, (c) Unilateral external fixator. Fragment 8 is located at the posterior of distal tibia.
Please cite this article in press as: Ramlee MH, et al. Finite element analysis of three commonly used external fixation devices for treating
Type III pilon fractures. Med Eng Phys (2014), http://dx.doi.org/10.1016/j.medengphy.2014.05.015
was cut approximately 20 cm above the medial tibial malleolus
[31,32]. A threshold of 700 Hounsfield units was used to differen-
tiate between cortical and cancellous bone [33]. To simulate type
III pilon fractures, a total of eight fragments (Fig. 1) were modelled
based on the Ruedi and Allgower classification [10–16,30]. A perfect
fit of the interfragments was simulated, i.e. there were no fracture
gaps between the fragments. However, the fragments were allowed
to move relative to each other with an assigned friction coefficient
of 0.3 [34]. All contact between articulating surfaces was assigned a
friction coefficient of 0.3 [34]. All three-dimensional models of the
bones were converted to a surface triangular mesh and saved in a
stereolithographic file format.
2.2. Cartilage and ligaments
The cartilage was modelled manually with an estimated uniform
thickness of 1 mm for the tibia, fibula, talus and calcaneus (Fig. 1)
[35,36]. The behaviour of the cartilage was simulated using the
Mooney–Rivlin hyper-elastic material properties with coefficients
of C01 = 0.41 MPa and C10 = 4.1 MPa [37–40]. A total of 34 ligaments
and three plantar fascias were modelled using linear spring ele-
ments with an assigned specific stiffness (Table 1). The use of linear
links to simulate the ligaments was found to be adequate and has
been reported in previous studies [40–43]. Multiple parallel linear
springs were used to better mimic the distribution of the origin and
insertion of the ligaments [39,40]. The position and insertion points
of all the ligaments were estimated based on Netter (2003) [44].
2.3. Finite element modelling
The bones and cartilage in the STL files were imported into
Marc.Mentat (MSC.Software, Santa Ana, CA). The software was
used to convert the completed three-dimensional model to linear
first order tetrahedral elements. Bones were assigned using lin-
ear isotropic material properties with elastic modulus of 7300 MPa
for cortical bone [50,51] and 1100 MPa for cancellous bone [52].
G Model
JJBE-2506; No. of Pages 9 ARTICLE IN PRESS
M.H. Ramlee et al. / Medical Engineering & Physics xxx (2014) xxx–xxx 3

Table 1 use of axial weight loading has become popular since this technique
Stiffness of ligaments.
is a way of testing bone quality and bone healing process [62]. In
Ligaments represented Stiffness (N/mm) References order to prevent rigid body movements during the analysis, the dis-
in the models tal surfaces of the calcaneus and all metatarsal bones were fixed in
Interosseous membrane (4 ligaments) 400 [45] all directions (Fig. 1). The relative micromovement of all simulated
Anterior tibiofibular (distal) 78 [46] models were measured between the proximal and distal fragments
Posterior tibiofibular (distal) 101 [47] at the lateral side.
Anterior talofibular 90 [46]
Posterior talofibular 70 [48]
Calcaneofibular 70 [48]
3. Results
Anterior tibiotalar 70 [46]
Posterior tibiotalar 80 [46]
Tibiocalcaneal 122 [46] 3.1. Stress distribution
Tibionavicular 40 [46]
Interosseous talocalcaneal 70 [45,48] The von Mises stress at the pin-bone interface at the tibia
Lateral talocalcaneal 70 [48]
and calcaneus is shown in Fig. 2. During the swing phase, the
Medial talocalcaneal 70 [48]
Posterior talocalcaneal 70 [48] observed peak values for the pin-bone interface at the tibia were
Dorsal talonavicular (2 ligaments) 70 [46] 24.9 MPa, 35.6 MPa and 84.9 MPa for the Delta, Mitkovic and Uni-
Calcaneonavicular (dorsal & plantar) 70 [46,48] lateral fixation devices, respectively. The difference in magnitude
Calcaeocuboid (dorsal & short plantar) 70 [46,48]
was even higher during the stance phase for the pin-bone inter-
Cuboideonavicular (dorsal & plantar) 70 [45,46]
Cuneonavicular (dorsal & plantar) 70 a
face at the tibia, where the Unilateral showed two times greater
Intercuneiform (dorsal & plantar) 70 a stress (399.0 MPa) than the Mitkovic (206.6 MPa) and three times
Tarsometatarsal (dorsal & plantar) 70 a greater stress than the Delta fixator (130.3 MPa). Generally, at the
Metatarsal (dorsal & plantar) 70 a tibia, the peak von Mises stress was found at the entrance cortex
Medial plantar fascia 200 [49]
of the pin-bone interface. During the swing phase, the magnitude
Central plantar fascia 230 [49]
Lateral plantar fascia 180 [49] of the maximum stress was 0.8 MPa, 3.6 MPa and 4.5 MPa for the
Long plantar 70 [45] Delta, Mitkovic and Unilateral fixators, respectively. On the other
a: assumed from neighboring ligaments. hand, the FE results in terms of von Mises stress were greater for
the simulated stance phase where the Unilateral generated at least
1.4 times greater (121.4 MPa) than the Mitkovic (87.2 MPa) and 27
Poisson’s ratio for both cortical and cancellous bones was simu- times greater than the Delta (4.5 MPa) frames. At the calcaneus,
lated with value of 0.3 [50,51] and 0.26 [52], respectively. Three high von Mises stress was observed at the pin-bone interface for
external fixator frames, i.e. the Delta, Mitkovic and Unilateral sys- both the swing and the stance phase. During the swing phase,
tems, were designed using three-dimensional (3D) Computer Aided the magnitude of stress for the Unilateral fixator was at least four
Design (CAD) software (Solidworks 2012, Dassault Systemes Solid- times greater (98.5 MPa) as compared to the Mitkovic (20.7 MPa)
works Corp., USA) with 5 mm pins and 11 mm rods. To simulate the and Delta (7.9 MPa) frames. Additionally, greater stresses were
Delta and Mitkovic fixators, two pins were positioned at the tibial observed during the stance phase, where the Unilateral fixator pro-
diaphysis, one pin at the body of the calcaneus and another pin at duced 382.5 MPa, 3.9 times larger than the Mitkovic (98.0 MPa) and
the first metatarsal (Fig. 1) [27,30]. For the Unilateral frame, only 9.2 times larger than Delta external fixator (41.5 MPa)
one pin was positioned at the tibial diaphysis and another pin at the The stress distribution amongst the three external fixators is
body of calcaneus (Fig. 1) [7]. All the fixators were meshed using illustrated in Fig. 3. During the swing phase, higher von Mises
3-Matic 7.1 (Materialise, Belgium) and were assigned with tita- stresses were predicted at the calcaneus pin for the Unilateral exter-
nium material properties with a Young’s modulus of 110,000 MPa nal fixator (113.6 MPa) followed by the Mitkovic (80.0 MPa) and
and Poisson’s ratio of 0.3 [53,54]. Mesh convergence analyses were the Delta (45.6 MPa) frame. For the Delta and Mitkovic systems,
performed and resulted in a variation in mesh size throughout the the proximal pin-bone interface of the tibia bone produced a small
model. The smallest mesh of size 1 was used for the pin-bone inter- stress of 25.0 MPa and 44.5 MPa, respectively, as compared to the
face, whereas a larger mesh size of 3 was used for the bone. The total distal pin-bone interface with a value of 27.0 MPa and 54.5 MPa,
number of elements and nodes for the Delta fixator was 675,000 respectively. At the first metatarsal bone, high stress of 43.5 MPa
and 157,000, respectively; for the Mitkovic fixator, this was 588,000 was found for the Mitkovic fixator, whilst the Delta frame only
and 140,000, respectively, and for the Unilateral frame, this was showed 7.5 MPa of stress at that particular bone. During the stance
510,000 and 112,000, respectively. Contact condition between the phase, the stress at the calcaneus pin for the Unilateral external fixa-
external fixators and bone was set as an explicit contact with a tan- tor (509.2 MPa) was at least 1.8 times greater than with the Mitkovic
gential friction coefficient of 0.4 [52,55,56]. Radial pre-stress was (286.0 MPa) and Delta (266.7 MPa) fixators. At the proximal pin of
not modelled at the interface between the bone and the fixators. the Mitkovic frame, the von Mises magnitude (125.9 MPa) was close
to magnitude of the Delta frame (120.2 MPa). On the other hand, a
small stress of 49.5 MPa was generated at the first metatarsal pin
2.4. Boundary conditions
of the Delta external fixator, whilst the Mitkovic frame (286.0 MPa)
showed 4.5 times greater stress.
In order to simulate human walking conditions, two physiolog-
ical loads were applied in this study: (1) the swing phase [57–59]
and (2) the stance phase [60,61] of a gait cycle, where the force 3.2. Displacement and micromovement
value was determined from the adjacent muscles such as the gas-
trocnemius and soleus. For the swing phase, 10% of the body weight Fig. 4 shows the displacement plot for the tibia bone. For the
was recorded on these particular muscles [57–59]. We assumed a swing phase, the greatest relative micromovement was observed
body weight of 70 kg in our study; therefore, 70 N was applied to for the Unilateral fixator (0.3 mm) as compared to the Mitkovic
the tibia in the axial direction to simulate the swing phase. For the and Delta (0.02 mm) frames. In contrast, the relative micromove-
stance phase, 50% (350 N) of the body weight was applied onto the ment was higher during the stance phase. The Unilateral fixator
foot, as has been reported by Cheung et al. and Simkin [60,61]. The (0.42 mm) generated 8.4 times greater micromovement than the

Please cite this article in press as: Ramlee MH, et al. Finite element analysis of three commonly used external fixation devices for treating
Type III pilon fractures. Med Eng Phys (2014), http://dx.doi.org/10.1016/j.medengphy.2014.05.015
G Model
JJBE-2506; No. of Pages 9 ARTICLE IN PRESS
4 M.H. Ramlee et al. / Medical Engineering & Physics xxx (2014) xxx–xxx

Fig. 2. The von Mises stress distribution for the tibia and calcaneus bones for (a) Delta frame, (b) Mitkovic fixation and (c) Unilateral external fixation.

Mitkovic (0.05 mm) and 14 times greater micromovement than the
Delta (0.03 mm) external fixators.
The contour plot for the displacement of external fixators is
shown in Fig. 5. When simulating the swing phase, it was demon-
strated that the maximum displacement produced by the Unilateral
fixator (8.7 mm) was at least three times greater than the dis-
placement produced by the Mitkovic (3.0 mm) and Delta (0.8 mm)
systems. During the stance phase, the Unilateral fixator generated
the highest magnitude of displacement (34.8 mm). The Delta sys-
tem was the most stable fixation system among the three constructs
examined with a maximum displacement of 3.8 mm. The Mitkovic
system showed a maximum displacement value of 13.4 mm.
4. Discussion
The use of an external fixator for treating type III pilon frac-
tures is a well-accepted surgical option. This system not only allows
minimally invasive surgery of the soft tissue to be performed, but
also maintains the ankle alignment whilst allowing early ankle
mobilization [17–19]. The results of using an external fixator such
as the Delta, Mitkovic or Unilateral frame have been shown to
produce favourable clinical outcomes as compared to internal fixa-
tors [17–19,23–26]. Stable fixation and early anatomic reduction
of all fractures and dislocations can minimize long-term mor-
bidity and hasten soft tissue healing [63,64]. The biomechanical

Please cite this article in press as: Ramlee MH, et al. Finite element analysis of three commonly used external fixation devices for treating
Type III pilon fractures. Med Eng Phys (2014), http://dx.doi.org/10.1016/j.medengphy.2014.05.015
G Model
JJBE-2506; No. of Pages 9 ARTICLE IN PRESS
M.H. Ramlee et al. / Medical Engineering & Physics xxx (2014) xxx–xxx 5

Fig. 3. The von Mises stress plot for the external fixator during swing and stance phase. (a) Delta, (b) Mitkovic and (c) Unilateral.

stability produced by these fixators, provides improved fracture
healing to occur. A correlation between improved stability (albeit
still allowing micromotion to occur) with improved healing has
been demonstrated in a previous study [65]. However, it is clear
that from our extensive literature review that a comparison of the
most common constructs used for type III pilon fracture treatments
appears to be lacking. Hence, the results presented in the present
study are the first that we are aware of. The results presented here
are of value not only for future research, but also serve as an objec-
tive measure for surgeons to justify the choice of one construct
over the other, although it may be necessary for further studies to
be conducted in order to support the choices made.
To build confidence in our FE results, we corroborated our data
with experimental studies of Bergmann et al. [66] and Wang et al.
[32]. The former measured hip contact and ground reaction forces
for four patients during the most frequent activities of daily living.
In order to compare our results with the work of Bergmann et al., we
simulated the ankle region of interest without a fixator. Our results
showed minimum and maximum ground reaction forces of 0.1 N
and 175.9 N, respectively, compared to 0.1 N and 108.7 N obtained

Please cite this article in press as: Ramlee MH, et al. Finite element analysis of three commonly used external fixation devices for treating
Type III pilon fractures. Med Eng Phys (2014), http://dx.doi.org/10.1016/j.medengphy.2014.05.015
G Model
JJBE-2506; No. of Pages 9 ARTICLE IN PRESS
6 M.H. Ramlee et al. / Medical Engineering & Physics xxx (2014) xxx–xxx

Fig. 4. The displacement plot for the tibia bone; (a) Delta fixation, (b) Mitkovic frame and (c) Unilateral external fixator.

by Bergmann et al. [66]. Wang et al. [32], on the other hand, used
nine ankles from cadavers to measure the contact pressure of the
subtalar joint using pressure-sensitive films. For the 600 N load
applied at the tibia, they reported a maximum contact pressure
of 5.13 ± 1.16 MPa. This is close to the result that we obtained from
our FE simulation, which was 5.48 MPa.
In the present study, the high stress at the pin-bone interface and
the surrounding tissues were in agreement with previous reports
[67,68]. The stress concentrated at this particular region is one of
the causes of an unstable external fixator construct and can lead
to pain and implant loosening [12,69–72]. However, this cannot be
avoided when using an external fixator since any designed implants

Please cite this article in press as: Ramlee MH, et al. Finite element analysis of three commonly used external fixation devices for treating
Type III pilon fractures. Med Eng Phys (2014), http://dx.doi.org/10.1016/j.medengphy.2014.05.015
G Model
JJBE-2506; No. of Pages 9 ARTICLE IN PRESS
M.H. Ramlee et al. / Medical Engineering & Physics xxx (2014) xxx–xxx 7

Fig. 5. The displacement plot for the external fixator during the swing and stance phase. (a) Delta, (b) Mitkovic and (c) Unilateral.

using this concept will inherently have to face this issue. Never-
theless, our results showed a more favourable result for the Delta
external fixator than the Mitkovic and Unilateral systems due to the
lower stress magnitudes as well as better stability with lower rel-
ative micromovement values. Our findings appear to be supported
by previously published clinical studies such as those by Cheema
et al. [27]. In their study, they observed that the design of Delta
frames provided the most stable construct, while preventing a high
incidence of getting deformities [27]. For long-term clinical results,
the use of the Unilateral external fixator should be avoided since
the finite element predictions showed the highest relative micro-
movement as compared to the Delta and the Mitkovic constructs.
In addition, the Unilateral system, which does not use a pin at the
first metatarsal bone, can cause forefoot equinus deformities [27].
Interfragment micromovement at the fracture site has been
reported as an important parameter that will assist in bone healing
process. Several studies using ovine has demonstrated that micro-
movement between 0.15 mm and 0.4 mm can assist in the healing
of a fracture gap not more than 3 mm [73,74]. In our analysis, we
simulated a perfect fit for the interfragments, so that there were no
fracture gaps present. The relative micromovement for the swing
phase for these bone fragments was therefore less than 0.02 mm
(Mitkovic and Delta) and 0.3 mm (Unilateral). During the the stance
phase, micromotions were observed to 0.03 mm (Delta), 0.05 mm
(Mitkovic) and 0.42 mm (Unilateral). This suggests that in vivo,
bone regeneration can be expected.
Nevertheless, it is worth noting that unstable fracture fixa-
tion leads to increasing stresses on implants [75–77]. In several
studies it has been shown that stress onto implants fixed at unsta-
ble sites have recoded levels in access maximum principal of
370–600 MPa [75] and von Mises stresses of 436–750 MPa [76,77]
for the plates. Similarly in our analysis, all three external fixators
also demonstrated maximum stress magnitudes at the fixator pin. It
is fortunate however, that the magnitude of these stresses did not
exceed the ultimate strength of titanium alloys used in our sim-
ulation (800–900 MPa) thus suggesting that the construct for all

Please cite this article in press as: Ramlee MH, et al. Finite element analysis of three commonly used external fixation devices for treating
Type III pilon fractures. Med Eng Phys (2014), http://dx.doi.org/10.1016/j.medengphy.2014.05.015
G Model
JJBE-2506; No. of Pages 9 ARTICLE IN PRESS
8 M.H. Ramlee et al. / Medical Engineering & Physics xxx (2014) xxx–xxx
fixations appears to provide adequate stability with minimal risk
of implant failure [78].
In treating type III pilon fractures, initial considerations such
as pin placement and the type of external fixator must be made
properly before the surgery can be conducted. Previous clinical
reports have mentioned that misplacing the pins or improper use
of these devices can lead to a high incidence of complications, with
pin infection and loosening in up to 50% of cases and malunion
rates of up to 45% [24,26,79]. In the simulations conducted here, we
only attempted to show the comparison of ankle external fixator
in terms of the biomechanical properties. Although the Unilateral
frame showed larger displacements and relative micromovements
compared to the other two constructs, stability could be better
achieved by placing the proximal pin closer to the fractured seg-
ments. The literature on pin placement is fairly limited, thus further
study is necessary to assess the biomechanical effects of different
pin orientations.
As with any study, there are limitations that need to be consid-
ered so as to not to overstate the findings. In the present study,
several assumptions and simplifications were made which may
have resulted in alterations to the predicted data. These limitations,
which are inherently particular to computer modelling involving
the reconstruction of complex joints such as the ankle, will be
present and are unfortunately unavoidable. First, it should be noted
that the model was simplified using isotropic material properties
in this simulation, thus excluding all other important factors that
may influence the prediction of fracture stability. Although more
complex modelling would yield more realistic outcomes, omitting
such details appears to be an acceptable practice as demonstrated
by many previous studies [39,40,50,51]. Further simplifications of
ligaments and plantar fascias modelling using linear links again
may have diverted the results from demonstrating true, real life
outcomes. The elements used to simulate the ligaments were not
modified, and therefore were allowed to resist both tension and
compression. Though this may not mimic the actual behaviour of
ligaments, the simplified properties of a spring have been used by
others with acceptable accuracy [40–43]. The insertion points of
the ligaments were estimated based on a reference book by Netter
(2003) [44] and confirmed by an orthopaedic specialist. This was
done as there are no published reports regarding the geometrical
details of all 37 ligaments modelled in our study. Considering the
existence of subject-specific variation in ligament insertion points,
we believe that these estimations were valid. The determination
of the region of interest for the analysis is another limitation of
our study. Due to constraints in computing resources, we modelled
only the distal half of the tibia and fibula. Nevertheless the FE anal-
ysis still valid as similar region of interest has been used by others
[31,32].
5. Conclusion
The results of finite element predictions suggest that the Delta
frame provides better stability and generates lower construct
stresses as compared to Mitkovic and Unilateral external fixators.
Our data therefore suggest that Delta fixators are superior for treat-
ing this type of fracture. However, further studies are required to
validate the outcome of these simulated studies, such as those of
cadaveric or clinical studies.
Ethical approval
Access to the CT images of the right lower limb used in this study
was granted by Dr. Zainun Bt. A. Rahman, Head of Department Diag-
nostic Imaging and Dr. Ghazali Ismail, Chairman of Clinical Research
Please cite this article in press as: Ramlee MH, et al. Finite element analysis of three commonly used external fixation devices for treating
Type III pilon fractures. Med Eng Phys (2014), http://dx.doi.org/10.1016/j.medengphy.2014.05.015
Centre, Hospital Tengku Ampuan Afzan, 25100 Kuantan, Pahang
Darul Makmur, Malaysia.
Acknowledgement
The work has been carried out using the research grants received
from eScienceFund, Ministry of Science, Technology and Innovation
Malaysia, FRGS Ministry of Education Malaysia, and UTM Research
University Grants. More than one of the authors of this paper was
supported under University of Malaya HIR-MOHE research grant.
Conflict of interest
None declared.
References
[1] Kapukaya A, Subasi M, Arslan H, Tuzuner T. Non-reducible, open tibial plafond
fractures treated with a circular external fixator (is the current classification
sufficient for identifying fractures in this area). Injury 2005;36:1480–7.
[2] Piper KJ, Won HY, Ellis AM. Hybrid external fixation in complex tibial plateau
and plafond fractures: an Australian audit of outcomes. Injury 2005;36.
[3] Marsh JL, Nepola JV, Wuest TK, Osteen D, Cox K, Oppenheim W. Unilateral
external fixation until healing with the dynamic axial fixator for severe open
tibial fractures. J Orthop Trauma 1991;5:341–8.
[4] Bonar SK, Marsh JL. Tibial plafond fractures: changing principles of treatment.
J Am Acad Orthop Surg 1994;2:297–305.
[5] Kapukaya A, Subasi M, Arslan H. Management of comminuted closed tibial pla-
fond fractures using circular external fixators. Acta Orthop Belg 2005;71:582–9.
[6] Mittal R, Matthews SJ, Zavras DT, Giannoudis PV. Management of ipsilat-
eral pilon and calcaneal fractures: a report of 2 cases. J Foot Ankle Surg
2004;43:123–30.
[7] Prayson MJ, Moon BS. Stabilization of the fractured tibial plafond. Oper Tech
Orthop 1999;9:216–28.
[8] Borrelli JJ, Ellis E. Pilon fractures: assessment and treatment. Orthop Clin N Am
2002;33:231–45.
[9] Spinosa FA. Chapter 19—classification of fractures and dislocations. Foot Ankle
Radiol 2003:415–51.
[10] Bartolozzi P, Lavini F. Fractures of the tibia pilon. Milan: Springer; 2004.
[11] Anwar R, Tuson KWR, Khan SA. Classification and diagnosis in orthopaedic
trauma. New York: Cambridge University Press; 2008.
[12] Hopton BP, Harris NJ. Fractures of the foot and ankle. Surgery 2010;28:502–7.
[13] Ruedi T, Matter P, Allgower M. Intra-articular fractures of the distal tibial end.
Hel Chir Acta 1968;35:556–82.
[14] Ruedi T. The treatment of displaced metaphyseal fractures with screws and
wiring systems. Orthopedics 1989;12:55–9.
[15] Ruedi T, Allgower M. The operative treatment of intra-articular fractures of the
lower end of the tibia. Clin Orthop Relat Res 1979;138:105–10.
[16] Ruedi T. Fractures of the lower end of the tibia into the ankle joint: results 9
years after opne reduction and internal fixation. Injury 1973;5:130–4.
[17] Liporace FA, Yoon RS. An adjunct to percutaneous plate insertion to obtain
optimal sagittal plane alignment in the treatment of pilon fractures. J Foot Ankle
Surg 2012;51:275–7.
[18] Dudko S, Kusz D, Wojciechowski P, Stoltny T. Operative treatment of ankles
fractures using internal osteosynthesis by a minimal surgical approach. Foot
2004;14:185–91.
[19] Mauffrey C, Vasario G, Battiston B, Lewis C, Beazley J, Seligson D. Tibial pilon
fractures: a review of incidence, diagnosis, treatment, and complications. Acta
Orthop Belg 2011;77:432–40.
[20] Pellegrini M, Cuchacovich N, Lagos L, Henriquez H, Carcuro G, Bastias C.
Minimally-invasive alternatives in the treatment of distal articular tibial frac-
tures. Fur Sprunggelenk 2012;10:37–45.
[21] Wall OR, Pinder R, Faraj AA. Ender’s nail fixation of tibial pilon fractures—a safe,
minimally invasive approach for high risk patients in a small district general
hospital. Inj Extra 2007;38:8.
[22] Etter C, Ganz R. Long-term results of tibial plafond fractures treated with open
reduction and internal fixation. Arch Orthop Trauma Surg 1991;110:277–83.
[23] Picanz J. Poor results mark ORIF of tibial plafond fractures. Orthop Today
1990;10:1–2.
[24] Teeny S, Wiss DA, Hathaway R, Sarmiento A. Tibial plafond fractures:
errors, complications, and pitfalls in operative treatment. Orthop Trans
1990;14:265–71.
[25] Rammelt S, Marti RK, Raaymakers ELFB, Grass R, Zwipp H. Joint preserving
reconstruction of malunited pilon fractures. Fur Sprunggelenk 2012;10:62–72.
[26] Sirkin M, Sanders R, DiPasquale T, Herscovici D. A staged protocol for soft tissue
management in the treatment of complex pilon fractures. J Orthop Trauma
1999;13:78–84.
[27] Cheema GS, Arora S, Sabat D, Singla J, Goel N, Maini L. The results of two-staged
operative management of pilon fractures—a review of 25 cases. J Clin Orthop
Trauma 2011;2:104–8.
G Model
JJBE-2506; No. of Pages 9 ARTICLE IN PRESS
M.H. Ramlee et al. / Medical Engineering & Physics xxx (2014) xxx–xxx
[28] Barbieri R, Schenk R, Koval K, Aurori K, Aurori B. Hybrid external fixation in the
treatment of tibial plafond fractures. Clin Orthop Relat Res 1996;332:16–22.
[29] Bone L, Stegemann P, McNamara K, Seibel R. External fixation of severely com-
minuted and open tibial pilon fractures. Clin Orthop Relat Res 1993;292:101–7.
[30] Mitkovic MB, Bumbasirevic MZ, Lesic A, Golubovic Z. Dynamic external fixa-
tion of comminuted intra-articular fractures of the distal tibia (type C pilon
fractures). Acta Orthop Belg 2002;68:508–14.
[31] Cheung JT-M, Zhang M, An KN. Effect of Achilles tendon loading on plantar
fascia tension in the standing foot. Clin Biomech 2006;21:194–203.
[32] Wang CL, Cheng CK, Chen CW, Lu CM, Hang YS, Liu TK. Contact areas and
pressure distributions in the subtalar joint. J Biomech 1994;28:269–79.
[33] Yosibash Z, Trabelsi N, Milgrom C. Realiable simulations of the human proxi-
mal femur by high-order finite element analysis validated by the experimental
observations. J Biomech 2007;40:3688–99.
[34] Chen WP, Tai CL, Shih CH, Hsieh PH, Leou MC, Lee MS. Selection of fixation
devices in proximal femur rotational osteotomy: clinical complications and
finite element analysis. Clin Biomech 2004;19:255–62.
[35] Millington SA, Grabner M, Wozelka R, Anderson DD, Hurwitz SR, Crandall JR.
Quantification of ankle articular cartilage topography and thickness using a
high resolution stereophotography system. Osteoarthr Cartil 2007;15:205–11.
[36] Akiyamat K, Sakai T, Sugimoto N, Yoshikawa H, Sugamoto K. Three-dimensional
distribution of articular cartilage thickness in the elderly talus and cal-
caneus analyzing the subchondral bone plate density. Osteoarthr Cartil
2012;20:296–304.
[37] Brown CP, Nguyen TC, Moody HR, Crawford RW, Oloyede A. Assess-
ment of common hyperelastic constitutive equations for describing normal
and osteoarthritis articular cartilage. Proc Inst Mech Eng H: J Eng Med
2009;223:643–52.
[38] Li Z, Kim J-E, Davidson JS, Etheridge BS, Alonso JE, Eberhardt AW. Biomechanical
response of the pubic symphysis in lateral pelvic impacts: a finite element
study. J Biomech 2007;40:2758–66.
[39] Gislason MK, Stansfield B, Nash DH. Finite element model creation and stability
considerations of complex biological articulation: the human wrist joint. Med
Eng Phys 2010;32:523–31.
[40] Bajuri MN, Abdul Kadir Mohammed Rafiq, Murali Malliga Raman, Kamarul T.
Mechanical and functional assessment of the wrist affected by rheumatoid
arhtritis: a finite element analysis. Med Eng Phys 2012;34:1294–302.
[41] Ezquerro F, Jimenez S, Perez A, Prado M, de Diego G, Simon A. The influence
of wire positioning upon the initial stability of scaphoid fractures fixed using
Kirschner wires: a finite element study. Med Eng Phys 2007;29:652–60.
[42] Tao K, Wang D, Wang C, Wang X, Liu A, Nester CJ, et al. An in vivo exper-
imental validation of a computational model of human foot. J Bionic Eng
2009;6:387–97.
[43] Yu J, Cheung JT-M, Fan Y, Zhang Y, Leung AKL, Zhang M. Development of a
finite element model of female foot for high-heeled shoe design. Clin Biomech
2008;23. S31-S8.
[44] Netter FH. Atlas of human anatomy. 3rd ed New York City, USA: ICON Learning
System; 2003.
[45] Pfaeffle HJ, Tomaino MM, Grewal R, Xu J, Boardman ND, Woo SL, et al. Tensile
properties of the interosseous membrane of the human forearm. J Orthop Res
1996;14:842–5.
[46] Siegler S, Block J, Schneck CD. The mechanical characteristics of the collateral
ligaments of the human ankle joint. Foot Ankle 1988;8:234–42.
[47] Beumar A, van Hemert WL, Swierstra BA, Jasper LE, Belkoff SM. A biomechanical
evaluation of the tibiofibular and tibiotalar ligaments of the ankle. Foot Ankle
Int 2003;24:426–9.
[48] Liacouras PC, Wayne JS. Computational modeling to predict mechanical func-
tion of joints: application to the lower leg simulation of two cadaver studies. J
Biomech Eng 2007;129:811–7.
[49] Iaquinto JM, Wayne JS. Computational model of the lower leg and foot/ankle
complex: application to arch stability. J Biomech Eng 2010:2010.
[50] Nakamura S, Crowninshield RD, Cooper RR. An analysis of soft tissue loading in
the foot—a preliminary report. Bull Prosthet Res 1981;18:27–34.
[51] Qiu TX, Teo EC, Yan YB, Lei W. Finite element modeling of a 3D coupled foot-boot
model. Med Eng Phys 2011;33:1228–33.
[52] Kim H-J, Kim S-H, Chang S-H. Bio-mechanical analysis of a fractures tibia with
composite bone plates according to the diaphyseal oblique fracture angle. Com-
pos B: Eng 2011;42:666–74.
[53] Fan Y, Xiu K, Duan H, Zhang M. Biomechanical and histological evaluation of the
application of biodegradable poly-l-lactic cushion to the plate internal fixation
for bone fracture healing. Clin Biomech 2008;23:S7–16.
[54] Benli S, Aksoy S, Havitcioglu H, Kucuk M. Evaluation of bone plate with low-
stiffness material in terms of stress distribution. J Biomech 2008;14:3229–35.
Please cite this article in press as: Ramlee MH, et al. Finite element analysis of three commonly used external fixation devices for treating
Type III pilon fractures. Med Eng Phys (2014), http://dx.doi.org/10.1016/j.medengphy.2014.05.015
9
[55] Cordey J, Borgeaud M, Perren SM. Force transfer between the plate and the
bone: relative importance of the bending stiffness of the screws and the friction
between plate and bone. Injury 2000;31:21–8.
[56] Tajdari M, Javadi M. A new experimental procedure of evaluating the
friction coefficient in elastic and plastic region. J Mater Process Technol
2006;1–3:247–50.
[57] Heintz S, Gutierrez-Farewik EM. Static optimization of muscle forces dur-
ing gait in comparison to EMG-to-force processing approcach. Gait Posture
2007;26:279–88.
[58] Anderson FC, Pandy MG. Static and dynamic optimization solutions for gait are
practically equivalent. J Biomech 2001;34:153–61.
[59] Kim S-H, Chang S-H, Son D-S. Finite element analysis of the effect of bending
stiffness and contact condition of composite bone plates with simple rectan-
gular cross-section on the bio-mechanical behaviour of fractures long bones.
Compos Part B 2011;42:1731–8.
[60] Cheung JT-M, Zhang M, Leung AKL, Fan YB. Three-dimensional finite element
analysis of the foot during standing—a material sensitivity study. J Biomech
2005;38:1045–54.
[61] Simkin A. Structural analysis of the human foot in standing posture. Tel Aviv:
Tel Aviv University; 1982.
[62] Aarnes GA, Steen H, Kristiansen LP, Festo E, Ludvigsen P. Optimum load-
ing mode for axial stiffness testing in limb lengthening. J Orthop Res
2006;24:348–54.
[63] Chandran P, Puttaswamaiah R, Dhillon MS, Gill SS. Management of complex
open fracture injuries of the midfoot with external fixation. J Foot Ankle Surg
2006;45:308–15.
[64] Zgonis T, Roukis TS, Polyzois V, Wukich DK. Surgical management of the unsta-
ble diabetic Charcot deformity using the Taylor spatial frame. Oper Tech Orthop
2006;16:10–7.
[65] Izaham RMAR, Kadir MRA, Rashid AHA, Hossain MG, Kamarul T. Finite ele-
ment analysis of Puddu and Tomofix plate fixation for open wedge high tibial
osteotomy. Injury 2012;43:898–902.
[66] Bergmann G, Deuretzbacher G, Heller M, Graichen F, Rohlmann A, Straus J,
et al. Hip contact forces and gait patterns from routine activities. J Biomech
2001;34:859–71.
[67] Donaldson FE, Pankaj P, Simpson AHRW. Bone properties affect loosen-
ing of half-pin external fixators at the pin-bone interface. Injury 2012;43:
1764–70.
[68] Brianza S, Brighenti V, Lansdowne JL, Schwieger K, Boure L. Finite element anal-
ysis of a novel pin-sleeve system for external fixation of distal limb fractures
in horses. Vet J 2011;190:260–7.
[69] Gardner TN, Mishra S. The biomechanical environment of a bone fracture
and its influence upon the morphology of healing. Med Eng Phys 2003;25:
455–64.
[70] Nash RA, Nunamaker DM, Boston R. Evaluation of a tapere-sleeve transcortical
pin to reduce stress at the bone-pin interface in metacarpal bones obtained
from horses. Am J Vet Res 2001;62:955–60.
[71] Richardson DW, Nunamaker DM, Sigafoos RD. Use of an external skeletal fixa-
tion device and bone graft for arthrodesis of the metacarpophalangeal joint in
horses. J Am Vet Med Assoc 1987;191:316–21.
[72] Williams TM, Nepola JV, DeCoster TA, Hurwitz SR, Dirschl DR, Marsh JL.
Factors affecting outcome in tibial plafond fractures. Clin Orthop Relat Res
2004;423:93–8.
[73] Claes LE, Wilke HJ, Augat P, Rubenacker S, Margevicius KJ. Effect of dynamiza-
tion on gap healing of diaphyseal fractures under external fixation. Clin
Biomech 1995;10:227–34.
[74] Goodship AE, Kenwright J. The influence of induced micromovement upon
healing of experimental tibial fractures. J Bone Jt Surg 1985;67B:650–5.
[75] Chen G, Schmutz B, Wullschleger M, Pearcy MJ, Schuetz MA. Computational
investigations of mechanical failures of internal plate fixation. Proc Inst Mech
Eng H: J Eng Med 2010;224:119–26.
[76] Ebrahimi H, Rabinovich M, Vuleta V, Zalcman D, Shah S, Dubov A, et al.
Biomechanical properties of an intact, injured, repaired, and healed femur:
an experimental and computational study. J Mech Behav Biomed Mater
2012;16:121–35.
[77] Moazen M, Mak JH, Etchels LW, Jin Z, Wilcox RK, Jones AC, et al. The effect of
fracture stability on the performance of locking plate fixation in periprosthetic
femoral fractures. J Arthroplast 2013;28:1589–95.
[78] Gorsse S, Miracle DB. Mechanical properties of Ti–6Al–4V/TiB compos-
ites with randomly oriented and aligned TiB reinforcement. Acta Mater
2003;51:2427–42.
[79] Redfern DJ, Syed SU, Davies SJM. Fractures of the distal tibia: minimally invasive
plate osteosynthesis. Injury 2004;35:615–20.