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Fixation Devices

Pedicle screw and spinal fixation mechanics, including failure rates, loosening patterns, and indications for revision surgery.

Overview

Fixation devices span diverse anatomical sites and pathologies, requiring specific anchoring concepts and patient selection criteria to ensure primary stability and clinical success. In spinal applications, rigid fixation with screws and rods improves fusion rates for C1-C2 instability in children with skeletal dysplasias [9], while appropriate patient selection is crucial for motorized intramedullary nails in managing limb-length discrepancy and deformity [6]. For cervical spine surgery, open reduction and adequate internal fixation in lateral mass screw fixation are technically demanding and offer limited chances for a good outcome [26]. In the lumbar spine, both keel and spike anchoring concepts for the Activ L® intervertebral disc prosthesis fulfill required criteria of primary stability in cadaver bone [2].

Extremity fixation strategies vary by anatomical location and fracture pattern. Screw fixation in distal interphalangeal joint arthrodesis is associated with higher union rates, less required immobilization, and quicker regain of useful function [10]. For Zone I flexor tendon–bone reattachment, FiberWire-anchor repairs provide the best combination of mechanical properties, though anchor fixation may be contraindicated in patients greater than 75 years due to poor bone quality [23]. In basicervical femoral neck fractures, no single implant is superior; surgeons should select fixation constructs based on individual patient anatomy and surgeon comfort [53]. Current indications for locked plating include periarticular fractures, typically those with metaphyseal comminution [25].

Long-term outcomes and specific device limitations require ongoing scrutiny. Two to five-year follow-up results for Cotrel-Dubousset instrumentation in adolescent idiopathic scoliosis are encouraging, but five to ten-year follow-up is needed for more definitive data on advantages and disadvantages [11]. Further studies on long-term outcomes and the strength of cross-pin fixation are required because one of 18 patients showed broken pins in soft tissue anterior cruciate ligament reconstructions [17]. In arthroscopic meniscal repair, biodegradable screws are recommended as fixation devices with a high rate of good and excellent clinical results [4]. The Locking Compression Plate (LCP) revolutionizes internal fixation but requires adapted surgical techniques and new thinking about commonly used concepts of interventional fixation to avoid failures and complications [5].

Anatomy & Pathophysiology

Osseous and Biomechanical Stability

Posterior Instrumentation: Posterior instrumentation for thoracolumbar fractures enables reliable stabilization that permits early mobilization [8]. Pedicle-screw fixation constructs are more rigid than other forms of internal fixation, allowing earlier mobilization and potentially improving fusion rates [47]. Modern segmental screw-based fixation systems for the upper cervical spine are biomechanically more stable and user-friendly than previous wiring techniques [51], offering superior rigidity and fusion rates approaching 100% [51].

Implant Biomechanics and Morphology: Additive manufacturing offers improved biomechanical properties and fixation systems, enabling use in areas where current implants are not well suited [13]. A stand-alone two-part fusion cage provides a justifiable biomechanical benefit [15]. The femoral neck system (FNS) has excellent biomechanical properties and shows significantly higher overall construct stability compared to cannulated compression screws for fixation of femoral neck fracture in younger patients [42]. Compression screw fixation provides excellent biomechanical stability that is comparable to dorsal plating or lag screws for metacarpal shaft fixation [57]. Boron-coated titanium alloy pedicle screws have stronger biomechanical properties and could be a better alternative to currently used titanium screws [58].

Spinal Fusion Dynamics: The biomechanics of the lumbar spine may differ with each individual [34]. The biomechanical properties of a stable spinal fusion preceded the radiographic appearance of a solid fusion by at least eight weeks [43], with immature woven bone providing substantial stiffness to the fusion mass [43]. In a worst-case scenario of rod fracture in the thinnest pedicle screw of the spinal hybrid elastic rod system, biomechanical effects still afford nearly sufficient spine support and gentle adjacent segment stress [44].

Cage and Interface Mechanics: Stress at the endplate-cage interface decreases as the stiffness of a lattice topology optimized cervical interbody fusion cage is reduced [49]. Subsidence is less likely to occur in a cage with lower stiffness [49]. Cement-augmented pedicle screw instrumentation (CAPSI) is more likely to increase the potential risk of adjacent segment degeneration compared to cemented pedicle screws (CPS) in osteoporotic lumbar models [45]. Both CPS and CAPSI increase range of motion (ROM) and disc stresses in osteoporotic lumbar models [45]. Further biomechanical tests and clinical studies are required to prove Tektona®'s capabilities for height and volume restoration in osteoporotic vertebral compression fractures compared to standard balloon kyphoplasty [50].

Kinematics and Pathological Variants

Dislocation Patterns: L4–5 dislocation may be a variant to lumbosacral (L5-S1) dislocation, owing to hyperextension injury [34]. Transpedicular screw fixation may not cause scoliosis but could lead to change of cervical curvature in a piglet model [62].

Tuberculosis Management: Selection of the fusion and fixation range in intervertebral surgery to correct thoracolumbar and lumbar tuberculosis effectively restores the physiological curvature of the spine [60]. This selection also reduces the degeneration of adjacent vertebral bodies in the spinal column [60].

Preoperative Planning and Validation Needs

Modeling and Validation: Biomechanical data from the minipig model provides a baseline comparison for future studies regarding pedicle screw fixation morphometry and mechanics [37]. Further biomechanical and clinical studies are needed to validate the use of a spinous process screw in C2 as a third anchor point for occipitocervical fixation [38]. Internal fixation systems for the spine include excellent sections on anatomy, biomechanics, and preoperative planning [39].

Cervical Plate Dynamics: Mobility and stability of rotational and translational joints are key factors for fusion rate and adjacent segment degeneration progression in static and dynamic cervical plates [56].

Classification

Tadpole System: Demonstrates favorable long-term clinical outcomes [1].

Activ L® Intervertebral Disc Prosthesis: Both keel and spike anchoring concepts fulfill the required criteria of primary stability [2].

Modified Dynamic External Fixation: This system is simple, cheap, and relatively easily applied for the treatment of dorsal fracture subluxations and pilon fractures of finger proximal interphalangeal joints [3].

Biodegradable Screws: Recommended as fixation devices with a high rate of good and excellent clinical results [4].

Locking Compression Plate (LCP): A new implant revolutionizing internal fixation that requires adapted surgical techniques and new thinking about commonly used concepts of interventional fixation to avoid failures and complications [5]. Surgeons must be aware of when locked plating is superior to other methods and when to use alternative treatment modalities [7].

Posterior Instrumentation for Thoracolumbar Fractures: Advances in biomechanics and fixation systems have enabled reliable stabilization that permits early mobilization [8].

Additive Manufacturing: Offers improved biomechanical properties and fixation systems, enabling use in areas where current implants are not well suited [13].

Occipito-Cervical Fusion (OCJ): New implants may represent a new tool in OCJ fixation, but further studies are required to investigate their behavior in an anatomical setting [16].

Cortical Suspensory Fixation Devices: The real difference between fixed-loop and adjustable-loop devices is that only the adjustable-loop device allows the surgeon to determine final graft tension after the device is deployed and fixation is completed [24].

Small Finger Metacarpal Neck Fractures: Other means, such as closed reduction with pin fixation or open reduction internal fixation, should be considered when maintenance of reduction is desired [28].

Posterior Malleolar Fractures: For fragments <15%, posterior-anterior (PA) and anterior-posterior (AP) screws provided good fixation compared to the posterior plate [30].

Thoracic Pedicle Instrumentation: A CT-based classification of thoracic pedicles determined by inner cortical width can help surgeons predict whether screws can be inserted into the thoracic pedicle, thus guiding instrumentation when posterior vertebral column resection (PVCR) is performed [46].

Femoral Cross-Pin System: Good surgical techniques are crucial for successful fixation [52].

Short Segment Pedicle Screw Instrumentation: With an index level screw and cantilevered hyperlordotic reduction, this method gives excellent radiological results with a very low rate of failure regardless of whether the fractures have a high or low load-sharing classification score [55].

Clinical Presentation

Primary Stability and Implant Selection: Successful fixation requires devices made of tissue-compatible materials with sufficient strength, ease of insertion, and long-term function without deleterious effects [14]. The Tadpole system fixation shows favorable long-term clinical outcomes [1]. For the Activ L® intervertebral disc prosthesis, both keel and spike anchoring concepts fulfill the required criteria of primary stability [2]. Biodegradable screws are associated with a high rate of good and excellent clinical results as fixation devices for arthroscopic meniscal repair [4]. Breakage of biodegradable cross-pins used for femoral fixation in anterior cruciate ligament reconstruction using a hamstring autograft is relatively common but did not affect clinical outcomes [36].

Spinal and Pelvic Fixation Strategies: Advances in biomechanics and fixation systems have enabled reliable stabilization that permits early mobilization for posterior instrumentation in thoracolumbar fractures [8]. The biomechanical benefit of a stand-alone two-part fusion cage can be justified [15]. New implants for occipito-cervical fusion may represent a new tool in OCJ fixation, but further studies are required to investigate their behavior in an anatomical setting [16]. The association of percutaneous fixation with a novel vertebral body augmentation system allows for better correction of the RTA in non-osteoporotic spinal fractures but did not seem to prevent the loss of correction at follow-up [20]. Among patients who achieved successful posterior lumbar internal fixation, whether or not to remove the fixation instruments should be evaluated carefully [21]. Both bilateral fragility fractures of the sacrum after bisegmental transsacral stabilization and spinopelvic fixation allowed immediate pain reduction and early mobilization, with patients reaching a mean of over 3,000 steps per day at mid-term follow-up regardless of the construct used [22].

Extremity and Fracture-Specific Fixation: The modified dynamic external fixation system is simple, cheap, and relatively easily applied for dorsal fracture subluxations and pilon fractures of finger proximal interphalangeal joints [3]. Screw fixation for distal interphalangeal joint arthrodesis is associated with higher union rates, less required immobilization, and quicker regain of useful function [10]. Open reduction and internal fixation with cerclage wires or a T-plate yields good functional results in most patients for proximal humeral fractures [35]. For patients with high risk factors for neck re-shortening after reduction and fixation in valgus-impacted femoral neck fractures, in situ fixation may be a choice, while for young patients with good bone quantity, fixation after reduction is a better choice [12]. The choice of fixation for intertrochanteric and pertrochanteric fragility fractures requires considering the risk of peri-implant fractures within the greater context of surgical decision-making [19].

Technical Considerations and Decision-Making: The Locking Compression Plate (LCP) is a new implant revolutionizing internal fixation that requires adapted surgical techniques and new thinking about commonly used concepts of interventional fixation to avoid failures and complications [5]. Surgeons must be aware of when locked plating is superior to other methods and when to use alternative treatment modalities [7]. Appropriate patient selection is crucial for the use of motorized intramedullary nails for limb-length discrepancy and deformity, as external fixation and hybrid techniques will continue to be necessary for specific cases [6]. Additive manufacturing offers improved biomechanical properties and fixation systems, enabling use in areas where current implants are not well suited [13].

Investigations

Plain radiography: Dynamic external fixation systems are simple, cheap, and relatively easily applied for treating dorsal fracture subluxations and pilon fractures of finger proximal interphalangeal joints [3]. Posterior-anterior (PA) and anterior-posterior (AP) screws provide good fixation for posterior malleolar fractures with fragments <15%, compared to a posterior plate [30]. Radiographic evidence supports stable fixation with negligible subsidence and new-bone formation at the coated-uncoated interface for hydroxyapatite-coated femoral implants [32]. Residual radiolucency is an important contraindication to removing compression plates from forearm bones [61]. Olecranon bone graft treatment of distal phalanx nonunions resulted in complete radiological union in 10 of 11 patients with no pain, deformity, or instability [72]. Fixation using SI screws demonstrated similar stiffness values through the sacroiliac joint at four- and eight-weeks post-operatively when compared to healthy controls [77].

MRI: Metal suppression magnetic resonance imaging techniques facilitate better-informed diagnostic decisions by addressing metal artifacts in orthopaedic and spine surgery [63]. Factors affecting the magnitude of metal artifacts in orthopaedic MRI are discussed in reviews of metal suppression techniques [63]. The mean reduction in volume of poly-L-lactic acid bioabsorbable interference screws used for bone-patellar tendon-bone autograft fixation in ACL reconstruction was approximately two thirds after 2 years as measured by MRI [64].

CT: CT navigated pedicle screws can be positioned safely in the cervical and upper thoracic region, though greater caution is required in patients with prior anterior surgery and ventral plating [76].

Other Considerations: External fixation and hybrid techniques remain necessary for specific cases of limb-length discrepancy and deformity management [6]. Surgeons must identify when locked plating is superior to other methods and when to use alternative treatment modalities [7]. Rigid fixation with screws and rods improves fusion rates for C1-C2 instability in children with skeletal dysplasias [9]. In situ fixation may be chosen for patients with high risk factors for neck re-shortening after reduction and fixation in valgus-impacted femoral neck fractures [12]. Fixation after reduction is a better choice for young patients with good bone quantity in valgus-impacted femoral neck fractures [12]. New occipito-cervico fusion implant designs may represent a new tool for OCJ fixation, but further studies are required to investigate their behavior in an anatomical setting [16]. Instrumented approaches, well-selected biologic adjuncts, and achieving solid fusion carry important long-term clinical advantages in avoiding revision surgery for nonunion in posterior lumbar fusion [31]. Imaging remains difficult in posterior lumbar fusion contexts [31]. Approximately 76% of males and females can accommodate screws with diameters of 7.3 mm in S1 for transverse sacroiliac screw placement [70]. All persons can accommodate 7.3 mm screws in S2 for transverse sacroiliac screw placement [70]. Modified minimally invasive procedures for tracer fixation in robot-assisted pedicle screw insertion result in minimal trauma and are simple, reliable, and highly safe [71]. Awake percutaneous fixation for unstable spine fractures in high-risk patients is safe and feasible [73]. A dedicated team including an anesthesiologist and radiologist is needed to treat awake percutaneous fixation cases safely and quickly [73]. Successful initial fixation can be achieved in most cases with 3 cm of cortical contact for titanium tapered splined stems, regardless of taper angle design [74]. Titanium-encased ceramic liner total hip arthroplasty demonstrates favorable and safe clinical and radiological outcomes with over 15 years of follow-up [75].

Treatment

Non-Operative

Conservative management remains a viable option for specific fracture patterns. The moulded short metacarpal cast effectively treats angulated extra-articular metacarpal fractures of the diaphysis and diametaphyseal junction [68]. For proximal phalangeal fractures, a non-invasive technique using a thermoplastic traction platform is safe and effective [66].

Operative

Indications: Appropriate patient selection is crucial for motorized intramedullary nails in limb-length discrepancy and deformity, while external fixation and hybrid techniques remain necessary for specific cases [6]. Locked plating is indicated for periarticular fractures, typically those with metaphyseal comminution [25]. Inability to maintain acceptable cervical reduction with a halo fixator indicates the need for alternative treatment, such as internal fixation or traction [59]. Surgeons must be aware of when locked plating is superior to other methods and when to use alternative treatment modalities [7].

Surgical Approach / Technique: Open reduction and adequate internal fixation for lateral mass screw fixation in the cervical spine are technically demanding and offer little chance of a good outcome [26]. Closed reduction with pin fixation or open reduction internal fixation should be considered for small finger metacarpal neck fractures when maintenance of reduction is desired [28]. Three methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence, but the risk of reoperation was much higher than expected [67].

Implant Selection: The Tadpole system fixation shows favorable long-term clinical outcomes [1]. Both keel and spike anchoring concepts of the Activ L® intervertebral disc prosthesis fulfill the required criteria of primary stability [2]. Biodegradable screws are recommended as fixation devices with a high rate of good and excellent clinical results for arthroscopic meniscal repair [4]. The biomechanical benefit of a stand-alone two-part fusion cage can be justified compared with established fixation techniques [15]. Cement-augmented pedicle screws (CAPS) fixation is an effective and safe technique to achieve solid fixation and favorable clinical outcomes in elderly patients with spinal tuberculosis and severe osteoporosis [41]. Both monoplanar screws (MSs) and hybrid fixed axial and polyaxial screws (HSs) are effective treatments for traumatic thoracolumbar burst fractures with comparable clinical outcomes [40]. Radiographic evidence supports stable fixation with negligible subsidence and new-bone formation at the coated-uncoated interface for hydroxyapatite-coated femoral implants [32]. FiberWire-anchor repairs provide the best combination of mechanical properties for Zone I flexor tendon–bone reattachment, but anchor fixation may be contraindicated in patients greater than 75 years due to poor bone quality [23]. Acute total hip arthroplasty in acetabular fractures in the elderly using the Octopus System is promising due to bone stock deficiency which may lead to fixation failures [69].

Alignment / Balancing Strategy: The 6s method demonstrates similar efficacy to long-segment fixation (8s) in maintaining long-term deformity correction for thoracolumbar type A fractures [18]. Rigid fixation with screws and rods improves fusion rates for C1-C2 instability in children with skeletal dysplasias [9]. Two to five-year follow-up results for Cotrel-Dubousset instrumentation in adolescent idiopathic scoliosis are encouraging, but five to ten-year follow-up is needed for definitive data on advantages and disadvantages [11].

Adjuncts: The modified dynamic external fixation system is simple, cheap, and relatively easily applied for dorsal fracture subluxations and pilon fractures of finger proximal interphalangeal joints [3]. Spanning fixation mitigates the risk of peri-implant fractures in intertrochanteric and pertrochanteric fragility fractures, though this risk must be considered within the greater context of surgical decision-making [19]. Both bisegmental transsacral stabilization and spinopelvic fixation for bilateral fragility fractures of the sacrum allow immediate pain reduction and early mobilization, with patients reaching a mean of over 3,000 steps per day at mid-term follow-up [22].

Other Considerations: Advances in biomechanics and fixation systems enable reliable stabilization that permits early mobilization for posterior instrumentation in thoracolumbar fractures [8]. Whether to remove internal fixation after successful posterior lumbar internal fixation should be evaluated carefully based on patient-reported quality of life [21].

Complications

Infection (PJI): No specific data on infection rates or management strategies are provided in the current evidence base for this section.

Aseptic loosening: Technical deficiencies associated with loosening of implants in plate and screw fixation of bicolumnar distal humerus fractures require validation through much larger studies [78]. Instrumentation failure, including anchor-related complications and rod breakage, occurs more frequently earlier in the course of lengthening surgeries using traditional growing rods or vertical expandable prosthetic titanium ribs for pediatric spine deformity [48].

Instability: Rigid fixation with screws and rods improves fusion rates in children with skeletal dysplasias and C1-C2 instability [9]. The 6s method demonstrates similar efficacy to long-segment fixation (8s) in maintaining long-term deformity correction in the treatment of thoracolumbar type A fractures [18]. Percutaneous fixation with a novel vertebral body augmentation system allows for better correction of RTA but did not seem to prevent the loss of correction at follow-up [20].

Periprosthetic fracture: No specific data on periprosthetic fracture rates or management are provided in the current evidence base for this section.

Thromboembolism: No specific data on thromboembolic events are provided in the current evidence base for this section.

Patellar / Extensor-mechanism: No specific data on patellar or extensor-mechanism complications are provided in the current evidence base for this section.

Stiffness / Arthrofibrosis: Screw fixation is associated with less required immobilization and quicker regain of useful function in distal interphalangeal joint arthrodesis [10].

Nerve palsy: No specific data on nerve palsies are provided in the current evidence base for this section.

Wound complications: No specific data on wound complications are provided in the current evidence base for this section.

Polyethylene wear: No specific data on polyethylene wear are provided in the current evidence base for this section.

Other Considerations: Successful fixation requires devices made of tissue-compatible materials with sufficient strength, ease of insertion, and long-term function without deleterious effects [14]. Tadpole system fixation shows favorable long-term clinical outcomes [1]. The Locking Compression Plate (LCP) requires adapted surgical techniques and new thinking about commonly used concepts of interventional fixation to avoid failures and complications [5]. Only a five to ten-year follow-up can provide more definitive data about the advantages and disadvantages of Cotrel-Dubousset instrumentation for adolescent idiopathic scoliosis [11]. In situ fixation may be a choice for patients with high risk factors for neck re-shortening after reduction and fixation in valgus-impacted femoral neck fractures, while fixation after reduction is a better choice for young patients with good bone quantity [12]. One of 18 patients showed broken pins in cross-pin fixation for anterior cruciate ligament reconstructions, indicating a need for further study on the strength of this fixation technique [17]. Only adjustable-loop cortical suspensory fixation devices allow the surgeon to determine final graft tension after the device is deployed and fixation is completed, unlike fixed-loop devices [24]. OLIF combined with bilateral posterior fixation is superior to OLIF combined with unilateral posterior fixation in terms of clinical and imaging outcomes in the long term for patients with osteoporosis [27]. Posterior percutaneous long-segment internal fixation requires less time, results in less blood loss, and causes less trauma compared to open fixation in the surgical treatment of thoracolumbar fracture in ankylosing spondylitis [29]. Suspension button fixation technique for revision ulnar collateral ligament reconstruction demonstrated comparable fixation strength to several historic controls of primary reconstruction techniques despite simulated ulnar cortical bone loss [33]. Titanium coating on polyetheretherketone oblique cages appears to have no negative effects on outcome or safety in the short term for transforaminal lumbar interbody fusion [54]. Bioabsorbable cross-pin femoral fixation for arthroscopic posterior cruciate ligament reconstruction was successfully employed in several patients with no instances of fixation failure [79].

Recovery

Light activity (weeks): Evidence does not provide specific week ranges for light activity or desk work return across the cited fixation devices.

Full activity (months): Evidence does not provide specific month ranges for full activity, manual work, or sport return across the cited fixation devices.

Complete recovery / outcome plateau (months): Two to five-year follow-up results for Cotrel-Dubousset instrumentation in adolescent idiopathic scoliosis are encouraging [11]. Five to ten-year follow-up is required to provide definitive data about the advantages and disadvantages of Cotrel-Dubousset instrumentation [11]. Mid-term or long-term survivorship shows no superiority of mobile-bearing total knee arthroplasty over fixed-bearing knees [65]. The theoretical advantages for mobile-bearing design to provide long-term durability have not been demonstrated by any outcome studies [65].

Rehabilitation protocol: Patients undergoing distal interphalangeal joint arthrodesis with screw fixation require less immobilization [10]. All patients in a preliminary case series obtained a regression from 2 to 3 stages in Dupuytren disease severity only with external fixation [80]. Removal of spinal implants without new instrumentation is not a realistic graduation protocol following growing-rod treatment [83]. Prolonged growing-rod treatment does not necessarily result in spontaneous, reliable fusion [83].

Functional milestones: Tadpole system fixation shows favorable long-term clinical outcomes [1]. Biodegradable screws are associated with a high rate of good and excellent clinical results as fixation devices for arthroscopic meniscal repair [4]. Screw fixation in distal interphalangeal joint arthrodesis is associated with higher union rates [10]. Patients undergoing distal interphalangeal joint arthrodesis with screw fixation seem to regain useful function more quickly [10]. The 6s method demonstrates similar efficacy to long-segment fixation (8s) in maintaining long-term deformity correction in the treatment of thoracolumbar type A fractures [18]. In the long term, OLIF combined with bilateral posterior fixation is superior to OLIF combined with unilateral posterior fixation in terms of clinical and imaging outcomes for patients with osteoporosis [27].

Other Considerations: Both keel and spike anchoring concepts of the Activ L® intervertebral disc prosthesis fulfill the required criteria of primary stability [2]. The modified dynamic external fixation system is simple, cheap, and relatively easily applied for treating dorsal fracture subluxations and pilon fractures of finger proximal interphalangeal joints [3]. Successful fixation requires devices made of tissue-compatible materials with sufficient strength, ease of insertion, and long-term function without deleterious effects [14]. One of 18 patients in a study on cross-pin fixation for ACL reconstruction showed broken pins, indicating the strength of this fixation technique needs further study [17]. Further studies on long-term outcomes are required for cross-pin fixation in ACL reconstruction [17]. Posterior percutaneous long-segment internal fixation requires less time than open fixation for surgical treatment of thoracolumbar fracture in ankylosing spondylitis [29]. Posterior percutaneous long-segment internal fixation results in less blood loss than open fixation for surgical treatment of thoracolumbar fracture in ankylosing spondylitis [29]. Posterior percutaneous long-segment internal fixation causes less trauma than open fixation for surgical treatment of thoracolumbar fracture in ankylosing spondylitis [29]. An instrumented approach, a well-selected biologic adjunct, and achieving a solid fusion carry important long-term clinical advantages in avoiding revision surgery for nonunion [31]. Load-to-failure testing of suspension button fixation for revision UCL reconstruction demonstrated comparable fixation strength to several historic controls of primary reconstruction techniques despite simulated ulnar cortical bone loss [33]. Approximately 20% of patients undergoing upper cervical spinal fusion surgery experienced delayed bony union [81]. Selection of the bearing surface in primary total hip arthroplasty is often 'experience-based' rather than 'evidence-based' due to limited direct comparisons at long-term follow-up [82].

Key Evidence

  • [L4] Tadpole system fixation shows favorable long-term clinical outcomes. (10.1186/1749-799x-9-33)
  • [L5] Both fixation systems fulfill the required criteria of primary stability. (10.1186/s12891-021-04544-7)
  • [L4] The modified dynamic external fixation system is simple, cheap, and relatively easily applied. (10.1177/1753193416674155)
  • [L4] Biodegradable screws can be recommended as fixation devices with a high rate of good and excellent clinical results. (10.1007/s00167-003-0411-6)
  • [L5] The Locking Compression Plate (LCP) is a new implant revolutionizing internal fixation that requires adapted surgical techniques and new thinking about commonly used concepts of interventional fixation to avoid failures and complications. (10.1016/j.injury.2003.09.026)
  • [L5] Appropriate patient selection is crucial, though external fixation and hybrid techniques will continue to be necessary for specific cases. (10.5435/jaaos-22-07-403)
  • [L5] Surgeons must be aware of when locked plating is superior to other methods and when to use alternative treatment modalities. (10.1016/j.injury.2009.01.003)
  • [L5] Advances in biomechanics and fixation systems have enabled reliable stabilization that permits early mobilization. (10.5435/00124635-200411000-00007)
  • [L3] Rigid fixation with screws and rods improves fusion rates. (10.2106/jbjs.n.00503)
  • [L4] Current data indicate that screw fixation is associated with higher union rates, and patients require less immobilization and seem to regain useful function more quickly. (10.1016/j.jhsa.2013.06.010)
  • [L4] The two to five-year follow-up results are encouraging, but only a five to ten-year follow-up can provide more definitive data about the advantages and disadvantages of this type of instrumentation. (10.2106/00004623-199274070-00013)
  • [L3] For patients with high risk factors, in situ fixation may be a choice, while for young patients with good bone quantity, fixation after reduction is a better choice. (10.1186/s12891-025-08393-6)
  • [L5] This technology offers improved biomechanical properties and fixation systems, enabling use in areas where current implants are not well suited. (10.5435/jaaos-d-19-00420)
  • [L5] The biomechanical benefit of a stand-alone two-part fusion cage can be justified. (10.1186/1471-2474-9-88)
  • [L5] These new implants may represent a new tool in OCJ fixation, but further studies are required to investigate their behavior in an anatomical setting. (10.1186/s12891-021-04112-z)
  • [L4] However, further studies on the long-term outcomes are required, and the strength of this fixation technique needs further study because 1 of the 18 patients showed broken pins. (10.1177/0363546508324691)
  • [L3] Furthermore, the 6s method demonstrates similar efficacy to long-segment fixation (8s) in maintaining long-term deformity correction. (10.1186/s13018-025-05509-5)
  • [L2] However, the choice of fixation for a given patient requires that this risk be considered within the greater context of surgical decision-making. (10.2106/jbjs.er.24.01169)
  • [L4] The association of a percutaneous fixation allows to obtain a better correction of the RTA but did not seem to prevent the loss of correction at follow-up. (10.1186/s12891-022-05272-2)
  • [L3] Among patients who achieved successful posterior lumbar internal fixation, whether or not to remove the fixation instruments should be evaluated carefully. (10.1186/s13018-022-03031-6)
  • [L3] Both minimally invasive fixation constructs allowed immediate pain reduction and early mobilization, with patients reaching a mean of over 3,000 steps per day at mid-term follow-up regardless of the construct used. (10.1302/0301-620x.103b3.bjj-2020-1454.r1)
  • [L5] FiberWire-anchor repairs provided the best combination of mechanical properties, while anchor fixation may be contraindicated in patients greater than 75 years because of poor bone quality. (10.1016/j.jhsa.2008.01.025)
  • [L5] The mechanical equivalency of the fixed-loop device and the one particular adjustable-loop device is not to be understated, but the real difference remains that only the adjustable-loop device allows the surgeon to determine final graft tension after the device is deployed and fixation is completed. (10.1016/j.arthro.2017.03.022)
  • [L5] Current indications for locked plating include periarticular fractures, typically those with metaphyseal comminution. (10.5435/00124635-200407000-00001)
  • [L4] Open reduction and adequate internal fixation are not easy and would seem to offer little chance of a good outcome. (10.2106/JBJS.L.01522)
  • [L3] In the long term, OLIF combined with bilateral posterior fixation is superior to OLIF combined with unilateral posterior fixation in terms of clinical and imaging outcomes. (10.1186/s13018-023-04262-x)
  • [L3] Other means, such as closed reduction with pin fixation or open reduction internal fixation, should be considered when maintenance of reduction is desired. (10.1016/j.jhsa.2015.05.013)
  • [L3] Posterior percutaneous long-segment internal fixation requires less time, results in less blood loss and causes less trauma compared to open fixation. (10.1186/s13018-022-03378-w)
  • [L3] For fragments <15%, PA and AP screws provided good fixation compared to the posterior plate. (10.1186/s12891-020-03594-7)
  • [L5] Recent long-term studies show that although imaging remains difficult, an instrumented approach, a well-selected biologic adjunct, and achieving a solid fusion all carry important long-term clinical advantages in avoiding revision surgery for nonunion. (10.5435/jaaos-22-08-503)
  • [L4] Radiographic evidence supports stable fixation with negligible subsidence and new-bone formation at the coated-uncoated interface. (10.2106/00004623-199307000-00018)
  • [L5] Load-to-failure testing demonstrated comparable fixation strength to several historic controls of primary reconstruction techniques despite the simulated ulnar cortical bone loss. (10.1177/0363546509350109)
  • [L4] The biomechanics of the lumbar spine may differ with each individual, and L4–5 dislocation may be a variant to lumbosacral (L5-S1) dislocation, owing to hyperextension injury. (10.1186/s12891-019-2921-5)
  • [L4] Open reduction and internal fixation with cerclage wires or a T-plate yields good functional results in most patients. (10.2106/00004623-200911000-00040)
  • [L4] Breakage of biodegradable cross-pins used for femoral fixation is relatively common but did not affect clinical outcomes. (10.1016/j.arthro.2012.06.010)
  • [L5] This biomechanical data could provide a baseline comparison for future studies. (10.1186/s13018-019-1292-9)
  • [L4] Further biomechanical and clinical studies are needed to validate this result. (10.1186/s12891-020-03258-6)
  • [L5] This book provides an objective review of currently available systems for internal fixation of the spine, with excellent sections on anatomy, biomechanics, and preoperative planning, though it lacks discussion on regulatory issues and patient selection for axial back-pain syndrome. (10.2106/00004623-199803000-00028)
  • [L3] Both MSs and HSs fixation are effective treatments for TTBFs and have comparable clinical outcomes. (10.1186/s13018-024-04547-9)
  • [L4] CAPS fixation is an effective and safe technique to achieve solid fixation and favorable clinical outcomes in elderly patients with spinal tuberculosis and severe osteoporosis. (10.1186/s13018-023-04099-4)
  • [L3] FNS has excellent biomechanical properties and shows significantly higher overall construct stability. (10.1186/s13018-021-02517-z)
  • [L5] The biomechanical properties of a stable spinal fusion preceded the radiographic appearance of a solid fusion by at least eight weeks, suggesting that immature woven bone provided substantial stiffness to the fusion mass. (10.2106/00004623-199711000-00013)
  • [L5] The study concluded the biomechanical effects still afford nearly sufficient spine support and gentle adjacent segment stress after rod fracture in a worst-case scenario of the thinnest PS of the SHE rod system. (10.1186/s12891-022-05768-x)
  • [L5] Biomechanical analysis showed that both CPS and CAPSI increase ROM and disc stresses in osteoporotic lumbar models, but CAPSI is more likely to increase the potential risk of adjacent segment degeneration compared to CPS. (10.1186/s13018-020-01650-5)
  • [L4] The proposed CT-based classification can help surgeons predict whether screws can be inserted into the thoracic pedicle, thus guiding instrumentation when PVCR is performed. (10.1186/1471-2474-15-278)
  • [L5] Biomechanical studies suggest these constructs are more rigid than other forms of internal fixation, allowing earlier mobilization and potentially improving fusion rates. (10.5435/00124635-199509000-00002)
  • [L3] Instrumentation failure, such as anchor related-complications and rod breakage, occurs more frequently earlier in the course of lengthening surgeries. (10.1186/s12891-024-07211-9)
  • [L5] We also observed that the stress of the endplate-cage interface decreased as the reduction of the cage's stiffness, indicating that subsidence is less likely to occur in the cage with lower stiffness. (10.1186/s12891-021-04244-2)
  • [L5] Further biomechanical tests and clinical studies have to proof Tektona®'s capabilities. (10.1186/s12891-020-03899-7)
  • [L5] Modern segmental screw-based fixation systems are biomechanically more stable and user-friendly than previous wiring techniques, offering superior rigidity and fusion rates approaching 100%. (10.5435/00124635-201102000-00001)
  • [L5] Good surgical techniques are crucial for successful fixation when using the femoral cross-pin system. (10.1177/0363546505275150)
  • [L5] The study could not determine superiority of one implant over the others and recommends that surgeons select fixation constructs based on the individual patient's anatomy and the surgeon's comfort with the implant. (10.5435/jaaos-d-17-00155)
  • [L1] The titanium coating appears to have no negative effects on outcome or safety in the short term. (10.1302/0301-620x.99b10.bjj-2016-1292.r2)
  • [L4] It gives excellent radiological results with a very low rate of failure regardless of whether the fractures have a high or low load-sharing classification score. (10.1302/0301-620x.96b4.33249)
  • [L5] The mobility and stability of rotational and translational joints are key factors for fusion rate and adjacent segment degeneration progression. (10.1186/s13018-024-04629-8)
  • [L5] The results from the current study support that compression screw fixation provides excellent biomechanical stability that is comparable to dorsal plating or lag screws. (10.1186/s12891-021-04200-0)
  • [L5] With stronger biomechanical properties, they could be a better alternative to currently used titanium screws. (10.1186/s12891-024-07864-6)
  • [L5] Inability to maintain acceptable cervical reduction with a halo fixator is an indication for alternative treatment, such as internal fixation or traction. (10.5435/00124635-199601000-00006)
  • [L3] It effectively restores the physiological curvature of the spine and reduces the degeneration of adjacent vertebral bodies in the spinal column. (10.1186/s12891-021-04335-0)
  • [L4] The presence of residual radiolucency is an important contraindication to removing the plate. (10.2106/00004623-199072010-00028)
  • [L5] It may not cause scoliosis but could lead to change of cervical curvature. (10.1186/s13018-015-0302-9)
  • [L5] This review provides a comprehensive overview of different metal artifacts in orthopaedic MRI and factors affecting their magnitude, discussing commonly applied techniques and recent technological advances to facilitate better-informed diagnostic decisions. (10.5435/jaaos-d-24-01057)
  • [L4] The mean reduction in volume of the poly-L-lactic acid screws as measured by magnetic resonance imaging after 2 years was approximately two thirds. (10.1177/0363546505285384)
  • [L4] The theoretical advantages for mobile-bearing design to provide long-term durability have not been demonstrated by any outcome studies, as mid-term or long-term survivorship shows no superiority over fixed-bearing knees. (10.1186/1749-799x-2-1)
  • [L4] This non-invasive technique using a thermoplastic traction platform is safe & effective in the management of proximal phalangeal fractures. (10.1016/j.jht.2021.02.001)
  • [L3] The three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence; however, the risk of reoperation was much higher than expected. (10.1016/j.arth.2024.03.049)
  • [L4] The moulded short metacarpal cast is an effective non-surgical treatment for angulated extra-articular metacarpal fractures of the diaphysis and diametaphyseal junction. (10.1177/17531934211024579)
  • [L4] This method of treatment is promising in the older population as there is deficiency of bone stock which may lead to fixation failures. (10.1016/j.arth.2012.12.003)
  • [L4] Approximately 76% of males and females can accommodate screws with diameters of 7.3 mm in S1, and all persons can accommodate the same screw in S2. (10.1186/s13018-020-01752-0)
  • [L1] The modified minimally invasive procedure for tracer fixation results in minimal trauma and is simple, reliable, and highly safe. (10.1186/s12891-020-03239-9)
  • [L4] The procedure resulted in complete radiological union in 10 of 11 patients with no pain, deformity, or instability. (10.1177/1753193409104494)
  • [L4] Awake fixation in extreme cases is safe and feasible; a dedicated team including an anesthesiologist and radiologist is needed to treat these cases safely and quickly. (10.5435/jaaos-d-21-00959)
  • [L5] For 3 cm of cortical contact, successful initial fixation can be achieved in most cases with both taper angle designs. (10.1016/j.arth.2021.04.013)
  • [L3] This acetabular component demonstrates a favorable and safe clinical and radiological outcome with over 15 years of follow-up. (10.1016/j.arth.2021.06.016)
  • [L3] CT navigated pedicle screws can be positioned safely although greater caution must be taken in patients who have previously undergone anterior surgery. (10.1302/0301-620x.99b10.bjj-2016-1283.r1)
  • [L4] Fixation using SI screws demonstrated similar stiffness values through the SIJ at four- and eight-weeks post-operatively when compared to healthy controls. (10.1186/s13018-024-05331-5)
  • [L4] Because of the relative infrequency of fixation problems and nonunion, a much larger study is needed to address technical deficiencies. (10.1016/j.jhsa.2015.07.009)
  • [L4] They report successful employment of this technique in several patients with no instances of fixation failure. (10.1007/s00167-008-0487-0)
  • [L4] All patients obtained a regression from 2 to 3 stages in disease severity only with external fixation. (10.1177/1558944718822086)
  • [L3] Approximately 20% of patients undergoing upper cervical spinal fusion surgery experienced delayed bony union. (10.1186/s12891-025-08582-3)
  • [L5] Selection of the bearing surface is often 'experience-based' rather than 'evidence-based' due to limited direct comparisons at long-term follow-up. (10.1302/2058-5241.3.180300)
  • [L4] Removal of spinal implants without new instrumentation is not a realistic graduation protocol following growing-rod treatment, as prolonged growing-rod treatment does not necessarily result in spontaneous, reliable fusion. (10.2106/jbjs.17.00031)

See Also

References

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a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.