Abstract
Up to now the internal fixation of fractured bones and joints has been managed by metal implants. There are certain associated disadvantages: the mechanical properties of the metals are stronger than those of cortical bone (“stress-protection”); the removal of the implants requires a second operation; an increasing number of patients are confronted with problems of sensitivity to metal components of the implants, especially nickel. About 40 different biodegradable polymers, copolymers and composites have been developed as substitutes for metal implants in internal fracture fixation. The early experimental and clinical results demonstrate their limitations. From the current point of view, it is not possible to transfer the designs and assembling principles of metal implants in orthopaedic surgery to biodegradable polymers. The attempt to simply mimic metal implants in polymers is condemned to fail from the very beginning. This is a review of the literature and of our first 100 patients operated on using implants made of self-reinforced polyglycolide acid and polydioxanone. The main difficulty with the material is the loss of stiffness in a time interval which is not long enough to guarantee bone healing. The development of a sterile sinus over the site of implantation is a problem also reported by other groups. Certain additives have to be inserted into the polymers to make them visible on conventional X-radiographs. Despite these drawbacks, however, there are indications for the isolated or adjuvant implantation of biodegradable materials. They could be employed in the treatment of osteochondral fractures and other defined injuries. The available literature on these indications will be discussed. A standardized set of possible indications for the use of different biodegradable devices in orthopaedic surgery is presented as are clear contraindications for their use at the present time. For the future, fixation devices adapted to the characteristic properties of polymers and adjusted to specific therapeutic problems will have to be developed.
Article PDF
Similar content being viewed by others
Explore related subjects
Discover the latest articles, news and stories from top researchers in related subjects.Avoid common mistakes on your manuscript.
References
Albrecht-Olsen P, Kristensen G, Lind T, Lavard P (1990) Arthroscopic fixation of a stage 4 fracture of the lateral talar dome using BIOFIX. Acta Orthop Scand 61 (Suppl 237):85
Anscomb AR, Hira N, Hunt B (1970): The use of a new absorbable suture material (polyglycolic acid) in general surgery. Br J Surg 57:917–920
Barranco VP, Solomon H (1972): Eczematous dermatitis from nickel (letter). JAMA 220:1244
Becker D (1988): Erhaltungsoperationen bei Radiusköpfchenfraktur mittels Pinnung mit dem resorbierbaren Material BIOFIX. Handchirurgie 20:157–159
Benson MKD, Goodwin PG, Brostoff J (1975): Metal sensitivity in patients with joint replacement arthroplasties. Br Med J 4:374–375
Bonke S, Scherer HJ, Fischer M (1973): Erfahrungen mit dem synthetischen, absorbierbaren Nahtmaterial DEXON. Muench Med Wochenschr 115:1851–1853
Bos RRM, Boering G, Rozema FR, Leenslag JW (1987): Resorbable poly (L-lactide) plates and screws for the fixation of zygomatic fractures. J Oral Maxillofac Surg 45:751–753
Böstman O, Vainionpää S, Hirvensalo E, Makela A, Vihtonen K, Törmälä, Rokkanen P (1987): Biodegradable internal fixation for malleolar fractures. J Bone Joint Surg [Br] 69:615–619
Böstman O, Mäkelä EA, Törmälä P, Rokkanen P (1989): Transphyseal fracture fixation using biodegradable pins in children: brief report. J Bone Joint Surg [Br] 71:706–707
Böstman O, Vainionpää S, Hirvensalo E, Makela A, Vihtonen K, Tönnälä P, Rokkanen P (1989): Ankle fractures treated using biodegradable internal fixation. Clin Orthop 238:195–203
Böstman O, Hirvensalo E, Vainiopää S, Vihtonen K, Törmälä P, Rokkanen P (1990): Degradable polyglycolide rods for the internal fixation of displaced bimalleolar fractures. Int Orthop (SICOT) 14:1–8
Brady JM, Cutright DE, Miller RA, Battistone GC, Hunsuck EE (1973): Resorption rate, route of elimination and ultrastructure of the implant site of polylactide acid in the abdominal wall of the rat. J Biomed Mater Res 7:155–166
Brekke JH, Olsen RAJ, Scully JR, Osbon DB (1983): Influence of polylactic acid mesh on the incidence of localized osteitis. Oral Surg 56:240–245
Burrows D, Creswell S, Merrett JD (1981): Nickel hands and hip prostheses. Br J Dermatol 105:437–444
Chavanaz M, Chabot F, Donazzan M, Vert M (1986): Further clinical applications of bioresorbable PLA 37,5 GA 25 and PLA 50 polymers for limited bone augmentation and bone replacement. In: Christel P, Meunier A, Lee AJC (Eds) Biological and biomechanical performance of biomaterials. Elsevier, Amsterdam, pp 233–238
Christel P, Chabot F, Leray JL, Morin C, Vert M (1980): Biodegradable composites for internal fixation. In: Winter GD, Gibbons DF, Plenk H Jr (Eds) Biomaterials. Wiley, New York, pp 271–280
Claes L (1989): Requirements on resorbable implant materials. In: Heimke G, Soltész U, Lee AJC (Eds) Clinical implant materials. Elsevier, Amsterdam, pp 161–167
Claes L (1990): Mechanical characterization of biodegradable implants. In: Hofmann GO (Ed) Biodegradable implants in orthopaedic surgery. Technik + Kommunikation, Berlin, pp 83–93
Claes L, Burri C, Kiefer H, Mutschler W (1986): Resorbierbare Implantate zur Refixierung von osteochondralen Fragmenten in Gelenkfldchen. Akt Traumatol 16:74–77
Craig PH, Williams JA, Davis KW, Magoun AD, Levy AJ, Bogdansky S, Jones JP (1975): A biological comparison of polyglactin 910 and polyglycolic acid synthetic adsorbable sutures. Surg Gynecol Obstet 141:1–10
Cutright DE, Beasley ID, Perez B (1971): Histologic comparison of polylactic and polyglycolic acid sutures. Oral Surg 32:165–173
Cutright DE, Perez B, Beasley JD, Larson WT, Posey WR (1974): Degradation rates of polymers and copolymers of polylactic and polyglycolic acid. Oral Surg 37:142–152
Daube JP (1986): Premiere application en chirurgie maxillofaciale des materiaux biodegradable poly-alpha-hydroxy-acides. Dissertation, Universite de Nice
Decker R, Ruf W (1988): Die Zuggurtung der Symphysenruptur mit geflochtenen Polydioxanon-Bändern (PDS). Z Orthop 126:14–18
Deluca PA, Lindsey RW, Ruwe PA (1988): Refracture of bones of the forearm after removal of compression plates. J Bone Joint Surg [Am] 70:1372–1376
Diehl K, El-Ahmad M, Franzl K (1987): Kapselbandchirurgie des Kniegelenkes mit resorbierbaren Materialien. Z Orthop 125:467–472
Dumbach J (1984): Zugschraubenosteosynthese nach Ramusosteotomie mit resorbierbaren Osteosyntheseschrauben aus Polydioxanon — Erste Ergebnisse. Dtsch Z Mund Kiefer Ges Chirurg 8:145–148
Dumbach J (1987) Osteosynthese mit resorbierbaren PDSStiften nach sagittaler Spaltung und Rückversetzung des Unterkiefers. Dtsch Zahnärztl Z 42:825–828
Eitenmüller J, Gerlach KL, Schmickal T, Muhr G (1987): Semirigide Plattenosteosynthese unter Verwendung absorbierbarer Polymere als temporäre Implantate. I. Einführung, chemische Zusammensetzung und materialkundliche Untersuchungen. Chirurg 58:759–763
Eitenmüller J, Gerlach KL, Schmickal T, Muhr G (1987): Semirigide Plattenosteosynthese unter Verwendung absorbierbarer Polymere als temporäre Implantate. U. Tierexperimentelle Untersuchungen. Chirurg 58:831–839
Eitenmüller J, David A, Pommer A, Muhr G (1990): Die Versorgung von Sprunggelenksfrakturen unter Verwendung von Platten und Schrauben aus resorbierbarem Polymer-Material. Hefte Unfallheilkd 212:440–443
Gay B, Bucher H (1985): Tierexperimentelle Untersuchungen zur Anwendung von absorbierbaren Osteosyntheseschrauben aus (PDS) Polydioxanon. Unfallchirurg 88:126–133
Gerlach KL (1988): Absorbierbare Polymere in der Mund- und Kieferchirurgie. Zahnärztl Mitt 78:1020–1024
Gerlach KL (1990): Treatment of zygomatic fractures with biodegradable poly (L-lactide) plates and screws. In: Heimke G, Soltész U, Lee AJC (Eds) Clinical implant materials. Elsevier, Amsterdam, pp 573–578
Getter L, Cutright DE, Bhaskar SN, Ausburg JF (1972): A biodegradable intraosseous appliance in the treatment of mandibular fractures. J Oral Surg 30:344–348
Haas HG (1986): PDS-Splinte zur Frakturbehandlung. Handchir Mikrochir Plast Chir 18:295–297
Hastings GW (1989): New advanced materials in orthopaedics. In: The Plastic and Rubber Inst (Ed) 6th Int Conf Polymers in Med and Surg. Hazell Press, London, pp 1.1–1.6
Haupt PR, Duspiva W (1988): PDS-Augmentationsplastik bei Kreuzbandverletzungen. Unfallchirurg 91:97–105
Heitemeyer U, Kemper F, Hierholzer G, Haines J (1987): Severely comminuted femoral shaft fractures: treatment by bridging-plate osteosynthesis. Arch Orthop Trauma Surg 106:327–330
Hidaka S, Gustilo RB (1984): Refracture of bones of the forearm after plate removal. J Bone Joint Surg [Am] 66:1241–1243
Hirvensalo E (1989): Fracture fixation with biodegradable rods. Forty-one cases of severe ankle fractures. Acta Orthop Scand 60:601–606
Hirvensalo E, Bostman O, Partio E, Tönnälä P, Rokkanen P (1990): Self-reinforced polyglycolide rods in 768 fractures and osteotomies. Acta Orthop Scand 61 (Suppl 237):43
Hoffmann R, Krettek C, Haas N, Tscherue H (1989): Die distale Radiusfraktur. Frakturstabilisierung mit biodegradierbaren Osteosynthesestiften (BIOFIX). Unfallchirurg 92:430–434
Hohlbach G, Schildberg FW, Stalling F, Höppner W (1987): Die PDS-Zuggurtung — eine Methode zur funktionellen Frühbehandlung der operativ versorgten Bandruptur im oberen Sprunggelenk. Chirurg 58:769–774
Hollinger JO (1983): Preliminary report on the osteogenetic potential of a biodegradable polymer of polylactide (PLA) and polyglycolide (PGA). J Biomed Mater Res 17:71–82
Holzmüller W, Rehm KE, Perren SM, Rahn B (1989): Das PDS-augmentierte Patellarsehnentransplantat zur Rekonstruktion des vorderen Kreuzbandes am Schafsknie. Chirurgisches Forum 1989 für experimentelle and klinische Chirurgie. Springer, Berlin Heidelberg New York
Illi OE, Weigum H, Mistelli F (1990): Biodegradable implant materials in fracture fixation. In: Hofmann GO (Ed) Biodegradable implants in orthopaedic surgery. Technik + Kommunikation, Berlin, pp 145–175
Jahn R, Diederichs D, Friedrich B (1989): Resorbierbare Implantate und ihre Anwendung am Beispiel der Radiusköpfchenfraktur. Akt Traumatol 19:281–286
Johnson EE, Urist MR, FinermanGAM (1990): Distal metaphyseal tibial non-union. Clin Orthop 250:234–240
Katz JL, Patel AD, Kellam JF, Schatzker J (1990): The incidence of refracture after hard-ware removal from long bones. (Abstract) SICOT Congress Montreal, .-14.9.1990, p 87
Köbler H, Wiechell W (1971): Trajektorienverlauf bei der Druckplattenosteosynthese und seine biomechanische Auswirkung. Chirurg 42:80–85
Krettek C, Hoffmann R, Haas N (1988): Stabilisation of distal radius fractures — biomechanical testing of K-wires and PDS-pins. In: Putter C de, Lange GL de, Groot K de, Lee AJC (Eds) Implant materials in biofunction. Elsevier, Amsterdam, pp 453–456
Kristensen G, Lind T, Lavard P, Olsen PA (1990): Fracture stage 4 of the lateral talar dome treated arthroscopically using BIOFIX for fixation. Arthroscopy 6:242–244
Kulkami RK, Pani KC, Nauman C, Leonard F (1966): Polylactid acid for surgical implants. Arch Surg 93:839–843
Laftman P, Sigurdsson F, Strömberg L (1980): Recovery of diaphyseal bone strength after rigid internal plate fixation. Acta Orthop Scand 51:215–222
Laftman P, Nilsson OS, Brosjö O, Strömberg L (1989): Stress shielding by rigid fixation studied in osteotomized rabbit tibiae. Acta Orthop Scand 60:718–722
Leenslag JW, Pennings AJ, Bos RRM, Rozema FR, Boering G (1987): Resorbable materials of poly (L-lactide). VI. Plates and screws for internal fracture fixation. Biomaterials 8:70–73
Leenslag JW, Pennings AJ, Bos RRM, Rozema FR, Boering G (1987): Resorbable materials of poly (L-lactide). VII. In vivo and in vitro degradation. Biomaterials 8:311–314
Leixnering M, Moser KL, Poigenfurst J (1989): Die Verwendung von Biofix C zur Stabilisierung von Innenknöchelfrakturen. Akt Traumatol 19:113–115
Leixnering M, Hintringer W, Poigenfürst J (1989): Operationstechnik und Ergebnisse bei der Stabilisierung von Knöchelfrakturen mit dem resorbierbaren Material BIOFIX C. Hefte Unfallheilkd 207:329
Link W, Carbon R, Beck H (1989): Osteochondrale Frakturen am Kniegelenk — Refixation mit Polydioxanon. Hefte Unfallheilkd 207:441–444
List JJJ vd, Horn JR v, Sloof TJJH, ten Cate LN (1988): Malignant epithelioid hemangioendothelioma at the site of hip prosthesis. Acta Orthop Scand 59:328–330
Lobenhoffer P, Blauth M, Tscherne H (1988): Resorbierbare Augmentationsplastik und funktionelle Nachbehandlung bei frischer vorderer Kreuzbandruptur. Z Orthop 126:296–299
Lütten C, Lorenz H, Thomas W (1987): Osteochondrosis dissecans: refixation mit ETHIPIN. Ethicon OP Forum 132:3–10
Mäkelä EA, Bostman O, Kekomäki M, Vainio J, Hirvensalo E, Södergard J, Törmälä P, Rokkanen P (1990): Biodegradable fixation of physeal fractures in children. Acta Orthop Scand 61 (Suppl 237):44
McKenzie AW, Aitken CVE, Ridsdill-Smith R (1967): Urticaria after insertion of Smith-Petersen vitallium nail. Br Med J 4:36–37
Nakamura T, Hitomi S, Watanabe S, Shimizu Y, Jamshidi K, Hyon SH, Ikada Y (1989): Bioabsorption of polylactides with different molecular properties. J Biomed Mater Res 23:1115–1130
Niederdellmann H, Bührmann K (1983): Resorbierbare Osteosyntheseschrauben aus Polydioxanon (PDS). Dtsch Z Mund Kiefer Gesichts Chir 7:399–400
Osterwalder A, Huben R v (1987): Die Verwendung von resorbierbarem Fixationsmaterial (PDS-Kordeln) am Schultergelenk. Helv Chir Acta 54:431–434
Ott G (1970): Fremdkörpersarkome, Experimentelle Medizin, Pathologie und Klinik, vol 32. Springer, Berlin Heidelberg New York
Partio EK, Böstman O, Vainionpää S, Pätiälä H, Hirvensalo E, Vihtonen K, Törmälä P, Rokkanen P (1988): The treatment of cancellous bone fractures with biodegradable screws. Acta Orthop Scand 59 (Suppl 227):18
Partio EK, Böstman O, Hirvensalo E, Pätiälä H, Vainionpää S, Vihtonen K, Törmälä P, Rokkanen P (1990): The indication for the fixation of fractures with totally absorbable SR-PGA screws. Acta Orthop Scand 61 (Suppl 237):43–44
Partio EK, Hirvensalo E, Böstman O, Vainionpää S, Vihtonen K, Pätiälä H, Rokkanen P (1990): Operative technique in fixation of cancellous bone fractures with totally absorbable SRPLLA and SR-PGA screws. Acta Orthop Scand 61 (Suppl 237) 85
Penman HG, Ring PA (1984): Osteosarcoma in association with total hip replacement. J Bone Joint Surg [Br] 66:632–634
Rehm KE, Schultheis KH (1985): Bandersatz mit Polydioxanon (PDS). Unfallchirurgie 11:264–273
Rehm KE, Schultheis KH, Bopp P, Ecke H (1984): Biomechanische Untersuchungen vom resorbierbaren Bandersatz und deren klinische Bedeutung. In: Chirurgisches Forum '84 für experimentelle and klinische Forschung. Langenbecks Arch Chir (Suppl):207–211
Rehm KE, Helling HJ, Claes J (1989): Biologisch abbaubare Osteosynthesematerialien. In: Bünte H, Junginger T, Holzgreve A (Eds) Jahrbuch der Chirurgie 1989. Biermann, Zülpich, pp 223–232
Riddick DH, DeGrazia CT, Maenza R (1977): Comparison of polyglactic and polyglycolic acid sutures in reproductives tissue. Fertil Steril 28:1220–1225
Rokkanen P, Vainionää S, Törmälä, Kilpikari J, Böstman O, Vihtonen K, Laiho J, Tamminmäki M (1985): Biodegradable implants in fracture fixation: early results of treatment of fractures of the ankle. Lancet 1:1422–1424
Rokkanen P, Hirvensalo E, Böstman O, Vainionpää S, Törmälä P (1990): Absorbable rods in internal fracture fixation. (Abstract) XVIII SICOT-Congress, Montreal, 9.9.1990, p 183
Rostoker G, Robin J, Binet O, Blamontier J, Paupe J, LessanaLeibowitch M, Bedonelle J, Sonneck JM, Garrel JP, Millet P (1987): Dermatitis due to orthopaedic implants. J Bone Joint Surg[Am] 69:1408–1412
Rozema FR, Bos RRM, Boering G, Leenslag JW, Pennings AJ, Verweij AB (1988): Absorbable bone-plates and screws for the fixation of malar fractures. In: Putter C d, Lange GL d, Groot K d, Lee AJC (Eds) Implant materials in biofunction. Elsevier, Amsterdam, pp 251–255
Ruf W, Schult W, Buhl K (1990): Die Stabilisierung von Malleolarfrakturen und Flakeverletzung mit resorbierbaren Polyglykolid-Stiften (BIOFIX). Unfallchirurgie 16:202–209
Rustemeier M, Ganßmann M (1986): Versorgung von knöchernen Strecksehnenabrissen mit resorbierbaren Materialien. Handchir Mikrochir Plast Chir 18:302–303
Sangmeister M, Hette K, Knaepler H, Gotzen L (1990): Sportfähigkeit nach Behandlung der Tossy-Verletzungen mit resorbierbarem Fixationsmaterial. Hefte Unfallheilkd 212:274–275
Santavira S, Saito T, Konttinen YT, Partio EK, Grönblad M, Rokkanen P (1989): Immunologic response to polyglycol acid implant material in vivo and in vitro. SOT (Finn J Orthop Trauma) 12:165–168
Santavira S, Konttinen YT, Saito T, Grönblad M, Partio EK, Kemppinen P, Rokkanen P (1990): Immune response to polyglycolic acid implants. J Bone Joint Surg [Br] 72:597–600
Schauwecker HH, Dreithaler B, Kaiser M (1990): Wiederherstellung des frakturierten Radiusköpfchens mit resorbierbaren Stiften. Vortrag 54. Jahrestg DGU, Berlin, 28.11.-1.12.90
Steinmann R, Gerngroß H, Hartel W (1990): Die Verwendung bioresorbierbarer Implantate (BIOFIX) in der Chirurgie. Akt Traumatol 20:102–107
Terjesen T, Benum P (1983): The stress-protection effect of metal plates on the intact rabbit tibia. Acta Orthop Scand 54:810–818
Tonino AJ (1988): The clinical use of plastic plates for osteosynthesis in human fractures. In: Putter C d, Lange GL d, Groot K d, Lee AJC (Eds) Implant materials in biofunction. Elsevier, Amsterdam, pp 177–180
Tonino J, Davidson CL, Klopper RJ, Linclau LA (1976): Protection from stress in bone and its effects. Experiments with stainless steel and plastic plates in dogs. J Bone Joint Surg [Br] 58:107–113
Törmälä P, Pohjonen T, Helevirta P (1990): Biodegradable self-reinforced composite materials: manufacturing, structure and properties. In: Hofmann GO (Ed) Biodegradable implants in orthopaedic surgery Technik + Kommunikation, Berlin, pp 130–144
Vainionpää S (1987): Biodegradation and fixation properties of biodegradable implants in bone tissue. Academic dissertation, University of Helsinki
Vert M, Christel P, Chabot F, Leray J (1984): Bioresorbable plastic materials for bone surgery. In: Hastings GW, Ducheyne P (eds) Macromolecular biomaterials. CRC Press, Boca Raton, pp 119–142
Vihtonen K, Pätiälä H, Rokkanen P, Pellinen M, Törmälä P (1990): Preliminary results of reinsertion of ruptured ulnar collateral ligament of the first metacarpophalangeal joint with totally biodegradable polylactide (PLLA) pin. Acta Orthop Scand 61 (Suppl 237):44
Woo SLY, Akeson WH, Courts RD, Rutherford L, Doty D, Jemmott GF, Amiel D (1976): A comparison of cortical bone atrophy secondary to fixation with plates with large differences in bending stiffness. J Bone Joint Surg [Am] 58:190–195
Woo SLY, Simon BR, Akeson WH, McCarty MP (1977): An interdisciplinary approach to evaluate the effect of internal fixation plate on long bone remodeling. J Biomech 10:87–95
Wüstner MC, Partecke BD, Buck-Gramcko D (1986): Resorbierbare PDS-Splinte zur Frakturstabilisierung und für Arthrodesen an der Hand. Handchir Mikrochir Plast Chir 18:298–301
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Hofmann, G.O. Biodegradable implants in traumatology: a review on the state-of-the-art. Arch Orthop Trauma Surg 114, 123–132 (1995). https://doi.org/10.1007/BF00443385
Received:
Issue Date:
DOI: https://doi.org/10.1007/BF00443385