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76 (); 153-160
doi:
10.1016/j.jor.2026.03.023

The biomechanical effects of different materials on the application of femoral external fixator: Stainless steel versus titanium alloy and healthy versus osteoporosis bone properties

, , , ,
a Bone Biomechanics Laboratory (BBL), Department of Biomedical Engineering and Health Sciences, Faculty of Electrical Engineering, Universiti Teknologi Malaysia, Johor Bahru, Johor, 81310 UTM, Malaysia
b Rehabilitation Nexus (RehabNex) Research Group, Universiti Teknologi Malaysia, Johor Bahru, Johor, 81310 UTM, Malaysia
c Department of Orthopaedics and Spine, Prince Court Medical Centre, Kuala Lumpur, 50450, Malaysia
d School of AI and Advanced Computing, Xi'an Jiaotong – Liverpool University, Suzhou, China
e Department of Biomedical Engineering, Faculty of Engineering, Universiti Malaya, Kuala Lumpur, 50603, Malaysia

⁎Corresponding author: Muhammad Hanif Ramlee. muhammad.hanif.ramlee@biomedical.utm.my

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

External fixation stabilizes fractured bones externally, ensuring proper bone union through optimal frame stability. Since different materials provide varying mechanical properties, this study investigated an external fixation system under two conditions: (1) fixator materials (stainless steel vs. titanium alloy) and (2) bone properties (healthy vs. osteoporotic).

A 3D fractured femoral bone model was reconstructed with a unilateral fixator and analyzed using the Finite Element Method (FEM) under stance phase loading.

The findings revealed that both bone and fixator materials influenced fixation stability. A healthy bone combined with a titanium fixator showed lower stress at the pin–bone interface, potentially reducing the risk of pin tract infection. Interfragmentary movement was 104% higher in osteoporotic bone than in healthy bone, while the titanium fixator exhibited only 1.67% more movement compared to stainless steel, indicating comparable performance. Despite its lighter weight and biocompatibility, titanium's advantage in fixation stability was minimal. However, its lower interface stress may improve clinical outcomes. In contrast, external fixation in osteoporotic patients should be planned cautiously due to higher risk of secondary fractures arising from reduced bone strength and increased micromotion at the fracture site.

This study demonstrates that fixator material significantly affects stability. It provides orthopaedic surgeons, clinicians, and researchers with insights that may support improved treatment strategies.

Abstract

Highlights

•The stability and efficacy of external fixation in different material properties have been successfully investigated.•Titanium-based fixator showed better performance than stainless steel by providing less stress on the pin-bone interface.•The use of external fixator in patients with osteoporotic bone disease is an alarming state as it is unstable.

Keywords

Femur
External fixator
FEA
Stainless steel
Titanium alloy
1

1 Introduction

Many orthopaedic experts reported that external fixator provides bone and soft tissue stabilization, thereby promoting bone healing.1,2 Commonly employed as a temporary fixation method, external fixators can be applied rapidly with minimal blood loss.3 Lawal et al.4 reported an average fixation duration of three months, with the shortest and longest fixation times being six weeks and one year, respectively, for open diaphyseal fractures of long bones, including the femur and tibia. However, the use of external fixators is also associated with a high rate of complications, such as pin tract infection, malunion, and joint stiffness.5,6 Nevertheless, ongoing studies continue to focus on mitigating these complications 7–9.

For new tissue formation during bone healing, in addition to patient condition, fracture type, and treatment method, mechanical factors play a key role.7,10 Low displacement and controlled interfragmentary movement in the fractured area create a favorable mechanical environment believed to enhance bone healing.11,12 Conversely, excessive micromotion of implanted pins can hinder the osteointegration process, increasing the risk of pin loosening.9 Stress and strain at the pin–bone interface are also critical: lower values reduce the likelihood of loosening and pin tract infection.13,14

To achieve favorable mechanical conditions, the stability of the external fixator is essential. Stability depends on the fixator's overall configuration and its individual components, such as rods, pins, and screws.7,15,16 Material selection further influences the biomechanical and bioactive properties of implants, thereby affecting both stability and complication rates.17,18 Inappropriate material selection may increase displacement and stress, particularly at the pin–bone interface.19 Currently, external fixators are manufactured from titanium alloys, stainless steel, carbon fiber, and hydroxyapatite (HA) coatings.8,9,14,19 Titanium alloy implants have demonstrated several advantages. Their lower modulus of elasticity reduces stress shielding, thereby preventing osteoporosis and allowing fracture healing with callus formation.20 Titanium also has better osteointegration properties, promoting better bone–implant contact.21 Compared to stainless steel, titanium implants are associated with fewer pin-related complications, as demonstrated in clinical studies.9,18,20 Although many studies suggest that titanium is more favorable,14,18 there is still limited biomechanical evidence to justify its superiority.9,22 Therefore, further investigation is warranted.

Beyond the material of the fixator, bone quality itself significantly influences treatment outcomes. External fixators seemed to be widely used in patients with osteoporosis, often with positive results 23–26. However, ageing and conditions such as osteoporosis and osteomalacia can deteriorate bone properties,14 reducing rigidity, fatigue resistance, and fracture resistance.23 These changes increase the risk of pin loosening, fixation failure, and complications such as non-union, malunion, and re-operation.14,23,27,28 While these complications are primarily described in clinical studies, biomechanical investigations addressing pathological bone conditions remain limited. To date, fewer than ten published reports have assessed the biomechanics of external fixators in pathological bone.14,29 Thus, further biomechanical studies are crucial to provide practitioners with evidence-based guidance in treatment selection.

In response to this research gap, the present study evaluates the influence of fixator material on its performance in different pathological bone conditions using three-dimensional (3D) geometrically validated bone models via finite element analysis (FEA). First, two fixator materials including stainless steel and titanium alloy were compared. Second, healthy and osteoporotic bone models were simulated to assess fixator efficacy in osteoporotic patients. These findings aim to provide orthopaedic surgeons, clinicians, and researchers with insights that support improved treatment strategies.

2

2 Methodology

The Finite Element Method (FEM) enables simulation of clinical scenarios and facilitates biomechanical evaluation of bone implants.30 Accordingly, this study employed FEM to analyze the stability and mechanical behavior of external fixators. Primary output variables included von Mises stress and strain, particularly around the pin–bone interface and fixator frame. Interfragmentary movement at the fracture site and overall fixation displacement were also examined.

2.1

2.1 Finite element modeling

The femoral bone was modeled using Mimics software (Materialise Technologies, Leuven, Belgium). Computed tomography (CT) datasets of a healthy 27-year-old male (169 cm, 75 kg) were obtained from Hospital Tunku Ampuan Afzan, Kuantan, Malaysia. The left femur was segmented and reconstructed into a 3D model with ethical approval from the same hospital. Cortical and cancellous bone layers were differentiated using Hounsfield Units (HU): 750–3071 HU for cortical bone and 200–750 HU for cancellous bone. To simulate an oblique fracture, the bone was sectioned at the diaphysis.

The external fixator was reconstructed via reverse engineering in SolidWorks CAD software (Dassault System SolidWorks Corp., Waltham, USA). A unilateral frame configuration was used, consisting of an 11 mm rod, six 5 mm screws, and six clamps. The fixator was fitted onto the bone model in 3-matic software (Materialise Technologies, Leuven, Belgium). All models were meshed with first-order tetrahedral elements 31–33. Mesh convergence analysis ensured model accuracy and reliability. Bone mesh elements measured 4.5 mm (29,025 nodes, 160,794 elements), while fixator mesh elements measured 1.0 mm (128,562 nodes, 484,965 elements). To ensure accurate pin–bone interface results, mesh sizes at the interface were mirrored across pins and bone, as illustrated in Fig. 1.

3D FE model used in the analyses.
Fig. 1 3D FE model used in the analyses.
2.2

2.2 Finite element simulation

All materials were assumed isotropic, homogeneous, and linearly elastic. Two fixator materials which were stainless steel and titanium alloy, were analyzed in the first phase, with bone properties modeled as healthy. In the second phase, bone properties were adjusted to represent healthy and osteoporotic conditions, with stainless steel fixators applied. Mechanical properties used in the analyses are summarized in Table 1.

Table 1 Mechanical properties used in the analyses.
Young's modulus (GPa) Poisson ratio
Healthy cortical bone31,32. 16.5 0.3
Healthy cancellous bone31,32. 0.15 0.3
Osteoporotic cortical bone34 4.95 0.3
Osteoporotic cancellous bone34 0.045 0.3
Stainless steel35 190 0.3
Titanium alloy9,36 110 0.3

Cortical and cancellous bone layers were modeled as fully bonded, while interfaces between fixator pins and bone, and between fracture surfaces, were modeled as partially bonded, with a friction coefficient of 0.3 μ.37 To simulate early weight-bearing, boundary conditions fixed the distal femur, and stance-phase loading was applied at the proximal femur, representing joint force (320N x, −170N y, −2850N z) and muscle force (−310N x, 0N y, 1200N z).31,32Fig. 1 illustrates these boundary conditions using Marc Mentat (MSC Software, Santa Ana, CA).

3

3 Results

3.1

3.1 Titanium vs. stainless steel fixator materials

Stress concentrations in both fixators were highest at the clamp region, functioning as a pivot point. Titanium-based fixators exhibited lower von Mises stress (135.4 MPa) than stainless steel (198.2 MPa). At the pin–bone interface, higher stress was observed laterally, particularly proximally and at the pins farthest from the fracture. Titanium fixation demonstrated lower peak stress (102.5 MPa) than stainless steel (144.0 MPa). Stress contours are shown in Fig. 2.

von Mises stress distribution of the bone between stainless steel and titanium-based materials.
Fig. 2 von Mises stress distribution of the bone between stainless steel and titanium-based materials.

Strain distributions at the pin–bone interface were also lower in titanium alloy fixation. Proximal bone strain reached 3.5 μ for stainless steel and 3.2 μ for titanium, while distal values were 1.3 μ and 1.2 μ, respectively, an 8% difference. Peak strain occurred at the pin farthest from the fracture, with opposite lateral/medial distributions in proximal and distal regions. Strain contours are presented in Fig. 3.

Strain distribution of the bone fixated with stainless steel and titanium materials.
Fig. 3 Strain distribution of the bone fixated with stainless steel and titanium materials.

Displacement values showed slightly greater movement in titanium fixators: 1.63 mm compared to 1.53 mm for stainless steel. Corresponding bone displacements were 5.70 mm (titanium) and 5.41 mm (stainless steel). Stainless steel fixators thus showed 5.77% less displacement. At the fracture site, interfragmentary movement was 0.475 mm for stainless steel and 0.483 mm for titanium, a negligible 1.67% difference. Fig. 4 illustrates these results.

Intefragmentary movement of the fracture site.
Fig. 4 Intefragmentary movement of the fracture site.
3.2

3.2 Healthy vs. osteoporotic bone

Fixator frames in osteoporotic bone showed substantially higher stresses than in healthy bone (390.2 MPa vs. 198.2 MPa; a 65.2% difference). At the pin–bone interface, osteoporotic bone also exhibited greater stress (267.1 MPa vs. 144.0 MPa; 52.5–59.9% difference). Stress distributions were consistent with earlier findings, with higher values in lateral and proximal bone, and at the farthest pins. Fig. 5 shows the stress contours.

von Mises stress distribution of the bone and fixation for different bone properties.
Fig. 5 von Mises stress distribution of the bone and fixation for different bone properties.

Strain distributions were markedly greater in osteoporotic bone, more than doubling those in healthy bone (102.8–114.8% difference). Maximum strain reached 10.9 μ in osteoporotic bone versus 3.5 μ in healthy bone, localized at the farthest pins. Unlike stress, maximum strain distributions were mirrored between proximal and distal regions. Contours are shown in Fig. 6.

Strain distribution of the bone for healthy and osteoporosis properties.
Fig. 6 Strain distribution of the bone for healthy and osteoporosis properties.

Displacement was also larger in osteoporotic bone: 16.12 mm versus 5.41 mm in healthy bone. Fixator displacement was 4.53 mm versus 1.53 mm. Interfragmentary movement doubled, from 0.48 mm in healthy bone to 1.52 mm in osteoporotic bone (a 104% difference), as shown in Fig. 7.

Interfragmentary movement at the fracture site for both healthy and osteoporosis properties.
Fig. 7 Interfragmentary movement at the fracture site for both healthy and osteoporosis properties.
4

4 Discussion

Femoral fractures, particularly open fractures, are among the most prevalent38 and require systematic management.39 Treatment strategies include non-operative management, open reduction and internal fixation (ORIF), external fixation, and minimally invasive techniques.40 While both internal and external fixation have shown effectiveness, complex fractures unsuitable for internal fixation can be successfully treated with external fixators, including circular configurations.41 External fixators are typically unilateral, circular, or hybrid, with configuration influencing stability, mechanical performance, healing rates, and complication risks.16,42 Prior research identified unilateral fixators as offering the most favorable balance of stability and complication reduction.43 Thus, this study employed a unilateral model. Given that fixation stability is influenced by material properties, this study aimed to evaluate both fixator and bone materials.

Von Mises stress (VMS) is used to predict material yielding when stresses reach the yield limit.43 The results showed that stainless steel fixators exhibited higher VMS due to their greater stiffness; however, all values remained below the yield strengths of the materials (515 MPa for stainless steel 15 and 600 MPa for titanium alloy9), indicating a low risk of implant failure. VMS value at the pin-bone interface was noted higher at the lateral side of the bone. Since the fixator frame exhibits a cantilever-like bending deformation system, the pin at the entrance of the bone resisted the largest bending moment. Thus, concentrated the transfer of load at the lateral side of the bone and generated higher stresses.14 Between two materials, stainless steel and titanium alloy, titanium fixators produced lower stress at the pin–bone interface, conforming to previous research,44 reducing risks of stress shielding9 and pin loosening.14 Titanium also showed lower strain, consistent with prior clinical findings of reduced pin loosening and pain 9, 18.

Other than that, micromotion at the fracture gap supports bone healing when within 0.2–1.0 mm,15,45 but excessive movement (>2.0 mm) disrupts vascularization and delays healing.46,47 An overly stiff fixation is undesirable, as it can cause stress shielding, reducing physiological loading and leading to bone loss. Conversely, insufficient stiffness may result in instability and, in severe cases, secondary fracture. Both stainless steel and titanium fixators produced interfragmentary movements within this optimal range, with only minimal differences. Stainless steel was slightly stiffer, but both materials provided sufficient stability without excessive rigidity.

In osteoporotic bone, stress transmission at the bone–implant interface can exceed bone tolerance.23 In fact, according to Osterhoff et al.34, porosity accounted for 70% of elastic modulus and 55% of the yield stress of cortical bone, thus increased the possibility of bone yielding and increased the potential for pin loosening. Lower stress and strain decreased the bone yielding and thus lowered the risk of pin loosening.14 This was reflected in the current study, where osteoporotic models exhibited significantly higher stress, strain, and displacement, approaching thresholds for bone yielding (200 Mpa48). Other than that, the maximum VMS on the fixator frame also increased by 65.2% in the osteoporotic bone model compared to the healthy model, indicating a substantially higher risk of implant failure. It also showed reduced stability with greater displacement, increasing the risk of delays healing and secondary fracture. Consequently, external fixation in osteoporotic patients carries increased risks of complications, including non-union and malunion,49 conforming to prior conclusion.29

Due to the limitations of the process, some assumptions were made. Modeling assumptions including isotropic bone, homogeneous fixator material, stance-phase loading, may limit generalizability. Although the bone model was simplified as a fully solid structure without pores, the distinctions between cortical and cancellous bone was maintained through their mechanical properties, which in reality are influenced by bone porosity. It was also made to maintain consistency in the results by minimizing the influence of multiple variables. The stance-phase loading was intended to simulate the early weight-bearing condition of a patient following implant application. Nonetheless, similar simplifications have been validated in prior FEA studies,50,51 and this study's findings provide meaningful biomechanical insights.

5

5 Conclusion

This study demonstrates that fixator material significantly affects stability. Titanium alloy fixators produced lower stress and strain at the pin–bone interface compared to stainless steel, thereby reducing risks of loosening and infection, while still maintaining comparable stability. For osteoporotic bone, external fixation proved biomechanically less stable, with substantially greater displacement and interfragmentary movement, suggesting increased risks of healing complications. Clinicians should exercise caution when applying external fixation in osteoporotic patients.

Consent

The consent form was signed by the subject prior to CT scanning procedure.

Ethical approval

Ref. no.: Versi 2.0, dated February 15, 2008, granted by Hospital Tunku Ampuan Afzan, Kuantan, Pahang, Malaysia.

Credit author statement

AUAA – original writing; analysis; methodology; visualization.

NBW – manuscript editing; methodology.

GHS – manuscript editing; resources; supervision.

MRAK – manuscript editing; resources; supervision.

MHR – manuscript editing; methodology; resources; supervision.

Ethical approval

Ref. no.: Versi 2.0, dated February 15, 2008, granted by Hospital Tunku Ampuan Afzan, Kuantan, Pahang, Malaysia.

Funding

This work was supported by Universiti Teknologi Malaysia (UTM) (grant no.: 07E46) and Universitas Sriwijaya Indonesia (grant no.: 1U051).

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