Stainless Steel
316L and Orthopaedic Applications
Steel Microstructure
Critical Must-Knows
- Definition: Iron-based alloy containing at least 10.5% Chromium (for passivation)
- Definition: The most common medical grade is 316L
- Mechanism: 316L: Iron (60%), Chromium (17-20% - passivates), Nickel (12-14% - stabilises austenite), Molybdenum (2-4% - resists pitting corrosion), Carbon (under 0.03% 'Low' - prevents sensitisation)
- Management: Manufactured via Cold Working (increases strength but reduces ductility) or Annealing
Clinical Pearls
- "Biocompatibility testing
- "Mechanical testing (Young's Modulus ~200 GPa - very stiff)
- "Prone to Crevice Corrosion and Fretting corrosion
- "Beware Nickel Allergy (10-15% of population)
Exam Warning
Know what 316L stands for: 300 series (Austenitic), 16% Chromium (approx), L = Low Carbon (under 0.03%). Low carbon is crucial to prevent the formation of Chromium Carbides at grain boundaries, which deplete chromium and lead to Intergranular Corrosion. Stainless Steel is Face Centred Cubic (FCC) - remember "Space filling" (Ductile).
Composition & Structure
- Iron (Fe): Base metal (~60%).
- Chromium (Cr): 17-20%. Forms surface Oxide layer (CrβOβ) resulting in Passivation (Corrosion resistance).
- Nickel (Ni): 12-14%. Stabilises the Austenitic (FCC) phase at room temperature. Allergen risk.
- Molybdenum (Mo): 2-4%. Resists Pitting corrosion.
- Carbon (C): under 0.03% (Low). Minimises carbide precipitation.
Crystal Structure:
- Austenitic: Face Centred Cubic (FCC).
- Non-magnetic.
- Ductile (can be contoured/bent intra-operatively).
- Work hardens (gets stronger as you bend/shape it).
- Cannot be heat treated for hardening.
At a Glance
316L stainless steel is an iron-based alloy with chromium (17-20%) for passivation via CrβOβ oxide layer formation, nickel (12-14%) to stabilize the austenitic (FCC) phase, molybdenum (2-4%) for pitting resistance, and low carbon (under 0.03%) to prevent sensitization. It has high stiffness (Young's modulus ~200 GPa) causing stress shielding, and is ductile allowing intraoperative plate contouring. Stainless steel is the most corrosion-susceptible orthopaedic alloy, prone to crevice corrosion under screw heads and fretting corrosion at plate-screw interfaces. Nickel allergy affects 10-15% of females, requiring titanium alternatives in sensitized patients. Never mix with titanium due to galvanic corrosion risk.
Cr-Ni-Mo-L316L Composition
| Cr | Chromium Corrosion resistance via CrβOβ passivation layer |
| Ni | Nickel Stabilizes Austenite (FCC) phase - makes it ductile |
| Mo | Molybdenum Pitting corrosion resistance |
| L | Low Carbon Less than 0.03% prevents sensitization |
| Cr | Chromium Corrosion resistance via CrβOβ passivation layer | Mo | Molybdenum Pitting corrosion resistance |
| Ni | Nickel Stabilizes Austenite (FCC) phase - makes it ductile | L | Low Carbon Less than 0.03% prevents sensitization |
Hook:ChRoMe NiMo - Low Carbon
Mechanical Properties
- Young's Modulus: ~200 GPa.
- Bone is ~15-20 GPa.
- High stiffness mismatch causes Stress Shielding.
- Yield Strength: Depends on processing (Annealed ~200 MPa vs Cold Worked ~1000 MPa).
- Fatigue Strength: Moderate.
- Ductility: High (allows plate bending).
Corrosion
Stainless Steel is the most susceptible of the modern orthopaedic alloys to corrosion.
- Crevice Corrosion: Under screw heads (low oxygen causes oxide layer to break down, and Cr cannot re-passivate).
- Fretting Corrosion: Micro-motion between plate and screw.
- Galvanic Corrosion: If mixed with Titanium (SS is the anode/active, Ti is cathode/noble). Never mix metals.
CFGPCorrosion Types of Stainless Steel
| C | Crevice Low-oxygen zones under screw heads where CrβOβ cannot re-passivate |
| F | Fretting Micromotion at the plate-screw interface mechanically disrupts the passive film |
| G | Galvanic Dissimilar metals (SS + Ti) form a cell; SS is anodic and corrodes |
| P | Pitting Localized passive-film breakdown by chloride; resisted by molybdenum |
| C | Crevice Low-oxygen zones under screw heads where CrβOβ cannot re-passivate | G | Galvanic Dissimilar metals (SS + Ti) form a cell; SS is anodic and corrodes |
| F | Fretting Micromotion at the plate-screw interface mechanically disrupts the passive film | P | Pitting Localized passive-film breakdown by chloride; resisted by molybdenum |
Hook:Crevices Fret, Galvanic Pits
Mechanisms of Corrosion in Orthopaedic Metals
- Identifies 10 corrosion mechanisms: pitting, crevice, mechanically-assisted crevice corrosion, fretting, fretting-initiated crevice corrosion, taper corrosion, galvanic, stress/tension, fatigue and inflammatory-cell-induced corrosion
- Position on the galvanic series and the ability to maintain a passive oxide film determine implant longevity
- Bio-tribocorrosion disrupts the passive layer and initiates pitting at micromotion interfaces
- Corrosion proceeds by oxidative metal dissolution releasing cations, current flow to the cathode, then deposition of metal oxides/hydroxides
Stress Shielding and Implant Stiffness in Plate Fixation
- Higher plate stiffness improves construct stability but increases the stress-shielding effect on underlying bone
- Interfragmentary strain between 2% and 10% is required for callus formation
- Plate material and design are key variables for balancing fixation stability against stress shielding
- Lower-modulus implant materials reduce load transfer away from healing bone
Pathophysiology of Hypersensitivity to Metallic Implants
- Metal ions (Ni, Cr, Co) act as haptens and drive a delayed (Type IV), T-cell-mediated hypersensitivity response
- European skin sensitisation rates: nickel ~20%, chromium ~4%, cobalt ~7%
- United States skin sensitisation rates: nickel ~14%, chromium ~4%, cobalt ~9%
- Cross-reactivity occurs between metal allergens, relevant when choosing alternative alloys
Nickel Allergy: Epidemiology and Clinical Review
- Nickel is the most frequent cause of contact allergy worldwide
- European general-population prevalence ~8-19% in adults, 8-10% in children/adolescents, with strong female predominance
- Jewellery and metal in clothing remain the main exposure sources; EU nickel regulation reduced prevalence and severity
- Allergic nickel dermatitis may be localized to the exposure site, widespread, or present as hand eczema
Nickel Allergy and TKA Outcomes: CoCr vs Nickel-Free
- Retrospective review of 20,324 primary TKAs; 282 patients had documented preoperative nickel allergy
- 243 received a nickel-free implant and 39 received a standard cobalt-chromium implant
- No significant difference in revision rate (survivorship 98% nickel-free vs 94% CoCr, P=0.9)
- No difference in KOOS-JR, VAS, LEAS, PROMIS or VR-12 scores between groups at 6 weeks or 1 year
Material Comparison
Stainless Steel vs Titanium
Standards for Implant-Grade Stainless Steel
- ASTM F138/F139 specify wrought 316L (low-carbon) stainless steel bar/wire and sheet/strip for surgical implants
- ISO 5832-1 is the international standard for wrought stainless steel for surgical implants
- Carbon is restricted to under 0.03% (the 'L' grade) to prevent sensitisation and intergranular corrosion
- Higher-nitrogen, low-nickel grades (ASTM F1586, ISO 5832-9) offer improved strength and reduced nickel content
Overview
Stainless Steel in Orthopaedics
Definition:
- Iron-based alloy with minimum 10.5% chromium
- Medical grade is 316L (low carbon)
- Most common implant material for fracture fixation
Key Properties:
- High stiffness (Young's modulus ~200 GPa)
- Ductile (can be contoured intraoperatively)
- Cost-effective compared to titanium
- Prone to corrosion in body environment
Stainless Steel Overview
| Property | Value | Clinical Significance |
|---|---|---|
| Chromium | 17-20% | Forms CrβOβ passivation layer |
| Nickel | 12-14% | Stabilizes austenite, allergen risk |
| Molybdenum | 2-4% | Resists pitting corrosion |
| Carbon | Less than 0.03% | Prevents sensitization |
Anatomy
Material Microstructure
Crystal Phases:
- Austenite (FCC): Stable phase in 316L at room temperature
- Ferrite (BCC): Present in ferritic steels, not 316L
- Martensite (BCT): Present in hardened steels
Microstructural Features:
- Grain boundaries (potential corrosion sites)
- Inclusions (impurities, stress concentration)
- Passive layer (CrβOβ surface oxide)
Steel Phase Comparison
| Phase | Crystal Structure | Properties |
|---|---|---|
| Austenite | FCC (Face-Centered Cubic) | Ductile, non-magnetic, work-hardenable |
| Ferrite | BCC (Body-Centered Cubic) | Magnetic, less ductile |
| Martensite | BCT (Body-Centered Tetragonal) | Hard, brittle, heat-treatable |
Classification
Classification of Stainless Steels
By Crystal Structure:
- Austenitic (300 series): 316L, 304 - most orthopaedic implants
- Ferritic (400 series): Magnetic, less corrosion resistant
- Martensitic: Hardened surgical instruments (scalpels)
- Duplex: Mixed austenite/ferrite
Stainless Steel Types
| Type | Examples | Orthopaedic Use |
|---|---|---|
| Austenitic | 316L, 304 | Plates, screws, nails |
| Martensitic | 420, 440C | Surgical instruments, blades |
| Ferritic | 430 | Not used (magnetic) |
Clinical Assessment
Preoperative Considerations
Patient Assessment for SS Implants:
- Nickel allergy history (cheap jewelry rash)
- Metal hypersensitivity (Type IV)
- Prior implant reactions
- MRI requirements (artifact considerations)
Indications for Stainless Steel:
- Fracture fixation (plates, screws, nails)
- Temporary fixation devices
- Cost-sensitive settings
- When intraoperative contouring needed
Implant Material Selection
| Factor | Choose SS | Choose Titanium |
|---|---|---|
| Nickel allergy | Avoid | Preferred |
| Cost priority | Yes | No (expensive) |
| Plate contouring | Excellent | Notching risk |
| MRI imaging | Artifact | Minimal artifact |
Investigations
Implant-Related Investigations
Imaging:
- Plain radiographs: Assess implant position, loosening
- CT: Metal artifact but can assess fixation
- MRI: Significant artifact with SS (vs minimal with Ti)
Laboratory:
- Serum metal ions (Cr, Ni, Mo)
- CRP, ESR if infection suspected
- Aspiration if effusion present
Investigation Modalities
| Test | Indication | Limitation with SS |
|---|---|---|
| X-ray | Implant assessment | Standard, no issues |
| MRI | Soft tissue assessment | Significant artifact |
| Metal ions | Metallosis suspected | Elevated in corrosion |
Management

Implant Selection Strategy
When to Use Stainless Steel:
- Fracture fixation (temporary implant)
- No nickel allergy
- Cost considerations
- Intraoperative plate contouring required
When to Avoid:
- Known nickel allergy
- Permanent implant (prefer titanium)
- Existing titanium implant (galvanic corrosion)
- Need for MRI follow-up
Management Decisions
| Scenario | Recommendation | Rationale |
|---|---|---|
| Nickel allergy | Use titanium | Avoid hypersensitivity |
| Cost priority | Use SS | Effective and economical |
| Existing Ti implant | Use titanium | Avoid galvanic corrosion |
Surgical Technique
Implant Handling
Plate Contouring:
- SS is ductile (can be bent intraoperatively)
- Work-hardening strengthens bent areas
- Avoid excessive bending (notch sensitivity)
Screw Insertion:
- Match screw type to plate system
- Avoid cross-threading
- Maintain uniform torque
Intraoperative Considerations
| Action | SS Advantage | Precaution |
|---|---|---|
| Plate bending | Ductile, malleable | Work-hardens with each bend |
| Screw insertion | Standard technique | Avoid cross-threading |
| Metal contact | Never mix with Ti | Galvanic corrosion risk |
Complications
SS Implant Complications
Corrosion Types:
- Crevice corrosion (under screw heads)
- Fretting corrosion (plate-screw micromotion)
- Galvanic corrosion (mixed with titanium)
- Pitting corrosion (localized oxide breakdown)
Biological Reactions:
- Nickel hypersensitivity (Type IV)
- Metallosis (tissue staining, osteolysis)
- Stress shielding (bone resorption)
Corrosion Complications
| Type | Mechanism | Prevention |
|---|---|---|
| Crevice | Low Oβ under screw heads | Minimize crevice design |
| Fretting | Plate-screw micromotion | Rigid fixation |
| Galvanic | Mixed metals (SS + Ti) | Never mix metals |
Postoperative Care
Post-Implantation Monitoring
Routine Follow-up:
- Serial radiographs for fracture healing
- Monitor for implant loosening
- Watch for signs of metal reaction
Implant Removal Considerations:
- Optional once fracture healed
- Consider if nickel sensitivity develops
- Reduces long-term corrosion exposure
Monitoring Parameters
| Sign | Possible Cause | Action |
|---|---|---|
| Dermatitis over plate | Nickel allergy | Consider removal |
| Chronic pain | Metallosis/loosening | Investigate, consider removal |
| Screw lucency | Corrosion/osteolysis | Metal ions, removal if progressive |
Outcomes
Stainless Steel Implant Outcomes
Fracture Fixation:
- Union rates equivalent to titanium
- Cost-effective for trauma fixation
- Reliable performance for temporary implants
Complications Rates:
- Corrosion-related issues: 1-5%
- Metal hypersensitivity: Less than 1% symptomatic
- Stress shielding: Variable
Outcome Comparison SS vs Ti
| Outcome | Stainless Steel | Titanium |
|---|---|---|
| Union rate | Equivalent | Equivalent |
| Corrosion rate | Higher | Lower |
| Stress shielding | More (stiffer) | Less |
| Cost | Lower | Higher |
Evidence Base
Key Evidence
Material Science & Corrosion:
- Ude/Laurencin (2023): galvanic-series position and passive-film integrity govern corrosion susceptibility
- Chung (2017): higher plate stiffness improves stability but increases stress shielding; IFS 2-10% needed for callus
Clinical Evidence:
- AhlstrΓΆm/Thyssen (2019): nickel allergy ~8-19% of European adults, female predominant
- Siljander (2023): no difference in TKA revision between CoCr and nickel-free implants in nickel-allergic patients
Evidence Summary
| Study | Finding | Implication |
|---|---|---|
| AhlstrΓΆm/Thyssen 2019 | Nickel allergy 8-19% adults, female predominant | Take a jewellery-allergy history before SS implant |
| Siljander 2023 | No revision difference CoCr vs nickel-free in TKA | Skin allergy alone does not mandate nickel-free implant |
| Ude/Laurencin 2023 | Galvanic position + passive film drive corrosion | Explains SS crevice/fretting susceptibility |
Differential Diagnosis: The Painful Stainless Steel Implant
A patient with a painful, swollen, or draining stainless steel implant has a narrow but high-stakes differential. The cardinal task is to exclude infection before attributing symptoms to metal.
Differential Diagnosis of the Symptomatic SS Implant
| Diagnosis | Key Features | Aspirate / Markers | Discriminator |
|---|---|---|---|
| Low-grade infection | Pain, warmth, sinus, late presentation | Neutrophil-predominant; CRP/ESR often raised; cultures may be negative | Extended 14-day culture, sonication, histology (acute PMNs) |
| Metal hypersensitivity | Dermatitis over implant, chronic pain | Lymphocyte-predominant; CRP/ESR normal-mild | Rash overlying implant; positive patch test / LTT; aseptic |
| Metallosis (corrosion) | Pain, effusion, tissue staining, osteolysis | Metal particles; elevated serum Cr/Ni ions | Black/grey debris; ICP-MS; often mixed-metal or fretting source |
| Aseptic loosening | Mechanical pain on loading, lucency | Non-inflammatory; markers normal | No sinus/erythema; progressive radiographic lucency |
| Stress shielding | Asymptomatic bone thinning under plate | Normal | Cortical osteopenia beneath rigid plate; refracture risk post-removal |
Controversies & Areas of Uncertainty
- Cutaneous allergy vs deep implant failure: Whether a positive skin patch test predicts symptomatic peri-implant hypersensitivity remains unresolved. Most nickel-allergic patients tolerate stainless steel and CoCr implants; the Siljander 2023 TKA cohort found no difference in revision between CoCr and nickel-free implants in nickel-allergic patients. Routine use of costly nickel-free implants for skin allergy alone is not strongly supported.
- Best test for implant metal allergy: Patch testing reflects skin sensitisation, not necessarily deep-tissue reactivity; the lymphocyte transformation test (LTT) may be more specific but is not widely validated or available. No gold-standard diagnostic test exists.
- Routine implant removal after union: Whether to remove stainless steel hardware after fracture healing (to reduce long-term corrosion exposure and stress shielding, balanced against refracture and re-operation risk) is debated and largely driven by symptoms and patient factors rather than firm evidence.
- Stainless steel vs titanium for trauma: No high-quality RCT demonstrates a difference in union rates; choice is driven by cost, MRI needs, intraoperative contourability and allergy rather than proven outcome superiority.
- Nitrogen-strengthened low-/nickel-free steels: Higher-strength, reduced-nickel austenitic grades exist but have limited long-term clinical outcome data and are not yet standard of care.
MANIAWhen to Choose Titanium over Stainless Steel
| M | MRI needed Titanium produces minimal artifact for follow-up imaging |
| A | Allergy Strong nickel allergy history favours nickel-free titanium |
| N | Near existing Ti Avoid galvanic coupling with an in-situ titanium implant |
| I | Implant permanence Long-term/permanent implants benefit from titanium biocompatibility |
| A | Adjacent bone protection Lower modulus reduces stress shielding of healing/osteoporotic bone |
| M | MRI needed Titanium produces minimal artifact for follow-up imaging | I | Implant permanence Long-term/permanent implants benefit from titanium biocompatibility |
| A | Allergy Strong nickel allergy history favours nickel-free titanium | A | Adjacent bone protection Lower modulus reduces stress shielding of healing/osteoporotic bone |
| N | Near existing Ti Avoid galvanic coupling with an in-situ titanium implant |
Hook:Titanium for the MANIA cases
Exam Viva Scenarios
Use these scenarios to practise clinical reasoning and management decisions
Scenario 1: Nickel Allergy and Implant Selection
"You are consenting a patient for an ORIF of a distal radius fracture. She tells you she gets a rash from cheap earrings. What are the implications for your implant choice?"
Scenario 2: Galvanic Corrosion and Mixed Metal Implants
"A 55-year-old patient underwent ORIF of a distal femoral fracture 18 months ago. The original surgery used a stainless steel locking plate. He subsequently fell and sustained a proximal femoral shaft fracture above the plate. The on-call registrar added a retrograde femoral nail (titanium alloy) to stabilize the proximal fracture, overlapping with the existing stainless steel plate. Six months later, the patient presents with persistent thigh pain, swelling, and a draining sinus over the distal femur. X-rays show periosteal reaction and loosening of the distal screws. Aspiration of the sinus shows no bacterial growth on cultures, but analysis reveals metallic debris with elevated titanium and chromium ions. What is your diagnosis, what went wrong, and how do you manage this patient?"
Scenario 3: Implant Failure Analysis - Metallosis vs Infection vs Allergy
"A 42-year-old woman underwent ORIF of a tibia-fibula fracture with a stainless steel plate and screws 2 years ago. She now presents with chronic pain, swelling, and occasional drainage from the surgical scar. She also mentions she has developed a rash on her skin overlying the plate. Examination shows warmth, erythema, and fluctuance over the plate. Aspiration shows turbid fluid with WBC 15,000 (predominantly lymphocytes), but routine bacterial cultures are negative at 5 days. Serum inflammatory markers are mildly elevated (CRP 25 mg/L, ESR 35 mm/h). X-rays show periosteal reaction and mild screw lucency but no fracture. The patient is frustrated and demands answers. What is your differential diagnosis, how do you investigate this systematically, and what is your management approach?"
MCQ Practice Points
Clinical Pearl
Q: What is the composition and significance of 316L stainless steel used in orthopaedic implants?
A: 316L contains: Iron (~60% base), Chromium (17-20% for passivation via CrβOβ oxide layer), Nickel (12-14% to stabilize austenite), Molybdenum (2-4% for pitting corrosion resistance). The "L" designates low carbon (less than 0.03%). Low carbon prevents chromium carbide precipitation at grain boundaries, which would deplete chromium and cause intergranular corrosion (sensitization).
Clinical Pearl
Q: Why is stainless steel austenitic (FCC) structure and what properties does this confer?
A: Nickel stabilizes the Face-Centered Cubic (austenitic) phase at room temperature. Properties: (1) Non-magnetic - allows MRI imaging (though creates artifact), (2) Ductile - can be contoured intraoperatively, (3) Work-hardenable - becomes stronger when cold-worked/bent. Cannot be heat-treated for hardening unlike martensitic steel.
Clinical Pearl
Q: What are the types of corrosion affecting stainless steel implants and their mechanisms?
A: (1) Crevice corrosion: Under screw heads where low oxygen prevents re-passivation of the chromium oxide layer. (2) Fretting corrosion: Micro-motion between plate and screw disrupts oxide layer. (3) Galvanic corrosion: When mixed with more noble metals (titanium), SS becomes the anode and corrodes. (4) Pitting corrosion: Localized breakdown of passive layer, resisted by molybdenum content.
Clinical Pearl
Q: What is the clinical significance of nickel in stainless steel implants?
A: Nickel allergy (Type IV hypersensitivity) affects 10-15% of females and 2% of males. Clinical presentations include: dermatitis over implant, chronic pain, aseptic loosening. While cutaneous patch test positivity does not strongly predict implant failure, patients with severe nickel allergy (cheap jewelry rash) should receive titanium implants instead. Titanium is nickel-free.
Clinical Pearl
Q: How does stainless steel compare to titanium for fracture fixation implants?
A: Stainless steel: Higher modulus (200 GPa) provides rigid fixation but causes more stress shielding; lower cost; significant MRI artifact; ductile (can be bent intraoperatively); contains nickel allergen. Titanium: Lower modulus (110 GPa) closer to bone, less stress shielding; higher cost; minimal MRI artifact; excellent biocompatibility; no nickel. SS preferred for temporary fixation, Ti for permanent implants or nickel-allergic patients.
Guidelines, Registries & Global Practice
Standards & Global Epidemiology
Material Standards (international):
- ASTM F138/F139 and ISO 5832-1 define implant-grade wrought 316L stainless steel
- ASTM F1586 / ISO 5832-9: nitrogen-strengthened, low-nickel high-strength grades
- Carbon kept under 0.03% ("L") to prevent sensitisation/intergranular corrosion
Global epidemiology of nickel sensitisation:
- Nickel is the commonest contact allergen worldwide
- Adult prevalence ~8-19% (Europe), ~14% (US), with strong female predominance
- Symptomatic deep-implant hypersensitivity is uncommon and difficult to prove
Stainless Steel in Global Practice
| Factor | Detail | Relevance |
|---|---|---|
| Cost | SS markedly cheaper than titanium | Dominant in cost- and resource-limited trauma care worldwide |
| Availability | Universally stocked; simple manufacture | Workhorse for fracture fixation globally |
| Contourability | Ductile, easily bent intraoperatively | Valued where pre-contoured anatomic plates are unavailable |
Stainless Steel Quick Facts
Clinical summary
Composition
- β’Iron (Base)
- β’Chromium (greater than 10.5% - Passivation)
- β’Nickel (Austenite)
- β’Molybdenum (Pitting)
Properties
- β’Modulus: 200 GPa (Stiff)
- β’Structure: FCC (Austenite)
- β’Processing: Cold Worked
References
- AhlstrΓΆm MG, Thyssen JP, Wennervaldt M, MennΓ© T, Johansen JD. Nickel allergy and allergic contact dermatitis: a clinical review of immunology, epidemiology, exposure, and treatment. Contact Dermatitis. 2019;81(4):227-241. PMID: 31140194. doi:10.1111/cod.13327
- Siljander BR, Chandi SK, Debbi EM, McLawhorn AS, Sculco PK, Chalmers BP. A comparison of clinical outcomes after total knee arthroplasty in patients with preoperative nickel allergy receiving cobalt chromium or nickel-free implant. J Arthroplasty. 2023;38(7 Suppl 2):S194-S198. PMID: 37100098. doi:10.1016/j.arth.2023.04.048
- Ude CC, Dzidotor GK, Iloeje K, Nair LS, Laurencin CT. Corrosion of metals during use in arthroplasty. ACS Appl Bio Mater. 2023;6(6):2029-2042. PMID: 37261398. doi:10.1021/acsabm.2c01082
- Chung CY. A simplified application (APP) for the parametric design of screw-plate fixation of bone fractures. J Mech Behav Biomed Mater. 2017;77:642-648. PMID: 29101896. doi:10.1016/j.jmbbm.2017.10.025
- Kounis NG, Koniari I. Hypersensitivity to metallic implants: pathophysiologic and diagnostic considerations. Acta Biomed. 2018;89(3):428-429. PMID: 30333472. doi:10.23750/abm.v89i3.6718
- ASTM F138/F139; ISO 5832-1 / ISO 5832-9. Standard specifications for wrought 316L and nitrogen-strengthened stainless steel for surgical implants.