Functional load of plates in fracture fixation in vivo and its correlate in bone healing

In clinical practice efforts are made to apply a fixation plate on the side opposite the strongest muscle pull. This achieves an optimal distribution of compression between the fragment ends (principle of tension band plating ). This is however frequently impossible for anatomical or surgical reasons . In an 'in vivo' study lasting 8 weeks a standardized oblique osteotomy was performed on the tibia of 16 sheep in four different models of tension band plating (a contoured and an overbent plate with or without an interfragmen tary lag screw) were assessed. Tension on the plate surface was recorded by strain gauges for different gait speeds on the treadmill. These measuremen ts were performed throughout the experiment. Radiographs were taken at regu lar intervals in order to assess stability and polychrome sequential labell ing and microradiographs served to investigate the healing process. Possibl e relationships and/or interactions between plate tension and bone healing were investigated. Implant loading under bending strain was reduced the most for the combinati on of plate overbending with a lag screw. The insertion of a lag screw redu ces the surface strain on the plate whether it is contoured or overbent. Th e bending and torsional forces are greatest if a straight plate is used alo ne and the principle of tension band plating is not applied. Direct bone healing was only observed in the group with contoured plate and lag screw. Overbending combined with a lag screw provided only a relativel y unstable fixation. A residual gap immediately beneath the plate permits " dynamic compression" since the screws slide towards the osteotomy when load ed producing bone resorption under the plate and signs of screw loosening. The models with contoured and overbent plates without a lag screw were hist ologically assessed as very unstable with signs of secondary fragment displ acement, obvious callus formation, resorption at the fragment ends and unde r the plate, delayed and diminished Haversian remodelling and corrosion sit es at the screw heads and at the adjacent site on the plate hole. In all gr oups, stripping of the periosteum under the plate was associated with poros is of the corresponding cortex as a sign of temporarily impaired blood supp ly. A relationship between implant loading and/or unloading (stress shieldi ng) could not be demonstrated. Callus formation, measured quantitatively on the radiographs, is directly r elated to the strain on the plate. Direct bone healing is rapid and is seen histologically three weeks postoperatively, particularly for fixations wit h contoured plate and lag screw. The early appearance of fixation callus in the presence of an intact blood supply indicates a primary instability of the osteosynthesis. Later, it may be an indication of secondary instability. The time at which osteons appea r, their number and location provides information on the stability of the o steosynthesis. At a time when indirect fracture reduction and stabilization using minimally invasive techniques and implants is being propagated, addi tional ways and means must be sought to assess clinically the load on the i mplants and the risk of implant failure.