Biomechanical and biological aspects of defect treatment in fractures using helical plates.

The clinical case of figure 1 through figure 11 shows a series of impressive failures of plate fixation. The plates were repeatedly applied bridging a comminuted bone segment in a heavy patient. The biomechanical analysis elaborates why this happened and proposes an unconventional procedure to prevent this failure with a minimally invasive procedure. A plate bridging an open gap or a defect in a long bone diaphysis is exposed to full functional load. According to clinical observations such plate application often fails even without external load such as weight bearing. The plate risks to break through fatigue when exposed during a long time to cyclic loading. This type of failure has been observed even with broad plates as well in femoral as in tibiae. The first option to avoid such failure consists in protecting the plate by installing load sharing between plate and either bone or an additional implant. This reduces the load carried by the plate to a safe level. Load sharing with bone may be installed at surgery by establishing solid mechanical bridge between the two main fragments of the fractured bone. The optimal load sharing relies on a solid compressed contact between the main fragments. It can be established because the bone is able to take a large load which results in optimal protection of the plate. In the case of an extended comminuted bone segment it may be very difficult, traumatizing and inefficient to reconstruct the bone. In the present case it was impossible to establish load sharing through the bone. The second option protecting the plate is provided by callus bridging of the gap or defect. The formation of a solid callus bridge takes time but the fatigue failure of the plate also takes time. Therefore, the callus bridge may prevent a late fatigue failure. The surgeon may select one of several options: - Replacing the lack of bone support using a second plate which immediately alleviates plate loading. The drawback of application of a second conventional plate is the extent of surgical trauma at the critical site of healing. - Shingling and/or applying an autologous cancellous bone graft: This procedure provides initially no relevant load sharing but will do so after a couple of weeks. The mechanical coupling of the comparably soft graft and the main fracture fragments presents little problems. Applying a cortical bone graft: Such a graft does provide initial only small load sharing and does a less good job inducing callus than a cancellous graft. Furthermore, the coupling by callus between a somewhat rigid bone graft and the mobile main fracture fragments requires a solid maintained contact. If the cortical graft is fixed using implants with small contact area to the graft such as screws or cerclage loops, the local stress may be critical and the graft may break. When the cortical graft is fixed with cerclage wires the procedure must take into account the limited strength of the individual cerclage. Therefore multiple and well-spaced cerclages are required and may lead to success especially if an intramedullary component of the implant contributes to protection (6). The degree of unloading depends apparently on the stiffness of the material of the protecting splint. Though, more important is the effect of the dimensions of the splint. While titanium as a material is about 50% less stiff than steel, the thickness of the implant changes the stiffness with the third power. That is doubling the thickness results in eightfold increased stiffness. When considering the unloading by application of a second plate the leverage of the second plate plays an important role. The larger the distance between the axis of bending and the second implant the larger the protecting effect. The helical plate (2, 3, 7) as introduced by A.A.D. Fernandez offers biological and mechanical advantages. It can be applied without touching the fracture site maintaining the critical biology intact and provides mechanically efficient unloading. Its application is fairly simple: The helical plate is modified conventional long and small plate that is twisted between its ends about 90 degrees. The twist is applied using "bending irons" (4, 5, 8) whereby the force required is small and the exact degree of twist is not critical. Therefore the twist is applicable operating bending irons by hand. Assuming a situation where a plate bridging a defect or non-union has failed the broken plate is replaced by a similar implant: At the distal end of the bone fracture and opposite to the surgical approach a small incision allows to slide in the helical plate in such a way that proximally the plate ends on the same side of the limb as the replaced plate. Ideally the two plate ends meet and the application of the helical plate does not ask for an additional surgical exposure at this location. Otherwise a small minimally invasive exposure is required. The helical plate is then fixed to the main bone fragments using a couple of locked screws. The following case demonstrates the use and efficiency of the helical plate saving a situation where multiple attempts using conventional plates had failed. The successful final treatment of this case was performed by A. A. D. Fernandez.