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ELSEVIER

The influence
of external fixators
motion during simulated
walking
T. N. Gardner,

on fracture

M. Evans and J. Kenwright

Oxford Orthopaedic Engineering Centre, University of Oxford,
Orthopaedic
Centre, Windmill Road, Headington, Oxford, UK

Nuffield

ABSTRACT
This expamental
study examines the relative influence
ofJive uniluteral
external jixntors
on tibia1 fructure
.stnbility
during
simulated
walking.
Stability
during
routine patient
uctivity
i.c important,
because cyclic inter-fragmentary
motion, or strain, has been shown to affect ji-arlure
healing. In model stable fractures
simulating
early healing (six
weeks), it was found
thatjxators
do little to constrain
aguinst uxial interfraCgmentq
strains us great as 100% at
on[y nominal
weight-bearing
(6.0 kg). ?‘he,$e strains may orcur repeatably
at peak nmp?itudes
motion d7cringwalking
Similurly,
peak angular
movements
may &ad to additional
axial strains of up to 25% at the external
cortex and sheur movrmunt.r
may lead to shear strains OJ up to 100%. Such strains nre greut enough to yield and
possibly refracture
the intm gap fracture
tissue that may be composed of a combination
of gvanulation
tissue, Jibrou~~
rartiluCge, cartilage
and bone. It was also shown that the prowdure
releasing
the jxator
column
to trlesrope
(dynamizr)
hnr little inJluence
on peak cyclic axial motion and on loading
at the frarturr.
although
inrrenses
orrurrrd
in peak transverse
and torsional shear strains of up to 100%. Since permanent
interJiiqmentan
trarrskation
(dso arises Jirom thr consequent
compaction
of the intra g@ tissue, it may be permanent
displacement
rathm th,nn
nny rhnngr
in the amplitude
motion that is responsible for the benejrial
rffert on healing claimed for the drnnmizini poruduru.
In unstnblP fractures
that are unable to .support tibia1 load at the fracture.
the peak ampl~tude.~
of
ryrlir
movement
were as <great as those reported forJ+acture.r
stnbilizrd
bv pkast~r
rasts, and were appoximatrl~
twiw
the mo7~ernen t of the rtable frartur-es
simulating
enr!y healing.
There&e,
patients
with unstnblP frarlures
suiported
by cxttmal
fixators,
may be expected to have .similar pallerns
of hen&
to plnstcl-rastrd
pnlirnt.s
with similn~l;.ar2ure\.
C&riqht
0 1496 l&vim
Science I.td.for
IPlNH.

of

qf

qf

Keywords:
healing

Fracture,

external

Med. Brig. Phys., 1996, \‘ol.

fixator,

fracture

model.

inter

fragmentary

strain, fracture

mov~mcn~,

18, 305-313, June

INTRODUCTION
The biological process and speed of fracture healing is influenced by the inter fragmentary motion
permitted by the fracture fixation device. This is
because fractures usually heal by a combination
of two different processes. The ‘direct’ process of
repair involves relatively rigid fracture fixation
and primarily osteonal remodelling
at the fragment ends’. The more rapid ‘indirect’ process,
involves a more flexible fixation permitting some
degree of inter fragmentary
motion and results
primarily
in the formation
of callus, usually
initiated
at the periosteum’.
During
mainly
indirect healing with external fixation, it has been
shown that the nature of inter fragmentary
motion influences the speed of restoration of
mechanical integrity at the fracture, and therefore
of limb function.‘. Since the fixation frame pro-

vides the main constraint against this motion during regular motion-inducing
activities such as
walking, the performance of the fixator must have
a profound influence on the process and speed
of healing. Therefore, this study examines experimentally the influence of external fixators on fracture motion during simulated walking.
The properties of inter fragmentary motion that
influence healing (amplitude, direction,
frequency and strain rate)
Kenwright and Goodship showed that passive cyclic axial movements, that are applied mechanically
to tibia1 fractures, can be either inhibitory
or
stimulator-y to the process of indirect healing. For
example amplitudes of 2.0 mm axially in experimental fractures (corresponding
to 67% strain in
the 3.0 mm gaps used) was shown to delay callus
formation in comparison with ‘rigid fixation’, and
0.5 mm (corresponding to 17% strain) to produce

Here. bending and shear loads have been applied cyclically to model fractures at physiological frequency and strain rate. In practise however. The frequencies and strain rates used successfully to stimulate osteogenesis have been physiological. as well as the biological one. and in plastercasted patients shear and angulation was measured at between 3. and not of the controlled mechanical environment discussed above.Fracture motion during walking: T. Also. Any evaluation of the performance of unilateral external fixators must therefore encompass the ranges of variation possible in these two properties. Gardner et al. Owing to the different degrees of support. in an attempt to characterize the mechanical properties of each device. for example. although it may be difficult to control. With regard to the direction of movement. During the initial stages the fracture is stiffened rapidly by the arching and bridging of the callus at the periosteum. strain rate and the time of commencement of movement after injury have all been shown to influence healing by varying degrees. N. The disadvantage of angular movement is that it may cause random shear and axial movement. both in experimental fractures’ and in intact bonelo. Although the fractures may have all subsequently united. referred to as the ‘dynamizing’ function. other factors such as frequency. there is continuous change in the tissue composition and geometric structure of the fracture. The difficulty in assessing the importance of these studies arises from the uncertainty as to whether the experimental conditions were realistic. axial. Goodship and Kenwright and Kenwright and Goodship showed that axial movement can be a stimulus for healing in both humans and sheep. axial. tendon and ligament activity. The effect of shear on healing is unclear. it is not clear whether the healing rate could have been improved by reducing the movement in either study to the approximate strain shown to be beneficial by Goodship and Kenwright3. Of equal importance is the influence on inter fragmentary motion of the structural support to load offered at the fracture site by the interposing fragment ends brought into contact by tibia1 load. and subsequently through the process of uniting the inter fragmentary surfaces by fibrous connective tissue. As a consequence. the amplitude and direction of this motion is not expected to be appropriate. Also. the amplitude and direction of movement will reduce gradually and the demand on the fixator to provide constraint is expected to change. The loading is therefore very and it would require considerable complex. many forms of unilateral external fixators now incorporate an option for changing the degree of axial support provided by the frame. Cast-brace studies have indicated that tibia1 fracture movements can be more substantial although non-unions are uncommon5. while the time to commence this movement would seem to be as early as pain and discomfort allows”. but it is not generally used for unsupported fractures. in the natural environment of a fracture. resources to generate and validate an experimental. Here. culminating in directly formed bone by intamembranous or enchondral ossification13. the distinction must be made between the inter fragmentary motion of fractures where tibia1 load is ‘well-supported’ at the fragment ends and of fractures where load is largely ‘unsupported!.0 mm and 2” (for three stable fractures) and 2 cm and 21” (for an unstable fracture)6. using a variety of models and loading configurations14-17. when both bone fragments do not pivot precisely about the fracture centre. the forces or movements at a mid-diaphyseal tibia1 fracture site. In addition to displacement. a greater stimulus to callus formation and fracture stabilization. A more realistic approach has been attempted for this study. it is uncertain whether the observed behaviour is representative of real fractures of variable bone-end support that develop an increasing constraint to movement throughout the healing process. Consideration must be given to the influence this may have on load-bearing motion in well-supported fractures. Although active movement will probably provide the desired frequency and strain rate for an optimum healing response. the inter fragmentary motion of such fractures during patient activity is expected to be substantially different. The influence on motion of the load-bearing properties of the fracture site The structural and material properties of the fracture site influence the performance of the fixation system and therefore the amplitude and direction of inter fragmentary motion. and this affects the control of load-bearing movement by 306 the fixator framei2. fractures are regularly exposed to the random active movements that arise from the routine activities of weight-bearing and muscle flexion. Although significant shear movements have been shown to cause non-union in experimental fractures in the rabbit tibia*. Since the nature of motion will vary. angular movement has also been shown to stimulate substantial callus in rat tibiae’. The influence of the fixator on inter fragmentary motion (past work and present s-59 Numerous studies have been reported on the performance of different unilateral external fixators. bending and shear (transverse and torsional) loads arise through weight-bearing and through muscle. this effect should be considered in the performance evaluation of a fixator. Healing response is therefore a consequence of this mechanical environment. it is suggested that cells in healing bone may respond to intermittent shear strains by significant tissue proliferationg. and. Since motion at the fracture becomes more constrained by the stiffening callus. The magnitude of the loading ensured that the . analytical or numerical model that was able to predict. Owing to the morphology of healing. formed by enchondral ossification13.

Although an exact prescription for motion could not be obtained from the literature. resisted by spring pressure. and the corresponding peak displacements throughout the healing period were not always predominantly axial. to evaluate the relative performance of fixators with unstable fractures. weightbearing ground loads were frequently over 200 N from as early as 2 weeks. Experimental models In the laboratory model of the stabilized fracture (Figure I) each fixator frame was arranged in a standard geometric configuration. frame stiffness. Unfortunately. and the preferred motion. Modulsystem DAF. During the healing period (around 2-20 weeks). For the tests in the unlocked mode. If they do not. For the Dynabrace.amplitude and direction of the resulting inter fragmentary motion was representative of the spectrum of movements commonly occurring in patients during walking at two to four weeks post fixation.7 mm respectively) were frequently as significant as peak axial motion (of up to 1 . the Monotubes and Dynabrace were operated with zero spring return pressure and the Modulsystem was used with and without the ‘Dyno-ring’. only the fixator framework provided stability at the fracture site. whereas the Bi-role transfers all the tibia1 axial load to the fracture site. the effect of load bearing movement on healing is likely to be more inhibitory than stimulator-y. (Orthofix). This leaves axial motion. Also. If fixators control motion in this way. With the other four fixators this is achieved by the column sliding telescopically. provided that it is controlled in amplitude to avoid axial strains reaching yield level in the intra gap tissue”. Inter fragmentary motion in patients has been characterized in previous studies that have used a displacement transducer to monitor the 3dimensional movements of well-supported tibia1 fractures during y ical daily activities over the full period of healing 8. Therefore. tests were carried out using both the ‘dynamizing’ and ‘nondynamizing’ mode of operation of each fixator. patients may be encouraged to walk as early as discomfort allows. angulations in a vertical plane and transverse shear movements (of up to 1. no contribution to the support of tibia1 load was made from the fracture site. The same load combination was then applied to a model of an unsupported fracture (without fracture simulation material). which can be applied successfully to stimulate callus osteogenesis. may not. and its influence on inter fragmentary movement under load. Some flexibility is required to induce the indirect process of healing desired for external fixation. the preferred pattern of movement would be controlled axial motion. it seems prudent to avoid angular movement. four fracture simulation materials of increasing stiffness were fixed to the opposing fragment ends across the fracture site. The stiffness performances of fixators should be evaluated only in relation to their ability to control inter fragmentary motion during normal activity to that which is required for an optimum healing response. -These were the Dynabrace (Smith and Nephew) j Bi-roll (Hoffman). METHOD Fixators A group of unilateral external fixators currently used clinically were selected for the study of inter fragmentary motion. In this way. the red and blue Monotubes (Howmedica International). Since the effect of shear strain on healing is unclear. it was possible to form a general guide from what is already known. Although the merits of frame strength may be assessed easily. the Monotubes provide the possibility of using an adjustable spring pressure offering variable resistance to axial loading. In the early stages of healing. (the ‘Dyno-ring’) to resist axial movement. To model the increasing resistance. but how stiff must the fixator frames be or what is the motion required? As the means of appraisal. the means of appraising fixator performance in relation to the control of inter fragmentary motion are not readily available. The relative performance of each fixator was therefore evaluated from the disparity between the actual fracture site motion of a model during simulated walking. as angular motion causes non-uniform axial strain around the cortex and the pivot point can be difficult to control. This 307 . tibia1 load causes the groups of screw clamps either side of the fracture site to slide on the column towards each other. Here. and the Modulsystem is used with or without a compressible ring. The above tests were carried out using a model of a well-supported fracture and by applying the loads that simulated the spectrum of movement found in a group of patients with stable fractures. Where appropriate. since walking will provide the physiological frequencies and strain rates also found to be optimum for healing. Two 135 mm lengths of glass fibre tubing of 25 mm diameter were arranged in line to model the bone each side of a 60 mm gap. For these patients. the stiffening and strengthening of the fracture provided an increasing resistance to three-dimensional movement. and at a tube/screw clamp clearance of 70 mm.S mm) and often greater lg. the relative performances of the five frames were evaluated throughout a simulated period of healing. a criterion of performance was needed against which the performance of each fixator could be compared. with the avoidance of angular and shear motion. Two 6 mm diameter screws were fixed into each section at 200 mm between pair centres. except for some variation in the lateral spacing between bone screws as a result of the individual clamp designs.0” and 0. it seems prudent to expect fixators to avoid transverse and torsional movement at the fracture. In this first condition (the unsupported frature model). The fixator operations are therefore referred to as either locked (‘nondynamizing’) or unlocked (‘dynamizing’). where the individual dynamizing actions are generally different.

leading to the removal of the fixation device at an axial fracture stiffness of around 1000 N/mm **. The 50 N/mm material modelled the contribution to stiffness provided by a wellsupported fracture at about four weeks post fixationzo. WI i i8 0 I i ui Q motion moni(c) angular. and three angular rotations about the linear axes). in phase with the vertical load. A clockwise torsion 308 Pa 30 i iI i iI e 3 Loads (b) 4 Figure 2 The four tored at the fracture. (d) torsional shear directions of inter fragmentary (a) transverse shear. Measurements The Oxford Micromovement Transducer (OMT)” was clamped between the inner pair of screws parallel to the tibia and immediately adjacent to the fracture. This simulated a torsional loading of the tibia owing to a rotation of the foot about the long axis of the bone. The loads were combined as shown in Figure I and were applied cyclically using compressed air pulses from a pneumatic diaphragm thruster and cylinder thruster. 526 and 1430 N/mm. by offsetting the line of action of the axial load at the top end of the model bone (proximal) by 16 mm. These movements were then translated to obtain the inter fragmentary motion at the fracture site. Fixator Figure 1 The model fracture configuration. where a soft cartilaginous callus may be formed prior to ossification. 526 and 1430 N/mm fracture simulation materials. that sub sequently develop only a marginal gap. After this period the contribution of the fixator frame to axial stability of the fracture begins to reduce significantly*l. This secondary phase was modelled using the 385. (a) simulating walking An axial load of 220 N was applied along the longitudinal axis of the model tibia by the diaphragm thruster at the base. between the interposing fragment ends (the well-supported fracture model).75 Nm was applied to the fracture site about an axis parallel to the screws. of 2 Nm was applied by the piston thruster to the bottom (distal) end of the model tibia. and a computer was used to acquire load vs displacement data from the load cell and transducer over 6 s test periods. Movements at the transducer in response to the loading were measured in 6 degrees of freedom (three linear orthogonal directions. Axial. A load cell at the base of the model measured vertical reaction. to simulate the resistance to inter fragmentary motion provided by the callus of a healing fracture. A 30 mm diameter polyurethane disk of thickness 12. This period of low fracture stiffness is important because. Also. A bending moment of 1. In the second condition.Fracture motion duting walking: T. applied through the knee. installed at the lower end of the model tibia. while (c) and (d) illustrate angular movement and torsional shear movement. the fixator frame is expected to have a greater mfluence on movement at the fracture. Gardner et al. it is suspected that movement during early healing may have a greater effect on the outcome of healing. . bending and torsional loads are applied to the model bone cyclically and in phase. since there is potential for greater movement during the initial stages of fracture repair. The combination of loads on the unsupported fracture model produced approximately the spectrum of inter fragmentary movement observed in the group of fracture patients. to measure 3dimensional inter fragmentary movement under loading for both fracture models. to simulate physiological loading during walking model simulates the immediate post-operation behaviour of cornminuted fractures or unreduced fractures with substantial gaps owing to bone loss. as the fracture heals and stiffens.5 mm was bonded to aluminium rods. (b) axial. that were inserted into the ends of the two tubes across the fracture site. the gap tissue and periosteal callus mineralize form bone and remodel. This model simulates the behaviour of non-comminuted fractures well-reduced. During this later phase. and . at this early stage in healing. additional support was provided at the fracture site to simulate tibia1 loadbearing across the fracture. Four grades of simulation material were used that had axial stiffnesses of 50. N. This arrangement simulated a laterally eccentric loading of the tibia.385. and were finally reduced to the four directions of movement shown in Figure 2. Diagrams (a) and (6) illustrate the two linear movements of transverse shear and axial compression. (Angular movement was calculated in the plane for which the angle was the maximum).

for a well-supported fracture model in the ‘locked’ and ‘unlocked’ mode of each fixator. shear (mm) q Axial(mm) d 2.5 UN-Unlocked 0 Trans. Here. The greatest difference in axial movement was produced by the blue Monotube. That is.0 L UN Blue-Mono The unsupported only) fracture model (locked mode fracture model (locked Thp 50 N/mm . for an unsupported fracture model with the fixator in the locked mode. 0 L 50 N/mm). L UN Dynabrace Gl % b Red-Mono Bi-roll Modulry. it increased significantly in the unlocked mode. Dynabmce L-Locked 2.rimulation material. shear (mm) q Axial (mm) Angle (de& n Ton. than the blue Monotube.5 f- Inter fragmentary motion was examined in comparison with the desired motion performance already discussed. It is worth noting that peak move- 309 . here friction may be limiting the axial sliding at the fixator column. 2.28 mm).5 E E Y P 2.1 mm).5 05 0 Blue-mono Red-Mono UN Bi-roll L UN Modulsy. The greatest peak axial movement at the fracture site occurred with the blue Monotube and the Bi-roll. Since well-supported and unsupported fractures have substantially different behaviour. Peak angular movement appeared to reduce overall when the red Monotube was unlocked. (increasing when unlocked by 1. h and Figure 4 shows the peak amplitudes of inter fragmentary motion seen during simulated walking.0 L (b) Figure The well-supported unlocked mode) i UN 2. and the red Monotube (0. appears to have little influence on peak axial displacement. the locked fixator frames (with an average axial stiffness of 60 N/mmj2. and the fracture simulation material (of stiffness Trarw.34 mm). The Bi-roll allows the greatest axial movement with the fixator locked. 2 73 . but either remained unchanged or increased with the other fixators. Also. UN L UN Dynabrace a.0 3 2 1. E L 0. red Monotube and BiRoll fixators.5 I:@Lw 3 shows the peak amplitudes of inter fragmentary motion seen during simulated walkiqg. and the red Monotube against angular movement. with the Bi-roll also offering the least constraint against transverse shear and angular movement.5 u . The control of axial displacement was considered to be beneficial and the constraint imposed upon shear (both transverse and torsional) and angulation as being desirable. Here. re p resenting a fracture in the early stages of healing. r. (deg) ~hcw (deg) 1. 3. shear (deg) 0 L Blue-Mono 4 UN L Red-Mono UN L UN Bi-roll L Modulsy. they were addressed separately. The Modulsystem offered the greatest constraint against transverse shear. the mechanical properties of the fixator are as important as those of the fracture material in influencing inter fragmentary motion at around two to four weeks post fixation.0 n Angle Ton. movements are substantially greater than will be seen later with the well-supported fracture model.0 5 t ytf! 1. it was assumed that the object of unlocking the fixator is to alter the dynamic load at the fracture.(a) RESULTS 2. contribute almost equally to resisting tibia1 load (in the ratio of 60:50). without affecting the non-axial constraint (against angulation and transverse or torsional shear movement) ’ ’ . as did torsional shear. with the Dynabrace the expected change in overall stiffness. Transverse shear displacements were resisted better in the Dynabrace. Although the Modulsystem Provided some resistance to transverse shear in the locked mode. Unusually. Looking initially at the material of lowest stiffness (Figw-e-e(a)). when operating in the unlocked mode”.. the Dynabrace against torsional shear. This was caused by the looseness of the telescoping mechanisms in both the Monotube and Modulsystem. caused by unlocking the fixator. followed by the Modulsystem (0.

. (c) 526 N/mm.2 mm with the Dynabrace. Again. this was again owing to the fixator looseness when unlocked. axial movements were again largely controlled by the fracture material. (cl 2. the fracture movements were small (Figure 4(d) ) . both shear movements were again enhanced with the Modulsystem. and for the Modulsystem in the locked mode. 0 L UN Blue-Mono L UN Red-Mono L UN Bi-roll Ton. movements were constrained to within 0. peak axial movement did not appear to be influenced at all by the type of fixator or its mode of operation. Similarly. by unlocking the fixator and initiating fixator looseness.. x5 r 2 -0 I B 2. (b) 385 N/mm. Peak axial movements with the fixators locked were generally . perhaps at the half-way sta e to fixator removal at a stiffness of 1000 N/mm i5 . Again.Fracture motion during walking: 7: N. representing a fracture at the fixator removal stage. L UN Dynabrace (4 . With the 385 N/mm material (Figure4(b)).2” with the blue Monotube but less so with the Modulsystem (locked and unlocked).0 n 3 2 1..15 mm for all frames) were largely unaffected by the type of fixator or its mode of operation.5 c u. shear (dcg) L UN Modulsy. The fixator columns are either ‘locked’ or ‘unlocked’.and also on this occasion there was no sign of the increase in axial movement observed with the 50 N/mm material when unlocking the Monotubes and the Modulsystem.5 . DISCUSSION Inter fragmentary fracture motion in the well-supported Validity of the model. With the 526 N/mm material (Figure 4( c)).5 mm for all fixators in both the locked and unlocked modes. The Monotube fixators provided the greatest constraint against torsional shear movement. but the previous reduction in angular movement caused by unlocking the red Monotube was not apparent with this simulation material. representing a fracture. the model indicates that axial movement is reducing proportionately more than angular and shear movement during the initial stiffening of the fracture site simulating calcification. The validity of the model was first established before conclusions were drawn from the results. Transverse shear movement was constrained to below 0. L UN Dynabrace Figure4 Peak inter fragmentary motion at the ‘well-supported’ fracture model during simulated walking for the five fixators. Angular movement was below 0. it increased after unlocking with the Modulsystem. The 385 N/mm simulation maternal.0 E 55 0.5 B z 1. but shear. However. The 526 N/mm simulation material. With the 1430 N/mm material.25” with the blue Monotube. This was demonstrated by comparing movements in the model.4 and 0. Four fracture simulation materials of different stiffnesses are used to model the mechanical properties of the different stages of healing from the initial growth of the callus to its ossification (a) 50 N/mm. rather than by the fixator frames of comparatively low average stiffness.was substantial with the Bi-roll and the Modulsystem. Movements were between 0. peak axial movements were substantially reduced for all the fixators. and peak axial displacements (of around 0. Gardner et al. with torsional shear. owing to rotational looseness. Axial tibia1 load was resisted by the combined fracture and frame system in proportion to the individual stiffnesses of the system (1430:60). axial movement was not significantly changed by unlocking the Dynabrace and Bi-roll fixators. as fractures heal. but was again less constrained by the Modulsystern. using the low stiffness simulation material. and (d) 1430 N/mm ments in all directions were lowered by 50 to 100% by fitting the ‘Dyno-ring’ to the Modulsystern. In general. Therefore. again this was due to fixator looseness. Peak angular movements were best constrained 310 with both Monotubes. Transverse shear movements were constrained to less than 0. This material simulated the rapid increase in stiffness and the corresponding reduction in movement associated with the callus mineralization stage. with those measured in patients during early healing. this also reduced the additional transverse and torsional shear arising from the looseness of the telescoping mechanism. and only slightly with the blue Monotube.0 5 1. The 1430 N/mm simulation material. and generally movement was increased by unlocking the fixator. The influence on healing of angular and shear movement may therefore become more important than axial movement. but was less constrained in the Modulsystem.3 mm for the red Monotube and Biroll in both locked and unlocked modes.5 s 4 6 2. ii t t 0 L Blue-Mono UN L UN Red-Mono L UN Bi-roll L UN Modulsy.

and may cause an increase in the incidence of non-unions arising from inappropriate mechanical conditions. the transverse shears of up to 1. a 1. which showed reasonable correlation with transverse shears generally below 0. If refracture occurs regularly through walking. unlocking the fixators had little effect on axial movement. full recovery of the initial gap size on unloading occurs immediately in the model. Here. the loaddisplacement response of the simulated fracture material. transverse and torsional shear.05 for the difference. and angular movement to within 1” for the model. the formation and calcification of callus. a slight weakness in the model is exposed by unlocking the fixators. unlocking caused the angular movement at the fracture to be either unchanged or to increase. the fracture gap and the support to tibia1 load provided by the section of fractured tibia. This will result in an inhibitory affect on healing. rather than bend. Since at present no correlation has been made between the extremes of axial. This correlates reasonably well with measurements obtained from patients with initially fully reduced fractures. If. against shear and angular movement need to be stiffened. those that do not fUy COIIstrair. healing may also be affected detrimentally by the unlocking of the column. the reduction in bending of the Monotube leads to a reduction in angular movement at the fracture. contrary to general expectation. since fracture movement arises from the combined flexibility of the frame and the fracture material. that had axial movements of up to 1. for example.4” and 1. Also peak transverse shear was constrained to within 1. a trend of reducing axial movement was seen after unlocking the fixator. since this reduces the constraint against. This amplitude of strain will be sufficient to refracture all but the spongy granulation tissue formed in the first stage of healing”“. with the greatest constraint provided by the Monotube and Dynabrace fixators. and is a consequence of the degree of weight-bearing. In the same example. the average increase in torsional and transverse shear at the fracture site through unlocking was fotlnd to be around 100% I”. At 6 weeks post fixation. However. The overall reduction in peak angular movement for the red Monotube that occurred through unlocking the fixator column would reduce the risk of refracture in the healing callus. shear and angular movements measured in patients and their effect on healing. Therefore.7 mm and angular movements below 1. it is assumed that the fracture gap is 1 mm. simulating all but the initial stage of healing. axial movement was influenced only by the the stiffness of these materials.0 mm discussed earlier would cause a gap shear strain of 100%.0 mm. and this increase in shear has also been observed in tibia1 fracture patients stabilized by Modulsystems.0” recorded in patients. If it is considered that controlled axial movement may be applied to fractures to provide the desired mechanical regime for healing. the choice of’fixator is expected to have little influence on the peak axial movement and the healing of well supported fractures that are additionally stabilized b!. which is fully elastic. it tias only slight9 influenced by the contribution to combined stiffness made by any of’ the fixation devices.15”. where angular movement for the group of 10 patients reduced by an average of 28% through unlocking the columns”‘.8 mm while walking at 2 to 4 weeks post fixation’“. Peak cyclic axial movement was increased significantly with the low stiffness material by unlocking the Monotubes. a conservative approach to fixator design should be adopted. Therefore. For angular movement in the locked mode. Fix&or ptyformance. This was not the case with the Modulsystems in the clinical situation. Although the distribution of strain in the non-homogeneous gap tissue will be complex. The frames tested here should constrain against movements not universally accepted to be beneficial. although with the Modulsystem it again reduced significantly the constraint against other directions of movement (particularly trans- 311 . because of compression at the fracture site. which may contribute to the delayed union of some fractures. Also. at some point the capacity of the fractures to heal will be exceeded by the continual challenge to the physiological repair processes. With the other fixators. Here the fixator column is allowed to shorten telescopically. possibly because of a combination between the column not sliding telescopically (sticking) and the looseness in the column (slack) assisting angular movement. The least constraint against torsional shear was provided by the Modulsystem. although the number of patients measured was insufficient to provide statistical significance at f> > 0.4” angular movement would cause an axial gap strain of around 25% in line with the external cortex of the bone. the E-roll and the Modulsystem provided the least constraint at 1. For the three stiffer fracture materials. there is a risk of refracture at the external cortex with this degree of angular movement during walking. That is. and by unlocking the fixator where and when it is desirable. then do currently available unilateral external fixators enable the clinician to control this movement? The answer must be no. Since bending of the column imposes angular movement on the fi-dcture.between 1 and 2 mm for the model. Clinicians may only influence to a degree the magnitude and orientation of movement by providing support to tibia1 load through the fracture site (for example by reducing non-cornminuted fractures). and remains incomplete because of the plastic response. Therefore. but this was not the case in the clinical condition for a patient fitted with a blue Monotube”. but in the clinical situation recovery is timedependan t because of the viscoelastic response. In addition to the possibility of an inhibitory affect on healing. However. is not the same as fracture tissue which probably has a viscoelasticplastic response. maximum axial strains are unlikely to be much lower than 25%.

In the example. 2 mm (transverse shear) and 1.Fracture motion during walking: T. detailed distribution of strain may only be predicted by using comprehensive S-dimensional finite element models of the complex geometry of a real fracture. This means that the fixator will sup port only the initial 60 N (6 kg) of any tibia1 load before the gap is compressed and further movement is restricted. However. 1978. Here.5” (angular movement). This is because the axial compression of the stiffer materials was substantially lower than with the 50 N/mm material. any additional load thereafter is transferred between the fragment ends. which increases the potential for refracture. each 60 N of axial tibia1 load produces 1. 24 tibia1 load supported as it heals by the frac- 1. For largely unsupported fractures during this period. although inter fragmentary movement at the fracture may be small. and subsequently it was to provide some means of predicting the consequences of the mechanical An accurate characteristics of each fixator. it has become apparent from this limited study that fixator design does not make the best use of the little that is known about the influence of mechanical conditions on fracture healing. non-homogeneous Initially it was to provide legitimate mechanical conditions for the performance comparison. in conjunction with the measurements of inter fragmentary movement. Rahn BA./ . it has been found from clinical studies that the mean peak cyclic compression is of the order of 1. because of a comparatively low frame stiffness. Gallinaro P. for largely unsupported fractures. 2. there is more restriction to axial movement which is potentially beneficial. verse and torsional shear). 53: 783-786. in view of the difficulty of this approach. REFERENCES fixator ----stiffness VVeLs d&t-fiGtion 5 The proportion during progressive I 1100 fracture loa signs of stabilizing (at 4 weeks in this example) almost all the tibia1 load is very quickly transferred from the fixator to the fracture. For well-supported fractures. However. A more informed approach would be to avoid the reduced constraint in directions for which the effect of movement on healing is unclear. that may be disruptive. As soon as the fracture site shows r ---A-0 Figure ture 314 /- 4 . // . They are about twice the movements of the well-supported fracture during early healing (O-6 weeks). The results demonstrate the load-bearing interplay between the fixator frame and the fracture site. Baltensperger A and Peren SM. and in place of this the frame is comparatively flexible. Inter fragmentary fracture motion in the unsupported Movements are substantial at around 3 mm (axial). This may not be a practical solution. The biology of fracture healing in long bones. inter fragmentary strain may be substantial. Here the fracture may be loaded at almost full body weight and. // 4 /‘f:acture / ’ stiffness ------ of axial stiffening 20 General observations A criticism may be made of this study in relation to the measurement of inter fragmentary ‘movement’ at the fracture. BoneJoint Surg. and the prediction of ‘strain’ as movement in proportion to gap size. Garde et al. The influence on inter fragmentary motion mechanical conditions at the fracture site of For well-supported fractures.0 mm before most of the axial tibia1 load is transferred across the fracturelg. remain possible. 1971. Again. and are similar to those that occur with largely well-supported fractures using more flexible forms of stabilization such as plaster castP. Here. Primary bone healing: an experimental study in the rabbit. N. The curve of increasing fracture stiffness is obtained from the work of Cunningham et aLz3 against which an average frame stiffness of 60 N/mm can be compared. 60B: 150. Therefore. fracture movement is important since little resistance to movement is offered at the fragment ends. J. This can be explained using JQUW 5 showing the proportion of axial tibia1 load supported bv the bone ends across the fracture. McKibbin B. there is very little tissue solidity at the fracture and it is then that the degree of support from the interposing fragment ends is critical. in the initially locked mode.0 mm of compression. during the progressive stiffening of a fracture as it heals. load equates directly with movement. while the shear and angular movements. during the initial stage of healing (O-4 weeks). there was a reduction in the angular movement imposed at the fracture site by column bending. this period may be prolonged in the case of an unsupported fracture. therefore movement at the fracture may be substantial although inter fragmentary strain may be small. the control of inter fragmentary motion during patient activity and the consequent effect on healing should be of great concern. It has been necessary to take this simplistic view of what is really a non-isotropic strain field within a material for two reasons. the dominant influence on fracture motion is the degree of weight-bearing. There was no reduction in angular movement through unlocking the Monotubes as seen with the least stiffest simulation material. Therefore the healing response for unsupported externally fixated fractures may be closer to that of a fracture stabilized by plaster. . J Bone andJoint Surg.

In: O. Chao YS and Kasman RA. I?lfalZhrzlkunde 1977: 80: 161-164. 19. Evans M and Kenwright J. 66B: 538-545. I)esign and performance of a fracture monitoring transducer.3. 1974. Menczel J.Societies. Clin. 1984.J. and Rel. Clinical Biomechanics 1994. and I&l. 1970. Louis. Fleming BS. Clin. C/in. Clin. Toikkanen S and Leino.. Res. Gardner TN and Evans M. Lanyon LE. 1974. 9: 51-59. Qiniral Biomrchanirs 1992. 11. 4. 8. I&s. and Rel. Clin. 67-B/4: 650-655.y.J. Goodship AE and KenwrightJ. Lindholm TS. Kenwright J. Biomech. Cunningham JL. 1. 1989. Brighton CT. Comparative study of fracture gap motion in external fixation. 3-Dimensional movement at externally fixated tibia1 fractures and osteotomies dllring normal patient function. 1988. . Lindholm RV. j. Sarmiento A. A&L Orthop. in press. Bcwze. 1983. 180: 23-33. Trans ASME 1983.i. Controlled mechanical stimulation in the treatment of tibia1 fractures. Behrens Bending F. The stimilus for mechanically adaptive bone remodelling. Comparisons of mechanical performance in four types of external fixators. The biomechanics of fracture healing. Reinecke S and Pope MH. BoneJoinl Sung. Yamagishi M and Yoshimura Y. 21. 6. Hayes WC. Hardy JRW and Richardson JB. Prof. Rubin CT. 1985. San Diego. ]. Clin. Evans M. 105: 130-143. In: Principle.. Cunningham JL. 37A: 1035-1068. Cli. Kristianssen ‘I’ and Pope M. stiffness of unilateral and bilateral frames. 1989. 40: 721-728. 1995. eds. Robin GC. Gardner TN. Orth. Res. 11: 118-122. The effect of forced inter-fragmental movements on the healing of tibia1 fractures in rats. UK. 6: 736-748. J Biomed. Monitoring fracture site properties with external fixation. Perren SM and Cordey J. 1983. OtThop. 20. Functional bracing of tibia1 fractures. Orthop. Neale G. Can walking heal fractures.Joint Surg 1984. Orth. 10: 6469. Die Gewebsdifferenzierung in der Fracturheilung. 14. 250: 50-57. REX 1990. Mechanical evaluation of external fixators used in limb lengthing. Kcnwright . Kenwright J and Goodship AE. Simpson AHRW and TurnerSmith AR. 2nd. Rng. Fleming B. 1982. Makin M and Steinberg R. Mosby Co. Relative stiffness. 7: 231-239. Correlations between mechanical stress history and tissue differentiation in initial fracture healing.? o/j-acture healing: Instructional rour. Murray JA. Bow . j. Orth. 13. The treatment of fractures with a dynamic axial fixator. 7. Aldegheri R and Renzi Brivio L. 1955. 17. 135-147.~teopm-osis. Wiley. Kristiansen T. 105: 120-126. Orthop. V. Jofe MH and White AA. Lippert FG and Hirsch C. 16. Evans M. 313 . 22. J. The influence of induced micromovement upon the healing of experimental fractures. St. 23. Three dimensional measurcment of tibia fracture motion by photogrammetry. Paley D. Monatsschrift f.Te IpCture. Measurement of fracture movement in patients treated with unilateral external fixation. and Rel. 241: 36-47 . Meeting OJ Combined Orthopmdir Research . 2: 191-195. McCoy MT.Joint Surg.. Blenman PR and Beaupre GS. transverse displacement and dynamisation in comparable external fixators. Evans M. Koch TW and Kovacevic N. Biomed. Carter DR. 1988. 178: 103-110. 9. 18. 10. 105: 202. 1987. Simpson AHRW. Orth. Johnson WD.5. Catagni M. Gardner TN. O’Connor JA and Goodship AE. Beaupre GS. ed. 12. Res. Scund. lhg. De Bastiani G. 60-82. C.