Review Article

Stress Modulation of Fracture

Fixation Implants

Abstract
Michael J. Beltran, MD Stress modulation is the concept of manipulating bridge plate
Cory A. Collinge, MD variables to provide a flexible fixation construct that allows callus
formation through uneventful secondary bone healing. Obtaining
Michael J. Gardner, MD
absolute stability through the anatomic reduction of all fracture
fragments comes at the expense of fracture biology, whereas
intramedullary nailing, which is more advantageous for diaphyseal
fractures of the lower extremity, is technically demanding and often
may not be possible when stabilizing many metaphyseal fractures.
Overly stiff plating constructs are associated with asymmetric callus
formation, early implant failure, and fracture nonunion. Numerous
surgeon-controlled variables can be manipulated to increase flexibility
without sacrificing strength, including using longer plates with well-
spaced screws, choosing titanium or stainless steel implants, and
using locking or nonlocking screws. Axially dynamic emerging
concepts, such as far cortical locking and near cortical overdrilling,
provide further treatment options when bridge plating techniques
are used.

O rthopaedic implants have

From the Department of
Orthopaedics, San Antonio Military
Medical Center, Fort Sam Houston,
TX (Dr. Beltran), the Department of
Orthopaedic Surgery and
Rehabilitation, Vanderbilt University
Medical Center, Nashville, TN
(Dr. Collinge), and the Department of
Orthopaedic Surgery, Stanford
University Medical Center, Palo Alto,
CA (Dr. Gardner).
The views expressed in this article are
those of the authors and do not
necessarily reflect the official policy or
position of the Department of Defense
or the US Government.
J Am Acad Orthop Surg 2016;24:
711-719
DOI: 10.5435/JAAOS-D-15-00175
Copyright 2016 by the American
Academy of Orthopaedic Surgeons.
evolved over the past 75 years,
especially those used to treat
diaphyseal and metaphyseal frac-
tures. Improved metallurgy and
instrumentation have expanded the
indications for intramedullary nail-
ing to metaphyseal fractures. Lock-
ing technology has enhanced the
ability to obtain stable fixation in
osteoporotic bone, and the wide-
spread availability of anatomically
precontoured plates allows less
invasive application of implants to
maximally preserve fracture site
biology. Despite these improve-
ments, mechanical complications
remain common, especially non-
union and malunion of metaphyseal
fractures stabilized with plates.1
Recent evidence suggests that
overly stiff plate fixation constructs
may be responsible for asymmetric
and inadequate callus formation,
early fixation failure, and late
nonunion.2,3
Stress is defined as force per unit
area. Excessive implant stresses can
predispose fracture fixation devices
to failure. Stress modulation involves
harnessing surgeon-controlled fixa-
tion variables to create a flexible
fracture environment that promotes
reliable, timely, secondary bone
healing. According to the strain the-
ory of Perren, plating constructs must
have mechanical characteristics that
are neither too stiff nor too flexible to
promote callus formation and avoid
fracture complications, such as non-
union, malunion, and implant fail-
ure.4,5 An understanding of fracture
healing coupled with the knowledge
of how to modulate the stiffness of
plates allows the surgeon to tailor a
fracture construct that accommo-
dates the mechanical and biologic
conditions present in a given patient.

October 2016, Vol 24, No 10 711

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Stress Modulation of Fracture Fixation Implants

Performed appropriately, the mod-
ulation of plate stiffness can provide
the best chance of obtaining pri-
mary union and avoiding fracture
complications.
Background
Recognizing the importance of stress
modulation is not new. The modern
era of fracture fixation plating, pio-
neered largely by the AO (Arbeitsge-
meinschaft für Osteosynthesefragen)
group, initially was characterized by
rigid compression plating. This
method requires as rigid a construct as
possible, results in no motion at the
fracture site, and allows primary bone
healing through haversian remodel-
ing. This was the primary fracture
plating technique used in the 1960s
and 1970s and remains effective for
many fracture patterns. As clinical
experience expanded, however, sur-
geons noted several drawbacks with
this technique. First, the soft-tissue
dissection needed to obtain precise
fracture reduction and compression
often was too extensive to provide an
appropriate biologic environment for
fracture healing. Second, it was
observed that healing often was pro-
longed and that the bone became
porotic and weak beneath the plate.
Many authors attributed these results
to the mechanical consequences of
using a rigid implant and stress
shielding by the plate,6-8 although
another common theory at the time
blamed cortical necrosis caused by
periosteal damage.9
In response to these observations,
many surgeons began to evaluate the
characteristics and effectiveness of
plates with reduced stiffness, which
would transmit more load to the bone
in theory and expedite the healing
process. Thus, as early as the 1970s,
the drawbacks of traditional stainless
steel plates were recognized.7,8 Over
the subsequent decades, many
experimental plate designs were
developed with the goal of reducing
axial stiffness to improve healing.
Foux et al6 developed plates with
elongated holes and elastic inserts
that controlled screw motion. Using
a canine model, the authors found
that various ranges of elasticity all
led to better healing than that seen
with standard stainless steel plates.
Throughout the 1980s, many frac-
tures were treated definitively with
external fixation, including fractures
of the tibial shaft. Because external
fixation permits direct access, manip-
ulation, and alterations, it provided an
ideal vehicle for studying the relation-
ship of fixation stiffness to fracture
healing.10 Generally, healing was
found to improve when a small
amount of motion was permitted
across the fracture site.11 In addition,
these series of experiments led to the
concept of external fixation dynam-
ization to stimulate fracture healing.12
Metallurgy and Implant
Geometry
Modern orthopaedic fracture fixa-
tion implants typically are manufac-
tured using one of three commercially
available metals: grade 316L stainless
steel, commercially pure titanium, or
titanium alloy, typically type Ti-6Al-
4V, although other alloys are avail-
able. All three metals exhibit similar
properties compared with other
orthopaedic biomaterials, such as
ceramics; however, the differences
among the three are substantial and
affect the interaction between a fixa-
tion construct and a given fracture
environment. The most important
physical properties of metals for
orthopaedic fracture fixation appear
to be stiffness and fatigue strength.
In general, elasticity describes a
material’s ability to return to its
original resting length and shape
after being subjected to stress and
undergoing deformation. Stiffness is
related linearly to elasticity and is
described according to Young’s
modulus of elasticity. Titanium and
titanium alloy have approximately
half the stiffness of stainless steel,
more closely approximating that of
cortical bone13 (Table 1). The stiff-
ness mismatch between stainless steel
and cortical bone long has been
postulated as a reason for porosity
and bone loss beneath plates as a
result of stress shielding,1-3 although
this hypothesis has been challenged.14
Fatigue strength, also called endur-
ance strength, describes the ability of a
material to resist failure during cyclic
loading at stresses under the ultimate
tensile strength of a material. In theory,
an infinite number of cyclic loads under
the fatigue limit can be applied, with-
out leading to failure. Although stain-
less steel has been shown to be superior
at high stress with relatively fewer
cycles, titanium and its alloys demon-
strate superior properties under the
clinical conditions of repetitive high
cycling at low stress, as seen during
ambulation.13 Most closed section
intramedullary nails and interlocking
screws manufactured today are

Dr. Collinge or an immediate family member has received royalties from Advanced Orthopaedic Solutions, Biomet, Smith & Nephew, and
Synthes; serves as a paid consultant to Biomet, Smith & Nephew, and Stryker; and serves as a board member, owner, officer, or committee
member of the Foundation for Orthopedic Trauma. Dr. Gardner or an immediate family member serves as a paid consultant to
BONESUPPORT AB, KCI/Acelity, Pacira Pharmaceuticals, Stryker, and Synthes; has received research or institutional support from
Synthes; and serves as a board member, owner, officer, or committee member of the Orthopaedic Trauma Association. Neither Dr. Beltran
nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or
institution related directly or indirectly to the subject of this article.

712 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Michael J. Beltran, MD, et al

Table 1
Mechanical Properties of Orthopaedic Biologic and Implant Materials
Ultimate Tensile Strength Yield Strength 0.2% Offset Elastic Modulus
Material (MPa)a (MPa) (MPa)

Muscle 0.2 NA NA
Skin 8 NA 50
Cartilage 4 NA 20
Fascia 10 NA NA
Tendon 70 NA 400
Cortical bone 100 80 15,000
Cancellous bone 2 NA 1,000
Plaster of Paris 70 20 NA
Polyethylene 40 20 1,000
PTFE Teflon 25 NA 500
Acrylic bone cement 40 NA 2,000
Titanium (pure, cold worked) 500 400 100,000
Titanium (AI-4V, alloy F136) 900 800 100,000
Stainless steel (316L, annealed) .500 .200 200,000
Stainless steel (cold worked) .850 .700 200,000
Cobalt chrome (cast) .450 .50 20,000
Cobalt chrome (wrought, .300 .300 230,000
annealed)
Cobalt chrome (wrought, cold 1,500 1,000 230,000
work)
Super alloys (CoNiMo) 1,800 1,600 230,000

MPa = megapascals, NA = not applicable, PTFE = polytetrafluoroethylene, CoNiMo = cobalt nickel molybdenum
a
Ultimate tensile strength, or maximum force in tension, yield strength at 0.2% offset, is defined as the strength at which the strain in the material
(change in length/original length) is 0.2%, a usual standard for metals, elastic modulus, or stress/strain.
Reproduced with permission from Jo MJ, Tencer AF, Gardner MJ: Biomechanics of fracture and fracture fixation, in Court-Brown C, Heckman JD,
McKee M, et al: Rockwood and Green’s Fractures in Adults, ed 8. Philadelphia, PA, Lippincott Williams and Wilkins, 2015, pp1–42.

fabricated from titanium alloys rather
than stainless steel because of the
improved fatigue properties associated
with these alloys and in an effort
to minimize interlocking screw failure.
The stiffness and strength of a given
construct must be evaluated based on
implant geometry and fabrication
methods in addition to the physical
properties of the metal. The bending
strength of a rectangular plate is
related exponentially to its thickness,
such that increasing its thickness even
by a few tenths of a millimeter sub-
stantially increases its ability to resist
fatigue failure. As a result, a thick
titanium plate has much greater
stiffness and fatigue strength than
does a thin stainless steel plate, inde-
pendent of the properties of the metal
used. The strength of a cylindrical
structure, such as a nail or screw, is
related exponentially to its radius.
Thus, 5-mm interlocking screws are
preferred to smaller-diameter screws,
when nail diameter allows.
Application of biomechanical
principles to orthopaedic implants
can be difficult because of their
irregular shapes and contours. Few
plates are fabricated in a true rectan-
gular fashion, and none are solid,
because screw holes are necessary
(Figure 1). Reliefs thin out areas on
the underside of a plate, and are
commonly designed to preserve
periosteal tissue and blood flow;
many plates are recessed “on the
flat” between the screw holes. These
nonuniform aspects make compari-
son of plates difficult in the absence
of direct studies, even among plates
fabricated from similar materials. In
general, plates are weakest where
they are thinner and where holes,
which act as stress risers, are present.
These weak points are the regions
where plates tend to fail under cyclic
loading. Notching and sharp cor-
ners, as opposed to smooth transi-
tions, also have been shown to affect
the fatigue limit of a metal implant.
Biomechanics
Perren15 first described the fracture
strain theory in 1979, explaining
how and why fractures heal based on
the stability of the local mechanical

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Stress Modulation of Fracture Fixation Implants

Figure 1 required to resist bending or torsional

forces that may loosen the lag screw.
In contrast, relative stability con-
structs require just enough fracture
micromotion to create an environ-
ment suitable for callus formation.
This is the basis for the stiffness
modulation of fracture implants, the
preservation of fracture biology
through indirect reduction tech-
niques, and the use of submuscular
plates or intramedullary nails. The
process of endochondral ossification
requires a small amount of motion to
form bone.16 If a plate construct is
too stiff, not enough motion occurs,
and callus formation cannot
develop; nonunion and eventual
implant fatigue failure are inevitable
(Figure 2). A construct that is too
flexible predisposes the bone to
inadequate callus formation, gener-
ating a hypertrophic nonunion and
plastic deformation of the implant,
with resulting malunion. Using a
sheep tibial fracture model, Epari
et al4 quantified the ideal range for
compressive stiffness. Unlike exter-
nal fixation, plate constructs that are
Photographs demonstrating the variation in plate geometry among commonly too flexible also fail under earlier
available implants. Front (A) and side (B) views of common plate designs. Note
the asymmetric screw hole design and the recessed underside of the plate. Both cyclic loading, compared with stiffer
designs alter the stiffness and strength of the fixation construction independent constructs.17
of the plate material. C, Photograph of a commonly used distal femur locking Locking plate mechanics differ
plate. Although the screw hole shape and spacing are uniform, the plate is from conventional plating largely
recessed “on the flat,” altering the plate’s mechanics.
because of screw behavior. Non-
locking screws rely on compression
environment. In general terms, strain gap, forms only fibrous tissue. to the bone. The frictional interface
is the movement at a fracture gap Perren’s work forms the framework between the plate and the bone dic-
divided by the original distance of for understanding the difference tates stability, and motion can occur
the gap and is expressed as a per- between absolute and relative sta- at the screw-plate interface. It is likely
centage. Strain directly correlates to bility and explains why a large that these screws loosen sequentially
the mode and efficiency of fracture increase in the use of bridge plating and subcatastrophically with time
healing. If sufficient stiffness is pre- for comminuted metaphyseal frac- and physiologic activity in a way that
sent to reduce strain to #2%, a tures has been observed over the permits stiffness to degrade slightly
fracture will heal with haversian re- past 30 years. during the early healing phases. In
modeling, primary bone healing. When stabilizing simple diaphyseal contrast, locking screws create a
Micromotion at a fracture site that fractures, absolute stability classi- fixed angle with the plate. Because no
creates between 2% and 10% strain cally has been achieved using a lag motion occurs at the screw-plate
will heal by way of endochondral screw and neutralization plate. The interface, the stresses are transferred
ossification through callus forma- lack of any motion at the fracture site to the plate and are concentrated at
tion (secondary bone healing), is necessary to provide the optimal the level of the fracture.
whereas strain .10%, indicating a environment for primary bone heal- Interfragmentary motion is required
higher level of motion or a smaller ing, and sufficient implant stiffness is to obtain callus formation, and it

714 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Michael J. Beltran, MD, et al

occurs through the elastic bending of Figure 2

the plate when a locked plate is used.
Factors that drive more plate bend-
ing encourage more fracture motion,
particularly at the far cortex,
because the eccentric plate position
leads to a slight bending moment,
with minimal motion at the near
cortex adjacent to the plate. This last
point explains the asymmetric callus
seen in numerous studies1-3,18 and is
the impetus for emerging design and
technique features aimed at pro-
moting more symmetric fracture
healing through more uniform axial
motion.
When comparing plate constructs,
several factors affect implant stiff-
ness. Screws placed in the diaphysis
may be all locking, all nonlocking (ie,
conventional), or a combination of
the two (the hybrid technique). Plate
length and screw density can be
altered, and working length can be
manipulated by directed screw
placement in select holes near the
fracture. Taken collectively, it is clear
that many variables affect overall AP radiographs of the distal femur demonstrating atrophic nonunions at 6
construct stiffness. months postoperatively in an older patient (A) who underwent total knee
arthroplasty and in a younger patient (B). A notable lack of callus formation is
Unicortical locking screws also are seen and may be caused in part to the stiffness of the bridging implant and lack of
available and can affect the stiffness of motion.
the construct. The working length of a
unicortical screw is simply the thick-
ness of the near cortex, whereas the trically predispose the patient to hybrid construct provided a reduced
working length of a bicortical screw fixation failure under torsion, even in plate-bone distance. In another oste-
is the outer diameter of the bone. As healthy bone.22,23 oporotic model, Doornink et al27
a result, bicortical screws offer The use of hybrid fixation con- found that bicortical hybrid constructs
improved bending and torsional structs recently has been validated in were 42% stronger than all-locking
resistance. Constructs consisting of all several clinical and biomechanical constructs in torsion and were
unicortical locking screws in the oste- studies.24-26 In choosing hybrid fixa- nearly equivalent in axial compres-
oporotic diaphysis may lead to tion, nonlocking and locking screws sion and bending. In an osteopo-
simultaneous pullout failure. Bicort- are used to provide fixation in rotic model, Bottlang et al28 also
ical screws should be used in these the diaphysis. Because stiffness and demonstrated that replacement of a
locations whenever possible. In fatigue strength are affected by the single locking screw with a non-
healthy bone, unicortical screws distance between the plate and the locking screw at the end of a con-
reduce construct stiffness without bone, a nonlocking screw or screws struct increased the bending strength
affecting fatigue strength.19 The may be used first to reduce the plate of the construct by 40%.
encouraging early results seen from to the bone. Then, locking screws Balancing the length of the plate
first-generation locking plates clini- may be added to complete the con- against the level of the fracture and the
cally confirm this observation,20,21 struct. Chesser et al24 found that the amount of comminution is another
but the surgeon must be careful when strength of a hybrid construct was important variable that is within the
applying the screws because diaphy- similar to that of an all-locking con- surgeon’s control. Increasing the plate
seal unicortical screws placed eccen- struct in an osteoporotic model but the length distributes the stresses of

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Stress Modulation of Fracture Fixation Implants
Figure 3
AP radiograph showing a distal
femoral fracture treated with a
dynamic plating construct using an
overdrilling technique. At 3 months,
callus has formed at the lateral cortex
under the plate (oval). The
overdrilled “halo” around a
diaphyseal screw can be seen
(arrow).
weight bearing over a greater length
of the implant, preventing stress
concentration at the level of the
fracture.29,30 Distribution of stress
over a greater plate length also off-
loads end screws and improves
overall construct strength. Previous
work has suggested that the plate
length should be 7 to 8 times the
length of the fracture for simple pat-
terns and 2 to 3 times the length of the
fracture when addressing comminu-
tion, but the longest plate that is
anatomically possible should be used
when feasible.31
In addition to choosing a longer
plate, it is important to place an
appropriate number of screws. Screw
fill should not exceed 40% to 50% of
available holes and more than four
diaphyseal screws are not required,
even in osteoporotic bone.32,33
Increased screw density can increase
716
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
the overall stiffness of the construct
substantially.
Plate working length is also critical
to consider, especially when bridge
plating metaphyseal fractures. The
distance between the articular screw
cluster and the nearest diaphyseal
screw adjacent to the fracture sets the
working length. As demonstrated by
Stoffel et al,32 plate constructs em-
ploying near-near and far-far screws
are by far the stiffest for diaphyseal
fixation, and they have the narrow-
est working length. Recent clinical
evidence suggests that a narrow
working length predisposes the
fracture to distal femoral nonunion
regardless of other implant factors,
and multiple biomechanical studies
have demonstrated that a longer
working length reduces stiffness.17,34
Concerns about the reduced fatigue
strength of constructs with a longer
working length have been validated
by Ricci et al,17 who demonstrated in
a comminuted distal femoral model
that constructs with a longer work-
ing length, although less stiff, failed
at fewer loading cycles compared
with those with a shorter working
length. To balance the need for a
greater working length without sac-
rificing fatigue strength, Bellapianta
et al35 studied the use of screw hole
inserts, which thread into the locking
screw holes of a plate but do not
provide fixation into bone. They
found that screw hole inserts sub-
stantially increased the fatigue
strength of the plate without an
appreciable increase in construct
stiffness. Screw head inserts are
available from several plate manu-
facturers and can be fabricated easily
intraoperatively by cutting the
threads off a locking screw.
The concept that increased axial
motion can improve fracture healing
and result in more symmetric callus
recently has been studied in vitro, in
animal models, and in clinical studies.
Modern solutions to the problem of
creating an axially dynamic construct
Journal of the American Academy of Orthopaedic Surgeons
include near-cortex overdrilling36,37
and specialized screws that allow
toggle at the near cortex.38-42 The
simplest method of creating a
dynamic construct involves drilling a
hole in the near cortex that allows
clearance for the near screw shaft to
toggle within the hole (eg, using a 5.0-
mm drill and a 4.0-mm screw shaft),
while maintaining fixation in the
plate and the far cortex. This tech-
nique provides increased near-cortex
motion in laboratory studies with no
increased failure under physiologic
loads.36,37 Early clinical data have
demonstrated increased callus for-
mation, particularly at the near cor-
tex18 (Figure 3).
Specialized implants also have been
developed to create a similar bio-
mechanical environment. One recently
developed design involves a pin within
a sheath that locks into the plate
and anchors at the far cortex. The
pin motion allowed more motion at
the near cortex42 and resulted in
increased callus volume, with greater
symmetry and higher strength, in a
sheep osteotomy model.41 Another
commercially available system, which
allows toggle between the screw and
the near cortex, also has shown
promise in an animal study.38 A
prospective observational study of
31 patients treated with this technol-
ogy reported uneventful healing in
30 patients at 1 year postoperatively,
with no fixation failure reported.40
Clinical Problems With
Bridge Plating
Fracture nonunion of the distal femur
has been reported in up to 20% of
patients in published clinical series
over the past decade,1-3 despite the
recent emphasis on biologically
friendly indirect reduction tech-
niques and submuscular implant
applications. These results are com-
parable to those achieved using
similar techniques with fixed angle

plates, such as the 95° angled blade
plate, or dynamic condylar screws.43,44
Several risk factors recently have
been identified that are associated
with a risk of nonunion. Rodriguez
et al34 evaluated patients with 283
distal femur fractures treated with
locked plating. They identified
obesity, open fracture, occurrence
of infection, and the use of stainless
steel plates as prognostic risk fac-
tors for nonunion. Ricci et al1
reviewed a series of patients with
335 distal femur fractures treated
with plating. They found that 64
fractures (19%) required reopera-
tion to promote union. Although
nearly half the reoperations were
performed as staged bone grafting
of metaphyseal defects associated
with open fractures, other inde-
pendent risk factors for proximal
implant failure included smoking,
obesity, and shorter plate length.
The highest reported healing rates
for unstable distal femur fractures
have been achieved using titanium
locking plates. The theoretical bio-
mechanical advantages of commer-
cially pure titanium and its alloys
appear to translate into clinical
improvement, although no high-
quality study has proven this asser-
tion definitively. Weight and Col-
linge21 reported on a series of 21
patients (most were young) with 22
high-energy distal femur fractures
treated with titanium locking plates.
They found that all 22 fractures
healed early without secondary sur-
geries. Furthermore, in a series of
.100 patients with distal femur
fractures managed with the Less
Invasive Stabilization System (Syn-
thes), Kregor et al20 reported a pri-
mary union rate of 93%. The series
also included 35 high-energy open
fractures, most of which healed
without planned secondary proce-
dures. Despite the findings of these
two studies and other earlier
encouraging clinical reports on the
benefits of titanium plating of distal
October 2016, Vol 24, No 10
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Michael J. Beltran, MD, et al
Table 2
Guidelines for Bridge Plating Constructs
The use of titanium implants should be considered. Surgeons and manufacturers
may opt for more titanium plating options in the future.
A longer plate should be used whenever possible to allow well-spaced fixation.
Less than 50% of diaphyseal screw holes should be filled. More than four
diaphyseal screws are rarely necessary.
A plate with a longer working length should be used, and the surgeons must
ensure that no screws cross the fracture.
If the working length of the plate is extreme, threaded screw inserts can be
placed across the comminuted zone.
The use of locking screws is indicated in the setting of short metaphyseal
segments and osteopenic bone.
The use of a system with polyaxial screw options should be considered when
screw crowding or engagement with adjacent implants is a concern.
Axially dynamic fixation may be considered based on early evidence, but support
for this choice is not strong.
femur fractures, most precontoured fracture instead of leading to mal-
locking implants in North America union. The flexible nature of nails is
continue to be fabricated from mirrored in the success seen with
stainless steel. ringed external fixation for select
metaphyseal and diaphyseal frac-
tures. Ringed external fixation
Plating Versus provides an extremely strong con-
Intramedullary Nails and struct but offers the flexibility nec-
External Fixation essary to allow predictable callus
formation. The stiffness of the
Stress modulation concepts are construct is manipulated easily by
applicable to intramedullary nails the choice, size, number, and loca-
and external fixators, as well. Over tion of wires and half pins. The goal
the past 30 years, intramedullary of bridge plating, therefore, should
nails have become the standard of be to strive for the kind of flexible
care for diaphyseal fractures of the fixation provided by nails and
tibia and femur, and indications for external fixators, while providing
the use of these nails recently have the strength necessary to prevent
expanded to metaphyseal fractures, fixation failure.
with the advent of modern nailing
platforms and instrumentation. The
rationale for nailing is clear. Implants Achieving a Balance
can be inserted with minimal insult to Between Flexibility and
the local fracture hematoma, pre- Stiffness
serving the biology, while the central
location of the nail and the flexible Surgeons managing fractures ame-
nature of the titanium alloy allows nable to bridge plating should be
sustained cyclic loading with a sub- familiar with flexible fixation con-
stantially reduced risk of early cepts and how to modulate implant
implant failure. Compared with stiffness. The available clinical and
plates, nail failures are rarely cata- biomechanical data can provide the
strophic because nearly all nail framework for choosing an appro-
constructs fail at the interlocking priate construct (Table 2). When
screws, which “autodynamizes” the choosing an implant, consideration
717
Stress Modulation of Fracture Fixation Implants
should be given to using titanium or
titanium alloy because these metals
have a lower Young’s modulus that
is similar to that of bone. However,
the biomechanical properties need to
be balanced against the drawbacks
of titanium, such as difficult con-
touring and cold welding. Hybrid or
nonlocking diaphyseal constructs
appear to be appropriate for the
management of most metaphyseal
fractures. Pure locking constructs
should be reserved for osteoporotic
bone with short metaphyseal seg-
ments. Longer plates with fewer
screws and lower screw fill should be
chosen whenever possible. The lon-
gest plate that is anatomically feasi-
ble is preferred, because these plates
can be applied submuscularly, which
preserves the biology, provides more
uniform distribution of stress, and
reduces implant fatigue. More than
four screws in the diaphysis rarely
are required, which helps keep the
screw fill low and minimizes the
stress concentration. Perhaps the
greatest difficulty lies in managing
the working length, especially for
comminuted metaphyseal fractures.
At least two holes should be left open
on either side of a fracture, unless the
zone of comminution is substantial.
In such a case, consideration should
be given to using threaded screw
inserts to maintain an appropriate
working length without predisposing
to early implant failure. Finally,
modern concepts, such as near cor-
tical overdrilling and the use of
axially dynamic locking screws,
should be considered for fractures
predisposed to nonuniform callus
formation.
Summary
Fracture fixation continues to evolve.
Management of metaphyseal frac-
tures with plates remains problem-
atic, especially those managed with
stainless steel implants, which have
718
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
consistently demonstrated nonunion
rates .10%. Early clinical experi-
ence with modern commercially
available fracture stabilization sys-
tems that allow increased stiffness
modulation appears promising.
When treating these fractures, the
surgeon should continue to optimize
fracture reduction and minimize
biologic insult. Most importantly,
the surgeon should be cognizant of
the mechanical implications of the
applied construct, taking into
account factors, such as the plate
material, the working length, and the
position of screws, to afford the
patient the best chance of obtaining
primary union without complica-
tions at the fracture site. Continued
research is necessary to elucidate the
optimal factors needed to modulate
fracture fixation constructs and to
reveal any additional factors that can
be manipulated to create a strong
and flexible construct.
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