Bone Plate Fixation: Its Relationship with Implant Induced Osteoporosis

J. R. Field

doi:10.1055/s-0038-1632576

Veterinary and Comparative Orthopaedics and Traumatology, Inhaltsverzeichnis

Vet Comp Orthop Traumatol 1997; 10(02): 88-94
DOI: 10.1055/s-0038-1632576

Review Article

Schattauer GmbH

Bone Plate Fixation: Its Relationship with Implant Induced Osteoporosis

J. R. Field

¹From the Equine Research Centre, Guelph, Ontario, Canada, and the Swedish University of Agricultural Sciences, Uppsala, Sweden

› Institutsangaben

Abstract

Summary

The use of internal fixation devices for fracture repair induces profound changes in the affected bone. The factors implicated in the development of implant induced osteoporosis have been extensively studied. The processes following bone plate fixation which results in vascular and structural changes to the bone have not been accurately described. There are many inconsistencies in the design of experimental studies and in data interpretation which confound the issue.

Implant induced osteoporosis appears to be a biphasic phenomenon following the application of rigid internal fixation, with an early-onset osteonecrosis (8-12 weeks) elicited through cortical vascular insufficiency, followed by osteoporosis (24-36 weeks) induced by stress redistribution.

The development of implant induced osteoporosis appears to involve mechanical factors (surgical trauma, screw placement, rigidity of the fixation device), acting in conjunction with vascular insufficiencies related to the bone-plate interface contact area and pressure distribution.

Whatever the pathogenesis, the end result is a thinning of the diaphyseal cortices. Should implant removal be deemed necessary such osteoporosis is a cause for concern in view of the bones predisposition to refracture following plate removal. The degree of cortical osteoporosis observed appears to be time-dependent following internal fixaton and as such the clinical outcomes, after implant removal, are also related to the timing of removal.

Numerous factors have been implicated in the development of the vascular and structural changes that follow the plating of bone. It appears that implant induced osteoporosis has a multifactorial pathogenesis involving surgical trauma, screw placement and the rigidity of the fixation device. Elements involved in the interface between plate and bone, such as interface contact area and pressure, are also implicated in the pathogenesis.

Keywords

Osteoporosis - internal fixation - stress protection

Volltext

Referenzen

REFERENCES
1 Rahn BA, Gallinaro P, Baltensperger A. et al. Primary bone healing. An experimental study in rabbits. J Bone Joint Surg 1971; 53-A: 783-6.
2 Slatis P, Karaharaju E, Holmstrom T. Structural changes in intact tubular bone after application of rigid plates with and without compression. J Bone Joint Surg 1978; 60-A: 516-22.
3 Uhthoff HK, Dubuc FL. Bone structure changes in the dog under rigid internal fixation. Clin Orthop 1971; 81: 165-70.
4 Currey JD. The mechanical consequences of variation in the mineral content of bone. J Biomech 1969; 2: 1-11.
5 Wolff J. Das Gesetz der Transformation der Knochen. Berlin: Hirschwalk; 1892
6 Roux W. Gesammelte Abhandlungen über Entwicklungsmechanik der Organismen. Leipzig: Englmann; 1895
7 Tonino AJ, Davidson CL, Klopper PJ, Linclau LA. Protection from stress in bone and its effects. J Bone Joint Surg 1976; 58-B: 107-13.
8 Akeson WH, Woo SYL, Coutts RD. et al. Quantitative histological evaluation in early healing in cortical bones immobilized by stainless steel and composite plates. Calcif Tiss Res 1975; 19: 27-37.
9 Woo SYL, Akeson WH, Coutts RD. et al. A comparison of cortical bone atrophy secondary to fixation with plates with large differences in bending stiffness. J Bone Joint Surg 1976; 58-A: 190-5.
10 Claes L. The mechanical and morphological properties of bone beneath internal fixation plates of differing rigidity. J Orthop Res 1989; 7: 170-7.
11 Paavolainen P, Karaharju E, Slatis P. et al. Effect of rigid plate fixation on structural and mineral content of cortical bone. Clin Orthop Rel Res 1978; 136: 287-93.
12 Stromberg L, Dalen N. Atrophy of cortical bone caused by rigid internal fixation plates. Acta Orthop Scand 1978; 49: 448-56.
13 Moyen BJ, Lahey PJ, Weinberg EH. et al. Effects on intact femora of dogs of the application and removal of metal plates: a metabolic and structural study comparing stiffer and more flexible plates. J Bone Joint Surg 1978; 60-A: 940-7.
14 Paavolainen P, Holstrom T, Slatis P. Bone remodeling and its effect on the biomechanical properties of cortical bone after rigid plate fixation. J Biomech 1980; 3: 798
15 Woo SL, Lothringer KS, Akeson WH. et al. Less rigid internal fixation plates: Historical perspectives and new concepts. J Orthop Res 1984; 1: 431-49.
16 Gerber C, Mast JW, Ganz R. Biological internal fixation of fractures. Arch Orthop Trauma Surg 1990; 109: 295-303.
17 Laftman P, Sigurdsson F, Stromberg L. Recovery of diaphyseal bone strength after rigid internal plate fixation. Acta Orthop Scand 1980; 50: 215-22.
18 Laftman P, Nilsson OS, Brosjo O, Stromberg L. Stress shielding by rigid fixation studied in osteotomized rabbit tibiae. Acta Orthop Scand 1989; 60: 718-22.
19 Terjesen T, Benum P. The stress-protecting effect of metal plates on the intact rabbit tibia. Acta Orthop Scand 1983; 54: 256-62.
20 Uhthoff H, Finnegan M. The effects of metal plates on post-traumatic remodeling and bone mass. J Bone Joint Surg 1983; 65-B: 66-71.
21 Langkamer VG, Ackroyd CE. Removal of forearm plates. A review of the complications. J Bone Joint Surg 1990; 72-B: 601-4.
22 Rosson JW, Petley GW, Shearer JW. Bone structure after removal of internal fixation plates. J Bone Joint Surg 1991; 73-B: 65-7.
23 Glennon JC, Flanders JA, Beck KA. et al. The effect of long-term bone plate application for fixation of radial fractures in dogs. Vet Surg 1994; 23: 40-7.
24 Muir P, Markel MD, Bogdanske JJ. et al. Dual-energy X-ray absorptiometry and force plate analysis of gait in dogs with healed femora after leg-lengthening plate fixation. Vet Surg 1995; 24: 15-24.
25 Janes GC, Collopy DM, Price R. Bone density after rigid plate fixation of tibial fractures. J Bone Joint Surg 1993; 75-B: 914-7.
26 Reudi TP, Luscher JN. Results after internal fixation of comminuted fractures of the femoral shaft with dynamic compression plates. Clin Orthop Rel Res 1979; 138: 74-6.
27 Smith MM, Vasseur PB, Saunders HM. Bacterial growth associated with metallic implants in dogs. J Am Vet Med Assoc 1989; 195: 765-7.
28 Harrison JW, McClain DL, Hohn RB. et al. Osteosarcoma associated with metallic implants. Clin Orthop Rel Res 1976; 116: 253-7.
29 Sinibaldi K, Rosen H, Liu SK. et al. Tumours associated with metallic implants in animals. Clin Orthop Rel Res 1976; 118: 257-66.
30 Akeson WH, Coutts RD, Woo SYL. Principles of less rigid internal fixation with plates. Can J Surg 1980; 23: 235-9.
31 Carter DR, Shimaoka EE, Harris WH. et al. Changes in long bone structural properties during the first eight weeks of plate implantation. J Orthop Res 1984; 2: 80-9.
32 Uhthoff H, Bardos DI, Liskova-Kiar M. The advantages of titanium alloy over stainless steel plates for the internal fixation of fractures. An experimental study in dogs. J Bone Joint Surg 1981; 63-B: 427-34.
33 Terjesen T, Apalset K. The influence of different degrees of stiffness of fixation plates on experimental bone healing. J Orthop Res 1988; 6: 293-9.
34 Perren SM, Klaue K, Pohler O. et al. The limited contact dynamic compression plate (LCDCP). Arch Orthop Trauma Surg 1990; 109: 304-10.
35 Tayton K, Bradley J. How stiff should semirigid fixation of the human tibia be?. J Bone Joint Surg 1983; 65-B: 312-5.
36 Bostman OM. Current concepts review. Absorbable implants for the fixation of fractures. J Bone Joint Surg 73-A: 148-53.
37 Rokkanen P, Vainionpaa S, Tormala P. et al. Biodegradable implants for fracture fixation: Early results of treatment of fractures of the ankle. Lancet 1985; 1: 1422-4.
38 Field JR, Hearn TC, Arighi A. Investigation of bioabsorbable screw usage for longbone fracture repair in the horse: Interfragmentary compression and axial load response in equine cadaver longbone fractures. VCOT 1995; 8: 191-5.
39 Cheal EJ, Hayes WC, White AA. et al. Stress analysis of compression plate fixation and its effects on long bone remodeling. J Biomech 1985; 18: 141-50.
40 Cheal EJ, Hayes WC, White AA. et al. Stress analysis of a simplified compression plate fixation system for fractured bones. Comput Struct 1983; 17: 845-55.
41 Beaupre GS, Carter DR, Orr TE, Csongradi J. Stresses in plated long-bones: The role of screw tightness and interface slipping. J Orthop Res 1988; 6 (01) 39-50.
42 Rhinelander FW. The normal microcirculation of diaphyseal cortex and its response to fracture. J Bone Joint Surg 1968; 50-A: 784-800.
43 Rhinelander FW, Wilson JW. Blood supply to developing, mature and healing bone. In: Bone in Clinical Orthopaedics. Sumner- Smith G. ed. Philadelphia: Saunders WB; 1982: 81-158.
44 Reichert IL, McCarthy ID, Hughes SP. The acute vascular response to intramedullary reaming. Microsphere estimation of blood flow in the intact ovine tibia. J Bone Joint Surg 1995; 77-B: 490-3.
45 Tothill P. Bone blood flow measurements. J Biomed Eng 1984; 6: 251-6.
46 Swiontkowski MF, Senft D, Taylor S. et al. Plate design has an effect on cortical bone perfusion. Trans Orthop Res Soc 1991; 15: 387
47 Daum WJ, Simmons DJ, Chang SL. et al. Effect of fixation devices and radiostrontium clearance in the intact canine femur. Clin Orthop Rel Res 1985; 194: 306-12.
48 Daum WJ, Simmons DJ, Calhoun JH. et al. Regional alterations in long bone produced by internal fixation devices. J Orthop Trauma 1988; 2: 241-4.
49 Early PJ, Sodee DB. Principles and Practice of Nuclear Medicine. New York: Mosby; 1995: 339-50.
50 Kirby BM, Wilson JW. Effect of circumferential bands on cortical vascularity and viability. J Orthop Res 1991; 9: 174-9.
51 Trias A, Frey A. Cortical circulation of long bones. J Bone and Joint Surg 1979; 61-A: 1052-9.
52 Luethi U, Dueland T, Rahn BA. Relationship between plate-bone contact area and blood supply in internal fixation. J Biomech 1980; 13: 779-80.
53 Korvick DL, Newbrey JW, Bagby GW. Stress shielding reduced by a silicon platebone interface. A canine experiment. Acta Orthop Scand 1989; 60: 611-15.
54 Staller GS, Richardson DW, Nunnamaker DM. Contact area and static pressure profile at the plate-bone interface in the nonluted and luted bone plate. Vet Surg 1995; 24: 299-307.
55 Jacobs RR, Rahn BA, Perren SM. Effects of plates on cortical bone perfusion. J Trauma 1981; 21: 91-5.
56 Perren SM, Cordey J, Rahn BA. et al. Early temporary porosis of bone induced by internal fixation implants. A reaction to necrosis, not stress protection?. Clin Orthop Rel Res 1988; 232: 139-51.
57 Gautier E, Cordey J, Mathys R. et al. Porosity and remodeling of plated bone after internal fixation: Result of stress shielding or vascular damage. Proc 4th European Conference on Biomaterials, Biomat, Biomech. 1983: 195-200.
58 Gautier E, Rahn BA, Perren SM. Effect of different plates on internal and external remodeling of intact long bones. Trans 32nd Orthop Res Soc 1986: 322
59 Dueland R, Rahn BA, Perren SM. et al. Morphological effect on bone with standard and experimental plate conformations. Trans 32nd Orthop Res Soc 1986: 323
60 Dueland R, Varga JS, Rahn BA, Perren SM. Early morphological effect on bone with standard and experimental plates. Trans 32nd Orthop Res Soc 1986: 391-2.
61 Ganz R, Mast J, Weber BG, Perren SM. Clinical aspects of 'bio-logical' plating. Injury 1991; 22 (Suppl. 01) 4-8.
62 Kowalski M, Schemitsch EH, Senft D. Comparative evaluation of the effect of plate design on fracture healing with special reference to cortical bone blood flow and biomechanical properties. Trans 39th Orthop Res Soc 1993: 569
63 Smith SR, Bronk JT, Kelly PJ. Effect of fracture fixation on cortical bone blood flow. J Orthop Res 1990; 8 (04) 471-8.
64 Simmons DJ, Daum WJ and Calhoun JH. Regional alterations in long bone strontium clearance produced by internal fixation devices. Part II. Histomorphometry. J Orthop Trauma 1988; 2: 245-9.
65 Frost HM. Structural adaptations to mechanical usage. A proposed 'three-way rule' for bone modeling. Part 1. VCOT 1988; 1: 7-17.
66 Uhthoff HK, Boisvert D, Finnegan M. Cortical porosis under plates. Reaction to unloading or to necrosis. J Bone Joint Surg (Am) 1994; 76-A (10) 1507-12.
67 Uhthoff HK, Foux A, Yeadon A. et al. Two processes of bone remodeling in plated intact femora: An experimental study in dogs. J Orthop Res 1993; 11 (01) 78-91.