title: Timely fracture-healing requires optimization of axial fixation stability.
abstract: BACKGROUND
  Bone-healing is known to be sensitive to the mechanical stability of fixation. However, the influence on healing of the individual components of fixation stiffness remains unclear. The aim of this study was to investigate the relationship between the initial in vitro fixation stiffness and the strength and stiffness of the callus after nine weeks. We hypothesized that axial stiffness would determine the healing outcome.
  
  
  METHODS
  A standardized midshaft osteotomy of the right tibia was performed on Merino-mix sheep and was stabilized with either one of four monolateral external fixators or one of two tibial nails inserted without reaming. The in vitro stiffness of fixation was determined in six loading conditions (axial compression, torsion, as well as bending and shear in the anteroposterior and mediolateral planes) on ovine tibial specimens. Stiffness was calculated by relating displacements of the fracture fragments, determined by means of attached optical markers, and the loads applied by a materials testing machine. Torsional testing until failure of the explanted tibiae was performed with use of a standard materials testing machine after nine weeks of healing to determine the failure moment and the torsional stiffness of the healed tibia.
  
  
  RESULTS
  External fixation in sheep generally resulted in higher fixation stiffness than did conventional unreamed tibial nailing. The use of angle-stable locking screws in tibial nailing resulted in fixation stiffness comparable with that of external fixation. The highest torsional moment to failure was observed for the external fixator with moderate axial stiffness and high shear stiffness. The fixator with the highest axial stability did not result in the highest failure moment. Low axial stability in combination with low shear stability resulted in the lowest failure moment.
  
  
  CONCLUSIONS
  In this study, a clear relationship between the stability of fixation and the mechanical strength of the healing tibia was seen. Moderate levels of axial stability were associated with the highest callus strength and stiffness.
authors.affiliation: Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Free and Humboldt-University of Berlin, Augustenburger Platz 1, D - 13 353 Berlin, Germany.
authors.forename: Devakara R
authors.initials: DR
authors.lastname: Epari
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Kassi
authors.forename: Hanna
authors.initials: H
authors.lastname: Schell
authors.forename: Georg N
authors.initials: GN
authors.lastname: Duda
mesh_terms: D000818:Animals; D001696:Biomechanical Phenomena; D001858:Bone Nails; D005592:Fracture Fixation / Q000295:instrumentation / Q000379:methods*; D017102:Fracture Healing / Q000502:physiology*; D010027:Osteotomy; D011859:Radiography; D012044:Regression Analysis; D012756:Sheep; D018709:Statistics, Nonparametric; D013978:Tibial Fractures / Q000000981:diagnostic imaging / Q000601:surgery*