title: Delayed bone healing following high tibial osteotomy related to increased implant stiffness in locked plating.
abstract: BACKGROUND
  Asymmetrical callus formation and incomplete bone formation underneath stiff locking plates have been reported recently in clinical and experimental fracture healing studies. After similar effects were observed in the outcome of high tibial osteotomy (HTO) patients, a retrospective study was performed to quantify the frequency and level of such incomplete healing cases.
  
  
  METHODS
  Twenty-three patients treated with medial open wedge HTO and locking plate (Tomofix™) for posttraumatic or congenital genu varum were investigated. No bone grafts were applied to fill the osteotomy gap. The median correction angle was 8° (5-18°). Elective hardware removal was performed after a median of 19.5 months (12-58 months) following an uneventful clinical course. The most recent postoperative X-ray available (median 21 months; 13-56 months) was evaluated for consolidation of the osteotomy. We performed an in vitro biomechanical experiment using the same HTO on a loaded cadaver knee joint to compare interfragmentary movements (IFMs) when using regular locking screws with the Tomofix™ plate and screws that enabled dynamic stabilisation of this plate.
  
  
  RESULTS
  Fifteen patients (65%) displayed incomplete consolidation of the osteotomy underneath the locking plate (10.9% of the osteotomy length) and cortical deficiency. The time to implant removal for these patients of 27 months was longer than the 21 months for the patients with a complete osteotomy gap healing. The biomechanical experiment demonstrated that very low IFMs and corresponding interfragmentary strain occur underneath the plate when using regular locking screws. Replacement with dynamic screws resulted in an increased IFM.
  
  
  CONCLUSIONS
  These results support the hypothesis that low bone formation underneath locking plates is induced by increased stiffness. This high stiffness situation could be altered by replacing the standard screws with dynamic screws which allow for a movement of 0.35mm perpendicular to the screw axis. This resulted in an approximately threefold increase in the IFM and may be a potential concept to avoid incomplete bone healing under stiff plate fixations.
authors.affiliation: Ulm University, Department of Orthopaedic Trauma, Albert-Einstein-Allee 23, 89081 Ulm, Germany. Electronic address: goetz.roederer@uniklinik-ulm.de.
authors.forename: Götz
authors.initials: G
authors.lastname: Röderer
authors.affiliation: Ulm University, Department of Orthopaedic Trauma, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
authors.forename: Florian
authors.initials: F
authors.lastname: Gebhard
authors.affiliation: Ulm University, Institute of Orthopaedic Research and Biomechanics, Ulm, Germany.
authors.forename: Lutz
authors.initials: L
authors.lastname: Duerselen
authors.affiliation: Ulm University, Institute of Orthopaedic Research and Biomechanics, Ulm, Germany.
authors.forename: Anita
authors.initials: A
authors.lastname: Ignatius
authors.affiliation: Ulm University, Institute of Orthopaedic Research and Biomechanics, Ulm, Germany.
authors.forename: Lutz
authors.initials: L
authors.lastname: Claes
mesh_terms: D000368:Aged; D001860:Bone Plates / Q000009:adverse effects; D001863:Bone Screws; D020878:Device Removal; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000379:methods; D017102:Fracture Healing; D006801:Humans; D008297:Male; D008875:Middle Aged; D010012:Osteogenesis; D010027:Osteotomy / Q000379:methods; D011183:Postoperative Complications; D012189:Retrospective Studies; D013978:Tibial Fractures / Q000503:physiopathology* / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D016474:Weight-Bearing
keywords: Bone healing; Dynamic locking; Locking plate; Osteotomy