Less rigid internal fixation plates: historical perspectives and new concepts.

In the application of "rigid" plates for diaphyseal fractures, lack of callus healing and overprotection of the underlying bone are viewed by many investigators as undesirable consequences. Potential solutions offered to overcome these deficiencies include modification of the timing of plate removal, use of biologically degradable materials for plates so that stress-shielding can be minimized, and use of less rigid plate fixation systems. This study emphasizes the selection of appropriate design criteria for less rigid plate-fixation systems. To accomplish this goal, the axial, bending, and torsional stiffness parameters are considered in place of the oversimplified terms such as "flexible plate" or "elastic fixation." With the aid of finite element modeling and simplified bench experiments, we performed parametric studies and singled out the plate axial stiffness as the dominant factor in altering the bone stresses. As a result, we designed two experimental plates, one a thin Ti-6Al-4V (titanium with 6% aluminum and 4% vanadium) alloy plate with low stiffness in axial and bending directions, and the other a tubular stainless steel plate with low stiffness in the axial direction but moderate stiffness in bending and torsional directions. The low-stiffness Ti-6Al-4V alloy plate was first tested in a demanding bilateral canine midshaft osteotomy, and proved to be inadequate. Both experimental plates were successful in the unilateral osteotomies, with the tubular plate yielding the best results. After 6 months of plating, the bones beneath the tubular plate had superior mechanical and structural properties as compared to those of the control "rigid" stainless steel and the Ti-6Al-4V alloy plates. Application of this plate prolonged for 9 months did not cause reduction in bone properties and strength. The success of the tubular plate is due to its moderate bending and torsional stiffnesses, which provide adequate fixation to achieve callus union, while its low axial stiffness permits the underlying bone to share the physiological stresses needed for bone remodeling. These drastic changes in mechanical demands on the internal fixation plate during the early healing phase and the postunion remodeling phase are discussed.