SLR - February 2019 - Charlotte George
Reference: Bottlang M, Tsai S, Bliven EK, Rechenberg B, Kindt P, Augat P, Henschel J, Fitzpatrick DC, Madey S. Dynamic Stabilization of Simple Fractures with Active Plates Delivers Stronger Healing Than Conventional Compression Plating. J Orthop Trauma. 2017 Feb; 31(2):71–77.Scientific Literature Review
Reviewed By: Charlotte George, DPM
Residency Program: Saint Francis Hospital and Medical Center, Hartford, CT
Podiatric Relevance: Evidence-based medicine has shown that controlled dynamization at the fracture site leads to bone callus formation and faster, stronger healing at the fracture site compared to rigid fixation. The gold standard for plating of a simple diaphyseal fracture remains anatomic reduction and absolute stabilization using compression plating. The controlled animal study was designed to determine if dynamic stabilization with active plates delivers stronger healing compared to standard compression plating on simple anatomically reduced fractures.
Methods: Twelve sheep were randomly assigned to receive a standard compression plate or an active locking plate for stabilization of an anatomically reduced tibial osteotomy. Absolute stability was achieved in the compression plate (CP) group using standard compression plating principles. The active locking plate (ACTIVE) group achieved dynamic stabilization using six locking screws inserted in the elastically suspended locking holes of active plates after anatomic reduction of the fracture, with no attempt at compression of the osteotomy. Fracture healing was assessed each week starting at postoperative week 3 using biplanar radiographs to measure callus size. Sacrifice of the animals occurred at week 9 to allow testing of the healed tibiae and contralateral tibiae strength using torsion until failure, whereupon CT of tested tibia was obtained to assess fracture pattern.
Results: Radiographs revealed callus formation in all 12 specimens; with week 3 revealing three times the callus formation in the ACTIVE group compared to the CP group, and at week 9, six times the callus formation. Mechanical torsion testing after implant removal demonstrated the strength of the ACTIVE specimens in terms of energy was 147 percent greater than in CP specimens. Compared to torsion of the contralateral limb, CP retained 24 percent of their native strength with ACTIVE at 64 percent strength recovery. CT analysis of specimens after torsion to failure revealed that six of the ACTIVE specimens fractured outside the callus zone, and all of the CP specimens fractured across the original osteotomy site.
Conclusion: The results of the in vivo study showed that dynamic stabilization with active locking plates delivers stronger healing of a simple anatomically reduced osteotomy compared with standard compression plating. The results of the ACTIVE plates having 64 percent of native tibial strength at week 9 and the CP plates only 24 percent is clinically significant in regards to ability for early return to function and mitigation of fixation failure. Due to the results being specific to the ovine osteotomy model, a prospective clinical trial would be required to assess if active plating can reduce healing complications and facilitate earlier return to function. These results may challenge the acceptance that compression plating for simple fracture patterns remains the gold standard.