Influence of size and stability of the osteotomy gap on the success of fracture healing

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Abstract
Flexible fixation of fractures with minimally invasive surgical techniques has become increasingly popular. Such techniques can lead to relatively large fracture gaps (larger than 5 mm) and considerable interfragmentary movements (0.2‐5 mm). We investigated the influence of the size of the fracture gap, interfragmentary movement, and interfragmentary strain on the quality of fracture healing. A simple diaphyseal long‐bone fracture was modeled by means of a transverse osteotomy of the right metatarsus in sheep. In 42 Sheep, the metatarsus was stabilized with a custom‐made external ring fixator that was adjustable for gap size and axial interfragmentary movement. The sheep were randomly divided into six groups with three different gap sizes (1, 2, or 6 mm) and small or large interfragmentary strain (approximately 7 or 31%). The movement of the fracture gap was monitored telemetrically by a displacement transducer attached to the fixator. After 9 weeks of healing, the explanted metatarsus was evaluated mechanically in a three‐point bending test to determine bending, stiffness and was radiographed to measure the amount of periosteal callus formation. Increased size of the gap (from 1 to 6 mm) resulted in a significant reduction in the bending stiffness of the healed bones. Larger interfragmentary movements and strains (31 compared with 7%) stimulated larger callus formation for small gaps (1‐2 mm) but not for larger gaps (approximately 6 mm). The treatment of simple diaphyseal fractures with flexible fixation can be improved by careful reduction of the fracture; this prevents large interfragmentary gaps. The experimental fracture model for the metatarsus showed that the healing process was inferior when the gap was larger than 2 mm.