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Mechanobiologie der Frakturheilung Teil 2

Bedeutung für die Osteosynthese

Mechanobiology of fracture healing part 2

Relevance for internal fixation of fractures

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Zusammenfassung

Klinische Studien erlauben keine quantitative Korrelation zwischen der Beschreibung der Osteosynthesestabilität und dem Erfolg der Knochenheilung. Damit ist keine gezielte biomechanische Verbesserung der Osteosynthesetechnik möglich. Die geeignetste Größe, um die Stabilität der Osteosynthese quantitativ zu beschreiben, ist die Steifigkeit der Frakturfixation. Diese wurde für verschiedene Osteosyntheseverfahren in vitro biomechanisch und in wenigen Studien in vivo am Patienten bestimmt. Mithilfe numerischer Knochenheilungsprogramme ist es erstmals möglich, die in der Grundlagenforschung gefundenen Regeln zur Gewebedifferenzierung (Knochenheilung) zu nutzen, um günstige Osteosynthesesteifigkeiten zu berechnen. Am Beispiel der Tibiafraktur mit einer Marknagelstabilisierung konnten die Möglichkeiten der numerischen Simulation der Frakturheilung gezeigt werden. Solche Programme erlauben die Simulation des Einflusses verschiedener Osteosynthesefaktoren wie Marknageldurchmesser, Frakturform, Frakturspaltbreite und Nagelmaterial. Um aufwendige Berechnungen für verschiedene Osteosynthesen zu vermeiden, wurde ein Kennfeld berechnet, das die zu erwartende Knochenheilungsqualität in Abhängigkeit von der axialen Steifigkeit und der Schersteifigkeit der Osteosynthese darstellt. Vergleicht man die aus der Literatur bekannten Steifigkeiten der wichtigsten Osteosyntheseverfahren mit diesem Kennfeld, wird deutlich, dass die Verfahren meistens eine sehr geringe Scher- und/oder Torsionssteifigkeit aufweisen und damit die Heilung verzögern können. Bei der Plattenosteosynthese dagegen gibt es neben geeigneten und zu geringen Steifigkeiten auch Situationen, wo hohe axiale Steifigkeiten direkt unterhalb der Platte nur kleinste Gewebedehnungen erlauben, die einen zu geringen Reiz für die Knochenneubildung setzen und dadurch eine Verzögerung der Knochenheilung verursachen können.

Abstract

Clinical studies do not allow a quantitative correlation between stability of fracture fixation and outcome of bone healing. This limits the biomechanical improvement of fracture fixation techniques. The most practical quantitative parameter to describe the stability of a fracture fixation is the stiffness. This can be determined for several types of fixation through biomechanical methods and in some clinical studies in vivo. By using numerical fracture healing models, it is now possible to use the tissue differentiation rules found in basic research to calculate optimal stiffness parameters for various fixation techniques. For a tibial fracture as an example the possibilities of a numerical fracture healing simulation have been demonstrated. The effects of the diameter of an intramedullary nail, type of fracture, fracture gap size and nail material on healing could be demonstrated. To circumvent complex and time consuming calculations for several fixations a map was calculated which shows the expected bone healing quality as a function of the axial stiffness and the shear stiffness of the fixation device. By comparing the stiffness of various fixation techniques with the stiffness map it becomes evident that the methods most often used (e.g. unreamed nail, plate and external fixator) have a low shear and/or rotational stiffness that is too low to achieve the optimal healing outcome. The high axial stiffness of plates next to the plate surface can lead to very low tissue strain directly adjacent to the plate and can delay the bone healing process at this location.

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Danksagung

Mein Dank gilt allen ehemaligen Mitarbeitern, die aktiv an der mechanobiologischen Forschung zur Frakturheilung beteiligt waren.

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  1. Institut für Unfallchirurgische Forschung und Biomechanik, Universitätsklinikum Ulm, Helmholtzstraße 14, 89081, Ulm, Deutschland

    L. Claes

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Correspondence to L. Claes.

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L. Claes gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine vom Autor durchgeführten Studien an Menschen oder Tieren.

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L. Claes, Ulm

W. Mutschler, München

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Claes, L. Mechanobiologie der Frakturheilung Teil 2. Unfallchirurg 120, 23–31 (2017). https://doi.org/10.1007/s00113-016-0281-2

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