THE

USE

OF

SEMI-RIGID

PLATES

CARBON-FIBRE-REINFORCED

FOR

FIXATION

RESULTS
KEITH

TAYTON,

CHRISTOPHER

From

the

Department

of

generally
theoretically,

very
but

emphasised
The

that

arguments

discussed
occasional
by such

satisfactory,
also works
further
and

of fractures

method

by which

decision
To

to use
achieve

unrestricted

shaft

for

of the

the

tibia

internal
it has
the

fixation

be

allowed,

with

a fixation
used the
rigidity

of

ofthe

the

must
thickness

be

once

from

from

The

experience

external

callus,

between
remodelling
in theory,

and

rigid

has

to

take

fixation

place

problems
particularly
surgical

dependence
of

implant
if there

technique.

on the
failure
have
More

plate

has
of
of
of

directly

primary
or
this may be
that
in the

common

VOL.

64-B,

for reprints
should
be
British
Editorial
Society

No.

I. 1982

leads

to

in a proportion
of cases,
been
any shortcomings
in

K. J. J. Tayton,
FRCS,
Senior
Lecturer
C. Johnson-Nurse,
FRCS,
Registrar
Professor
B. McKibbin,
MD,
MS. FRCS
J. Bradley.
PhD.
Research
Engineer
G. Hastings.
PhD.
Senior
Lecturer
Requests
1982

inevitably

and

1
f

equally

Royal

HASTINGS

infirmary,

Trent

serious

that
semi-rigid
results
are from
widespread

fixation
preliminary

use ofsuch

is

not only
desirable
trials only, and it is

plates

can

be advocated.

the osteopenia
which
develops
beneath
very strong
steel
plates
as a result
of the protection
against
stress
which
they
confer
(Tonino
et al. I 976;
Paavolainen
et al.
1 978).
The
weakening
of the bone
from
this
is so
troublesome
that rates of refracture
of up to I .5 per cent
are

reported

(Muller

activity

possible,

human
subject
it is an extremely
slow
process
and
current
recommendations
for the tibia suggest
that steel
plates
cannot
be removed
safely
for at least
I 8 months
after
the injury
(MUller
et al. 1979).
Such
necessarily
prolonged

GARTH

et al.

once

and

1979);

since

after removal
to a certain

this

has

been

refracture
of the plate,
amount
of

done.

The problem,
therefore,
is to preserve
the advantages
of rigid
internal
fixation
while
eliminating,
if

desirable
that we

complications,
both
the virtual
elimination
inhibits
the formation

bone
ends:
the
so-called
bony union.
However
desirable
clinical
experience
has shown

Cardiff

Stoke-on-

restricted

splint-

has evolved

the

Surgery,

BRADLEY,

can occur
for up to two years
all patients
have
to submit

joints

external

concept

with

union

the

very strong,
and if steel
necessary
for this strength

fracture.

brought
to light two important
which
stem from the fact that
movement
at a fracture
totally

be

fixation,

that this rigidity

is not only necessary
but also
(Muller
et a!. I 979),
and it is with this concept
issue.
Increasing

before

not

neighbouring

freedom

view
the

there
are
properly
on the

is achieved,

been
taken.
maximal
benefit

JOHN

from epoxy
resin reinforced
with carbon
fibre. These have
fixation
of 20 fractures
of the human
tibia. The results
are

internal

will

McKIBBIN,

Polytechnic,

is necessary

indications

FRACTURES

TRIALS

Orthopaedic

and
support
the
in practice.
However,

experience

of the

movement

imposes

take

and

Staffordshire

here,
since
few would
deny
that
fractures
which
can only be treated
means.
This
paper
will concentrate

age. Such
plates
are

BRIAN

Traumatic

North

HUMAN

PRELIMINARY

Semi-rigid
plates have been constructed
used in animal
trials and also for internal

been

should

OF

JOHNSON-NURSE.

and

fixation

OF

PLASTIC

is

prolonged

dependence

on

the

implant.

It has

been
pointed
out
elsewhere
(McKibbin
1 978)
that
security
of fixation
and
rigidity
are
not
necessarily
synonymous,
and that the ideal fixation
for a fracture
is
one which
offers security
to the extent
that normal
use of
the limb
movement
bony

is possible,
and
at the fracture

union

callus-in

by

the

other

protection
should

sufficient
to
hence
promote

development

words,

on such a system
with the flexibility

flexibility
site, and

of

semi-rigid

external

fixation.

allow
rapid

bridging
Dependence

would
be limited
to a short period,
and
offering
only a small degree
of stress

to the

bone,

be minimised.
It would
appear

that

the

development

this goal

cannot

of osteopenia
be achieved

by

persisting
with
steel
plates,
whose
low resistance
to
fatigue
stresses
will not tolerate
the repetitive
small
movements
required,
and
an unacceptable
rate
of
implant
failure
would
result.
Clearly
an alternative
implant
fatigue

material
tolerance

is necessary,
is higher
than

whose
steel, but

elasticity
and
whose
strength

is similar.

Department
of Traumatic
and Orthopaedic
Surgery.
The Welsh
National
School
of Medicine.
Cardiff
Royal
Infirmary.
Cardiff
CF2
I SZ, Wales.
Department
of Bioengineering.
North
Staffordshire
Polytechnic.
co Medical
Institute.
Hartshill
Road,
Stoke-on-Trent.
England.

sent to Mr K. J. J. Tayton.
of Bone
and Joint
Surgery

0301-620X182/l004-O1OS

$2.00

I 05

106

K. TAYTON,

C.

JOHNSON-NURSE,

B.

After
testing
a number
of alternative
materials
animals,
our choice
fell finally
on epoxy
resin reinforced
with carbon
animals
by
their

fibre
Claes

objective

which
has been
and his colleagues

was

the

avoidance

successfully
(1980),
of stress

in

McKIBBIN,
LilliestrOm
with

used
in
although

protection.

In

J.

(I 971).

an

intact

tibiae

were

The

bones

of the

tibia,

study,

all

now

reported.

MATERIALS
The

semi-rigid

plate

reinforced
resin.

plastics
The

running

plate

AND

used

is constructed

(CFRP),

the

from

plastic

is multilaminated

in different

METHODS

with

directions

one

in this

in each

the

of the
case

carbon-fibre-

being

reinforcing

lamina

an

epoxy

carbon

of the

resin

fibres

(Figs

I and

wide

felt

the

intact

Clinical

tibia

ratio
in the

with

applied

to

drained
maintain

in bed

removed.

As soon

up

both

for

and

fixed

individuals
weight

the

clinically

through

the

and

days,

only

days

position.

the
but,

radiologically

wounds
and

were

of Paris
All
and

being
patients

plaster

were

which

varied

patients

were

mobiised

cases,

with

were

as soon

for
All

in

most

at regular

and,

the
days

of all patients

plates

figure.
chosen

comfortable,

progress
the

two

dressings

it
and

excluded.

of injury,
for

to

mid-shaft

were
being

a neutral
the

useful
of the

of plaster

I 0 days,

to be sound
incision

the

fractures

slab

fracture
The

was

be

sufficiently

3 to
fixed

activity

tibia

fragments,

until

leg felt

original

osteotomised

a few

in

ankle

tests

Owing

the

drainage

the

of walking-sticks.
was judged

within

of all

bending

strength.

fractures

a back

from
on

would

vacuum

stripped

animals,

oblique
butterfly

tibia

and

fractured

individual

between

with

intervals

both

to four-point

undisplaced

a few

animal,
bending

bandages,

as the

fracture
unrestricted

reduced

death,

between

short

with

pressure

remained

assistance

those
to the

dressed

each

ultimate

animal
and

applied

were

bearing

same

Transverse

After

submitted

of strength

and

routinely

from
then

measurements

including

were

then

two-weekly

week.

and

compound

plates

was

approximately

removed
were

stiffness

the

trial.

at

twenty-fifth

in the

that

between

2).

their

variations

was

osteotomy

killed

tissues.
establish

double

the

soft

clinical

are

until

and
to

trial,

were

fifth

conjunction
with the Bioengineering
Department
of the
North
Staffordshire
Polytechnic,
Stoke-on-Trent,
a
plate
was
developed
for use in the tibia
(Bradley,
Hastings
and Johnson-Nurse
1980).
The
preliminary
results
of its use, first in animals
and then
in a limited

HASTINGS

plate.

sheep

the

G.

This

identical

The
from

BRADLEY,

was

intervals.
removed

as the

When

the

the

tibia

from

wound

the

followed

was

healed,

allowed.

RESULTS
Animal
trial.
In Group
1 all osteotomies
with the production
of abundant
external
Fig.

normal
strength
20 weeks.
In
rapidly

with

healed
callus

rapidly
(Fig. 4),

in the bone being

achieved
after about
Group
2, again
all osteotomies
healed
good

external

callus

formation

(Fig.

5),

normal
strength
being
achieved
by about
25 weeks.
Clinical
trial.
Details
of the 20 patients
who entered
the
trial are summarised
in Table
I. Nineteen
of them
were
male,
and one was female,
their
average
age being
21
,45F*n

Figure
1 -The
eight-hole
standard
design
of CFRP
plate
shown
above
an eight-hole
broad
steel
DCP
of the
AO
design.
Figure
2-Diagram
of the CFRP
plate
to illustrate
the laminated
structure
and varying
directions
of the carbon
fibres
within
the layers.
The
have

mechanical

been

strength
steel

tests),

fatigue

CFRP

tibia,

Two

material

their

ultimate

of these

of similar

new

plates

design

(Fig.

is far greater

than

to constant
modulus

strain
for

the

amplitude
CFRP

being

to bone

using

stainless

of sheep

were

used.

steel

AO

screws

the

first,

of

dynamic

second

group

was

performed

then

being

compression
of sheep

of one

bone

approximately

sites,

an

animal

groups

osteotomy

broad
mid-shaft

this

and

of steel).

is fixed

osteotomy

this

from

plates

(Youngs

that

made
I 980),

mOrTnt
(Nm)

diameter.

trial.

transverse

AO

submitted

elasticity

plate

millimetres

Animal

strength

one-third

et al.

of steel

(when

is their

of plates
(Bradley

that

counterparts

as also
The

with

the

approximately
4.5

elsewhere

compares

3). However,
their

characteristics

reported

Bending

had

tibia,

a double

with
one

model

the

and

(DCP)

the
fixed
made

osteotomy

production

centimetre
similar

through

reduced
plate

that

of

the

of

Olerud

the
and

of

CFRP.
through
segment

two

one
Fig.

osteotomy

Danckwardt-

The
the
of

Angiation

an eight-hole

performed

between

a single

mid-shaft
with

of an avascular

long
to

In

(degiees)

Graph
to show
the bending
characteristics
of four plates
with black
circles
marking
their
limits
of elasticity.
Steel
bends
at this point,
whereas
CFRP
breaks.
The four plates
tested
are an eight-hole
broad
AO dynamic
compression
plate,
the two different
models
of CFRP
plate used in the trial, and the CFRP
plate removed
from the only case
of non-union
in the trial.

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

THE

USE

OF

SEMI-RIGID

CARBON-FIBRE-REINFORCED

years.

PLASTIC

Ten

of the

accidents
The

and
first

designed

on

the

intent

fractures

were

10 were
football
seven
patients
the

AO

107

PLATES

sustained

in road

traffic

injuries.
were
treated

with

plates

compression

model

dynamic

of reducing

the fracture

gap

with

to a minimum

in

order
to limit the strain
on the implant.
However,
this
idea proved
to be counterproductive
since the additional
protection
to the plate was more than offset
by the loss of
strength
produced
by having
large
oval
screw
holes.
Although
six of these
seven
patients
went on to sound
union,
three of them complained
of severe
aching
pain at
the fracture
site on bearing
weight.
develop
a hypertrophic
non-union
mechanical
failure
of the plate
due

The only patient

(Case
6) suffered
to a manufacturing

defect.
Because
of these
initial experiences,
of the plate
was increased
by substituting
holes
for the DCP
slots,
and no attempt
compress
subsequent
definite
modification
plate
are illustrated

Figure
4-Radiograph
of the left tibia of a sheep
eight
weeks
after it
was subjected
to a single
osteotomy
and internal
fixation
with
an
eight-hole
CFRP
plate
(radiotranslucent).
A well-developed
external
callus
is clearly
shown.
Figure
5-Radiograph
of a double
osteotomy
in a sheeps
tibia eight weeks
after it was created
and semi-rigidly
fixed.
Abundant
callus
is clearly
visible.
Table

I. Details

of the

Time

Site

Eight-hole

dynamic
R tibia

R tibia

and

R tibia

First sign of
external
callus
(days)

Type
compression

fractures.
The
effects
on the physical
properties
in Figure
3.

revised
standard
plate
1 3 patients.
All progressed

was
most

Plate
(weeks)

Complications

plate
45

43

fibula

Short

oblique

24

53

and

fibula

Traverse

92

47

R tibia

and

fibula

Oblique

32

16

Deep

infection

R tibia

and

fibula

Traverse

44

57

Severe

ache

L tibia

and

fibula

Short

oblique

167

37

Hypertrophic

R tibia

Short

oblique

42

39

with

butterfly

at fracture

site

non-union.

Bone

plate

R tibia

and

fibula

Transverse

90

46

R tibia

and

fibula

Transverse

42

39

10

L tibia

and

fibula

Transverse

78

47

II

R tibia

and

fibula

Short

83

54

12

R tibia

and

fibula

Oblique

1 19

52

13

L tibia

and

fibula

Short

66

51

Deep

14

R tibia

Oblique

56

59

Associated

IS

L tibia

and

fibula

Transverse

48

29

Deep

16

L tibia

and

fibula

Transverse

48

48

17

R tibia

and

fibula

Short

oblique

54

48

18

L tibia

and

fibula

Large

butterfly

72

33

19

R tibia

and

fibula

Short

oblique

42

39

20

R tibia

and

fibula

Short

oblique

55

41

VOL.

64-B,

No.

I.

1982

used
on
satisfactorily

removed

oblique

standard

of this
of the

until:

Short

Eight-hole

the stiffness
round
screw
was made
to

20 patients
Fracture

Case

This
remaining

oblique
with
oblique

butterfly
with

with

butterfly

butterfly

infection
fracture

of R femur

infection

to
a

graft

performed

the

I 08

K. TAYTON,

C. JOHNSON-NURSE,

B.

MKIBBIN,

J.

BRADLEY,

G.

HASTINGS

._____
Fig.
Case
with

Fig.

I . Figure
6-Radiograph
a radiotranslucent
CFRP
centre.

on

the pain
infection,

the

with
were

fixed

the
able

fractures.

illustrative

tibia

mid-shaft
had

healed
weight
He
after

youth

with

an

into

and

with

the

on

with
amount

style

tenth

day

was

due

and

after

developed

at the

no

he

was

was

case

illustrates

CFRP

week

in bed

after

the

with

the

injury

plate.

tibia

However.

unrestricted

side

satisfactory

the

was

forty-eighth
removed

eighth

so returned
week

and

the

the

patient

activities.

problems

in this series
on the lateral
ofthe

By the
plate

by the

ones,
bone,

clinically.

with

wound

had
side

their
plates
of the tibia.

had
and

In this

the
they

plate

healing,

positioned

all appeared

patient

the

the

first

well buried
This patient,
on the
to be most

external

callus

the

wound
bearing

was

a radiograph

even

he

without
noted

injury

with

day

plate

was

activities.

He

fibula

in the semi-rigidly
callus
to develop.

plated

patient

was

allowed

he was

clinically

still

The

after

tibia
injury

home
normal

the plate
line had

an intact

fragment
10).

have

8) showed

the

was involved
in a football
fracture
of the lower
shaft

(Fig.

any
to

(Fig.

to normal

days
and

admitted

and therefore
by when
the

after

to return

(49

fracture

continued

callus

weeks

allowed

hospital
fixed
which

of this callus
I 7 weeks,

that

the

the

He

a large

a butterfly

ofthe

of scaffolding.

all subsequent

medial

this

external

to be sound,

obviate
muscle

first

fixed

internally

The

home

from
over

bruising.

Forty-three

patient

troubles.

fibula.

was

to

judged

At
a good

as an erector
was

I 6 patients

of the

weeks

7).

discharged

discharge

football.

site.

further

fragment

a standard

his job

To

He was

three

(Fig.

months

17. A 20-year-old
man
he sustained
an oblique
and

after
fracture

swelling

playing
six

9).

but
plate

superficial

fracture

the

fracture

so the

sufficient
movement
can occur
tibia to enable
a good
external

lower

I 2) and

returned

be

football.

CFRP

after

painless

to

(Fig.
and

This

tibia

now

oblique

6) and

line through
the centre
untouched
for a further

disappeared

Case
which

but

(Fig.

football.

developed

the fracture
a radiotranslucent

of walking-sticks.

of

restraints.

removed

refused,

and

of playing

plaster,

(Fig.

weeks

a red

cheerfully

had

the

t%5()

fracture)

a short

as a result

DC

assistance

returned

considerable

has

varus

eight-hole

well

a persistent
was kept

will

was
callus

to playing
he had

fracture

of deep
later.

return
to

exceptions

Fig.
showing
with

week

HISTORIES

sustained
tibia

an above-knee

displaced

with

histories

CASE

of his right

treated

fixed

two

a position
of varus.
Figure
7-Radiograph
a large external
bridging
callus
has developed,
large
callus
has almost
uniform
radiodensity.

under

1. A I 7-year-old

initially

In the

case

ILLUSTRATIVE
Case

production
of external
to take weight
virtually

was found
to be due to the presence
further
details
of which
will be given

Some
described.

lower

Fig.

showing
the fractured
tibia displacing
into
plate.
Figure
8-Six
months
after fracture,
Figure
9-Ten
months
after
fracture
the

to sound
bony
union,
callus,
and all but two
painlessly

partially
was

and

attached

internally

(Fig.

bearing

accident
in
of the right

1 1), and
weight.

requested

to the
fixed
after

Four
permission

with
one
weeks
to

Case
17. Figure
I 1 -The
fracture
after
fracture

10-Radiograph
showing
fixed with a CFRP
plate.
a good
external
bridging

THE

JOURNAL

the initial
fracture.
Figure
1 2-Eight
callus
has developed.

OF BONE

AND

JOINT

Figure
weeks

SURGERY

THE

appeared

about

the

same

time

line

was

seen

in it.

transverse
Case
the

11.

An

lower

(Fig.

1 8-year-old

third

youth

of the

was

internally
plate

mobilised

extremely

well,

walking

By the

sixteenth

site
line

fracture,

(Fig.

gradually
the

This

week
faded

plate

was

case

as with

the

a short
fixed

large

(Fig.

was

four

callus

15)

and
normal

days

typical

had
noted

then,

but

later
on

54

double

of
injury

with

The

an

patient
the

developed
through

activity

no

fracture

of a sports

unaided

still

and

the

oblique

compression.

completely

a line

CARBON-FIBRE-REINFORCED

others

as a result

without

removed

illustrates

SEMI-RIGID

fibula

a very

I 4), although

OF

sustained
and

CFRP

fracture

tibia

tibia

standard

This

The

right

eight-hole
day.

I 3).

USE

at the
its centre.

weeks

after

fracture

to be clinically
15.

An

mid-shaft
(Fig.

16).

The

the

became
weeks

of

leg,

tibia
plate

infected

and

I 7). The

but six weeks

youth

tibia

CFRP
(Fig.

from

and

was

healed

days

fixed
after

r3ther
was

his accident

a transverse

as a result

internally

two
patient

sustained

fibula

VOL.

64-B,

Figure
16-Radiograph
of bone caused
by deep

No.

I.

1982

showing
the initial
fracture.
infection.
Figure
1 9-Radiograph
the tibia.
The old fracture
line

Figure

17-The
24 weeks
is still visible

on

slowly
then

fracture

of a road

the

the
over

but
the

to bear

he complained

traffic

lateral

accident,

allowed

Case
I 1 . Figure
13-Radiograph
showing
the initial
fracture.
Figure
14-Radiograph
16 weeks
after
subsequent
fixation
with a radiotranslucent
CFRP
plate.
Because
of difficulty
with contouring
the plate,
was fixed with five screws
above
and three
below.
Note
the development
of a large external
callus
with
radiotranslucent
centre
similar
to that
mr
8.Figure
IS-Radio1
raph
54 weeks
after
fracture,

Case
15.
rarefaction

of a large
site following
case,
the line
but appeared

irrelevant.

18-year-old

of the left

standard

allowed.

109

PLATES

the lower
leg, and subsequent
development
external
bridging
callus
at the fracture
semi-rigid
fixation.
As in the preceding
through
the centre
of the callus
was seen,
Case

ninth

PLASTIC

of the
accident

side

with

the

wound

following
weight

of severe

pain

three
on this
at the

fracture
and
the fracture
a somewhat
showing
a

fixed fracture.
Figure
18-Six
weeks
after
fracture
after injury
showing
a large external
callus
on the medial
on the lateral
side of the tibia.

there
side

is
of

110

K.

Case
large
good

fracture

site

(Fig.

presence
with

of deep

symptoms.
the

infection

week

grew

fracture,
able
external
later
and

allowed

patient

to carry

progressed

looked

He

was

to

well

and

finally

four

allowed

fracture.

weeks

on the

unrestricted

He

is

free

flOW

Although

no

near-disastrous

case,

it must

and

attempt

be

is

and

to speculate

been

incapacitated

so a few

after

first

without

had

to

long

bony

was

sustaining

his

was

quite

predicted

of the

(Fig.

The

20).

compression

man

right

tibia

fracture

was

CFRP

plate.

sustained

while

the

and
and

after

bearing

weight

with the aid ofa

but

patient

required

weeks.

Radiographs

large
Very

cortical
defect
little reaction

callus

finally

strong

union

weeks

after

the

patient

that

remained
was observed

appeared

was

evident

the

injury

the

three

days

walking-stick.

Ofl

the
callus

the

only

been

fracture

The

he was
wound

the

using

mohilised.
healed

was fixed

six

a very

the medial
side of the tibia (Fig. 21).
for the first nine weeks.
but external
twelfth

week;

radiographically
was

well

23 weeks

after

(Fig.
developed

22)
and

of the

in this

manner

with

of plate

failure

due

very

high.

In this

the

stress,

but

allowed

patient

a good

and
the

by 47
plate

strong

a
to

case

the
rapid

to a normal

returned

human

place

via

healing

area

of

an

bone

to

callus

and

the

bone

ends,

of the
again

with

attainment

that

in these

was

due

of

can
and
sheep

to

rapid

bone

in the
must

plate

the
by

early

lie in the

allowed

production

of normal

in

of union

hence

CFRP

was

bone

question

and

the

union
callus

experiment

healing
the

quickly
normally.

rapid

second
no

quickly

the

certain

is obviously

Once

heal

such
bridging

strength

single

achieved

diaphysis

as

the

relatively

segment

strength

callus.

being

external

worked
to

avascular

of living

all the

plate

about

the

union

there

linking

union

to be quite

bone

With

CFRP
subjected

walked

none

devised.

the

tibiae

in order

primary

the

that

in the
take

of

strength

the

external

by about

25

weeks.
The

well,

for about

fracture

the

injury

day.

of a walking-stick
when

of

of a football

in bed

healing

been
the

sheep

animals

therefore,

..

infected-76
for such tibial
the absence
of

following

after

a year.

clear

osteotomies

might

originally

as a result
fixed

assistance

showed

quite

fihula

internally

and

with
the

However,

in this

it

a transverse

risks

have

than

in

external
mid-shaft

the

It

weeks
26-year-old

fixed

the

sustained

in less

osteotomy,

infection.
A

would

activities

trouble.

DISCUSSION
a

is a

the fracture

normal

been

then

to occur

style

has been fixed. a

fracture
showing
side where
it has

weeks

infection

with a rigid plate

and then become
being
the usual time recommended
fixation
to remain
in position
even
in

3.

HASTINGS

no further

fracture

only

union

life

had

plate,

he was

Furthermore,

this

the

fatigue

the

has

steel
not

conceal

serious

rigid
metal

patient

operation

fixed
weeks

Case

G.

was allowed

patient
he

plate

problems.

fixation.

on how

BRADLEY,

The
and

of the

weeks

the

made

that

of internal

by

and the sinus excised

rapidly.
and after

of open

emphasised

of all forms

is salutary
have

33 weeks

consequences

problem

24

weight-bearing.

activities

and

a sinus.
week

At

removed.

Had
his

side

sixteenth

19)

of symptoms

J.

treated

medial

leg.

(Fig.

of guarded

MKIBBIN,

wound

the

controlled
Although

by the

and

normally

appear.

unsupported

developed

touch.

therefore

totally

the CFRP
plate was removed
from the bone.
packed
open.
Both
sinus
and wound
healed

precautionary

to

occurring

appeared

the

well

tender

on weight-bearing

aureus.
on

very

which

began

B.

showing
the initial
fracture.
Figure
21 -After
the fracture
on the medial
side. Figure
22-Radiograph
23 weeks
after
bridging
callus
laterally.
and to a lesser
degree
on the medial
filled
in the cortical
defect.

rarefaction

gaiter.

callus

painlessly

callus

JOHNSON-NURSE,

diagnosed.

plaster

external

walk

and

bone
was

Staphylococcus

the
to

reddened

showed

and

He was

ninth

which

was
18)

antibiotics

C.

3. Figure
20-Radiograph
cortical
defect
remains
development
of external

which

radiograph

TAYTON,

strate

purpose

that

semi-rigid

subject.

deliberately
initial

clinical

undoubted,

fixation

human
subjects

of the

the

are
As

far

borne
as

semi-rigidly
is the

results

first
are

out

we

are

plated

published
most

THE

study

was

theoretical

to demon-

advantages

in

practice

aware,

this

fractures
and,

as can

series

in
be

of

in

OF

BONE

AND

JOINT

of

human
seen,
the

encouraging.

JOURNAL

the

SURGERY

THE

The
been

desirability

shown

appeared
went
on
patients

for

in all cases,
to produce

non-union

have

shown

that

of the

desirable,

some

it is well

leads

to

(Case

implant,

has

of a design

movement

at the

that

of

which

that

fracture

excessive

and

non-union

tibia:

however,

has to be
movement
whether
subjects.

this

that
at

no one knows
any
particular

further

varies

juxtaposition

of
warrant

Bradley

JS,
Biomater

Hastings
GW,
1980;1:38-40.

Claes

L, Curri
behaviour
1980:215-63.

the

and

fragments

infected

development

have been
life style

fixed

fractures

of osteopenia.

As a result

allowed
to return
immediately
after removal
of their plates,

some
time
to come.
However,
standard
design
of CFRP
problems
have
been
encountered,

it

this design
use.
Finally,

of
nor

new

will eventually

to
and

permanently

not

is less

than

the

of fracture
it

using
the
stronger
plate,
only
minimal
and we believe
that

prove

although

method

some
detail,
including
the

First,

is clearly

deeply

has

there
have been
no problems.
Despite
the very encouraging
results,
these
plates
are experimental
and the work needs
to be restricted
for

fixation

emphasis.

with

callus

and bridges
small
1 5 offers
the hope

of the

or between

semi-rigid

bridging

so far

human

the amount
fracture,
bones

and
of

in the

problems

all patients
their normal

the

at present

between

advantages

apparent

accurate

place

speculative

amount

become

to take

external

nature
in this respect
experience
in Case

evidence

and desirable
It is tempting
to

is highly

conceded
desirable

Three
have

is bound
this

the

since

111

be so prolonged
or potentially
disastrous
with
plates
as with other
forms
of internal
fixation.
in no case
has there
been
any radiographic

is

suggest
that the excessive
flexibility,
which developed
in
the plate in Case 6 (see Fig. 3), represents
a limit beyond
which

3),

PLATES

may not
semi-rigid
Thirdly,

movement

1955)

between
excessive
been
established.

site

(Case

most forgiving
defects.
Secondly,

and
in all
cause

PLASTIC

essential

callus

6) the

(Watson-Jones

boundary
has never

site

bridging

leading
to excessive
moveUnfortunately,
although
we

known

non-union

important
movement

at a fracture

one

has now been

abandoned,
ment
at the fracture
site.

CARBON-FIBRE-REINFORCED

in varying
quantities,
rapid
sound
union

In that

failure

SEMI-RIGID

external

although
a fairly

one.

was

OF

of movement

clearly,

except

USE

satisfactory

problems

fixation

should
complicated

be

discharged

from

arising

from

been

outlined

have
remembered
cases
all

to totally

14 months

for general

that
patients

unrestricted

the

date

this
in
even
were

activities

of their

fracture.

REFERENCES

McKibbin

Johnson-Nurse

C, Kinzl
L, Fitzer
in vivo.
In: Uhthoff

B. The

biology

of fracture

C. Carbon
E, H#{252}ttner W.
JD, ed. Current
healing

fibre

reinforced

epoxy

Less rigid fixation

concept
ofinternal

in long

bones.

as a high

strength

low

with carbon
fibre
reinforced
fixation
offractures.
Berlin,

J Bone

Joint

Surg

[Br]

modulus

material

materials:
Heidelberg,

for internal

fixation

mechanical
characteristics
New York:
Springer-Verlag

1978;136:287-93.
DavIdson
CL,

Watson-Jones

VOL.

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No.

1, 1982

Kiopper
and

P.1, Linclau
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LA.
4th

Protection
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Edinburgh

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stress
and

in bone

London:

and

and

1978;60-B:1SO-62.

Muller ME, Allgower

M, Schneider
R, Willenegger
H. Manual
ofinterna/
fixation.
Berlin,
Heidelberg,
New York:
Springer-Verlag,
Olerud
S, Danckwardt-Lilliestrom
G. Fracture
healing
in compression
osteosynthesis.
Acta
On/top
Scand
1971 ;Suppl
I 37.
Paavolainen
P, Karaharju
E, Sl#{224}tis
P, Ahonen
J, Holstrom
T. Effect
of rigid plate fixation
on structure
and mineral
content
of cortical
Orthop
Tonino
P4,

plates.

its effects.J

E & S Livingstone

BoneJoint
Ltd.

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195S.

[Br]

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bone.

C/in