Optimizing compression: Comparing eccentric plate holes and external tensioning devices

Objective Elimination of interfragmentary motion in fracture fixation using plates to impart compression and promote primary bone healing through absolute stability has been well described as a reliable and successful method to treat simple transverse and short oblique fracture morphologies. Our hypothesis is that dynamic compression plating augmented by external compression techniques would produce and maintain a significantly greater amount of compression than using the plate alone. Methods Simple transverse diayphyseal fractures were simulated in nine 4th generation composite bone models. A load cell was placed within the transverse fracture osteotomy and stabilized and compressed using either eccentric screw placement in a dynamic compression plate alone or augmented with an opposite segment Verbrugge clamp or articulated tensioning device (ATD) compressing using a screw outside of the plate. Dynamic plate compression was evaluated independently and in conjunction with the external compression techniques. Statistical analyses were carried out using a linear mixed effects model and pairwise comparisons between conditions with a significance set at a P-value <0.05. Results Both of the external compression techniques (Verbrugge and ATD) achieved significantly higher compression than the plate compression technique alone with 78% (P < 0.001) and 134% (P < 0.001) more compression respectively. The measured compression across the osteotomy after screw application and removal of external compression decreases by 17% for the Verbrugge device (P = 0.215) and by 22%, after removal of the ATD device (P = 0.038). For both techniques, adding additional screws in eccentric (load) position further increases compression. Conclusion Plate compression is a reliable method for inducing compression across transverse and short oblique fractures. Augmenting plate compression technique with external compression techniques (Verbrugge clamp or ATD) allows for a significantly greater compressive load to be achieved. Compression lost after removal of the external compression device indicates that the maximal compression attainable across a fracture may not be reliably maintained with standard dynamic compression plating techniques.