Fracture fixation, then and now: When implants learn to heal.

Abstract

Conventional fracture fixation has long provided reliable mechanical stability, yet it remains largely passive in the biological process of healing. The persistence of nonunion, delayed union, and implant-related complications reveals the limitations of a fixation-centric paradigm. Emerging advances in materials science, biology, digital technologies, and implant design have progressively challenged this model, opening the door to a broader reframing of fracture management. To propose a conceptual and strategic reframing of fracture management-shifting emphasis from mechanical support alone toward a dynamic, multidimensional dialogue where implants actively sense, respond, and adapt to the biological environment. A narrative and conceptual synthesis of contemporary literature integrating evidence from materials science, biomechanics, bioengineering, immunology, and digital health. Core design principles and translational pathways are identified to outline how modern technologies support a biologically centred reframing of fracture care. Five foundational principles - designed temporality, biological integration, mechanical modulation, therapeutic multifunctionality, and feedback intelligence - underpin a framework for a dynamic host-implant dialogue. Ten technological pathways demonstrate how this interactive paradigm translates into practice, encompassing material, mechanical, biological, and data-enabled strategies that integrate mechanical, biological, and digital intelligence. This evolution reframes fracture care: from fixing bones to orchestrating healing. It marks a genuine philosophical shift - from implants as static hardware to treatment as a dynamic partnership between biology, technology, and clinical judgement.