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CHAPTER 5

Locking Plates: Development,


Biomechanics, and
Clinical Application
........................................................................
Michael A. Wagner, M.D. and Robert Frigg

DEVELOPMENT AND While investigating the biological effects of conven-


tional compression plates1 on the underlying cortex, Per-
BACKGROUND ren and colleagues34 made the important discovery that
Evolution of the Concepts of Fracture plates interfere significantly with the blood supply to the
Fixation underlying cortex. Porotic bone formation appeared to be
directly related to the amount of necrosis occurring
Historically, the most notable development in the treat- beneath the plate. This observation led to the development
ment of diaphyseal fractures has been a shift away from of plates that ensure limited contact between the bone and
the mechanical aspects of internal fixation toward the the implant, for example, the limited-contact dynamic
biological aspects. The emphasis in the fixation of diaphy- compression plate (LC-DCP) and the later development
seal fractures today is on the biology of the bone and on of noncontact plates.
preserving the blood supply to the bone fragments.6,32,37 In the 1990s, Krettek et al.26,27 popularized minimally
It has been recognized that open direct anatomic invasive percutaneous plate osteosynthesis techniques
reduction, that is, direct manipulation of bone fragments, using conventional implants inserted through small inci-
as was generally carried out during internal fixation pro- sions and submuscular tunnels. Cadaveric studies demon-
cedures (compression method with conventional plates) strated better preservation of the periosteal vasculature
to achieve interfragmentary compression, was a major with these minimally invasive methods than with standard
cause of devitalization of the bone fragments.28 open exposures for internal fixation.10,11
Imaginative thinking led to the development of the The principle of biological internal fixation consists of
wave plate4 and bridge plate. The basic idea is to leave minimizing the biological damage caused by indirect re-
the fracture zone and its fragments undisturbed by fixing duction, by the surgical approach, and by contact between
the plate to the intact part of the bone on the proximal the implant and the bone.3,32,37 Minimizing such damage
and distal sides of the fracture zone. can be achieved, but it implies less precise reduction and
The technique of bridge plating (splinting method with less stable, more flexible fixation.
plates) was developed to help prevent the devitalization of
fragments in multifragmentary fractures.19,38 The fracture Background and Development of the
is first reduced by indirect technique. The fragmentation Technology of Locked Plates
zone is then bridged with a plate that is fixed to the main
proximal and distal fragments. This maintains length, The Zespol system, the first plate that functioned as a fixa-
rotation, and axial alignment. This type of internal fixation tor for stabilizing long bones, was developed in the 1970s
is a form of splinting. It is not absolutely stable, and union in Poland.16 It functions mechanically as an external fixa-
occurs through callus formation. This plating technique is tor, and the locked plate is above the skin.
indicated for the fixation of multifragmentary fractures.
To minimize damage to the vascularization of osseous SCHUHLI NUT
tissue and the surrounding soft tissues, indirect reduction Several 95 fixed-angle devices, such as the blade plate or
techniques have become as popular as open reduction dynamic condylar screw, have been used successfully to
and internal fixation.28 The alternative approach was advo- manage such injuries; however, these devices cannot be used
cated by Mast and colleagues,30 who introduced indirect in all situations. This shortcoming necessitated the develop-
reduction methods and biological solutions such as bridge ment of other methods to achieve fixed-angle or “locked”
plating for diaphyseal fracture fixation. internal fixation constructs. Early attempts to gain angular

143
144 SECTION 1  General Principles

stability of conventional screws placed through commer- compression plate7 (Fig. 5-1); the monocortical screws
cially available plates led to the development of the Schuhli appear to damage the endosteal blood supply less than
nut (Synthes, Paoli, PA).22 This device, essentially a conventional bicortical screws.
threaded washer, served two purposes: it allowed screws to The point contact fixator device (PC-Fix; Synthes,
lock into the plate, thereby preventing screw toggle, and it Paoli, PA) incorporates monocortical screws that lock into
limited the contact of the plate with the underlying bone a plate using a Morse cone mismatch that prevents screw
in an attempt to preserve periosteal perfusion. The results toggle as the screws are tightened to the plate.33 The
of biomechanical studies and clinical series have documen- undersurface of the plate is undercut to allow minimal
ted the improved stability and clinical utility of these devices points of contact with the bone, further reducing bony
in managing difficult nonunions and malunions.21 devascularization. The clinical success of this type of treat-
ment was astonishing: indirect healing resulted in early
RATIONALE BEHIND LOCKED INTERNAL and reliable solid union. At the same time, the severity
FIXATORS (LIFs) of complications declined, as there was a shift away from
Toward the end of the 1980s, the AO (Arbeitsgemeinschaft biological complications due to necrosis with sequestration
für Osteosynthesefragen)/ASIF (Association for Study of of bone and soft tissues toward rare complications result-
Internal Fixation) started to examine internal fixator sys- ing from inadequate mechanical stability.
tems to further develop their plates. The key to these Multiple European clinical series have documented
internal fixators is the locking mechanism of the screw high union rates and low complication rates using the
in the implant, which provides angular stability. This PC-Fix for fractures of the forearm.17,31
technical detail means that there is no need to induce Locking plate technology has also been used successfully
compression forces at the bone surface to stabilize the in both oral maxillofacial surgery and spinal surgery, where
bone–implant construct. The lack of compression improves stability is required without bicortical screw purchase.20,36
fracture healing, and the locking head screws obtain excel-
lent anchorage even in osteoporotic bone. This turns a plate DEVELOPMENT OF LOCKING HEAD SCREWS
into an internal fixator. It functions mechanically as an PC-Fix was the first type of plate fixator in which angular
external fixator but is implanted beneath the skin. This stability was achieved by establishing a conical connection
method of internal extramedullary locked splinting, which between the screw heads and screw holes. However, the
reduces mobility at the fracture site but does not eliminate tapered screw–plate connection does not provide axial
it, is designed to keep the bone fragments vital and to induce anchorage of the screw in the plate, so that point contact
indirect bone healing by callus formation. between the plate and the bone is still required to achieve
stability. A new type of thread connection between
POINT CONTACT FIXATOR the screw head and screw hole, resulting in angular and
The point contact fixator (PC-FIX; Synthes, Paoli, PA) axial stability, was therefore developed so that no contact
was developed in a joint venture by the AO Research at all is required for stability. The screw simply func-
Institute and the AO Development Institute. This implant tions as a Schanz screw. Angular stable implants and espe-
has minimal contact with the bone and is secured by cially angular stable noncontact plates are called locked
monocortically inserted screws. The screw’s tapered head internal fixators (LIFs). Their distinguishing mechanical
ensures that it jams in the plate hole and provides the feature lies mainly in the fact that stability is not achieved
required angular stability. Minimal contact between the by friction between the undersurface of the plate and
plate and the bone is still necessary to ensure axial stability. the bone, with all the associated disadvantages, but rather
Like the limited-contact dynamic compression plate (LC- by connecting elements between the extramedullary load
DCP), the PC-Fix has shown to disrupt the underlying carrier and the main fragments of the bone. The rigid con-
blood supply significantly less than the dynamic nection of the pins, blades, or bolts/screws to the load

FIGURE 5-1 Comparing the Limited Contact Dynamic Compression Plate (LC-DCP) (B) with the Dynamic Compression
Plate (DCP) (A) the contact area of the plate underside (shown in red), with the bone surface has been reduced
and later minimized to only points with the Point Contact Fixator (PC-FIX) (C).

A B C
CHAPTER 5  Locking Plates: Development, Biomechanics, and Clinical Application 145

FIGURE 5-2 A and B, Force distribution of a plate osteosynthesis without angular stability: The screw tightening moment
leads to surface pressure between the plate and bone. The friction thus created in the plate-bone contact zone
stabilizes the bone fragment in relation to the load carrier. This system only becomes statically secure after
bicortical screw fixation. Typical distribution of forces for a LIF osteosynthesis with angular stability: This
configuration is statically secure with only monocortical fixation since the locking head screw (LHS) is anchored
in a mechanically stable manner in the load carrier.

A B

carrier facilitates the mechanical bridging of the fracture Development of the Locking
zone without creating friction between the load carrier and Compression Plate (LCP)
the bone. This mechanical concept is similar to external
fixators (Fig. 5-2). LISS was originally designed as a device that would pro-
This type of thread connection has been incorporated vide angular stability and accommodate only locking head
into the new AO internal fixation systems—the less inva- screws; all of the plate holes are threaded. However, clini-
sive stabilization system (LISS) and the locking compres- cians found that this technology was too restrictive in
sion plate (LCP). The aim of the basic locked internal some cases and that an all-purpose implant system would
fixation technique is to achieve flexible elastic fixation to offer greater flexibility. Research and development work
trigger spontaneous healing, including the induction of
callus formation, supporting the principle of minimally FIGURE 5-3 A and B, The less invasive stabilization
invasive plate osteosynthesis (MIPO). system. LISS DF LISS PLT.
Development of LISS
The less invasive stabilization system (LISS) for the man-
agement of distal femoral fractures and proximal lateral
tibial fractures makes it possible to use a minimally inva-
sive surgical technique, applying the principle of fracture
fixation with relative stability. LISS is an anatomically pre-
shaped internal fixator that can be inserted percutaneously
by means of an adaptable insertion guide. Combined with
a trocar assembly, the handle also serves as an aiming
instrument for exact percutaneous placement of the self-
drilling, self-tapping locking head screws. Based on exten-
sive anatomic studies, the orientation of the individual
screws is predetermined and cannot be changed. The rea-
son for this is the angular stable screw–plate connection
that is achieved with the outer thread of the screw head
and the inner thread of the plate hole, which does not
allow variable orientation of the screw (Fig. 5-3).
LISS for the distal femur (LISS DF) and the proximal
lateral tibia (LISS-PLT) are implants that act as splints.
LISS acts mechanically as an internal fixator. This device
is a 100 percent locked internal fixator because only lock-
ing head screws (LHSs) are used. LISS is designed for
percutaneous insertion. A less invasive approach also is pos-
sible. Closed indirect reduction and pure splinting of the
fracture zone are important. Internal fracture fixation with
locked fixators is a new technology in which the aim is to
preserve biological conditions.*

*See references 9,10,11,14,15,18,29,35,38,41,42 and 44.


A B
146 SECTION 1  General Principles

FIGURE 5-4 A–C, Locking compression plate with combination hole. LCP combination hole combining two proven
elements. One half of the hole has the design of the DC/LC-DCP dynamic compression unit (DCU) for
conventional screws. The other half is conical and threaded to accept the matching thread of the locking head
screw providing angular stability.

A
B

in this area—with multidisciplinary collaboration among anatomic regions. These LCPs are anatomically preshaped
clinicians, researchers, developers, and manufacturers— to fit the average shape of specific bones and can be inserted
ultimately led to the concept of a combination hole, using open or minimally invasive techniques.
which has been incorporated into the most recent type of
plate—the locking compression plate, or LCP—a single- Other Technical Solutions for Locking a
plate system that allows the surgeon more choices.12,13,46,47 Screw in a Plate Hole
The LCP combination hole (Fig. 5-4) allows internal fix- There are many technical possibilities for locking a screw
ation to be achieved by the insertion of either conventional
into a plate hole. A threaded interface between plate hole
screws (into the unthreaded part of the hole) or locking head
and screw head creates a geometrical strong angular and
screws with angular stability (into the threaded part of the axial stable interlocking of the screw with the plate. The
figure-eight hole). The LHS can be inserted only at right
disadvantage of a threaded interface is the predefined
angles into the plate. The LCP hole also makes it possible
insertion axis of the screw in generic plates.
to insert different screw types into the same plate so that
So-called polyaxial locking head screws have the advan-
the surgeon can choose the type depending on intraoperative
tage that the insertion axis of the screw can be adapted to
requirements. In retrospect, combining two completely
the anatomy. This is an advantage for the use of generic
different anchorage techniques into a single implant was a
plates, which are shaped intraoperatively to compensate
logical approach and a straightforward, practical solution.
for the changed screw direction after the plate has been
With the LCP, the surgeon has two plating methods to
adapted to the bone surface.
choose from and is able to select the more appropriate.
Solutions used to mechanically lock polyaxial locking head
With its newly designed combination hole, the LCP makes screws in plates are based on friction or plastic deformation of
it possible to implement the methods of both compression
the screw–plate interface. If friction is used to lock a screw
and splinting for fracture stabilization in the same implant.
into a plate, the angular and axial stability of the locking head
The option of using the LCP either as a compression plate
screw in the plate relies on the friction generated during screw
or as an internal fixator provides ideal plate anchorage that
insertion or on tightening an additional locking element.
can be adapted to individual requirements. This signifi-
There are two current methods of achieving this:
cantly extends the range of indications in minimally invasive
plate osteosynthesis. 1. The locking element can be part of the plate hole
Two versions of the LCP with combination holes are (e.g., Polyax, DePuy, Raynham, MA; Numelock II,
available: a 4.5/5.0 large-fragment version and a 3.5 small- Stryker, Allendale, NJ). The Polyax system is shown
fragment version. Special plates also are available for many as an example (Fig. 5-5A). When it is not locked
CHAPTER 5  Locking Plates: Development, Biomechanics, and Clinical Application 147

FIGURE 5-5 A–C, Polyax system. FIGURE 5-6 A and B, NCB system.

A B 30⬚

In alignment with clinical preferences, more and more


plates are anatomically preshaped, internal fixators having
the advantage of not having to be perfectly adapted to
the bone surface. Screw placement and screw directions
in those anatomically preshaped plates are predefined on
the basis of anatomic studies. The goal of these studies is
to obtain the best screw placement, safest screw direction,
(see Fig. 5-5B), the bushing can toggle to a certain
extent. The system is locked by the screw exerting a
radial force (see Fig. 5-5C) on the bushing. In such
systems the angular stability is related to the frictional FIGURE 5-7 A and B, Litos system.
surface area (the thickness of the plate and the screw
angulation) and the force exerted.
2. Another possibility is to use a specially designed cap
that is inserted on top of the bone screw head and
screwed into the plate hole (e.g., NCB, Zimmer,
Warsaw, IN) (Fig. 5-6A). The screw itself can tog-
gle (Fig. 5-6B) to a certain extent and will be locked
at the desired angle. Here the angular stability is
related to the tightening force of the locking cap
and the screw angulation.
Plastic deformation of the screw–plate interface is
another well-known technique. It permits the locking head
screw to be fixed off-axis to the plate hole to some degree.
The plate material used to allow this deformation must be
“softer” than the screw material (e.g., Litos). The plate
hole has a lip (Fig. 5-7A), which, during screw insertion,
is deformed, creating geometric fit (see Fig. 5-7B).
The advantages of polyaxial locking head screws must
be compensated by plate size, implant material, or reduced
angular stability. Depending on the clinical indication,
these compromises can be acceptable. Until now, only sys-
tems with a threaded screw–plate interface could be used
for basically any plate thickness, size, and implant material.
In combination with the possibility to apply dynamic frac-
ture compression through the same screw hole, basically B
any plate indication can be covered with one system.
148 SECTION 1  General Principles

and strongest anchorage in the bone. In combination with of reduction, delayed union, and nonunion are complica-
external aiming arms, predefined screws can be placed in tions encountered with conventional plating techniques.
minimally invasive fashion through these aiming arms, With compression plating, stress risers caused by
through the anatomic preshaped plates, and into the bone. remaining screw holes and avascular bone under the plate
Where polyaxial systems will show real clinical benefits may lead to refracture after implant removal. The LC-
is still in discussion, especially with the tendency toward DCP with partial preservation of osseous blood supply
anatomically preshaped plates. However, in pelvic fractures may limit this complication.
and periprosthetic factures, these technologies could be
beneficial. LOCKING HEAD SCREWS
All locking head screws (LHSs) provide angular and axial
BIOMECHANICS stability inside the plate hole. They act more like bolts
The more recent locked internal fixators, such as LISS and than screws, and there is a complete absence of axial pre-
LCP with LHS, consist of plate and screw systems in loading within the screw during its insertion. The advan-
which the screws are locked into the plate. The locking tages of LHSs include improved anchorage in bone
process minimizes the compressive forces exerted on the resulting from the slight increase in the outer screw diam-
bone by the plate. This method of angle stable screw–plate eter and the altered loading conditions. Under functional
fixation means that the plate does not have to touch the loading they are loaded in bending and in axial load
bone at all (noncontact plates), which is particularly advan- depending on the external loading condition. LHSs can-
tageous for minimally invasive plate osteosynthesis. With not be used as lag screws. From a biological point of view,
these new screws, precise anatomic contouring of a plate they have the additional advantage of no contact between
is no longer necessary and the plate does not have to be the plate and bone, thereby protecting the blood supply
pressed onto the bone to achieve stability. This prevents to the bone (see Fig. 5-4A–C).
intraoperative primary displacement of the fracture caused Two different types of LHS are available: self-drilling
by inexact contouring of a plate and plate fixation with and self-tapping only for monocortical use and self-
conventional screws. LISS and special anatomic LCPs tapping for bicortical use (Fig. 5-8A and B). Each design
are preshaped to match the average anatomic form of the has distinct indications, contraindications, and pitfalls.
relevant site and require no further intraoperative alter- SELF-DRILLING, SELF-TAPPING LHS
ation. The basic locked internal fixator technique aims to
achieve flexible elastic fixation to stimulate spontaneous Self-drilling, self-tapping LHSs are used only as monocor-
healing, including the induction of callus formation. In tical screws in the diaphyseal segment of bone when excel-
addition, for the compression method of conventional lent bone quality is present. The cutting tip of the screw
plating technique, the use of locking head screws are a prevents destruction of the bone thread in the near cortex
great advantage. when there is a narrow medullary cavity because the screw
tip is able to penetrate the opposite cortex. When a self-
Different Screws and Different Fixation of drilling, self-tapping LHS is anchored in both cortices,
Plates onto the Bone the drilling unit protrudes well into the soft tissues, with
a potential risk of damage to the neurovascular structures
CONVENTIONAL SCREWS in that area. Furthermore, inserting a self-drilling, self-
When conventional bicortical screws are applied through a tapping LHS by percutaneous freehand technique (i.e.,
plate, the tightening of the screws compresses the plate without an aiming device) sometimes results in imperfect
onto the bone. The stability of this construct results from centering of the screw tip in the hole and angulation of
friction between the undersurface of the plate and the the LHS. Accordingly, bicortical purchase is less impor-
bone12–14,48,49 (see Fig. 5-4A–C). tant than with nonlocking plates. Avoiding bicortical
If a conventional cortex or cancellous bone screw is drilling also theoretically minimizes further damage to
inserted into the bone and tightened, axial preload of the the endosteal circulation and may decrease the risk of
threads in the bone will be achieved. This procedure pre- refracture after plate removal.14,48,49 Current locking plate
vents the micromovements that can lead to bone resorp- designs have used self-drilling, self-tapping monocortical
tion and, consequently, to screw loosening. screws (less invasive stabilization system, or LISS;
Conventional plating techniques for fracture fixation Synthes); this has eliminated the need to measure the
require adequate plate-bone contact and screw tightening length for percutaneous screw insertion, decreased inven-
to achieve stability between the plate and one surface. Loss tory, and minimized surgical time.

FIGURE 5-8 A and B, Different types of locking head screws. Self-drilling, self-tapping locking head screw. Self-tapping
locking head screw.

A B
CHAPTER 5  Locking Plates: Development, Biomechanics, and Clinical Application 149

SELF-TAPPING LHS Bicortical LHSs are recommended in the following


Self-tapping LHSs are used in the epiphyseal, metaphy- situations: weak osteoporotic bone, thin bone cortex that
seal, and diaphyseal segments of the bone when the inser- does not provide a sufficient working length for the screw,
tion of a bicortical LHS or the longest possible LHS is high torsional loading in the plated bone segment, a short
planned. The self-tapping LHS has a blunt rather than a main fragment that only allows a limited number of
sharp cutting tip. To provide good anchorage of the screw screws, in bones of small diameter, when a previous corti-
threads in both cortices, the self-tapping LHS should pro- cal reduction screw is replaced by an LHS, and after
trude slightly beyond the far cortex. destruction of the bone thread in the near cortex due to
Self-tapping LHSs need predrilling through the incorrect insertion of the LHS.
threaded drill sleeve. If this technique is performed cor- SELECTING THE TYPE OF SCREW 47,49
rectly, the mono- or bicortical self-tapping LHS is always
perpendicular and in the center of the threaded conical Four different types of screws can be used with the LCP.
part of the combination hole. Careful analysis of the intended function is required to
In the presence of osteoporosis, the bone cortex is usu- ensure optimal use of the different types (Table 5-1).
ally thin. In these conditions, the working length of a  Cortex screw, self-tapping cortex screw, cortex shaft
monocortical LHS is short, so that poor anchorage is screw
obtained even with locking head screws (Fig. 5-9A–D)
This difficulty can lead to complete loss of screw anchor-
 Cancellous bone screw
age, resulting in instability of the fixation—a common sit-  Self-drilling, self-tapping locking head screw (for
uation in bones that are subjected to mainly torsional monocortical use only)
loading (e.g., the humerus). The use of bicortical self-  Self-tapping locking head screw (for mono- or
tapping LHSs is recommended in all segments for all oste- bicortical use)
oporosis-associated fractures. This approach improves the The following factors are critical for the appropriate
working length and avoids potential problems at the inter- choice of screw:
face between the screw thread and bone (Fig. 5-10). Even
the shortest monocortical self-tapping LHS will destroy  The mechanical principle of fixation required:
the bone thread if the screw tip touches the opposite cortex  Locked splinting versus interfragmentary com-
before the screw head has locked into the plate hole. If this pression method
occurs, the LHS should be replaced with a bicortical self-  Locked internal fixator versus standard plating
tapping LHS, which will ensure anchorage in the opposite technique
cortex (Fig. 5-11A–C). The problem can be avoided at an
early stage of the procedure by drilling both cortices (e.g.,
 Plate fixation to the bone with LHS (noncontact
plate) or standard screw compression
in bones of small diameter such as forearm or fibula).
 Technique of reduction and plate insertion:
MONOCORTICAL OR BICORTICAL LHS  Minimally invasive plate osteosynthesis (MIPO)
technique versus open reduction and internal fixa-
Monocortical LHSs can be used only in the diaphyseal tion (ORIF)
segment of long bones when the bone quality is normal,  Epiphyseal area versus diaphyseal/metaphyseal area
when the cortex is thick enough to allow anchorage of the
screw with a sufficient working length of the thread, and Cancellous bone screws and cortex screws are designed
when the specific bone has a low loading level in torque. to create compression. They can be used as position

FIGURE 5-9 A–D, The working length of monocortical screws depends on the thickness of the bone cortex. In normal bone,
this working length is sufficient. In osteoporotic bone, by contrast, the cortex is usually very thin so that the
working length of a monocortical screw is insufficient. This difference in working length is important when
osteoporotic bones such as the humerus have to be stabilized. In normal bone, the length of anchorage of the
screw thread is sufficient enough to withstand rotational displacement. When there is osteoporosis, the
working length is very short due to the thin cortex, and under torque the bone thread will quickly wear out,
leading to secondary displacement and instability.

A B
C D
150 SECTION 1  General Principles

joint, whenever interfragmentary compression with eccen-


FIGURE 5-10 Improvement of the working length. In
osteoporotic bone with a very thin cortex, tric screw insertion or a lag screw is required, or with a
the standard use of bicortical screws is bridge plating technique with good bone quality. Cancel-
recommended, as the longer working lous bone screws or cortex screws are also used for reduc-
length leads to a much better torque tion of a fragment onto the plate. These screws are
resistance. usually anchored in both cortices; monocortical screw
insertion is only carried out exceptionally.
Cancellous bone screws and cortex screws have the
advantage that they can be angulated within the plate hole,
making it possible to reduce fragments onto the plate.
Their disadvantage is that they compromise the blood sup-
ply to the bone cortex owing to the need for direct contact
between the plate and the bone to allow load transmission
by a friction force (Table 5-2).
Earlier AO guidelines recommending specific numbers
of screws or cortices in each fragment should no longer be
the only deciding factor for anchoring a plate in the main
fragments. For adequate stabilization, it is more important
to insert a few screws with high plate leverage (e.g., a long
plate with enough distance between the LHSs in each
main fragment) to reduce the load on the screws.
From a purely mechanical point of view, two monocor-
tical LHS screws in each main fragment in the shaft area
screws, to compress the plate to the bone surface, or as lag are the minimum requirement to keep the construct stable.
screws—plate-dependent, inserted through a plate hole, or However, this type of construct will fail if one screw breaks
plate-independent—to create interfragmentary compres- owing to overloading or if bone resorption occurs at the
sion. In combination with a plate, these screws are also interface between the bone cortex and the screw thread,
used as eccentric compression screws or as fixation screws. leading to loosening (screw pull-out). The use of two
Their use is recommended when the screw has to be bicortical screws in each fragment does not improve the
inserted at an angle in cases of axial malalignment between situation in relation to screw fatigue failure, but it does
the bone and plate axis, to avoid screw penetration into a enhance the working length of the screw and thus improve

FIGURE 5-11 A–C, Danger of insertion of monocortical self-tapping LHS. In bones with a small diameter, the tip of the
screw can contact the opposite bone cortex before the screw head has engaged in the thread of the plate
hole. This leads to the destruction of the bone thread in the near cortex and complete loss of anchorage of
the screw. The situation can be resolved by using a threaded drill sleeve; the opposite cortex is drilled in the
correct axis, inserting a self-tapping bicortical LHS to obtain anchorage in the opposite cortex.

A B C
CHAPTER 5  Locking Plates: Development, Biomechanics, and Clinical Application 151

Table 5-1
Select the Correct Screw Type
Type of Screw Bone Segment Function of Screw Anchorage
Cancellous bone screw: partially Epiphysis Free, plate-independent lag screws* As long as possible
(i.e., cancellous shaft screw) or fully Metaphysis Plate lagging screws*
threaded
Plate fixation screw
Cortex screw, self-tapping cortex Diaphysis Free, plate-independent lag screw Monocortical or bicortical
screw Epiphysis Plate lagging screw
Metaphysis Plate fixation screw
Position screw
Reduction screw
Cortex shaft screw partially threaded Diaphysis Free, plate-independent lag screw Monocortical
Plate lagging screw
Self-tapping locking head screw Epiphysis Plate fixation screw Monocortical or bicortical (in metaphysis
Metaphysis Plate-dependent position screw and epiphysis as long as possible)
Diaphysis
Self-drilling, self-tapping locking head Diaphysis Plate fixation screw Monocortical
screw
*Only partially threaded cancellous screws can be used as lag screws.

the anchorage at the interface between the screw thread mechanical considerations alone. The longest possible
and the bone. Even when the surgeon ensures that all of LHSs are recommended, but penetration of the articular
the screws are inserted correctly, this type of construct surface must be avoided. The local anatomy and the length
can only be used in bone of good quality. For safety rea- of the epiphyseal and/or metaphyseal fragment are also
sons, a minimum of three screws per main fragment is relevant to the decision. In these cases, the use of meta-
recommended in all other cases. physeal plates or anatomically preshaped plates is recom-
When fractures are being fixed in the epiphyseal and mended to achieve balanced fixation, with load bearing
metaphyseal areas, neither the length of the plate nor the being distributed equally between the proximal and distal
number of screws should be chosen on the basis of plate segments anchored in the two main fragments.

Table 5-2
Different Functions and Rules of Screws
Function Type of Screw Effect Prerequisites
Lag screw Cortex screw* Interfragmentary compression Gliding hole, threaded hole for a fully
– free, plate- Cortex shaft screw{ threaded screw or partially threaded
independent
– plate lagging screw Cancellous shaft screw#
Eccentric screw ¼ Cortex and self-tapping Interfragmentary compression Dynamic compression unit (DCU) and
compression screw cortex screw hemispheric screw head of conventional
Cancellous bone screw screw
Plate fixation screw Cortex and self-tapping Friction between bone and plate For conventional screws, good bone
cortex screw quality and prebending of the plate
Cancellous bone screw
Self-tapping LHS Locking
Position screw Cortex and self-tapping Holds the relative position Threaded hole in each fragment
cortex screw between two fragments
– free, plate- Cancellous full threaded
independent bone screws
– through a plate hole Self-tapping LHS Only plate dependent
Reduction screw Cortex screw and self- Reduction onto the plate No interfragmentary compression
tapping cortex screw
LHS/Fine tunning Reduction of a butterfly LHS + screwdriver, screw hold sleeve
fragment
*Self-tapping screws are not recommended for use as lag screws.
{ and # partially threaded.
152 SECTION 1  General Principles

FIGURE 5-12 A and B, Load transfer from bone to splint. Plate and cortex screws (compression). Plate and locking head
screws.

Because the standard screws are free to toggle in the bar is far from the limb axis, creating a large bending
plate, stability requires bicortical purchase of these screws. moment.
However, with a locking plate construct, threads on the Since locking head screws are not tightened in the bone
screw head lock into corresponding threads in the screw but in the plate instead, no axial preload will occur
hole of the plate (see Fig. 5-2A and B), thus eliminating within the bone. The locking head screws cannot be over-
toggle. The forces are transferred from the bone to the tightened even in poor bone structures. Nevertheless, a so-
plate across the screw–plate threaded connection13,14,48,49 called press-fit technique through radial preload, as used
(Fig. 5-12A and B). Compression of the plate to the for pin-type connections, is applied to prevent harmful
underlying bone therefore is not required to achieve con- micromovements.
struct stability, and the blood supply to the bone directly The advantages of angular stability become far clearer
under the plate is preserved. for a system comprising several screws in a plate. In a
Full understanding of the mechanics of locking plates plate–screw configuration with nonlocking screws, con-
and monocortical screws requires an appreciation of the ventional screws are stand-alone screws, and sequential
prevailing forces these fixation constructs must withstand loosening of the screws occurs when force is applied. The
in different anatomic regions of a bone. Bone quality is less lack of angular stability permits each screw to align along
dense in the metaphysis than in the diaphysis. Therefore, the axis of force. This leads to gradual loosening with
locked screws are usually placed in long rows perpendicular pull-out of the individual screws. In the case of fixed-angle
to the applied load and the limb axis. When, in a medial application, en bloc fixation is achieved. The LHS can no
bony defect, a cantilever bending force is applied, multiple longer be regarded as a stand-alone screw, and the fixed-
locking head screws function like small blade plates, resist- angle connection between the plate and the screw head
ing the bending moment. Under the same circumstances, prevents screw orientation along the axis of force. Pull-out
conventional screw–plate fixation allows toggle and thus can occur only en bloc (Fig. 5-13A–E).
progressive varus deformity. In the diaphysis, locked The effect of en bloc fixation can be reinforced by con-
screws can also be inserted perpendicular to the axial load, vergent or divergent positioning of the screws, an approach
but they are then more commonly loaded in shear, similar applied chiefly in metaphyseal areas. Several screws inserted
to the prevailing conditions when half pins are inserted for in convergent or divergent positions and in fixed-angle
external fixation.14 technique achieve such a high level of stability that failure
The pull-out strength of a monocortical locked screw is can only be due to pull-out of the entire system or to plate
about 60 percent of the strength of a standard bicortical failure.
screw.14 In fact, a locked screw–plate construct can be The aspects of load transmission across a fracture stabi-
thought of as being similar to an implanted external fixa- lized with a locking screw plate device in comparison to
tor. Studies of the biomechanics of monolateral external existing devices demonstrates the theoretical, practical,
fixation have shown improved stability of constructs that and comparative advantages of the locking plate. To
incorporate wide spacing of half pins and placement of understand this comparison requires an appreciation of
the connecting bar as close to the bone as possible. A lock- the concepts of working length, mechanics of standard
ing plate construct might be considered the ultimate exter- plate stability, and the effect of cantilever bending.
nal fixator, with minimal soft tissue dissection, wide screw The working length of a plate-bone construct is the
spacing, locked screws, and the plate functioning as the length of plate unsupported by bone because of comminu-
connecting bar, placed extremely close to the mechanical tion, segmental bone loss, or other reasons.4 Bridge plates
axis of the bone. Although a direct comparison has not span large areas of comminution and thus typically have
been made, the ability to move the plate closer to the long working lengths.4 Although biologically advantageous
mechanical axis should markedly increase stability com- because they help preserve soft tissue, such constructs are
pared with a monolateral external fixator, in which the often at a mechanical disadvantage, especially when they
CHAPTER 5  Locking Plates: Development, Biomechanics, and Clinical Application 153

FIGURE 5-13 A–E, Pull-out of standard screws and locking head screws (LHS). Fixation with cortex screws. Pull-out
of cortex screws by a bending load. Sequential screw loosening. Fixation with LHS, en bloc fixation.
LHS provides greater resistance against bending loads. Pull-out of LHS with axial loading.

A
B

90⬚

C
D

are used for periarticular injuries, a common application. The external fixator also bridges almost the entire
These fractures frequently have short periarticular frag- length of the bone. In contrast, the length of the plate
ments and long working lengths; the result is coronal plane was a matter of controversy for some time. In the past, a
instability and consequent collapse when standard non- short (or too short) plate was often chosen to avoid a long
locking plates are used. To avoid this, a fixed angle must skin incision and extensive soft tissue dissection. With the
be provided between the plate and the fixation into the peri- newer techniques of indirect reduction, with subcutaneous
articular segment. This can be achieved with 95 fixed-angle or submuscular insertion of the implant and the new
devices. The locking screw–plate design facilitates a similar locked splinting method to bridge the fracture zone, the
mechanical advantage with multiple points of screw fixation. plate length can be increased without additional soft tissue
This is most important in fractures with long working dissection. Little or no additional biological damage is
lengths, short periarticular segments, and the absence of caused, and the plate length can be adapted to the
bony support on the side of the fracture opposite the plate. mechanical requirements of the specific fracture. From
the mechanical point of view, plate loading and screw
LENGTH OF THE IMPLANT loading should be kept as low as possible to avoid fatigue
The development of locking plates has resulted in rela- failure of the plate due to cyclic loading or pull-out of
tively unusual fixation constructs of long plates that use the screws due to excessive single overloading. A long plate
few, often monocortical, screws. Understanding the design should be used.
rationale and potential clinical applications of such un- Three segments of the plate can be distinguished: the
conventional plates requires a basic understanding of the middle segment at the fracture site between the two
biomechanics of plate fixation. innermost screws, and the proximal and distal plate seg-
The choice of the appropriate length of the LCP (and ments anchoring the implant onto the proximal and dis-
of all plates) is one of the most important steps in internal tal main fragments. The length of the plate and the
fixation. It depends on the fracture pattern and the positioning of the screws influence the loading conditions
method and mechanical principle being used for fixation. in the plate and screws. The length of the middle plate
In intramedullary nailing, there is no question regarding segment and the method of spanning the fracture are
the length of the nail, which is more or less equal to the responsible for the biological response of fracture healing
complete length of the fractured bone from one epiphysis (indirect healing, direct healing, or failure to heal)
to the other (Fig. 5-14). (Fig. 5-15).
154 SECTION 1  General Principles

FIGURE 5-14 Prerequisites for using the LCP as a locked internal fixator: long plate/fixator; adequate space between the
LHS in each main fragment. Avoid stress concentration while leaving out three or four plate holes without
screws in the fracture zone.

The ideal length for the internal fixator can be deter-


mined using two values: the plate-span ratio and the
plate–screw density.49 The plate-span ratio is the ratio of
plate length to overall fracture length. It was found empir- FIGURE 5-15 Importance of the plate-span ratio and
ically that the plate-span ratio should be greater than 2:1 plate–screw density in bridge plating
or 3:1 in multifragmentary fractures and greater than 8:1, technique. The schematic drawing shows
9:1, or 10:1 in simple fractures. The plate–screw density a mechanically sound fixation of a
is the proportion of the number of screws inserted to the multifragmentary diaphyseal fracture in the
lower leg. The ratio between the length of
number of plate holes. Values below 0.5 to 0.4 are recom-
the plate and the length of the fracture is
mended, indicating that fewer than half of the plate holes known as the plate-span ratio. In this case,
are occupied by screws. the ratio is high enough—that is,
approximately 3, indicating that the plate is
three times longer than the overall fracture
Locking Plates and the Splinting Method area. The plate–screw density is shown for
all the three bone segments. The proximal
Bridge plating can be carried out with both standard main fragment has a plate–screw density of
screws and locking head screws. The method of splinting 0.5 (three out of six holes occupied); the
the fracture zone with standard plates and conventional segment over the fracture has a density of
screws, using a “no-touch” technique combined with indi- 0 (none of four holes occupied); and the
rect reduction, was a great step forward when it was intro- distal main fragment has a density of 0.75
duced. Only the main fragments were fixed to the plate. (three out of four holes occupied). The
With conventional screws, it was necessary to preshape higher plate–screw density in the distal
main fragment has to be accepted, since
the plate to fit the main fragment.
for anatomic reasons there is no way of
However, LHSs are preferable for bridge plating proce- reducing it. The overall plate–screw density
dures, since it is easier to carry out the MIPO technique for the construct in this example is 0.43
because there is no need to preshape the plate and the frag- (six screws in a 14-hole plate).
ments do not pull on the plate, resulting in primary loss of
reduction. In addition, there is no disturbance—or only min-
imal disturbance—to the periosteal blood supply. It is possi-
ble to use both conventional screws and LHSs in normal-
quality bone. In soft osteoporotic bone, LHSs should be used
for additional stability. Technically, the locked splinting
method (pure splinting) can be carried out either with an
open approach or with the MIPO technique and indirect 50%
closed approximate reduction. LISS and LCP with LHS
Plate screw density 0.43

look like plates but, biomechanically, they are locked splints


or fixators (locked internal fixators) (Fig. 5-16A and B).
Fracture length

Plate length

0%
Locking Plates and the Compression
Method
CONVENTIONAL PLATING TECHNIQUE WITH
LOCKING PLATES
75%
Despite the advantages of locked internal fixators, there is
still a need for the anatomic reconstruction and absolute
stability that are provided by conventional plates and
CHAPTER 5  Locking Plates: Development, Biomechanics, and Clinical Application 155

The method of interfragmentary compression can be


FIGURE 5-16 A and B, Bridging the fracture zone with
a long plate. The bridging plate is only also achieved using the LCP as a compression plate for
fixed to the main fragments proximally axial compression (Fig. 5-18).
and distally. Fixation with conventional
screws presses the plate against the
bone, and the shape of the plate has to CLINICAL APPLICATION,
be adapted to the bone. Locked INDICATIONS, AND TECHNIQUES
internal fixator: LHSs are angular and
axial stable. No compression of the plate Concepts of Fracture Fixation
onto the bone is required to achieve The theoretical principles underlying fracture fixation are
stability. the establishment of stability—either absolute or relative
stability, meaning maximal or less mechanical stability
after osteosynthesis. The two methods applied to achieve
these goals are compression (static or dynamic) and splint-
ing (locked or unlocked). A variety of techniques and
implant techniologies are applied in the steps required to
carry out these two methods (Fig. 5-19 and Table 5-3).
Plate osteosynthesis has changed in the last decades.
The last milestone is the locking of screws in the plate
hole. In some situations the locked non-contact plates
have biological and biomechanical advantages over the
compression method with conventional compression
plating technique. These advantages of the locking com-
pression plate can be used best in combination with the
methodological principle of locked extramedullary splinting.
Less Invasive Stabilization System
The LISS approach is based on the use of anatomically
shaped buttress plates that are anchored by the insertion
of self-drilling and self-tapping monocortical locking head
screws.
The system consists of instruments required to join the
fixator and insertion guide together. These include the sta-
bilization bolt, fixation bolt, and drill sleeve. The other
instruments have been designed to facilitate the temporary
positioning of the fixator, the adjustment of its position,
and reduction before the first screws are inserted to attach
A B the fixator to the bone. These include K-wires that can be
inserted through the insertion guide and the aiming device
for K-wires.
The LISS plate is designed for the distal lateral femur
screws. Appropriate indications for the latter include intra- aspect (LISS-DF) and the proximal lateral tibia (LISS-
articular fractures, osteotomies, complex bone reconstruc- PLT) and acts as an anatomically shaped buttress plate
tion procedures, pseudarthroses, and fractures with trau- anchored with self-drilling, self-tapping monocortical
matic damage to the blood supply. A lag screw can also locking head screws. The screws are connected to the plate
be placed independently from the plate, with a protection by a thread on the outer edge of the screw head and on the
plate being fixed with locking head screws (Fig. 5-17A inner edge of the plate hole. LISS is an anatomically pre-
and B). This technique is much easier to perform than shaped internal fixator that can be inserted percutaneously
trying to insert a lag screw through a plate hole. There is by means of an adaptable insertion guide. As a true internal
no risk of primary loss of reduction. In soft osteoporotic fixator, the applied LISS fixation construct must be longer
bone, LHSs find a better hold and there is less or no risk than conventional plates. The LISS-DF and the LISS-
of screw loosening. PLT are available in three lengths (5, 9, and 13 holes), right

FIGURE 5-17 A and B, Protection plate with independent lag screw.

A B 45⬚
156 SECTION 1  General Principles

FIGURE 5-18 A and B, Compression plate. After FIGURE 5-19 Spectrum of stability.
reduction of this fracture, the plate is fixed
Spectrum of stability
with LHS to one fragment. Then an after fixation
eccentric cortex screw is inserted in the
dynamic compression part of the
combination hole at the other end of the
Absolute stability Relative stability
plate. Finally, stabilization with an Instability
additional LHS. No compression to the
periosteum in the fracture zone.
Interfragmentary compression plating Stability is a spectrum from
using dynamic compression unit. total to none
In other words
absolute to relative

and left versions. With the development of the LCP


combination hole, anatomically preshaped LCP-DF and
LCP-PLT are also available (Fig. 5-20A–D).
The screws are connected to the plate by a thread on
the outer surface of the screw head and a mating thread
on the inner surface of the plate hole. The angular stability
between the screws and the plate no longer requires any
compression between the plate and the bone to ensure
A secure anchorage. LISS is a noncontact plate. Each self-
drilling, self-tapping screw requires a new sharp drill bit
for drilling and a sharp tap to cut the thread, after which
the screw follows into the precisely prepared hole. The
monocortical self-drilling, self-tapping screws lock into
the plate and fasten the proximal and distal main fragments
after indirect reduction has been carried out. Owing to the
B locking design, the LHS does not need to obtain purchase

Table 5-3
Different Concepts of Fracture Fixation
Principle of Fracture
Fixation Bone
¼ Grade of Stabilization Method Technique and Implant Function Healing
Absolute stability ¼ high Compression Lag screw (conventional screw) Direct
Static* Lag screw and protection plate
Compression plate
Tension band
Dynamic{ Tension band plate
Buttress plate{
Splinting External splinting External fixator**
Intermedullary splinting Intramedullary nail**
Locked#
Internal extramedullary Bridging with standard plate
splinting
Bridging with locked internal fixator
External splinting Conservative fracture treatment (cast,
traction)
Unlocked} Intramedullary splinting Elastic nail
Relative stability ¼ low K-wire Indirect
*Fracture under compression—implant under tension.
{Compression under function.
#Locked splinting with control of length, alignment, and rotation.
}Splinting with limited control of length, alignment, and rotation.

**Can be changed to dynamic compression in case of a dynamically locked nail or dynamic external fixator.
{Using an angular stable plate–screw construct (i.e., LISS or LCP with LHS) as buttress plate, the plate acts as a blade plate. Occasionally a buttress plate may be considered as a splint.
CHAPTER 5  Locking Plates: Development, Biomechanics, and Clinical Application 157

FIGURE 5-20 A–D, Different types of internal fixators for the distal femur and the proximal lateral tibia. LISS-DF plate
LCP-DF plate LISS-PLT plate LCP-PLT plate.

in the second cortex and can easily be inserted percutaneously Table 5-4
and by self-drilling. This produces a better bone-plate con-
struct compared with the use of conventional screws. The sta- Indications for LISS DF in Femoral Fractures
bility of the bone-implant construct results from the angular  Supracondylar fractures (33-A1–A3)
stability of the plate–screw interface rather than from the fric-  Articular fractures (33-C1–C3)
tion generated between the plate and bone, as with conven-  Distal shaft fractures (32-B1–B3 and 32-C1–C3 if nailing is not
tional implants. This has mechanical advantages and avoids possible)
problems related to the bone-implant interface, such as the  Periprosthetic fractures (distal to hip prosthesis or proximal to
“windshield wiper” effect. knee prosthesis)
LISS resembles a plate but functions as a fully implanted  Repeated fracture with implants in place
fixator offering “biological” internal fixation. The primary  Fractures in osteoporotic bone
objectives are to minimize biological damage due to surgical  Pathological fracture
intervention, to provide an improved implant anchoring
especially in osteoporotic bones and immediate postoperative
active or passive motion of the adjacent joints, resulting in an
uneventful fracture healing. implants are already in situ (e.g., total knee replacements6)
whether or not they have a medullary stem. Since screws
LESS INVASIVE STABILIZATION SYSTEM FOR can be inserted into all seven distal screw holes, LISS offers
THE DISTAL FEMUR a high degree of stability and reliability in osteoporotic
bone. No other implant currently available has such a wide
INDICATIONS The indications for LISS DF include all
range of applications. There are certain cases for which LISS
extra-articular (supracondylar, distal shaft) and intra-artic-
provides a unique answer, especially when the distal femoral
ular fractures that cannot be treated with screws alone, for
block is short. These include multiplane, complex distal
example, Müller AO classification 33-A1–A3 and 33-C1–
articular injuries, especially with a short distal segment,
C3 fractures of the distal femur (Table 5-4).2,18,25,35,42,49
osteoporotic fractures, and fractures above a total knee
The LISS technique is advantageous in severe intra-
arthoplasty.
articular fractures,32 since it allows free placement of lag
screws and does not additionally disrupt the condylar APPROACHES The surgical procedure essentially
complex after reconstruction. It preserves the soft tissues in depends on whether or not an intra-articular fracture
the metaphyseal and diaphyseal regions as a result of mini- requires open reduction. In nonarticular fractures (Müller
mally invasive insertion and closed reduction.3,10,11,26,30,45 AO classification A1–A3) and fractures with simple artic-
LISS also makes it possible to stabilize fractures where ular involvement (Müller AO classification C1 and C2), a
158 SECTION 1  General Principles

lateral approach to the distal femur is used. A lateral para- fractures). In the Schatzker classification for tibial plateau
patellar approach is preferable for multiplane articular fractures, the indications include Schatzker type V and
involvement, medial-based intercondylar splits, additional VI fractures.
Hoffa fractures, and separate intercondylar notch frag- The LISS fixator is not specifically indicated for
ments. The surgeon utilizes the approach needed to view isolated fractures of the tibial diaphysis in the mid-third
the articular surface, and traditional lag screw fixation of but is quite useful for segmental shaft fractures involving
the articular surface is carried out. the proximal half of the tibia and for ipsilateral diaphyseal
For all displaced intra-articular fractures of the distal and bicondylar tibial plateau fractures. Other less common
femur (not only complex ones), a lateral parapatellar conditions in which the LISS PLT has been used include
approach should be selected that ensures an optimal over- pathologic lesions with impending fracture of the proximal
view of the articulation. The joint capsule can then be tibia and periprosthetic fractures.
divided in line with the split in the iliotibial ligament. A lateral approach to the tibial head is recommended
The technique of LISS fixation in displaced intra-articular for the treatment of extra-articular fractures of the proxi-
fractures starts with direct visualization and stable internal mal tibia. Access along the proximal contour of the tibia
fixation of the articular surface. Priority is always given to should be extended in a medial direction to detach the
precise anatomic reconstruction of the articular surface anterior tibial muscle close to the bone with part of the
(Figs. 5-21A and B and 5-22). muscle fascia on the bone being left intact to ensure easier
refixation of the muscle. The LISS PLT device is inserted
by sliding it onto the proximal tibia from the proximal side
LESS INVASIVE STABILIZATION SYSTEM FOR in a distal direction under the anterior tibial muscle.
THE PROXIMAL LATERAL TIBIA Attention should be given to correct positioning in the
INDICATIONS The indications for LISS PLT include condylar area and, particularly, on the tibial shaft. K-wires
fractures of the proximal shaft, the metaphysis, and intra- are used to fix this position and are advanced through the
articular fractures in which treatment with screws alone is insertion guide, and the self-drilling, self-tapping LHSs
not possible (Table 5-5). The principle of angular stable are mounted in the trocar assemblies (Fig. 5-23).
screw fixation gives the LISS PLT system distinct bio-
mechanical advantages over comparable devices for similar
IMPLANT-SPECIFIC PROBLEMS AND
indications. Once the system has been applied to the lat-
COMPLICATIONS
eral aspect of the tibia, it prevents varus collapse in meta-
physeal/diaphyseal fractures and in fractures of the tibial One of the complications specific to LISS DF is proximal
plateau with medial condyle involvement. This means that screw pull-out. Possible predisposing factors include fail-
the LISS PLT can also be used in the treatment of proxi- ure to place the LISS DF on the shaft laterally and possi-
mal tibial fractures that involve both the lateral and medial bly incorrect rotation, which causes tangential placement
condyles, that is, condylar fractures (Müller AO classifica- of the screws in the shaft cortex so that the screws gain
tion type 41-A2, A3, C1–C3 and all proximal 42-type purchase only in a small section close to the tip of the

FIGURE 5-21 A and B, In the case presented here, a lateral parapatellar approach with inclusion of the soft tissue injury was
chosen.

A B
FIGURE 5-22 Clinical case LISS-DF.

A B

C D E
160 SECTION 1  General Principles

Table 5-5 screw. Pull-out occurs typically after approximately 6 to


8 weeks, that is, as soon as the patient increases weight-
Indications for LISS PLT in Proximal Tibial bearing (Fig. 5-24).
Fractures If the plate lies too far toward the anterior or posterior
 Metaphyseal fractures (multifragmentary) aspects, the screws will not be centered in the medullary
 Proximal shaft fractures (multifragmentary, not nailable) canal and will not have adequate purchase. Incorrect posi-
 Segmental shaft fractures (not nailable) tioning of the LISS DF on the lateral condyle of the femur
 Articular fractures (41-A2, A3, C1, C2, C3) may result in soft tissue irritation.
 Fractures in osteoporotic bone
Bending and twisting of the LISS plate is not rec-
ommended, since this results in malalignment of the
 Pathological fractures
holes on the insertion guide with the corresponding plate
 Periprosthetic fractures
holes.

FIGURE 5-23 Clinical case LISS-PLT.

A B C
CHAPTER 5  Locking Plates: Development, Biomechanics, and Clinical Application 161

In some patients, use of a lateral locking plate is an alter-


FIGURE 5-23 (Continued)
native to double-plating techniques. Locked plating may
also provide an alternative to external fixation, thus mini-
mizing associated complications such as pin-site infection
and patient tolerance. The importance of anatomic reduc-
tion of the articular surface with lag screw fixation remains
paramount. The metaphyseal comminution is then
“bridged” by the plate with locked screw fixation of the
articular segment and with either locked or conventional
bicortical screw fixation of the diaphyseal segment. Great
care is taken to preserve soft tissue integrity and, therefore,
bone viability in the metaphyseal region, regardless of
whether an open or a percutaneous submuscular plate
application technique is chosen.
Other potential indications for locking plate technology
include periprosthetic fractures when total knee arthroplasty
is involved.2,23 Retrograde intramedullary fracture fixation is
difficult to use with posterior cruciate ligament–substituting
total knee arthroplasty designs because of the closed femoral
housing. Lugs, stems, or other portions of the femoral com-
ponent may also preclude the use of fixed-angle devices,
such as the blade plate or dynamic condylar screw. Locking
plates afford fixed-angle stability and permit the use of mul-
tiple distally locked screws, which often can be inserted
around such obstacles and provide stable distal fixation even
for very short distal fragments.
In some series, extra-articular or simple intra-articular
fractures of the distal femur and proximal tibia with short
periarticular fragments have demonstrated unacceptable
rates of malalignment with intramedullary nailing.35 The
use of locked plating constructs may provide improved fix-
ation in these patients and result in less malalignment.
If intramedullary nailing cannot be used for selected long
bone fractures with long working lengths, a bridge plate
technique with locked screw fixation may be a viable alter-
native. Other evolving applications for locking plate tech-
nology include fixation of corrective osteotomies,
malunions, and nonunions as well as applications for
orthopaedic oncology; however, published clinical data
for these applications are lacking.
LISS DF and LISS PLT procedures have been in clin-
D ical use since 1995. Several studies and a large number of
articles have been published on these procedures, reporting
both biomechanical and clinical advantages. The published
data show that LISS is a valuable treatment option for
fractures of the distal femur23–25,29,35,38,40–42,45,51 and the
CLINICAL EXPERIENCE
proximal tibia.5,15,35,40
The current indications for locking plate fixation are com- Most published clinical studies of locking plate fixation
plex periarticular fractures, especially those with comminu- have focused on the results of the LISS plate in fractures of
tion of the metaphyseal region. Comminuted distal the distal femur and proximal tibia. This device is an
femoral fractures with multiplanar articular involvement externally targeted plate designed for submuscular, extra-
are excellent indications24 (see Fig. 5-22). Locking plates periosteal application, with all screws locking to the plate.
allow the surgeon more options for fixed-angle fixation In one prospective trial that included nine European
while avoiding previously placed lag screws or fracture trauma centers, 112 patients with 116 fractures of the dis-
lines, such as the coronal (Hoffa) fracture of the distal tal femur were treated.42 Ninety-six patients with 99 frac-
femur. In the past, these obstacles sometimes precluded tures completed the study (mean follow-up, 14 months).
the use of traditional fixed-angle devices, such as the blade Twenty-nine percent of fractures were open; 91 percent
plate or the dynamic condylar screw. Bicondylar tibial pla- of fractures healed. Six patients required bone grafting to
teau fractures, in which coronal plane stability is required, achieve union, and four infections were reported. Average
may benefit from this type of fixation22,25 (see Fig. 5-23). knee flexion at union was 107 . Deviations greater than 5
162 SECTION 1  General Principles

FIGURE 5-24 A–D, Malalignment between the bone axis and plate leads to an eccentric plate position (A). At the far end of
the plate, a monocortical locking head screw will not anchor in the bone in these conditions (B). To overcome
the problem of insufficient anchorage of a monocortical self-drilling, self-tapping screw when the plate is
positioned eccentrically, it is recommended either to insert (C) a long bicortical self-tapping screw or
(D) a cortex screw that allows angulation in the plate hole.

C
D
B

from normal coronal or sagittal alignments were noted on had malalignment greater than 5 . Gosling et al.15 and
approximately 40 percent of postoperative radiographs. Ertl and Smith8 reported encouraging results using lateral
In a series of 66 patients with fractures of the distal locked plating as an alternative to double plating in
femur treated with the LISS plate, all fractures healed bicondylar tibial plateau fractures.
without loss of distal femoral fixation.24 Only three frac- An obvious interdependence has developed between
tures (5%) required bone grafting to achieve union. Three locked internal fixation technology and minimally invasive
patients (5%) had malalignments greater than 5 in any techniques of plate application. Although impressive union
plane. In another study, 54 fractures of the distal femur were rates have been reported, this may be the result of
treated with the LISS DF plate.38 Four had loss of proximal improved soft tissue handling techniques, a favorable
fixation, attributed to errors in surgical technique resulting biological environment, and the improved mechanical sta-
in incorrect implant placement on the femoral diaphysis. bility provided by locking plate technology. Additionally, it
Two infections and three delayed unions were reported. appears that monocortical fixation is adequate to achieve
Of the 27 patients who completed a minimum 1-year fol- union; in the absence of errors in surgical technique,
low-up, 20 (74%) had good or excellent results; 7 (26%) reported rates of fixation failure are low. When percutaneous
had alignment deviations greater than 5 in any plane. techniques are used, malalignments are more common, but
When the femoral LISS was used for 13 periprosthetic the operations are technically demanding. With increased
fractures above total knee arthroplasties, only one patient experience and the development of new techniques to
required bone grafting to achieve union.23 No cases of improve the accuracy of closed reduction, the frequency
varus collapse or distal fixation failure were noted. of such malunions should decrease. The long-term clinical
In another study, 46 complex intra-articular and extra- significance of the malalignments remains unknown.
articular fractures of the proximal tibia (45 patients) were
treated with the tibial LISS plate. Of the 16 open frac-
LOCKING COMPRESSION PLATE
tures, there was one infection. One patient required bone
grafting to achieve union; no varus collapse or loss of prox- Using the LCP, the surgeon is free to select the best treat-
imal fixation was reported. Six of the 46 fractures (13%) ment method—either the compression method or the
CHAPTER 5  Locking Plates: Development, Biomechanics, and Clinical Application 163

Table 5-6
Biomechanical Aspects of Plate and Screw Fixation
Fixation Method Fracture Configuration After Reduction Fixation Technique Screw Type*
Compression Simple fracture type > full contact Lag screw and Cortex screw as lag screw; cortex screws
(static or between the main fragments protection plate (1) neutral position or LHS (2) as plate screws
dynamic)
Compression plate Cortex screws in eccentric position or axial
(and lag screw) compression with a tension device and cortex
screws (1) in neutral position or LHS (2) as plate
screws
Tension band plate Plate position important support vis-à-vis support
is important, cortex screws in neutral position or
LHS (2) as plate screws
Buttress plate Cortex screws (1) in neutral position or LHS (2) as
plate screws
Splinting Multifragmentary fracture > partial or no Bridge plating or Cortex screws (1) in neutral position or LHS (2) as
contact between the main fragments locked internal fixator plate screws
Simple fracture type (in exceptional Bridge plating or Cortex screws (1) in neutral position as plate
cases) > full or partial contact between locked internal fixator screws or LHS (2) as plate screws
the main fragments
LHS, locking head screw(s).
*Bone quality: (1) Normal, (2) Poor, (2) Also for technical reason: no primary loss of reduction, accurate shaping of the plate is not needed, MIPO easier.

locked splinting method—to bridge the fracture zone in reconstruction procedures, pseudarthroses, and fractures
the individual patient. The type, number, and position of with traumatic damage to the blood supply.
screws used dictate the method and technique and must The compression method of fracture fixation, aiming
be appropriate to the fracture situation (Table 5-6). LCP for absolute stability, involves open reduction and internal
functions in accordance with the latest plating techniques, fixation (ORIF) using plates and cortex and/or cancellous
the aim of which is to achieve an optimal anchoring of the bone screws. This approach, the principles of which are
implant to the bone, to maintain fracture reduction outlined above, became established as a standard and suc-
throughout the fracture healing process, while reducing cessful technique for treating bone fractures. The success
the amount of surgery-related soft-tissue trauma and of the technique depends on the precision of the reduction
maintaining the bone vascularity. and the degree of stabilization. Wide surgical exposure is
The LCP combination hole allows internal fixation to necessary to achieve reduction, and soft tissues were often
be achieved by the insertion of either standard screws (into stripped from fracture fragments.
the unthreaded part of the hole) or locking head screws With experience, it became increasingly evident that
with angular stability (into the threaded part of the there was a biological price for precise reduction and abso-
figure-eight hole). LHSs can only be inserted at right lutely stable fixation. Handling, and even cleaning, of the
angles to the plate. The LCP hole also makes it possible bone fragments before and during reduction was likely to
to insert different screw types into the same plate so that result in dead bone that might only revascularize slowly
the surgeon is able to choose the type depending on and require long-term protection.
intraoperative requirements. In retrospect, combining two In some fracture situations, the LCP with combination
completely different anchorage techniques into a single holes can be used with a conventional plating technique,
implant was a logical approach and a straightforward, that is, fracture fixation using the compression method
practical solution. based on the principle of achieving absolute stability and
The option of using the LCP either as a compression direct bone healing. The surgical technique and instru-
plate or as an internal fixator provides ideal plate anchor- ments are similar to those used in conventional plating
age that can be adapted to individual requirements. This with DCP or LC-DCP.
significantly extends the range of indications in minimally Indications
invasive plate osteosynthesis. With the LCP, the surgeon  Simple fractures of the diaphysis and metaphysis:
has two plating methods to choose from and is able to cases in which precise anatomic reduction is neces-
select the more appropriate.
sary for the functional outcome; simple transverse
or oblique fractures with little soft-tissue compro-
LCP IN CONVENTIONAL COMPRESSION mise and good bone quality (compression plating or
PLATING protection plating in combination with a lag screw
Compression Method Conventional Plating Technique or tension-band plate)
Despite the advantages of locked internal fixators, there is  Intra-articular fractures (buttress plate)
still a need for the anatomic reconstruction and absolute
stability that are provided by conventional plates and  Delayed union or nonunion
screws. Appropriate indications for the latter include  Closed-wedge osteotomies
intra-articular fractures, osteotomies, complex bone  Complete avascularity of the bone fragments
164 SECTION 1  General Principles

The following conditions have to be met for the use of The guidelines for the compression method–
the compression method: conventional plating technique are shown in Table 5-7.
 Precise reduction of the fragments—in most cases Axial Compression After open and direct precise ana-
requiring open, direct reduction tomic reduction of the fracture and preshaping of the
 Precise anatomic preshaping of the plate (when the plate, interfragmentary compression is applied using the
protection plate is fixed with cortical screws) eccentric cortex screw option in the dynamic compression
 Good bone quality, to ensure adequate anchorage of unit (DCU) of the LCP’s combination hole. Fracture
cortex or cancellous bone screws compression can also be applied using a tensioning device.
Osteosynthesis is then completed with cortex screws
 Minor soft-tissue damage inserted in the neutral position.
Technique If different screws are combined in compression
The method of interfragmentary compression can be plating, the cortex screws should be inserted in the middle
achieved using the following approaches: of the plate in their eccentric positions first, to achieve
fracture compression. As a modification, the LCP can
 Compression plate for axial compression (in trans- initially be fixed to one of the main fragments with one
verse fractures) or two LHSs. Subsequently, compression can be applied
 Lag screw and protection plate (in oblique fractures) by inserting one eccentric screw into the other fragment
 Tension band principle using a plate or by applying the tensioning device. Osteosynthesis is
 Buttress plate and lag screw then completed with locking head screws.

Table 5-7
Guidelines for Plate Fixation in Simple and Multifragmentary Fractures
Simple Fracture Multifragmentary Fracture
Biomechanical principle Interfragmentary Splinting in exceptional cases without lag Splinting
compression screw
Reduction technique Mainly direct Indirect or percutaneous direct* Preferably indirect
Insertion At least partly open Open, less invasive, MIPO Closed, minimally invasive
Shaping of the plate Has to be fitted to bone Accurate shaping not needed with LHSs Accurate shaping not
surface needed with LHSs
Plate-span ratio (see >8:10/1 >2:3/1 >2:3/1
text) ¼ Plate length/
fracture length
Screw type/function  Cortex or cancellous screw  Cortex screws or LHS in good bone  Cortex screws or LHS in
as plate-dependent lag  LHS in poor bone and with MIPO technique good bone
screw  LHS in poor bone and
 Cortex screws in eccentric with MIPO technique
position for compression
 Cortex screw in neutral
position or LHS for plate
fixation
Monocortical/bicortical screw anchorage:
Conventional screw  Bicortical; lag screw  Bicortical  Bicortical
monocortical
LHS in the diaphysis  Self-drilling, self-tapping  Self-drilling/self-tapping monocortical or  Self-drilling/self-tapping
monocortical or self-tapping bicortical monocortical or
self-tapping bicortical self-tapping bicortical
LHS in the epiphysis/  Self-tapping bicortical, as  Self-tapping bicortical, as long as possible  Self-tapping bicortical,
metaphysis long as possible as long as possible
Plate screw density (see 0.4–0.3 0.5–0.4 0.5–0.4
text)
Screws per main 3;2 exceptionally 3;2 exceptionally 3;2 exceptionally
fragment (n)
Cortices per main 3–5 4 4
fragment (n)
Screw position in the Short middle segment Middle segment without screws, without lag Long middle segment
plate without screws screws; splinting method required or unprecise without screws
reduction*
Empty plate holes over 0–3 >2–3 3
the fracture
LHS, locking head screw; MIPO, minimally invasive plate osteosynthesis.
*Splinting of simple fractures should respect the biomechanical rules according to the strain theory.
CHAPTER 5  Locking Plates: Development, Biomechanics, and Clinical Application 165

Lag Screw and Protection Plate Interfragmentary com- loss of reduction. This technique is much easier than
pression of a simple fracture in the metaphyseal or diaphy- placing a lag screw through a plate hole (Fig. 5-25).
seal segment, or of an intra-articular fracture, can also be
accomplished using a lag screw inserted through the plate.
LOCKED SPLINTING WITH LOCKED INTERNAL
The additional cortex screws are again used to increase
FIXATORS
the friction between plate and bone. If there is good bone
quality and an open approach is possible so that accurate LOCKING COMPRESSION PLATE WITH
plate contouring can be carried out, then cortex or cancel- SPLINTING
lous bone screws can be inserted. This protection plate Internal Extramedullary Locked Splinting
construct helps protect the fractured bone from bending Method—Principle of Relative Stability
and torsional forces. New methods involving minimal risk were developed to
Conventional compression plating requires precise accelerate bone regeneration and bone healing in difficult
adaptation of the implant to the bone to maintain precise fractures. Whereas anatomic reduction of the fracture
reduction; the screws apply a compressive preload at the was the goal in the conventional plating technique, the
interface between the plate and the bone, and the frag- aim in bridging plate osteosynthesis for multifragmentary
ments are pulled toward the implant (see Fig. 5-4B). Using shaft fractures has been to reduce vascular damage to the
the LCP with cortex or cancellous bone screws therefore bone. The use of indirect reduction, as advocated by Mast
requires accurate shaping of the plate in the same way as and colleagues,30 was intended to take advantage of the
with a conventional LC-DCP. Imperfect shaping of the soft-tissue attachments on the bone fragments, which
plate leads to a mismatch between plate and bone surface align spontaneously when traction is applied to the main
resulting in primary loss of reduction when cortex or can- fragments.
cellous bone screws are tightened. If LHSs are inserted to Bridge plating can be carried out with both standard
support the reduction and compression being maintained screws and locking head screws. The method of bridging
by the lag screws, no uncontrollable forces due to pressure the fracture zone with standard plates and standard screws,
of the plate on the bone surface will be created. This way using a “no-touch” technique combined with indirect reduc-
the risk of primary reduction loss is eliminated. In osteopo- tion, was a great step forward when it was introduced.
rotic bone the use of locking head screws improves the Only the main fragments were fixed to the plate. For the
anchoring of the implant by its angular and axial stability plate fixation with standard screws, it was necessary to pre-
provided by the threaded screw head – plate hole interface. shape the plate to fit the main fragment. It is possible to
This improved anchoring can be very beneficial to protect use both standard screws and LHSs in normal-quality bone.
the lag screw placed through a plate hole or for the anchor- In areas with reduced bone mass the anchoring of the lock-
ing of a so-called neutralization or protection plate after the ing compression plate will be enhanced with the use of
placement of a plate independent lag screw. locking head screws. Bridge plating procedures in combina-
The lag screw can also be placed independently from tion with the MIPO technique, locking head screws are
the plate, with a protection plate being fixed with locking very helpful to compensate for the lack of the plate shape
head screws (see Fig. 5-17). There is no risk of a primary to the anatomical bone shape. In contrast with compression

FIGURE 5-25 A–E, Clinical case LCP compression method.

A B
(Continued)
166 SECTION 1  General Principles

FIGURE 5-25 (Continued)

D E

screws, the use of locking head screws will maintain the pre-  LCP as an external fixator in emergency situations
reduced fracture alignment.  Tumor surgery
In addition, there is no disturbance—or only minimal
disturbance—to the periosteal blood supply. Technically, Technique (see Table 5-7)
the locked splinting method (pure splinting) can be carried There are two prerequisites for using the LCP as a locked
out either using an open approach or with the MIPO internal fixator:
technique and indirect, closed, approximate reduction.  The bridging plate has to be long—the longer the
The LCP is used as a locked internal fixator to bridge plate, the better.
the fracture zone in a less invasive or MIPO technique,
that is, the locked splinting method with an internal
 The space between the locking head screws has to be
fixator, based on the principle of relative stability, is adequate.
applied in the following cases: Locking the screw into the fixator increases stability, and
 Multifragmentary fractures of the diaphysis and avoids the risk of primary dislocation of the fragment toward
metaphysis (Fig. 5-26) the plate induced by tightening the screws, and decreases the
risk of secondary fracture displacement due to toggling of the
 Simple fractures of the diaphysis and metaphysis (in screw within the plate hole. The advantages of locking head
cases in which approximate reduction is adequate for screws are that the screw length can be reduced to a monocor-
the functional outcome, although it is important to tical size and that self-drilling screws can be used, thus elim-
strictly observe the biomechanical principles of strain inating the need for length measurement. In good-quality
tolerance) bone, monocortical LHSs are adequate, but at least three
 Fractures in problem zones when there are relative screws should be inserted into each main fragment on either
contraindications to intramedullary nailing, for exam- side of the fracture. In osteoporotic bone, it is strongly recom-
ple, shaft fractures with anomalies of the medullary mended that at least three LHSs should be inserted into each
morphology, fractures in children and adolescents main fragment on either side of the fracture, and that at least
with open epiphyses, shaft fractures in children, shaft one or two of these LHSs should be inserted bicortically.
fractures in patients with multiple injuries (poly- Bicortical insertion of LHS is recommended in the
trauma, chest and traumatic brain injury) following circumstances:
 Open-wedge osteotomies (e.g., in the proximal tibia)
 Osteoporosis
 Periprosthetic fractures (Fig. 5-27)
 Thin cortex
 Other implants in situ
 High torsional forces during rehabilitation and phys-
 Secondary fractures or redislocation, instability after ical therapy
intramedullary nailing
 Short main fragment
 Delayed conversion from an external fixator to the
definitive internal fixation
 Small medullary diameter
CHAPTER 5  Locking Plates: Development, Biomechanics, and Clinical Application 167

FIGURE 5-26 A–F, Clinical case LCP splinting method.

A B
(Continued)

It is important to avoid stress concentrations at the fracture stability through interfragmentary compression and relative
site, and this can be achieved by leaving two or three plate stability by splinting with an internal fixator—can be
holes without screws in the fracture zone. Stress distribution combined.
is an important feature of the internal fixator technique as
INDICATIONS
stress concentration and implant failures are avoided.  Segmental fractures with two different fracture
LCP WITH A COMBINATION OF THE TWO patterns (one simple and one multifragmentary).
METHODS The compression method and splinting In these cases, conventional interfragmentary com-
method should be used in combination only in situations pression is used to stabilize the simple fracture while
in which the bone has been fractured in two different places. splinting with an internal fixator stabilizes the multi-
In these cases, the two biomechanical principles—absolute fragmentary fracture area.
168 SECTION 1  General Principles

FIGURE 5-26 (Continued)

C D

E F
FIGURE 5-27 A–F, Clinical case LCP periprosthetic fracture.

A B C

D E F
170 SECTION 1  General Principles

 Intra-articular fractures with a multifragmented MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS


extension into the diaphysis. In these cases, the ana- The newly developed locked internal fixators used in the
tomic reduction and interfragmentary lag screw LISS and LCP are based on the principles of biological
compression of the articular component are combined internal fixation and minimally invasive plate osteosyn-
with a bridging fixation from the reconstructed joint thesis (MIPO) (Table 5-8). The MIPO approach is possi-
block to the diaphysis (Fig. 5-28). ble with conventional plates, but there are additional
advantages if the MIPO technique is combined with the
use of a locked internal fixator—there is no need for pre-
COMBINATIONS OF DIFFERENT SCREWS It is cise contouring of the plate, drilling, measuring, or
possible to combine the two plating techniques—simulta- tapping, because self-drilling, self-tapping monocortical
neously applying compression with standard screws and LHSs are used. These screws lend themselves optimally
locking head fixation using a single plate—and this can to monocortical fixation, in which it is not necessary to
be valuable, depending on the indication. It is important select the length of the screw precisely and a protruding
to be familiar with the different features of both tech- screw tip is not able to damage or irritate the soft tissues,
niques. Probably the most frequent use of a combination tendons, or muscles.
technique will be in the treatment of fractures adjacent to Only small incisions are necessary to insert the plate in
the joint, with locking head screws being used to fix the MIPO technique—with benefits including not only
fragment close to the joint and standard screws being used improved cosmetic results but, above all, protection of
to apply axial compression between the metaphysis and the the fracture zone. “The skin protects the fracture zone
diaphysis in a simple fracture type (individual blade plate) from the surgeon.”
(Fig. 5-29). The technology developed for the blind insertion and
The splinting method can be carried out with an inter- application of internal fixators can also be used with open
nal fixator and an additional reduction screw (reducing the approaches. The open approach, using an aiming device,
plate onto the bone or reducing a displaced fragment) or can help the surgeon become accustomed to the more
positioning screw. In addition, the conventional screw- demanding technique of aligning the internal splint. The
plating technique (the compression method) can be used, locked monocortical screws require alignment of the implant
but with fixation of the protection plate using locking head and the bone axis within comparatively narrow limits. Open
screws (see Fig. 5-18). procedures can be used for initial training in the techniques.

FIGURE 5-28 A–F, Clinical case LCP combining two methods.

A B C D E F
FIGURE 5-29 A–F, Clinical case LCP individual blade plate.

A B

C D

E F
172 SECTION 1  General Principles

Table 5-8 PREREQUISITES


 Indirect closed reduction without exposure of the
Definition of MIPO fracture.
Access to the bone through soft tissue windows (not only small  Small incisions for insertion of the implants.
skin incisions but also careful gentle handling of deep layers of
the soft tissue).
 Implants that have minimal bone contact (e.g., LISS
and LCP). The internal fixators are slightly raised
Minimal trauma to the soft tissue and the bone by indirect
reduction. above the bone surface to eliminate any mismatch
Minimal additional trauma at the fracture site when direct
between the preshaped implant and the anatomy of
reduction is necessary. the bone.
Reduction tools which cause “small footprints.”  Elastic bridging of the fracture zone (principle of rel-
Implants with adequate bone-implant interface: ative stability stimulates callus formation).
 Noncontact plates, angular stable screws
 Plates/fixators are used as pure splints, that is, with-
 Monocortical screw fixation
out the additional lag screw effect.
 Self-drilling, self-tapping locking head screws can be
Optimized screw placement according to the anatomical region. used for monocortical insertion; self-tapping locking
head screws can be used for monocortical or bicorti-
cal insertion.
In addition, using LCP with LHS as a locked internal In LISS alone, a geometric correlation has to be
fixator (locked splinting method) in the MIPO technique achieved between the aiming device and the plate for
has many technical and biological advantages. closed application.

ADVANTAGES SHORTCOMINGS AND DISADVANTAGES


 Biological internal fixation avoids the need for pre-  The stability of the fracture fixation depends on the
cise reduction, especially of the intermediate frag- stiffness of the construct.
ments, and takes advantage of indirect reduction.  Closed reduction and intraoperative control of align-
 The aim of indirect reduction is to align the proxi- ment are not easy.
mal and distal main fragments. This avoids exposure  Minimally invasive plate application and fixation are
of the individual bone fragments. not easy.
 Submuscular/subcutaneous slide insertion techniques  With the predetermined screw orientation, possible
are possible. difficulties can arise when a locking head screw is
 Minimization of biological damage caused by the inserted (penetration of articular surface).
surgical approach, the reduction, and at the  Reduction toward the plate can be achieved only
implant-bone interface (MIPO). This is achieved at with special instruments or bumps or standard
the expense of precise reduction and rigid fixation. screws.
 Flexible elastic fixation to stimulate spontaneous  Excessive demands on the system: the bone is not
healing, including the induction of callus formation. carrying any load because it has not been precisely
 Locked internal fixators are noncontact plates; no reduced.
compression of the plate onto the bone is required.  Delayed healing in the diaphyseal region when bone
 There is no need for shaping when applying LISS or fragments are stripped of the periosteum after the
anatomically preshaped LCPs. injury or due to iatrogenic disturbance of the blood
 There is no need for exact preshaping of the LCP to supply (wrong reduction and fixation).
match the bone anatomy.
 There is no need for drilling, measuring, or tapping, BENEFITS OF MINIMALLY INVASIVE
since self-drilling monocortical LHSs are used. TECHNIQUES (MIPO) WITH LOCKED PLATES
 Preservation of all blood supply to the bone includ- (TABLE 5-9)
ing periosteal blood supply. It was originally argued that the tunneling required to
 There is a reduced risk of secondary loss of achieve blind insertion of the plate would result in the
reduction. same amount of damage as the open surgical approach.
 Locking the screw into the plate ensures angular However, studies conducted by Krettek’s group on the
as well as axial stability and eliminates any effect of ligating the perforating arteries, for example, dur-
unwanted movement of the screw (secondary loss ing open surgical procedures for femoral fractures, dis-
of reduction). proved this argument.10,11,27 Although MIPO techniques
 The technique works well in osteoporotic bone. can be used with plates and compression screws, the
 For treatment of multifragmentary, complex fractures. advantages of the technique using locked splints and
monocortical self-drilling screws are greater.
 MIPO is easier using locked noncontact plates. In surgical approaches involving access through con-
 There is improved local resistance to infection. tused areas of skin in which stability is required, the mini-
 Less risk of refracture. mally invasive approach offers considerable advantages.
CHAPTER 5  Locking Plates: Development, Biomechanics, and Clinical Application 173

Table 5-9 when there is some malalignment between the long bone
axis and the plate. In these situations, anchorage is not
Anatomically Preshaped Plates obtained with a short screw, despite the surgical sensation
Strong demands for anatomically preshaped plates that there is good tightening. Technically, the problem can
Advantages for anatomically preshaped plates: be solved either by inserting a long self-tapping LHS or by
 No intraoperative shaping of the plate required
using an angulated cortex or cancellous bone screw. The
problem can be avoided at an early stage of the procedure
 Plate helps achieve the anatomical reduction
by using the drill bit to center the screw and feel the bone
 Aiming blocks to insert the locking head screws
cortex before the monocortical self-drilling screw is
 Clear indications for a given implant inserted. Alternatively, a small incision can be made at
 Defined placement for a given implant the plate end and the position of the plate can be assessed
 Clear rules of how to use the given implant on the lateral side of the bone by manual palpation.
 Optimized screw placement according to the In addition, current locking plate designs can be used to
anatomical region maintain fracture reduction but only with anatomically
preshaped locked plates and a specific technique. For
example, for the complex distal femoral fracture, the distal
The mechanical benefits of these systems (i.e., locked fragment can be prepared to accept a LISS-DF or LCP
noncontact plates) are as follows. There is no need for pre- DF by placing the second from most distal LHS exactly
cise anatomic preshaping of the plate—a procedure which parallel to the knee joint. When the side plate is applied,
is in any case hardly possible with blind, minimally inva- limb alignment will be correct. With a nonanatomically
sive techniques. LCP used as an internal fixator with preshaped locking plate design, the fracture must be
LHSs are noncontact plates. This feature considerably reduced and limb alignment, length, and rotation set prop-
facilitates the MIPO procedure. The preshaped plates sup- erly before placement of any locked screws. Once a locked
plied by the manufacturer are based on measurements of screw has been placed above and below a fracture line, no
the average shape required, using computed tomography further reduction adjustment is possible unless the screws
data and cadaver bones. Since the plate does not need to are completely removed. Locked screws will not “pull”
be pressed onto the bone when it is being used as an inter- the plate down to the bone. This reduction maneuver is
nal fixator, minor variations in the bone will result in areas possible with special instruments or a temporary reduction
of plate stand-off from the bone. Anatomically preshaped screw. This lack of construct reduction capability, com-
LCPs are available for certain metaphyseal areas (the prox- bined with percutaneous plating techniques, can result in
imal/distal humerus, olecranon, distal radius, distal femur, higher rates of fracture malalignment than occur with for-
and proximal and distal tibia), and LISS devices are avail- mal open reduction and internal fracture fixation. New
able for the treatment of fractures of the distal femur and techniques are evolving to facilitate the accuracy of closed
the proximal lateral tibia. An additional advantage of the reduction of such difficult fractures. Surgeons contem-
anatomically preshaped plates is that they make it possible plating a percutaneous approach should be experienced in
to insert the screw in an appropriate direction to suit the conventional open techniques and be cognizant of their
anatomic conditions, allowing optimal anchorage. The differences.
guiding blocks help ensure the correct axial insertion of Another concern is the rigidity of a locked screw plate
the drill sleeves and locking head screws. If required, stan- construct. For example, in diaphyseal or metadiaphyseal
dard screws can be inserted before the guiding block is areas, any fracture distraction at the time of reduction or
positioned. fracture resorption during healing will be held rigidly by
Less experienced surgeons can also use this technique such constructs and potentially result in delayed union or
with an open, but less invasive, approach. The fracture zone nonunion. In this situation, no load-sharing can occur
remains untouched. The MIPO technique is a great step with locked screws on either side of a fracture. If the frac-
forward in minimally invasive surgery (MIS) to treat frac- ture is repetitively loaded, the plate may eventually fracture
tures. To avoid complications and to shorten the learning or fixation may be lost. This is true in cases of simple frac-
curve, a reasonably invasive surgery (RIS) is recommended. ture patterns and fracture fixation in a diastasis. The inter-
nal fixator will keep the diastasis and as a consequence may
delay the fracture healing. This can lead to the risk of a
DISADVANTAGES AND COMPLICATIONS OF
cyclic overload of the plate and of the fracture bridging
LOCKED SCREWS/PLATES
segment of the plate, between the two closest to the frac-
Several potential disadvantages of locking plate fixation ture placed screws, spans over less than 2–3 empty
exist. One is that the surgeon may completely lose the feel screw holes. Because of these concerns and the additional
for the quality of the bone during screw insertion and cost of a locking plate compared with an equivalent but
tightening, when the screw head engages in the conically nonlocking plate, locking plates probably should be used
threaded plate hole. When tightening the screws, the sur- selectively for fractures that have demonstrated high failure
geon has no tactile feedback as to the quality of screw pur- rates with conventional plating techniques.
chase in the bone. Because the screws lock into the plate The lack of angulation within a nonanatomically pre-
holes, they all abruptly stop advancing when the threads shaped plate can be a disadvantage in the epiphyseal bone
are completely seated in the plate, regardless of bone qual- segment. The disadvantage of current locking plate design
ity. Transcutaneous insertion of short monocortical LHSs is the inability of the surgeon to alter the angle of the
in the diaphyseal area is critical at the end of the plate, screw within the hole and still achieve a locked screw.
174 SECTION 1  General Principles

The use of certain screw holes in the plate potentially


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176 SECTION 1  General Principles

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