HSS Journal

, Volume 7, Issue 2, pp 164–169

Evidence for Success with Locking Plates for Fragility Fractures

Review Article

Abstract

Fixation of fragility fractures with plates and screws often results in loss of fixation and need for revision surgery. Locking plates and screw were introduced to improve fixation of fragility fractures and have been in use for a decade. This review was conducted to compile evidence that locking plates and screws improve fixation of fragility fractures. A search of PubMed was performed to identify biomechanical studies as well as clinical series of fragility fractures treated with locking plates. Biomechanics papers had to use models of osteoporotic bone and had to directly compare locking plates with traditional plates. Clinical studies included case series in which locking plates were applied to elderly patients with fractures of the proximal humerus and periprosthetic distal femur fractures. Most studies are retrospective case series. Locking plates lead to greater stability and higher loads to failure than traditional plates. When applied to proximal humerus fractures, uncomplicated healing occurs in 85% of patients. Constant and Dash scores approach normal values. For distal femoral periprosthetic fractures, union rates of 75% are reported with a malunion rate of 10%. Early evidence suggests that locking plates improve results of treatment of proximal humerus fractures and distal femoral periprosthetic fractures in the elderly. Loss of fixation is associated with failure to achieve stability at the fracture site. Principles of fracture fixation in osteoporotic bone defined prior to the introduction of locking plates should still be applied.

Keywords

osteoporosis fragility fractures locking plates proximal humerus supracondylar femur fractures 

References

  1. 1.
    Alho, A.: Mineral and mechanics of bone fragility fractures. Acta Orthop Scand 1993;64:227–32.PubMedCrossRefGoogle Scholar
  2. 2.
    American Academy of Orthopedic Surgeons: The Burden of Musculoskeletal Diseases in the United States. ed. Joshua Jacobs, 2008, Rosemont, IlGoogle Scholar
  3. 3.
    An Y.H., Young, F.A., Fang, Q., Williams, K.R.: Effects of Cancellous Bone Structure on Screw Pullout Strength. Univ of South Carolina Orthopedic Journal 2000; 3: 22–26Google Scholar
  4. 4.
    Baumgartner, M.R., Curtin, S.L., Lindskog, D.M., Keggi, J.M.: The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am.1995;77:1058–64.Google Scholar
  5. 5.
    Blatter, G., Konig, H., Janssen, M., Magerl, F.: Primary femoral shortening osteosynthesis in the management of comminuted supracondylar fractures. Arch Orthop Trauma Surg 1994; 113:134–37.PubMedCrossRefGoogle Scholar
  6. 6.
    Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, Kohut G, Ekelund A, Muller M, Audigé L, Babst R. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma. 2009;23:163–72PubMedCrossRefGoogle Scholar
  7. 7.
    Clavert P, Adam P, Bevort A, Bonnomet F, Kempf JF. Pitfalls and complications with locking plate for proximal humerus fracture. J Shoulder Elbow Surg. 2010;19:489–94.PubMedCrossRefGoogle Scholar
  8. 8.
    Cornell, C.N.: Techniques for Internal Fixation of Long Bone Fractures in Patients with Osteoporosis. J Am Acad Orthop Surg 2003; 11: 109–119PubMedGoogle Scholar
  9. 9.
    Cornell, C.N., Levine, D., Pagnani, M.J.: Internal fixation of proximal humerus fractures using the screw-tension band technique. J Orthop Trauma 1994;8:23–27.PubMedCrossRefGoogle Scholar
  10. 10.
    Court-Brown CM, Cattermole H, McQueen MM.J. Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment. Bone Joint Surg Br. 2002; 84: 504–8CrossRefGoogle Scholar
  11. 11.
    Court-Brown CM, Garg A, McQueen MM. The translated two-part fracture of the proximal humerus. Epidemiology and outcome in the older patient. J Bone Joint Surg Br. 2001 ; 83: 799–804.PubMedCrossRefGoogle Scholar
  12. 12.
    Court-Brown CM, McQueen M. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. J Bone Joint Surg Am. 2009; 91: 2771PubMedGoogle Scholar
  13. 13.
    Duralde XA, Leddy LR. The results of ORIF of displaced unstable proximal humerus fractures using a locking plate. J Shoulder Elbow Surg. 2010;19: 480–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Egol, K.A., Koval, K.J., Zuckerman, J.D.: Current state of the art: Functional recovery following hip fracture in the elderly. J Orthop Trauma 1991; 5(3):318–24.CrossRefGoogle Scholar
  15. 15.
    Egol, K.A., Kubiak, E.N., Fulkerson, E., Kummer, F.J., Koval, K.J.: Biomechanics of Locked Plates and Screws. J Orthop Trauma 2004; 18: 488–493PubMedCrossRefGoogle Scholar
  16. 16.
    Ehlinger M, Adam P, Moser T, Delpin D, Bonnomet F. Type C periprosthetic fractures treated with locking plate fixation with a mean follow up of 2.5 years. Orthop Traumatol Surg Res. 2010; 96: 44–8PubMedCrossRefGoogle Scholar
  17. 17.
    Einhorn, T.A.: The Structural Properties of Normal and Osteoporotic Bone. AAOS Instructional Course Lectures 2003; 52: 533–539.Google Scholar
  18. 18.
    Ekeland, A., Engesaeter, L.B., Langeland, N.B.: Influence of age on mechanical properties of healing fractures and intact bones in rats. Acta Orthop Scand, 1982;53:527–34.PubMedCrossRefGoogle Scholar
  19. 19.
    Fankhauser, F., Boldin, C., Schippinger, G., Haunschmid, C., Szyszkowitz, R.: A New Locking Plate for Unstable Fracctures of the Proximal Humerus. Clin Orthop Relat Res 2005; 430: 176–181.PubMedCrossRefGoogle Scholar
  20. 20.
    Fulkerson E, Tejwani N, Stuchin S, Egol K. Management of periprosthetic femur fractures with a first generation locking plate. Injury. 2007; 38: 965–72.PubMedCrossRefGoogle Scholar
  21. 21.
    Gardner MJ, Boraiah S, Helfet DL, Lorich DG. The anterolateral acromial approach for fractures of the proximal humerus. J Orthop Trauma. 2008; 22: 132–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Gardner, MJ, Evans, JM, Dunbar,RP: Failure of Fracture Plate Fixation. J Am Acad Orthop Surg. 2009 Oct;17(10):647–57.PubMedGoogle Scholar
  23. 23.
    Gardner MJ, Weil Y, Barker JU, et al. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma 2007;21:185–91.PubMedCrossRefGoogle Scholar
  24. 24.
    Gautier, E., Sommer, C.: Guidelines for the Clinical Application of the LCP. Injury 2003; 34S-B: 63–67CrossRefGoogle Scholar
  25. 25.
    Hepp P, Theopold J, Voigt C, Engel T, Josten C, Lill H. The surgical approach for locking plate osteosynthesis of displaced proximal humeral fractures influences the functional outcome. J Shoulder Elbow Surg. 2008; 17: 21–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Herrera DA, Kregor PJ, Cole PA, Levy BA, Jönsson A, Zlowodzki M. Treatment of acute distal femur fractures above a total knee arthroplasty: systematic review of 415 cases (1981–2006). Acta Orthop. 2008; 79: 22–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Kim T, Ayturk UM, Haslell A, Miclau T, Pullitz CM. Fixation of osteoporotic distal fibula fractures: A biomechanical comparison of locking versus conventional plates. J Foot Ankle Surg. 2007; 46: 2–6.PubMedCrossRefGoogle Scholar
  28. 28.
    Konrad G, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Südkamp N. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Surgical technique. J Bone Joint Surg Am. 2010; 92 Suppl 1 Pt 1:85–95PubMedCrossRefGoogle Scholar
  29. 29.
    Kristiansen, B., Christensen, S.: Plate fixation of proximal humerus fractures. Acta Orthop Scand, 1986; 57:320–23.PubMedCrossRefGoogle Scholar
  30. 30.
    Large TM, Kellam JF, Bosse MJ, Sims SH, Althausen P, Masonis JL. Locked plating of supracondylar periprosthetic femur fractures. J Arthroplasty. 2008 Sep;23(6 Suppl 1):115–20.PubMedCrossRefGoogle Scholar
  31. 31.
    Lill, C.A., Fluegel, A.K., Schneider, E.: Sheep model for fracture treatment in osteoporotic bone: A pilot study about different induction mechanisms. J Orthop Trauma, 2000;14:559–66.PubMedCrossRefGoogle Scholar
  32. 32.
    Lucas, T.S., Einhorn, T.A.: Osteoporosis: The role of the orthopedist. J Am Acad Orthop Surg, 1993;1:48–57.PubMedGoogle Scholar
  33. 33.
    Mast, J., Jakob, R., Ganz, R. (eds): Planning and reduction technique in fracture surgery. Berlin, Germany, Springer-Verlag, 1989.Google Scholar
  34. 34.
    Micic ID, Kim KC, Shin DJ, Shin SJ, Kim PT, Park IH, Jeon IH. Analysis of early failure of the locking compression plate in osteoporotic proximal humerus fractures. J Orthop Sci. 2009 Sep;14(5):596–601.PubMedCrossRefGoogle Scholar
  35. 35.
    Minihane, KP. Lee, C., Ahn, C., BS, , Zhang, L. Merk, BR. Comparison of Lateral Locking Plate and Antiglide Plate for Fixation of Distal Fibular Fractures in Osteoporotic Bone: A Biomechanical Study. J Orthop Trauma 2006; 20: 562–566PubMedCrossRefGoogle Scholar
  36. 36.
    Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Innovations in the management of displaced proximal humerus fractures. J Am Acad Orthop Surg. 2007 Jan;15(1):12–26. ReviewPubMedGoogle Scholar
  37. 37.
    Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Management of proximal humeral fractures based on current literature. J Bone Joint Surg Am. 2007 Oct;89 Suppl 3:44–58.PubMedCrossRefGoogle Scholar
  38. 38.
    Norrish AR, Jibri ZA, Hopgood P. The LISS plate treatment of supracondylar fractures above a total knee replacement: a case-control study. Acta Orthop Belg. 2009; 75: 642–8.PubMedGoogle Scholar
  39. 39.
    Olerud P, Ahrengart L, Söderqvist A, Saving J, Tidermark J. Quality of life and functional outcome after a 2-part proximal humeral fracture: A prospective cohort study on 50 patients treated with a locking plate. J Shoulder Elbow Surg. 2010 Mar 18. [Epub ahead of print] PMID: 20303288Google Scholar
  40. 40.
    Perren, S.M.: Evolution and Rationale of Locked Internal Fixator Technology: Introductory Remarks. Injury 2001; 32S-B: 3–9.Google Scholar
  41. 41.
    Peterson MG, Cornell CN, Paget SA, Allegrante JP. Five-Year Survival in a Cohort of Hip Fracture Patients: The Predictive Role of Pre-fracture Health Status. HSS J. 2008; 4: 43–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Ricchetti ET, DeMola PM, Roman D, Abboud JA. The use of precontoured humeral locking plates in the management of displaced proximal humerus fracture. J Am Acad Orthop Surg. 2009; 17: 582–90.PubMedGoogle Scholar
  43. 43.
    Ricchetti ET, Warrender WJ, Abboud JA. . Use of locking plates in the treatment of proximal humerus fractures. J Shoulder Elbow Surg. 2010;19(2 Suppl):66–75PubMedCrossRefGoogle Scholar
  44. 44.
    Ricci WM, Loftus T, Cox C,Borrelli J. Locked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplasty. J Orthop Trauma. 2006; 20: 190–6.PubMedCrossRefGoogle Scholar
  45. 45.
    Röderer G, Erhardt J, Kuster M, Vegt P, Bahrs C, Kinzl L, Gebhard F. Second generation locked plating of proximal humerus fractures-A prospective multicentre observational study. Int Orthop. 2010 Apr 25. [Epub ahead of print] PMID: 20419453Google Scholar
  46. 46.
    Schatzker, J.: Fractures of the distal femur revisited. Clin Orthop 1998; 347:43–56PubMedGoogle Scholar
  47. 47.
    Silver, J.J., Einhorn, T.A.: Osteoporosis and aging. Clin Orthop, 1995;316:10–20PubMedGoogle Scholar
  48. 48.
    Sjostedt, A., Zetterberg, C., Hansson, T., Hult, E., Ekstrom, L.: Bone mineral content and fixation strength of femoral neck fractures. Acta Orthop Scand, 1994;65:161PubMedCrossRefGoogle Scholar
  49. 49.
    Snow M, Thompson G, Turner PG. A mechanical comparison of the locking compression plate (LCP) and the low contact-dynamic compression plate (DCP) in an osteoporotic bone model. J Orthop Trauma. 2008;22:121–5.PubMedCrossRefGoogle Scholar
  50. 50.
    Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Konrad G. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009; 91: 1320–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Thanasas C, Kontakis G, Angoules A, Limb D, Giannoudis P. Treatment of proximal humerus fractures with locking plates: a systematic review. J Shoulder Elbow Surg. 2009; 18: 837–44.PubMedCrossRefGoogle Scholar
  52. 52.
    Tinetti, M.E., Baker, D.I., Gottshall, M., et.al.: Home based multi-component rehabilitaiton program for older persons after hip fracture: A randomized trial. Arch Phys Med Rehab 1999; 80:916–22.PubMedCrossRefGoogle Scholar
  53. 53.
    Xiong Y, Zhao Y, Wang Z, Du Q, Chen W, Wang A. Comparison of a new minimum contact locking plate and the limited contact dynamic compression plate in an osteoporotic fracture model. Int Orthop. 2009; 33:1415–9.PubMedCrossRefGoogle Scholar
  54. 54.
    Zehnder S, Bledsoe JG, Puryor A. The effects of screw orientation in severely osteoporotic bone: a comparison with locked plating. Clin Biomech 2009 ;24: 589–94.CrossRefGoogle Scholar

Copyright information

© Hospital for Special Surgery 2011

Authors and Affiliations

  1. 1.Hospital For Special SurgeryNew YorkUSA
  2. 2.Weill Cornell College of MedicineNew YorkUSA

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