CURRENT STATE OF THE ART The Current Status of Locked Plating: The Good, the Bad, and the Ugly Eric J. Strauss, MD, Ran Schwarzkopf, MD, Frederick Kummer, PhD, and Kenneth A. Egol, MD A refined understanding of bone biology and the roles Abstract: Locked plate technology has evolved in an effort to tissue vascularity and gap strain play in fracture healing, con- overcome the limitations associated with conventional plating tributed to the development of the concept of bridging plate methods, primarily for improving fixation in osteopenic bone. The osteosynthesis and the use of locked plate technology.3,5 The development of screw torque and plate-bone interface friction is success of bridging fixation spurred an interest in creation of unnecessary with locked plate designs, significantly decreasing the an internal fixator. The Schuhli-Nut, Pc-Fix, and Zespol plates amount of soft tissue dissection required for implantation, preserving were early attempts at creating an internal fixator.6,7 By firmly the periosteal blood supply, and facilitating the use of minimally fixing the screw to the plate, the plate screw construct could invasive percutaneous bridging fixation techniques. The locked plate act as a fixed-angle device, with the screws functioning as is a fixed-angle device because angular motion does not occur at the threaded locked bolts.4,8,9 Similar to the bars of an external plate screw interface. The use of locked plate technology allows fixator, plates were not applied directly to the bone, thereby the orthopaedic surgeon to manage fractures with indirect reduction providing elastic fixation, which facilitated fracture union techniques while providing stable fracture fixation. The secure ÔfeelÕ through secondary bone healing with callus formation.3,5,9 of locked plates, ease of application, and the low incidence of Free of the need to apply the plates directly to the bony surface, complications noted in early clinical reports have contributed to the the locked plate created a more biologic approach to the proliferation of this technology. Along with reports of clinical suc- management of fractures, allowing for indirect reduction using cesses, as the use of fixed angle/locked plates has increased, clinical minimally invasive percutaneous plating techniques. failures are being noticed. This review will focus on the biomechanics The secure feel of locked plates, the relative ease of of locked plate technology, appropriate indications for its use, lab- application, and the low incidence of complications reported in oratory and clinical comparisons to conventional plating techniques, early clinical studies contributed to the proliferation of this and potential mechanisms of locked plate failure that have been technology for fracture fixation. Laboratory and clinical studies observed. demonstrated that locked plate fixation for certain fracture Key Words: locked plate, failure, complications types provided superior construct stability and improved outcomes.4,10–17 As the use of fixed-angle/locked plates in- (J Orthop Trauma 2008;22:479–486) creased, reports of clinical failures came along with reports of clinical successes. As a result, the current paper reviews the biomechanics of locked plate technology, appropriate indications INTRODUCTION for its use, laboratory and clinical comparisons with conven- tional fixation techniques, and identifies the potential mecha- For the past 50 years, the general principles of fracture nisms of locked plate failure that have been observed. fixation have been developed, tested, and promoted by the AO group.1,2 The original principles included direct fracture exposure, precise reduction, and rigid internal fixation through Biomechanics of Locked Plate Technology compression in an effort to achieve an anatomic fracture Fracture fixation with traditional compression plating union.3,4 This conventional fracture management technique techniques uses the frictional force created between the plate often required a significant surgical exposure, altering the bio- and bone to counteract the external forces experienced at the 18 logic environment at and around the fracture site through soft fracture site. Stability with these traditional plate and screw tissue stripping and devascularization.4,5 Consequences of constructs is primarily achieved via screw torque. Variables iatrogenic soft tissue trauma, however, often resulted in the such as bone quality and fracture comminution affect the development of delayed fracture union, nonunion, and infection. quality of screw thread purchase and the resultant fixation stability achieved with compression plating. By a variety of mechanisms, the screws in a locked plating system are Accepted for publication April 4, 2008. From the Department of Orthopaedic Surgery, New York University-Hospital designed to lock into the plate, eliminating screw toggle and 3,8 for Joint Diseases, New York, New York. creating a fixed-angle, single-beam construct. When using The authors did not receive grants or outside funding in support of the current locked plates in a bridging manner, the edges of the fracture manuscript. The devices that are the subject of this manuscript are FDA are not compressed together at the fracture site as is com- approved. 4 Reprints: Kenneth A. Egol, MD, 301 East 17th Street, New York, NY 10003 monplace with conventional plating techniques. Instead, the (e-mail: [email protected]). locked plate acts as an internal-external fixator to bridge the Copyright Ó 2008 by Lippincott Williams & Wilkins fracture, providing relative stability while allowing enough J Orthop Trauma Volume 22, Number 7, August 2008 479 Strauss et al J Orthop Trauma Volume 22, Number 7, August 2008 strain at the fracture site to promote secondary healing with callus formation.3,5,8,9 Biomechanically, the locked plate system is designed to convert the shear forces experienced at the implant with the application of load into compressive forces at the screw- bone interface.3,19 This force conversion is beneficial in fracture fixation because cortical bone is stronger against compressive loads than shear loads. Additionally, the angular stability of locked screws allows the applied load to be more evenly distributed amongst the component screws, avoiding significant load concentration at a single screw-bone in- terface.3,4,20 This leads to the overall fixation strength of the locked plate system, equaling the sum of fixation strengths of all screw-bone interfaces instead of that of a single component screw as in conventional plating.3,8,19,20 Acting as an internal-external fixator, the fixation rigidity of the locked plate system benefits from the proximity of the plate to the bone and fracture site, with locked screw lengths being significantly shorter than conventional external fixator pins.3 The overall stability provided by the locked plate system across the fracture site becomes dependent on the amount of load applied and the mechanical properties of the plate itself.3,4 The extent of the elastic motion that occurs is dictated by the length of FIGURE 1. Example of plate bending that occurred in a 63- the plate, the cross-sectional area of the plate, the material year-old mam who sustained a spiral periprosthetic left femur properties of the plate, the density and diameter of the inserted fracture 1 month after a total knee replacement. The fracture screws, and the use of unicortical versus bicortical screws.3,4,21 was managed with a 15-hole locked plate construct. As seen on The choice of locked plate length is a key element in the fracture the (A) anteroposterior and (B) lateral x-rays taken at the fixation stability provided by the construct and varies according 3-week follow-up visit, repeated stresses concentrated over the to fracture pattern.22 Recommendations regarding the length of fracture site exceeded the mechanical stiffness of the locked the locked plate typically include using an implant that is 8 to plate, leading to plate bending. Use of a longer plate would 10 times the length of the fracture in simple patterns and 3 times have better distributed the stresses associated with weight- the length in comminuted fracture patterns.4,21,23,24 At least bearing at the fracture site, avoiding the complication seen in this case. 2 screws per main fragment should be inserted, with 3 cortices of purchase for simple fractures and at least 2 screws and 4 cortices met, it is important to complete maximal fracture compression for comminuted fractures.3,21,24,25 Additionally, a screw-to-hole with lag screws before locked screws are inserted, and the plate ratio less than 0.5 limits the bending moments experienced at the should be placed on the tension side of the fracture to most proximal and distal screws, and a span of 2 to 3 open screw neutralize the forces acting on the interfragmentary compres- holes should be left over the fracture site to help limit the con- sion screws.3 centration of stress at the adjacent screw-bone interfaces.4,23,26,27 Newer locked plate designs, including those using Indications for Locked Plate Fixation combination-hole technology, allow surgeons to incorporate The current indications for locked plate fixation include aspects of locked plating and compression plating into 1 complex periarticular fractures, comminuted metaphyseal or implant. In combining the two fixation methods, the surgeon diaphyseal fractures, periprosthetic fractures, and fractures potentially negates the theoretical advantages of each, creating occurring in poor quality bone.4,8,19,24 Locked plates may also an