IJCRR - vol 06 issue 01, January, 2014
Date of Publication: 30-Nov--0001
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USE OF LOCKING PLATES IN FRACTURE MANAGEMENT
Author: Raza A., Kailash K., Mahalingam S.
Abstract:The history of fracture management can be traced back to the prehistoric times. It was not until the late nineteenth and early twentieth century that operative treatments of fractures were contemplated. However operative treatment of fractures at that time was associated with devastating results secondary to infection with high morbidity and mortality. As a result, the mainstay of treatment of fractures remained traction and closed reduction within plaster of Paris. On the other hand, non-operative treatment of fractures was associated with the development of joint stiffness, disuse osteopenia and muscle atrophy, collectively described as „Fracture disease?. During 1950s, the Swiss AO group standardized the use of plating systems. The AO group revolutionized the concept of rigid stable internal fixation with early functional mobilisation which resulted in a positive impact on fracture disease. With time, surgeons started gaining more confidence in the operative management of fractures when better results were obtained while adhering to the principles of strict asepsis and using antibiotics. The article describes the use of modern locking plates in the management of fractures in different areas. Overall, the literature supports using locking plates for fixation of periarticular fractures of long bones, multifragmentary fractures of diaphysis and metaphysis and periprosthetic fractures. Locking plates are not the panacea for all type of fractures. As clinical experience with locking plate broadens, new indications and applications will emerge.
Keywords: Locking plate, Internal fixation.
The history of fracture management can be traced back to the prehistoric times. Analysis of bones of Neolithic man shows both successful and unsuccessful attempts in fracture fixation . It was not until the late nineteenth and early twentieth century that operative treatments of fractures were contemplated. Later, devices were developed that could be applied to the broken bone either externally or internally to hold the fracture and let it heal in the required position. External fixation was first attempted by Albin Lambotte in 1902  and Gerhard Kuntscher developed his intramedullary nail in 1938. However operative treatment of fractures at that time was associated with devastating results secondary to infection with high morbidity and mortality. As a result, the mainstay of treatment of fractures remained traction and closed reduction within plaster of Paris. On the other hand, nonoperative treatment of fractures was associated with the development of joint stiffness, disuse osteopenia and muscle atrophy, collectively described as „Fracture disease?.During 1950s, the Swiss AO group standardized the use of plating systems . The AO group revolutionized the concept of rigid stable internal fixation with early functional mobilization which resulted in a positive impact on fracture disease. With time, surgeons started gaining more confidence in the operative management of fractures when better results were obtained while adhering to the principles of strict asepsis and using antibiotics. The contribution by AO group in the understanding of fracture healing, management and internal fixation is undisputedly enormous.
Development of Locking plates
The fixation achieved by conventional plate-bone construct is based on friction between the plate and bone interface. As the plate is firmly pressed against the periosteum, it impairs the periosteal blood supply with subsequent poor and slower bone healing. With time surgeons and researchers recognised the importance of biological environment of the fracture. The principle of “Biological Internal Fixation” emphasized more flexible fixation to encourage the callus formation, with less precise direct reduction thus reducing surgical trauma . As a result Zespol plates and Schuhli nuts were introduced to convert conventional plate into fixed-angle device with plate acting as internal fixator. Later, the point contact fixator (PC-Fix) and Less Invasive Stabilisation Systems (LISS) were developed by AO, which had even minimal contact areas on the bone with improved preservation of periosteal and endosteal blood supply . Thus locking plates were developed to achieve biological internal fixation with relative stability, yet strong enough to allow early functional mobilisation.
How Locking Plates Work
Conventional plates owe their stability to firm contact with bone surface, and reducing this contact also reduces the stability of implant-bone construct. In order to maintain such low contact to allow for biological fixation and yet stay stable, locking plates are designed as „fixed angled devices?. „Fixed-angle device? means that when screws are placed in the plate and stress is applied, the angle between the plate and screws does not change. In order to achieve this, locking head screws were developed which can lock within the screw holes of the locking plate by virtue of their threaded heads. Once locked, these screws even under stress maintain their relative position with respect to the plate, thus providing both angular and axial stability. In a conventional plate, loosening of one screw renders instability by reducing the contact pressure between the plate and bone. Thus loosening of even one screw can potentially jeopardize the overall stability with rapid sequential loosening, as is seen in osteopenic and osteoporotic bones. This however is not seen in locking plates where stability is not based on interface friction as the plate-screw construct acts as a composite structure. Currently locking plates are being used for treating a wide variety of fractures. Let us briefly consider different areas of the body where these plates have been used while comparing them with other treatment modalities.
Proximal Humeral Fractures
Proximal humeral fractures are the third most common osteoporotic fractures after hip and distal radius with females having higher risk than men . The large majority of these fractures are managed non-operatively as they are mostly stable and minimally displaced ( <1 cm ) . Various biomechanical studies have compared PHILOS (Proximal Humeral Internal Locking System) and LCP-PH (Locking Compression Plate-Proximal Humerus) with intramedullary nails and other conventional plates. Overall, the locking plate-bone construct has always been found to be more stiffer in torsion and bending when cyclical loads are applied as shown by Edwards et al.  and Kralinger et al. . A study performed by Fuchtmeier et al, however, showed that intramedullary implants were superior in bending and torsional stiffness than extramedullary implants . It is important to emphasize that results were based on only five loading cycles leading to implant failure whereas in the human body implant-bone constructs are subjected to different types of load. Cyclical loading as tested by Edwards et al  and Kralinger et al  predominates in human function. Thus studies performed using cyclical loading are a more true representation of normal physiological loading conditions. Increased rigidity of the implant; although both biomechanically and theoretically attractive, has been attributed to the enblock cutout of the whole implant . According to a systematic review, one major factor of re-operations was cut-out after loss of reduction. They recommended that the ideal elastic to rigidity ratio still needs to be determined in order to achieve the best outcome . Operative fixations of proximal humeral fractures are not devoid of complications. It has been shown that the risk of osteonecrosis, neurovascular complications and deep infections are minimal when a fracture is fixed with indirect techniques using percutaneous wire fixation or intramedullary nailing. Fenichel et al. and Keener et al.  have shown no occurrences of any of the above mentioned complications by percutaneous wire fixation. According to a recent systematic review and other studies, the overall incidence of AVN ranges from 4% to 11.1% when locking plates are used [29,51,63,65]. The incidence of deep infection was shown to be mean 2.2% and loss of reduction ranging from 3.7% to as high as 12.2%. Primary implant failure, an uncommon complication, was found to be 0.7% . The intraoperative error of choosing incorrect length of the screws is the commonest complication with the use of PHILOS plate, which ranges from 2% to 17.9% . This has also been confirmed by a prospective multicentre study done by Sudkam et al. .
Humeral Shaft and Distal Humeral Fractures
The majority of humeral shaft fractures can be treated conservatively [12,58]. Conservative methods are associated with prolonged immobilisation and subsequent lengthy rehabilitation. Although conventional plating allows early mobilisation, it requires an extensive approach. This extensive approach can be detrimental to fracture healing and can cause iatrogenic nerve injury . The use of an intramedullary nail has also been found to be associated with iatrogenic nerve injury along with high incidence of delayed union and shoulder pain [8,30]. Locking plates have been recommended to be used for comminuted fractures and osteopenic bones as they provide angular stability. In addition, these plates can be applied using a minimally invasive technique to avoid the complications associated with the extensive approach . However, there is still a potential for iatrogenic nerve injury. In anterior approach, the injury to musculocutaneous nerve can be avoided by an extended distal incision with careful exposure of the nerve. In a cadaveric study, the author suggests to insert the distal locking screws by an open approach . The radial nerve is most commonly injured in the spiral groove which can be avoided by using unicortical screws in the middle one third of the shaft of humerus. Distal humeral fractures constitute 2-6% of all fractures. The principle of treating distal humeral fractures involves anatomical reduction with primary stabilisation to allow early rehabilitation. These fractures are notoriously associated with stiffness even after short duration of immobilisation. Due to reduced cortical thickness, the adequacy of screw purchase with stable fixation is quite challenging. This can result in non-unions as high as 75% . Both locking and conventional plates can be used in the operative treatment of distal humeral fractures, but the bility to achieve primary stable fixation with conventional plating is limited in those fractures which are associated with osteopenia, metaphyseal communition and inability to achieve cortical contact. These are the fractures where locking plate should ideally be used. Most support doublecolumn plating but the configuration in which the plates should be applied remains controversial. Overall, the plates are normally applied either orthogonally or in parallel configuration .
Distal Radius Fractures
Distal radius fractures are the most commonly occurring fractures. Most of these fractures are treated conservatively in cast immobilisation. There are many surgical options available to operatively treat these fractures. Among these include closed reduction & pin fixation, external fixation and ORIF. Since a large majority of these fractures are also osteoporotic in nature, precontoured locking plates were developed with the view to provide stable fixation subsequently reducing the risk of loss of reduction and collapse of fracture site whilst facilitating early joint mobilization. The concept behind achieving fracture stability by using fixed angled devices is based on their ability to function as „neutralization devices? by supporting the subchondral bone without depending on distal screw purchase . In osteoporotic fractures of distal radius, the strongest remaining bone is the subchondral plate; hence both smooth and threaded pegs provide reliable fixation if applied immediately below the subchondral bone . The criss-cross orientation of the locking head screws and pegs provide a 3- dimentional scaffold that cradles the articular surface . One of the most important aspects of treatment outcome is the functional status of the injured hand and wrist. Studies performed using conventional plating [7,13], external fixator [18,22,41] and volar locking plate  showed good to excellent functional outcome. However, the average grip strength was more than 90% in the case of conventional plating and externally fixation. Only 25% of the patients had excellent and 49% had good grip strength in the study performed by Hakimi et al. using volar locking plate . Rizzo et al. compared volar locking plates, external fixation and pining . The external fixation group was associated with higher DASH score and frequent hand therapy visits, thus volar locking plate was recommended to be more appropriate than external fixation. The use of external fixator also carries the risk of pin track infections, however most of these infections in the studies done were superficial and treated successfully with oral antibiotics leading to no subsequent complications [23,57]. One of the well known complications of using volar plating, whether locking or conventional, is rupture of flexor pollicis longus tendon. This complication is not seen with use of external fixator. The use of Kirschner wire for fixation of severely communited unstable intra-articular fracture is not recommended. K-wires are mostly indicated and appropriate for the Colle?s type distal radial fracture lying near to the joint which are deemed unstable by plaster immobilisation or similar fractures presenting with secondary displacement after initial plaster immobilisation . Two common complications of K-wire fixation of distal radial fractures are nerve irritation (12%) and wire migration (10%) . Locking plate fixation of those fractures amenable to treatment with K-wire fixation will not only be cost ineffective but should be considered an over treatment when good results have been shown by other studies [32,62].
The LISS (Less Invasive Stabilisation System) and LCP (Locking Compression Plate) have been there since 1980?s for the treatment of femoral fractures. Although the starting point of locking devices in femur was for the treatment of sub-trochanteric fractures, LISS plate and LCP are developing a place in the treatment of the diaphyseal and distal femoral fractures. Intramedullary nails are in widespread use for femoral shaft fractures. Clinically significant rotational malunion have been found to be as high as 30% in femoral shaft fractures treated with intramedullary devices . A biomechanical study performed by Citak, et al. comparing rotational strain pattern of intramedullary devices with both conventional and locking plates has shown clinically significant rotation in both statically and dynamically locked nails averaging 14.2o and 15.7o respectively . Only 3.8o of rotational strain was seen when comparable physiological loads were applied to a locking plate-bone construct and this was found to be statistically significant. This demonstrates the superiority of the locking plates in controlling the rotational deforming forces under laboratory physiological loads. Supracondylar fractures of femur are one of the most challenging fractures to treat. These fractures can vary from purely supracondylar to fractures with intra-articular extension. Marked communition is a hallmark of these injuries especially in osteoporotic bones and multiple trauma. These injuries can sometime present as periprosthetic fractures in elderly patient with knee arthroplasty. Many different implants have been used to fix fractures of the distal femur namely condylar blade plate, intramedullary nail, DCS and buttress plating. Earlier results of fixing these fractures internally were not encouraging. Neer et al. showed 90% satisfactory results with nonoperative treatment in comparison to 52% with internal fixation . Later studies performed by applying AO principles of fracture management markedly improved the outcome in these fractures. Thus Schatzker et al. quotes 75% good results with internally fixed supracondylar fractures in comparison to 32% managed non-operatively . Severely comminuted and osteoporotic supracondylar fractures still pose a major challenge. Since the advent of the concept of „Biological plate fixation? more emphasis has been placed on preserving bone biology. The use of a LISS and LCP were developed in order to minimise the problems associated with other internal fixation devices, most of which rely on the friction between bone and implant for stability. The use of LISS plate in treating such complex and challenging fractures has resulted in a reasonably satisfactory outcome. In one study, Schutz, et al. achieved 90% union rate . In another study, Syed et al. has reported 88% union rate in 25 patients of supracondylar fractures being treated with LISS plate . Overall there was 12% infection rate including two superficial and one deep infection, both successfully treated with antibiotics . Interestingly, Schutz et al. and Syed et al.showed a revision rate of 23% and 12% respectively [60,64]. The main reason of revision was found to be delayed/non-union in both studies. A comprehensive systematic review on using LISS plate in supracondylar fractures of 663 patients with 694 fractures, revealed a 40% complication rate. The common complications were residual deformity (38.4%), implant malpositioning (11.2%) and infection (9.8%) .
Tibial plateau fractures involve proximal tibia in its articular and meta-epiphyseal segments . The normal valgus alignment of lower limb with reduced bone strength of lateral tibial plateau relative to medial results in a greater frequency of lateral than medial tibial plateau fractures . Minimally displaced fractures are treated nonoperatively, however, displaced fractures mostly require surgical fixation. Complex proximal tibial fractures are high energy injuries with severe soft tissue damage and extensive comminution. The use of locking plates is recently being explored in the management of such fractures [9,17,25,34,56]. Locking plates respect the biological environment of fracture and can be also applied by minimally invasive technique, however a prospective randomized study on the treatment of bicondylar tibial plateau fractures has failed to reveal any obvious advantage over conventional plates in terms of fracture healing, infection rate and adequacy of fixation . Diaphyseal and extra articular distal tibial fractures are frequently treated with intramedullary devices. Studies have revealed good outcome with the use of reamed intramedullary nails in terms of fracture union and functional status . Kayali et al. did not find any statistically significant difference between two groups of patients treated with either an intramedullary nail or locking plate . However, patients treated with an intramedullary nail can have symptoms of anterior knee pain which can be as high as 29% . In these cases, even if the nail is removed, 50% have persistent anterior knee pain. The tibia is a subcutaneous bone and distal part of this bone has limited muscle attachments, thus making it prone to delayed and non-unions. One of the most challenging varieties of distal tibial injuries are pilon fractures. These fractures involve distal tibial metaphysis with intra articular extension into the ankle joint. A number of different devices are available for the treatment of these fractures namely conventional plates and screws and external fixation. Complications range from 20-50% . Joveniaux et. al. reported an overall 30% complication rate of conventional plating, limited internal fixation using screws/Kwires and external fixation in distal tibial fractures . Whereas Hazarika et al. showed better results using LISS plate and 10% non-union rate . Hasenboehlr et al. also showed comparable results with LCP used in a minimally invasive fashion . In this study, two out of three non-unions were seen in patients with history of peripheral vascular disease and chronic alcohol abuse with heavy smoking. The high profile of the locking plate with limited soft tissue cover over distal tibia can result in pressure ulcers or hardware irritation requiring removal .
The incidence of peri-prosthetic fractures is only 0.3% to 2.5% . These fractures pose a grave challenge to trauma surgeons as they are difficult to treat requiring lot of experience and novel approaches. Due to the presence of previous implant, there is already limited bone available to achieve fracture stability. Also the presence of cement can make it extremely difficult and often impossible to use intramedullary devices in the treatment of these fractures. Locking plates have been found to be an effective option in the treatment of these fractures particularly using MIPO technique. LCP is commonly used for proximal femoral periprosthetic fractures and LISS for the distal ones. These plates when applied using minimally invasive technique preserve periosteal circulation allowing biological fixation. In order to avoid compromising the cement mantle or prosthesis, unicortical locking screws can be used. This can be further augmented by the use of cerclage wires [11,69]. Those authors who have employed minimally invasive techniques have shown lower implant failure and non-union rates. Buttaro, et al. used LCP for Vancouver type B1 fractures using open technique . He noticed 43% implant failure in those fractures where LCP was not augmented with cerclage wire and strut graft and recommends this combination. He attributes implant failure secondary to extensive soft tissue stripping thus compromising bone healing. According to a systematic review by Smith, et al. the non-union rate of LISS plate for distal femur peri-prosthetic fractures was 3.5% . A meta-analysis of 195 periprosthetic fractures showed a complication rate as high as 30% . Kobbe, et al. conducted a midterm follow up of patients with peri-prosthetic fractures treated with LISS plate and found Harris hip score of 79.5% . He also noted two cases (13%) of screw pull out. The study by Kregor et al. on supracondylar fractures around total knee arthroplasty showed complete unions in all the treated patients with LISS plate . There was no incidence of screw pull out in his study. Several other case series have shown benefit of locking plates in fixing periprosthetic fractures [26,27,28,68].
Locking plates were developed to overcome the problems associated with fracture management of osteoporotic bones. Locking plates are part of the evolution of extra-medullary techniques to preserve biology, allow controlled movement (relative stability), encourage fracture healing and yet still allow early mobilization . The superiority of locking plates has been proven by many biomechanical studies. Although some clinical trials have shown benefit, conclusive evidence is still lacking. This is due to the relative lack of good high powered randomised control trials. Even systematic reviews have failed to give a final verdict due to the lack of well controlled studies. The literature supports using locking plates for fixation of periarticular fractures of long bones, multifragmentary fractures of diaphysis & metaphysis and periprosthetic fractures. Ultimately, locking plates are not the panacea for all type of fractures. As clinical experience with locking plate broadens, new indications and applications will emerge. Overall, surgeons have started using these devices confidently in treating fractures and with time more evidence will be generated to further define the role of locking plates in the treatment of fractures. Until then, the treatment choice is still largely based on surgeon?s preference.
We acknowledge the valuable comments of Mr Robert Smith, Consultant Orthopaedic Surgeon, Wrightington, Wigan and Leigh NHS Trust in the preparation of this review article.
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