LOCKING COMPRESSION PLATE IN FRACTURES OF OSTEOPOROTIC BONES

BY DR.YOGESH SHIVMURTI KHANDALKAR M.B.B.S.,D.ORTHO,M.Ch(ORTHO)(USAIM)

INTRODUCTION
LIFE IS MOVEMENT, MOVEMENT IS LIFE Life is defined here is said to be present only if active movement is there. To put this principle into practice is what every orthopedic surgeon concerned about. To achieve full movement at a particular joint after a fracture is most important is early mobilization. This has to be pain free mobilization to have full support from patients side. Mobilization restores rapid return of blood flow to bone and soft tissues and also prevents fracture disease. Plate is an implant which is fastened to the bone for the purpose of fixation. It can be protection or neutralization or tension band plate. The shape of plate is an adaptation of plate to the local anatomy and does not denote any function. THE AIM OF ANY SURGICAL FRACTURE TREATMENT IS TO RECONSTRUCT THE ANATOMY AND RESTORE THE FUNCTION.

OSTEOPOROSIS AND FRACTURES

Osteoporotic fracture treatment remains a challenge for the surgeon, often with unpredictable outcomes. In this series of cases highlights current aspects of these fractures and focuses on advances in implant design and surgical techniques. Osteoporosis is a skeletal disorder characterized by compromised bone strength, predisposing to an increased risk of fracture in the clinical setting, it can be defined as a reduction in bone mass of > 2.5 SD below the mean for the young adult.1-4 This is confirmed in this study by DEXA SCAN. More than 40% of women and 14% of men over the age of 50 years will experience fracture due to osteoporosis.4 Globally approximately 200 million people are at risk of sustaining an osteoporotic fracture each year.5 It is expected that osteoporosis will become epidemic to come as a result of the increasing number of elderly people.6 By 2012, 25% of the European population will be over the age of 65 years and by 2020, 52 million people will be over this in United States. The most frequent osteoporotic fractures seen in men arise in the spine, and wrist.7 In women the common fracture sites include the wrist, spine, humors femur and ribs. In the rising incidence of proximal fracture of the femur represents the most important socio-economic impact of osteoporosis.8 In 2000, there were approximately 424000 hip fractures worldwide and 1098000 in women. Based upon altering demographics and the increase in life expectancy is estimated that by 2025 there will be an increase of 89% in men, resulting in 800000 hip fractures per year, and in women
2

the

numbers

will

rise

by

69%

to

1.8

million.8

Osteoporosis is characterized by thinner cross- linking connections within trabecular bone.9 Endosteal diaphyseal restoration and medullary expansion are common in both men and women changes in diameter of the inner and outer cortices affect the bending and torsional characteristics of the entire bone and predispose to low-energy fractures, which often have a complex pattern at tissue level, there is a decrease in the cancellous bone mineral density.10,19 There is also a decrease in the density of cortical bone, because of an increase in porosity, which can affect the holding of screws.11 The healing of a fracture in osteoporotic bone passes through the normal stages and concerned with union of the fracture although the healing process is prolonged.12 There is evidence of animal models. NamkungMatthail et al.13, showed a 40% reduction of callus in the cross-sectional area and a 23% reduction in bone mineral density in the healing femur of an osteoporotic bone (postoophorectomy and low calcium diet). Similar results demonstrating that healing took longer in rats, and both stiffness and strength remain below the values of controls, where found Meyer et al.14 The major technical problem facing the surgeon is difficult secure fixation, less corticocancelleous screw purchase leading to decrease pull-out strength of implants. BMD correlates linearly with holding power of the screws15-16. In osteoporotic bone microfracture and loosening of implant, resorption of the bone is due to reduced strength tolerance.17-18 The operative treatment of metaphyseal fractures in the elderly is associated with an increased rate of complications; and implant failure occur in 2% to 10% of fractures, malunion in 4% to 40% and re-operation to 23%.19-24
3

The high rate of complications has encouraged extensive research into the development of which can improve the bone-implant interface by preventing high stress and distributing the load transmitted to bone in a load-sharing, rather than load-bearing way. Techniques of the internal fixation which aim to provide absolute stability with lag screws are usually inappropriate in Buttress-plate fixation of metaphyseal fractures is effective in osteoporotic bone as it avoids strains at a single screw while the implant provides a large contact area at the bone-implant surface again reducing strain.22

Fixed-angle devices, such as the angled blade plate, are very useful as they resist angular deformation and torsion, and the strain is reduced because the blade has a large surface and initial success with fixed- angle implants such as the blade plates 23-24has led t the development of screws which are rigidly fixed to the plate. This was first achieved by adding Schuhli nuts (S Paoli, Pennsylvania) to standard plates and, more recently, with threaded holes incorporated into the plate, the so-called LOCKING COMPRESSION PLATED (LCP)25-26. Plated with locking- head screws also produced a fixedangle device and have similar mechanical properties. The holding power of implant can be increased further by having locked screws at multiple fixed angles.27 Thus LCP has achieved the purpose of angle stability and bone to plate interface and secured fixation in fractures of osteoporotic bones. Thus LCP is a plate of new era. An early example of this tried was the pint contact fixator.28
4

The main advantage of the locking-plate device is the mechanical couple between the screw and the plate (fixed-angle device) so that even if the screw-bone interface fails, the screw plate interface remains intact. Complete failure of fixation is still possible, and is seen in very severe osteoporosis, but all screws on one side of the fracture fixation must fail simultaneously. The implants such as the locking compression plate and the less invasive stabilization system significant advantages in osteoporotic bone.22 Comparison between conventional and locking plated have been conducted in distal29 and diaphyseal 30 fractures of the humans and were to be better suited to provide stable and reliable fixation. A review of the available literature in the field of plate osteosynthesis31 came to the same conclusion. Similar developments to include principle of angular stability in intramedullary nails are now underway.32-33 The treatment of unstable fractures of the proximal humerus using the se nails has demonstrated that a stable osteosyntheis is achievable in very old patients.34

LOCKING COMPRESSION PLATE:35-36

It is equivalent to external fixator, which is shifted close to the bone. The Combination hole present in the LCP was designed by Mr. Michael Wagner & Mr. Robert Frigg in order to incorporate a threaded hole alongside a dynamic compression unit. A LCP-combination hole has two parts: 1. DCP unit- for cortical and cancellous screws 2. Conical thread unit- for L.H.S. (Locking Head Screw) 5 THUS LCP IS A NEW ERA IN THE TREATMENT OF FRACTURES OF OSTEOPOROTIC BONES.

It is an advantageous in patients with severe osteoporosis.

For treating fractures with open reduction and internal fixation. ASIF (Association for Study of Problems in Internal Fixation) have propounded a 1. Accurate and anatomical reduction. 2. Rigid internal fixation 3. Atraumatic technique on bone soft tissues. Working hypothesis comprising of four principles. 4. Early pain free active mobilization especially during first ten postoperative days.

AIMS AND OBJESCTIVES:1) To study efficacy of L.C.P. as a treatment modality in case of fractures of osteoporotic bones. 2)To evaluate the progression of fracture healing in osteoporotic bones. 3)To study effects of fixation fractures by locking compression plate .

MATERIALS AND METHODS

During the period from Aug 2007 to Dec 2010, 35 cases of osteoporotic fractures confirmed by DEXA scan were selected and prospective study has done. Type of study Sample Size Study Duration Prospective 35 Patients included in the study 40 Months

Selection of Patients: Any patient with # of osteoporotic bones was included in the study. Compound Grade 1; 1/ Gustillo Andersons # type and closed # were also treated. According to the requirement of the patient the surgical procedure was done as: - Open reduction & Int. Fix. OR - Minimally invasive plate osteosynthesis (MIPO)

Individual case study

X-rays classified all #s according to type & BMD (Bone Mineral Density) Confirmed by DEXA machine. 7

DEXA MACHINE

Each patient underwent a detailed history taking, clinical examination and assessment of # site. (As per attached proforma)

Fractures were classified whether intraarticular or extraarticular.

MANAGEMENT:-

a)Management in causality:On admission, the detailed history was asked regarding mode of injury, time since injury, any primary treatment taken, and any significant past history. Patient was thoroughly assessed clinically. Patients vital parameters were checked, associated-head, chest, abdominal injuries were looked for. On local examination skin condition, presence of Haemarthrosis, instability at joint and any distal neurovascular compromise was looked. Any other associated limb or bone fracture was checked. Depending on the vital parameters and general condition, an intravenous access was sought for and intravenous fluids were given whenever necessary. All other injuries and associated fractures were immobilized and taken appropriate care. If associated contused, lacerated wounds were present, they were given a thorough wash and cleaned with savlon, hydrogen peroxide, normal saline, betadine and dressing was applied. Bolus dose of intravenous broad-spectrum antibiotic was given when associated wounds. Intravenous/ Intramuscular NSAIDs were given after systemic injuries were ruled out. Anteroposterior, lateral, and oblique, views radiographs of affected part were taken. 9

b) Management thereafter:-

As required, the patients with Haemarthrosis, associated dislocation, compartment syndrome, were subsequently taken to operation theatre. In patients with associated unclean wounds, at other sites, surgical debridement under appropriate anesthesia was done. The wound was cleaned with savlon, hydrogen peroxide, normal saline, betadine and dressed. Broad-spectrum antibiotic covering gram positive, gram negative and anaerobes were started. Tetanus toxoid and antitetanus serum were given. Investigation: The patients who were admitted and were subsequently operated had following investigation done a) Routine Investigations:Hemoglobin %, Bleeding time, Clotting time, Peripheral blood smear, Urine- routine and microscopy. b) For operative point of view: Blood sugar level, blood urea level, serum electrolytes, electrocardiogram and chest skiagram were done. Radiographs of affected part in anteroposterior and lateral view formed a major part in deciding the modality of treatment for a particular fracture. The following questions arose: Q. What was the type and degree of comminution of fracture? Q. Was the depression anterior of posterior/ Q. Will bone grafting be required? Q. Were the collateral and cruciate ligaments avulsed in case of knee injury and ankle injury? Answer the above questions and you will be on the right path 10

INSTRUMENTS AND IMPLANT:-

- Full Swiss AO- synthes instrumentation and implant set - Screwdrivers having a torque limiting devices that avoids stripping of the screw heads after they are locked in the plate. - Plates also permit standard self tapping titanium screws which can be used in normal compression mode with all the advantages of compression technique. - Minimal invasive technique required image intesifier and radiolucent operation table. All the operations were performed in operating room of high standards.

INSTRUMENTS:A.O.Standard instruments were used as follows: 1. Guide sleeve 2. A.O. drill bit 3. A.O. depth gauge 4. A.O. drill guid 5. A.O. torque limiting screw driver 6. A.O. quick coupling system 7. A.O. plate bender 8. A.O. standard screw driver 11

STANDARD A.O. (LARGE FRAGMENT) SET

STANDARD A.O. (SMALL FRAGMENT) INSTRUMENT

Diagnosis of osteoporosis: Diagnosis of osterporosis was confirmed by DEXA machine scan. Patient selected for study was screened for osteoporosis.

12

OPERATIVE PROCEDURE:-

Preoperative planning: It was done for every patient managed by this technique. Preoperative roentgenogram of affected part was taken in anteroposterior, lateral and if required oblique views. These roentgenograms were assessed to determine type of fracture amount of displacement or depression present, probable length of screws required for particular case; particular direction of the screw insertion required to achieve compression at fracture site and to avoid neurovascular damage. Preoperative planning in each case was helpful in minimizing intra operative decision-making, shortens the operative time and hence improves the results. Preoperative PHYSICIAN check up was done in every case.

Anesthesia:The operative procedure was performed under spinal anesthesia, I.V. regional anesthesia or general anesthesia depending up on patients physical fitness and requirement under pneumatic tourniquet control. Positioning the patient: Patient was in supine position. The image intensifier was placed on the opposite side of the table and positioned perpendicular to the table.

Patients Preparation:Preoperative scrubbing with savlon and 7.5% povidine iodine scrub for at least 10 min was done and mopped off with spirit and painting was done with 10% povidines iodine and spirit. 13

Appropriate surgical approach for affected fracture part was made depending upon upper or lower extremity bone under all aseptic precautions. Whenever necessary MIPPO technique was used, otherwise fracture site was exposed. As tissue respect is important in every surgery tissue handling was kept to minimum. periosteum was stripped only from the site where the LCP was to be applied. Open reduction was achieved using bone holding forceps and LCP was fixed on the reduced fragment with plate holding device. Whenever necessary few k wires were used to maintain the reduction Anatomical reduction again confirmed under Image-Intensifier- A.O. Principle. Drilling done using standard A.O. drill for LCP. Now 3.5 or 4.5 mm depending upon type of the plate screws are inserted in combihole of LCP. There was no need of tapping A.O. titanium screws as they are self tapping screws. Closure was done using vicryl 1-0 and Ethilon 2-0. Negative suction drain was kept depending upon need and site of fracture. Dressing done on 5th, 9th & 11th post operative day. Alternate sutures were removed on 9th and all sutures removed on 11th post operative day. Every patient was taught post operative exercises. For lower limb walking without weight bearing with the aid of crutches was started a few days afterwards. Exact timing of beginning of partial and full weight bearing was judged individually but generally this was not before 6-8 weeks. Follow up with detailed objective assessment was carried out. Radiographs were taken at 6, 12, 14, 16, 24, 48, 72 weeks. Early and late complications were recorded and adequately managed. Pain assessment of each patient done with VISUAL ANAGLOUGUE SCALE & grading done according as excellent, good, fair, poor. 14

Range of movement compared with previous normal movement with each patient and graded as excellent, good, fair, and poor.

VISUAL ANALOUGE SCALE

15

OBSERVATIONS AND RESULTS

Total number of cases were - 35

Table No.1

Age in years 60-70 70-80 80-90

No. of cases 25 08 02

Percentage 71.42 22.86 5.72

Most of cases were old age group of 60 to 70 years. Table No. 2 Sex- Male Sex- Female 09 26 25.72 74.28

Female predominated as commonly involved in home activity and had fall.

16 Table No. 3

Bone involved Femur Humerus Radius-Ulna Tibia- Fibula Total

No. of cases 06 12 14 03 35

Percentage 17.14 34.28 40.00 08.58 100

Table No. 4 Type of fracture Transverse Oblique Comminuted Total No. of cases 20 11 04 35 Percentage 57.15 31..42 11.43 100

Transverse fractures were most suitable for compression. For comminuted fractures with large fragments fixation done with interfragmentary screws.

17

Table no.5 Type of fractures Simple fracture Compound fractures Gustilo- Anderson type I Gustilo- Anderson type II 01 No. of cases 31 04 03 Percentage 88.58 11.42

Type I & Type II compound fractures were primarily treated with debridement under anesthesia. These patients were temporarily immobilized with slab support or external fixator and antibiotics were administered. These were taken for definitive surgery after wound healing. Table No. 6 Mechanism of injury Type of injury Vehicular accidents Fall From stair-case Fall in bathroom Fall on road No. of cases 04 31 14 13 04 Percentage 11.43 88.57

Patients predominantly had fall. 18

Table No. 7

Fractures in upper limb Fractures in lower limb

23

65.72%

12

34.28%

Upper limb fractures predominated compared to lower limb.

Table no. 8 Radiological features considered 1. Anatomical reduction 2. Compression 3. Position of plate 4. Placement of screws 5. Interfragmentary compression 6. Primary union 7. Presence/ Absence of infective changes 8. Disuse osteoporosis 9. Implant complications Table No. 9 No. of cases Screw loosening No screw loosening 00 35 Percentage 00 100

19 Table no. 10 Minimum cortices secured in plating different bones

Humerus Radius Ulna Femur Tibia Fibula

6 5 5 7 6 5

Table No. 11 No. of cases Postoperative immobilization No immobilization 28 80 07 Percentage 20

Patients having comminution and compound injuries were immobilized temporarily.

20

Table No. 12

Weight bearing in lower limb fracture Early Delayed Late 10th post operative day 10th day of 5 weeks More than 6 weeks 6 3 3 50 25 25

Table No. 13 Post operative stiffness in adjacent joints Restriction upto 10 deg. Restriction upto 30 deg. Restriction more than 30 deg. Mild Moderate Severe 04 02 02

Table No. 14 Stiffness in UL Stiffness in LL 05 03

Postoperative stiffness: It was observed in (10%) cases. Two cases had ipsilateral fractures of femur, tibia and patella. 21

Table No. 15 UNION Metaphysis

No. of weeks

0-2

2-6

612

12-14

14-16

16-18

No. of cases Percentage

00

00

00

19 54.28

00

00

Diaphysis No. of weeks 0-2 2-6 612 No. of cases Percentage 00 00 00 00 16 45.72 00 12-14 14-16 16-18

Healing in 12-14 weeks for metaphyseal and 14-16 for diaphyseal fractures is considered as excellent.

22

Table no. 16 Infection Superficial Deep No. of cases 03 01 Percentage 8.58 2.86

Table No. 17

Complications 1) 2) Postoperative stiffness Infection Superficial Deep 3) 4) Delayed union Malunion 08 03 01

5) 6) 7) 8)

Nonunion Implant failure DNVC Re-fracture

23 Table no. 18 BMD Scores T-SCORE -2.5 to -3.5 -3.5 to -4.0 No. of patients 21 14

Table No. 19 Range of movement compared to previous level

Range of movement

Excellent (75%)

Good (5075%)

Fair (2550%) 07 20.00

Poor (<25%)

No. of cases Percentage

23 65.72

05 14.28

Satisfactory Result= Excellent + Good = 66.72+14.28= 80%

Table No. 20 Pain relief (V.A.S.) No. of cases Percentage Excellent (0,1) 24 68.58 Good (2,3,4) 06 17.14 Fair (5,6,7) 05 14.28 Poor (8,9,10)

Satisfactory Result= Excellent + Good = 68.58+17.14 = 85.72% 24

Table No. 21 Grading of Result Excellent Pain relief Range of movements Union 68.58 65.72 100 Good 17.14 14.28 00 Fair 14.28 20.00 00 Poor 00 00 00

Satisfactory Results= Excellent + Good

25

DISCUSSION
The objective of fracture management is the restoration of optimal preinjury status by safes and most reliable method. Early mobilization and return to pre-injury environment also provides a psychological stimulus to healing. Every fracture leads to a complex tissue injury involving the bone and surrounding soft tissue envelope. Immediate after fracture and during the repair phase, the following are evident: 1. Local circulatory disturbances, 2. Local inflammation, 3. Pain, 4. Reflex immobilization/ adjustment of joints and surrounding muscles.

These factors lead to development of fracture disease which is described by Lucas-Championniere in 1907. Fracture disease is evident clinically as chronic edema, soft tissue injury and patchy osteoporosis. Edema, per se, induces intermuscular fibrosis and atrophy. These fibrotic process cause muscle to develop unphysiological adhesions to bone and fascia and therefore joint stiffness and contractures. In case of osteoporotic bones internal fixation of fractured bone is challenge with regular implant due to weal holding capacity. There is loosening of screws of back firing of screws. There may be loosening of plate also. But LCP has revolutionized the treatment by giving angular stability in internal fixation of fractures and locking head screws. 26

LCP while fixed to bone acts as monoblock unit so chances of implant loosening are very less as with previous plates. Blood supply of bone beneath the LCP is well maintained as it acts like internal ex-fixator and plate is well away from bone surface which is very important in case of osteoporotic bones. So it does not hamper local blood healing of fixed fractures of osteoporotic bones which is confirmed in our series of 30 cases so also helps in early pain free mobilization of operated fractures of osteoporotic bones. LCP is made up of titanium which is a tuff material and resistant to corrosive effect. This reduces chances of implant failure and infection due to stresses across the plate and even after fall after fixation in case old people. So cost of resurgery and stress of resurgery is avoided in case old osteoporotic people. Titanium is also resistant to infection and this important fact proved in our series with cases of two superficial and one

deep infection. Thus LCP is ideal implant in compound fractures of osteoporotic bones. So also added advantage of this material is it does not interfere with investigation like M.R.I. study in case of elderly patients with fractures of osteoporotic bones. LCP is bio-friendly and body-friendly material is it can be kept in body lifelong. So cost of resurgery, stress of resurgery and stress of implant removal in osteoporotic bones is avoided. Thus it has helped to avoid socioeconomic burden in our community. Significant factors which affect union are initial displacement, communication, associated soft tissue wounds, infection and distraction. Lambotte (1907), Dannis (1949), Kuntscher (1935), Charnley (1948) and others have already demonstrated importance of compression and its tolerance by bone. 27

Muller (1963), Willenger, Bagby and others have advocated use of rigid internal fixation of diaphyseal fracture.

The significant factors which affect union of fracture are displacement, comminution, associated soft tissue injuries, infection, and distraction of fracture fragments and adequacy of blood supply. By treating these patients with LCP it was possible to mobilize then early and reduce the changes of fracture diseases. By early rehabilitation, good physiotherapy these patients could return to their work early and could ones again start their earning. This not only helps patients and their family financially but psychologically also. The patient is much happier and satisfied. In the present series treatment of fractures in these patients with

LCP was of immense benefit as it facilitated early pain free post operative mobilization of the patients, without a cumbersome plaster. This prevented joint stiffness and muscle wasting to a large extent and helped nursing care and prevention of bedsores and plaster sores. At operation, when dealing with the fracture, the most important aspects taken into consideration were perfect anatomical reduction. This was relatively easy in short oblique and transverse fractures. For comminuted fractures, perfect anatomical reduction was difficult, but could be achieved with the help of interfragmentary screws in cases with large butterfly fragments. 28 The technique of applying a LCP is quite an exacting technique, Requiring considerable technical skill and a well equipped instrument trolley. Operating time required was shortened as more experience was gained. The results of our study were quite comparable with the standard series, where the average period required for union of the fracture was 12 weeks. In case of primary union, where no callus is seen it is difficult to assess union. Minimal callus was seen in few cases mainly due to periosteal strapping, and did not take part in consolidation of the fracture. Follow up X-rays were also looked up carefully for presence of infective changes, osteoporosis and implant complications. The signs of nonunion, such as increasing fracture gap on roentgenograms and pain on walking were not encountered in the present series. Also no case of stress fracture of the plate was seen.

In present series 35 cases were included. Most of patients in our series were females from 60-70 years age group; from low socio economic and middle class family; some of them were daily wedge earners. Period of immobilization and hospitalization mattered a lot for them from economic point of view as well. Most commonly involved bones were humerus and radius-ulna. Mostly transverse and oblique fractures predominated in our series. Compression can be easily applied to these fractures after achieving good anatomical reduction. 29

As against that is comminuted fractures compression is difficult to achieve unless comminution is restricted to only one or two butterfly fragments. In case of bad comminution we used MIPO technique which shows good results. 88.58% were simple fractures and 11.42% were compound fractures. These were Gustilo-Anderson type I and II compound fractures which were initially treated with debridement, suturing, temporary immobilization and antibiotics. After complete wound healing, on an average after 7-10 days these were taken for LCP fixation. Most of cases were fall i.e. 31 of which 14 had fall in bathroom, 13 over stair-case and 04 on road. There were 04 cases of RTA who had fracture due to minor trauma because of osteoporosis as later on confirmed by DEXA scan. Because of post operative pain and inflammation response to physiotherapy was poor in the first 3 days. But later on relative pain free mobilization could be started in these patients. 07 patients were required

immobilization for 4-6 weeks due to comminution of fracture and associated ipsilateral injuries. 65.72% patients had fractures in upper limbs and 34.28% in lower limbs. After rigid fixation of fractures with LCP active mobilization is very easily isolated and single limb fractures.

30

Important fractures considered: Plate was positioned on tension side of fractures so as to convert tension forces into compression forces whenever possible. Interfragmentary compression could be achieved with separate screws as well as passing through the plate with over drilling of proximal cortex. Radiological union is said to exist when the fracture line was totally obliterated. In case of primary union where no callus was seen it is difficult to access the union. Minimal callus was present in many cases which was mainly due to periosteal stripping and did not take part in consolidation of the fracture. Follow up X-rays were looked at carefully for presence of infective changes, osteoporosis and implant complications.

Radiological union was seen after a period of average 12 weeks for metaphyseal fractures and 14 weeks for diaphyseal fractures. Total obliteration of fracture line was taken as radiological union. Superficial infection was observed in 03 patients. This was restricted to suture tracts only and could be taken care of easily with proper wound care and use of antibiotics. 01 case of deep infection was seen in patients who had compound injury graded as Gustilo-Anderson type II. They were initially treated by through debridement followed by antibiotics and internal fixation after wound healing. 31 Post operative stiffness was observed in 08 cases which were put on physiotherapy and subsequent gain of good range of movement achieved. The complications can be avoided in case of fractures of osteoporotic bones by observing following points learned over period of two years1) Proper selection of patients 2) Thorough post operative preparation 3) Aseptic and atraumatic operative technique 4) Selecting proper size screws and plates

32

SUMMARY & CONCLUSIONS

Our series included 35 cases of fractures of osteoporotic bones. Osteoporosis was confirmed by DEXA machine. Most of the patients were female. Common age group of patient was 60-80 years. All patients were without plaster after surgery which was a problem with previous implants but not in case with LCP. All patients had pain free, early and effective mobilization after surgery. LCP provides optimum hold and stability in case of osteoporotic fractures as LCP gives angular stability with locking head screws. It acts as monoblock construct. Locking minimizes the compressive forces exerted by the plate on the bone.

As LCP has combination hole, depending upon fracture situation, it can be used in either a conventional technique (compression principle), bridging technique (internal fixator principle), or a combination technique (compression and bridging principles). Thus LCP has improved patient compliance in case of fractures of osteoporotic . bones.

33 In the modern day Orthopedic practice with widened indication of internal fixation LCP is an excellent device in osteoporotic bone. Moreover it decreases morbidity in old osteoporotic patients. As function of affected limb is very much important in old people, LCP offers early mobility and union by fracture site compression compared to other devices. It does not require post operative external support hence increases patients compliance. It has following advantages: 1) Less surgical exposure 2) Rigid internal fixation 3) Interfragmentary compression 4) Early post operative mobilization 5) Less chances of infection 6) Less chances of stiffness 7) Early and good post operative pain relief 8) Less chances of delayed union, nonunion, and malunion 9) Decrease hospital stay

10) Early occupational rehabilitation 11) Implant can be kept for life long unless complication 12) Body friendly material THUS LOCKING COMPRESSION PLATE IN FRACTURES OF OSTEOPOROTIC BONES IS THE BEST MODALITY OF TREATMENT AT PRESENT TIME. 34

Recent Advances
1)Failure of proximal Femoral LCP with open reduction and internal fixation, 2)Good use in periprosthetic fracture Vancouver B1 femoral fracture- JBJS SEPT.2007 89(9) 1964-9 3)Elbow arthrodesis using two LCP Sept.2007 vol.8 issue 3 page 141 to 146-Techniques in elbow & shoulder surgery 4)Free vascularised fibular bone grafting combined with LCP for massive bone defects in lower limb Journal of international orthopaedics 26 jan.2012 5)FUTURE DEVELOPEMENT FEB.2012= POLYAXIAL LOCKING COMPRESSION PLATES TO FIX SCREWS IN VARIOUS DIRECTIONS.

BIBLIOGRAPHY
1) Kanis JA, Oden A, Johnell O, et at. The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int 2001; 12:417 2 LC. 2) Mori S, Harruf R, Ambrosius W, Burr DB. Trabecular bone volume and microdam-a~ accumulation in the femoral heads of women with and without femoral neck fractures. 1997; 21: 521-6. 3) Bassey EJ, Rothwell MC, Littlewood JJ, Pye OW. Pre- and postmenopausal women different bone mineral density responses to the same high- impact exercise. J Bone Mi 1998; 13: 18054) Eastell R, Lambert H. Strategies for skeletal health in the elderly. Proc Mutr Sac 200L 80. 5) Cummings SR, Kelsey JL, Nevitt MC, ODowd KJ. Epidemiology of osteoporosis an osteoporotic fractures. Epidemiol Rev 1985;7-178. 6) Smith DP, Enderson BL, Maull KI. Trauma in the elderly: determinanats of outcome. ; Med J 1990; 83:171-7. 7) Seeman E, Bianchi G, Adami S, et at. Osteoporosis in men: consensus in premature tissue Int 2004; 75:120-2.

8) Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos 1997; 7:407-13. 9) Goldstein SA, Goulet Z, McCubbrey D. measurement and significance of three-dimensional architecture to the mechanical intergrity of trabecular bone. Calcify Tissue Int 1995; 53 (Suppl1): 127-33. 35 10) Prevrhal S, Njeh CF, Jergas M, Genant HK. Imaging and bone densitometry of steoporotic In: An YH, ed. Internal fixation in osteoporotic bone. New York: Thieme Inc., 2002:51. 11) seebeck J, Goldhahn J, Morlock MM, Schneider E. Mechanical behavior of screws normal and osteoporotic bone. Osteoporos Int 2005; 16 (Suppl2):101-1 12) Lopez MJ, Edwards III RB, Markel MD. Healing of normal and osteoporotic bone. If ed. Orthopaedic issues in osteoporosis. Boca Raton: CRC Press, 2003:55-70. 13) Namkung-Matthail H, Appleyard R, Jansen J, et at. Osteoporosis influences the ease of fracture healing in a rat osteoporotic model Bone 2001; 28:80-6. 14) Meyer RA Jr, Tsahakis PJ, Martin OF, et al. Age and ovarietomy impair both the normalization of mechanical properties and the accretin of mineral by the fracture cal rats. J Orthop Res 2001; 19:428-35. 15) Perren SM. Backgrounds of the technology of internal fixators. Injury 200;34 (Suppl 2).

16) Chapman JR, Harrington RM, Lee JM, et at. Factors affecting the pullout strength of cancellous bone screws. J Biomech Eng 1996; 118:391-8. 17) Koval KJ, Meek R, Schemitsch E, et al. An AOA critical issue: geriatric trauma: youn J Bone Joint Surgery (Am) 2003; 85-A: 1380-8. 18) Liu JG, Zu XX. Stress shielding and fracture healing. Zhonghua Yi Xue Za Zhi 1994; 5, 51 9. 36 19) Stover M. Distal femoral fracture: current treatment, results and problems. Injury 2001 (Suppl 2): 3-13. 20) Syed AA, Agarwal M, Giannoudis PV, Matthews SJ, Smith RM. Distal femoral fracture long-term outcome following stabilization with L1SS. Injury 2004; 35:599-607. 21) Bergman RJ, Gazit O, Kahn AJ, et at. Age-related changes in osteogenic stem cells J Bone Miner Res 1996; 11:568-77. 22) DIppolito G, Schiller PC, Ricordi C, Roos BA, Howard GA. Age-related osteogenic of mescenchymal stromal stem cells from human vertebral bone marrow. J Bone Miner 1999; 14: 1115-22. 23) Instrum K, Fennell C, Shrive N, et al. Semitubular blade plate fixation in proximal humerus fractures: a biomechanical study in a cadaveric model. J Shoulder Elbow Surg 1998; 7:1. 24) Jupiter JB, Mullaji AB. Blade plate fixation of proximal humeral nonunions. Injury 1994; 25:30 1-3. 25) Kolodziej P, Lee FS, Patel A, et al. Biomechanical evaluation of the schuhli nut. Clin 1998; 347:79-85.

26) Simon JA, Dennis MG, Kummer FJ, Koval KJ. Schuhli augmentation of plate and screw fixation for humeral shaft fractures: a laboratory study. J Orlhop Trauma 1999; 13:1961. 27) Schutz M, Sudkamp NP. Revolution inplate osteosynthesis: new fixator systems. J (Sci 2003; 8:252-8. 28) Haas N, Hauke C, Schutz M, Kaab M, Perren SM. Treatment of diaphyseal fractures forearm using the point Contact Fixator (PC-Fix): results of 387 fractures of a prospec multcentric study (PC-Fix II). Injury 2001; 32 (Suppl 2): 51-62. 29) Korner J, Diederichs G, Arzforf M, et al. A biomechanical evaluation of methods of c humerus fracture fixation using locking compression plates versus conventional reconstruction plates. J Orlhop Trauma 2004; 18:28693 30) Wenzl ME, Porte T, Fuchs S, Faschingbauer M, Jurgens C. Delayed and non-union humeral diaphysis: compression plate or internal plate fixator? Injury 2004; 35:55-60 31) Egol KA, Kubiack EN, Fulkerson E, Kummer FJ, Koval KJ. Biomechanics of locked plates and screws. J Orlhop Trauma 2004; 18:488-93. 32) Plecko M, Kraus A. Internal fixation of proximal humerus fractures using tile locking humerus plate. Oper Orlhop Traumato 2005; 17:25-50. 33) Stannard JP, Harris HW, McGuin G Jr, Volgas DA, Alonso JE. Intramedullary nailing humeral shaft fractures with a locking flexible nail. J Bone Joint Surg (Am) 2003; 85-A: 10. 37

34) Mathews J, Lobenhoffer P. Results of the provision of unstable proximal humeral fractures geriatric patients with a new angle stabilizing antegrade nail system. Unfallchirung 2004: 1 07:372-80. 35) AO/ASIF Principles of fracture management, Ruedi T. et. Al, Thieme Verlag, 2000. 38 36) Schatzker j, changes in AO/ASIF principles and methods

39

Proforma
Name: Age: Case No.: Date of admission: Date of discharge: Chief complaints: History: Mode of injury Whether case of polytrauma Hypovolemia History of head injury On exam: Inspection Compound/Closed Deformity/Scar/Sinuses/Swelling Palpation Abnormal bony mobility DNVC Rom at adjacent joint Pain at # Site Osteoporosis + / Sex:

Post operative management: Period for which pt- immobility 40

Period for which pt is on antibiotic Suture removal Mobilization of adjacent joint Weight bearing

Post operative observations: Wound healing. Edema of part. Changes of sudeck osteodystrophy. Joint and complications.

41

Shoulder

Elbow

Wrist

Hip

Knee

Ankle

Stiffness Painful arc syndrome Active abduction Stiffness Myositis Ossificans Range of flexion Range of extension Stiffness Deformity Dorsiflexion Palmer flexion Sudeck dystrophy Stiffness Active flexion Active abduction Active adduction Active internal rotation Active external rotation Swelling Stiffness Flexion deformity Active extension Effusion Crepitus Patellar tap Stiffness Sudeck dystrophy Deformity Active plantar flexion Active dorsiflexion Deformity- Equinus

42

Pre operative x -ray

Intra-operative MIPO Technique

post operative X-RAY

Pre-operative x-ray fracture proximal end ulna

Intra - operative

Post operative x-ray

Post operative ROM