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EDITORIAL

Flexible Fixation with Locking Plates

L ess than a decade has passed since an editorial entitled ‘‘When Evolution Begets
Revolution’’ was published in this Journal. At that time, the editor stated that locked
plating was the ‘‘next great advance in orthopaedic traumatology’’ but tempered his enthusiasm
with the observation that ‘‘this wave of enthusiasm will surely be followed with an analysis of
the inherent problems, followed by a truer understanding of the role of these implants.’’1 Today,
this statement holds true. Clinical experience has shown both the relative strengths and
weaknesses of locked plating. For example, after the early popularity of filling every plate hole
with a locked screw, orthopaedic traumatologists learned that widely spaced combinations of
locked and nonlocked screws could more effectively provide stable fracture fixation.2,3 It is
apparent that nearly 10 years after the introduction of these implants, the indications for the use
of locked plates have yet to be precisely defined (Fig. 1).
Clearly the use of fixed-angle locked screws is advantageous for periarticular fracture
fixation in metaphyseal bone. Although not proven by prospective clinical trials, the benefit
of indirect support of the articular surface provided by locked screws appears to be common
sense, especially in the weightbearing extremities. Clinicians argue that the necessity for
two incisions and for secondary bone grafts is lower than in the era of nonlocked plate
fixation.4 In fact, the use of minimally invasive approaches to address the articular surface
and the subsequent percutaneous plating is so convincing that a prospective randomized
study may not even be a necessity.
One particular challenge appears to lie in the rigidity of locked plate constructs,
which results in considerably less motion at the facture site. When using locked plates for
bridging plate osteosynthesis, fracture union occurs by secondary bone healing, which
requires some motion at the fracture site. In 2006, Kubiak stated that locked plates were
‘‘comparable with extremely rigid fixators and run the risk of becoming nonunion
generators.’’5 Likewise, Uhthoff felt that ‘‘rigid plates led to cortical porosis, delayed
bridging, and refractures.’’6
Locked plates certainly provided a significant step in the evolution to more robust
fracture fixation. It is also recognized that there are some inherent problems with this new
technology. We therefore felt that a critical update on clinical and biomechanical aspects of
locked plating is warranted. Specifically, we evaluated the findings related to the strength
and stiffness of locked plating constructs drawn from the recent literature.

Key Findings Concerning Construct Strength


Locking screws improve fixation strength in osteoporotic bone compared with
compression plating, particularly in case of metaphyseal fixation. However, locking screws
may not be necessary for diaphyseal fixation in strong bone, because they may not improve
fixation strength compared with standard compression screws.
Conversely, locking screws can also decrease fixation strength for two reasons. First, the
focused load transfer of locking plates through fixed-angle screws causes a stress riser at
the plate end that increases the fracture risk compared with conventional plates. Replacing the
outermost locking screw with a conventional screw reduces this stress concentration and
significantly improves construct strength.7 Second, elevating a locking plate over the bone
surface significantly reduces the torsional strength of the fixation construct compared with
a nonlocked plate that is compressed to the bone surface. Unicortical locking constructs are
particularly weak in torsion. Adding one bicortical locking screw to an otherwise unicortical
construct has been shown to improve torsional strength.8

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Editorial J Orthop Trauma  Volume 25, Number 2 Supplement, February 2011

Key Findings Concerning Construct Stiffness


Locked plating constructs can be as stiff as nonlocked
constructs and are typically one order of magnitude stiffer
than external fixators.8 The stiffness of locked plating
constructs can be modulated. Most clinicians recommend
omitting one or two holes on each side of the fracture to
reduce the inherently high stiffness of locked plating
constructs and to initiate spontaneous fracture healing with
the generation of callus.9 Furthermore, changing the
material properties can decrease the stiffness of locked
plates. More flexible titanium plates are recommended over
more rigid stainless steel plates to increase motion at the
fracture site. Although both of these approaches can
increase fracture motion at the far cortex as a result of
plate bending, they have little effect on fracture motion
adjacent to the plate (Fig. 2).
Clinically, maximizing construct strength is a definite
goal that can be supported by locked plating technology. In
contrast, it remains challenging to define a construct
stiffness that stimulates fracture healing and to configure
a locked construct of such adequate stiffness. This
supplement focuses on the effects of construct stiffness
on fracture healing in the quest for locked plating constructs
that not only provide durable fixation, but that also provide
an adequate mechanical environment to promote fracture
healing.
We thank the senior editor for the opportunity to be
guest editors of this particular issue. We hope that it adds to
the knowledge and the enthusiasm of the readership to use
locked plates in a way that is helpful in the clinical practice
and in the ability to heal difficult fractures.
FIGURE 1. A failed locking plate after a segmental femoral fracture

FIGURE 2. (A) Anteroposterior and lateral of a L femur fracture in a 50-year-old man after a bicycle accident. (B) Anteroposterior
and lateral x-rays after locked plating. (C) Plate failure at 8 weeks postoperatively.

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J Orthop Trauma  Volume 25, Number 2 Supplement, February 2011 Editorial

REFERENCES 7. Bottlang M, Doornink J, Byrd GD, et al. A nonlocking end screw can
1. Sanders R. When evolution begets revolution. J Orthop Trauma. decrease fracture risk caused by locked plating in the osteoporotic
2004;18:481–482. diaphysis. J Bone Joint Surg Am. 2009;91:620–627.
2. Freeman AL, Tornetta P 3rd, Schmidt A, et al. How much do locked screws 8. Fitzpatrick DC, Doornink J, Madey SM, et al. Relative stability of locked
add to the fixation of ÔhybridÕ plate constructs in osteoporotic bone? plating fixation in a model of the osteoporotic femoral diaphysis. Clin
J Orthop Trauma. 2010;24:163–169. Biomech (Bristol, Avon). 2009;24:203–209.
3. Gardner MJ, Griffith MH, Demetrakopoulos D, et al. Hybrid locked plating of 9. Stoffel K, Dieter U, Stachowiak G, et al. Biomechanical testing of the
osteoporotic fractures of the humerus. J Bone Joint Surg Am. 2006;88: LCP—how can stability in locked internal fixators be controlled? Injury.
1962–1967. 2003;34(Suppl 2):B11–B19.
4. Musahl V, Tarkin I, Kobbe P, et al. New trends and techniques in open Hans-Christoph Pape, MD
reduction and internal fixation of fractures of the tibial plateau. J Bone Joint F. Pauwels Professor and Chairman
Surg Br. 2009;91:426–433.
University of Aachen Medical Center
5. Egol, KA, Kubiak EN, Fulkerson E, et al. Biomechanics of locked plates
and screws. J Orthop Trauma. 2004;18:488–493. Aachen, Germany
6. Uhthoff HK, Poitras P, Backman DS. Internal plate fixation of Michael Bottlang, PhD
fractures: short history and recent developments. J Orthop Sci. 2006; Legacy Biomechanics Laboratory
11:118–126. Portland, OR

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