Severe Osteoporotic Fractures:

New Approaches in Fixation

Okayama Medical Center

Toru, Sato M.D.

Topics
Fixation Technique
Locking Compression Plate
Blade ( Rotational or Spiral )
Tension band wiring
Buttress plate
Bone Cement
Clinical application

LCP (Locking Compression Plate)

Angular Stability
Dynamic Compression

LCP Plate hole design and screws

Compression Plate

Internal Fixator

Biomechanics Force Transmission

Conventional plate

n
o
i
s
s
e
r
p
m
o
C

Internal Fixator

Locking plate

Biomechanics Force Transmission

Conventional plate

n
o
i
s
s
e
r
p
m
o
C
Friction

Internal Fixator

Locking plate

Implant

Biomechanics Force Transmission

Conventional plate

n
o
i
s
s
e
r
p
m
o
C
Friction

depending on
bone quality

Locking plate

Implant

independent of
bone quality

Advantages of locking plate

1. Improved stability

ty
i
l
i
b
a
t
S
r
a
l
Angu

2. Accurate plate contouring unnecessary

3. Less disturbance of periosteal blood supply
4. Less screw loosening

Advantages of locking plate

1. Improved stability

ty
i
l
i
b
a
t
S
r
a
l
Angu

2. Accurate plate contouring unnecessary

3. Less disturbance of periosteal blood supply
4. Less screw loosening

Bending force

Sequential screw pullout

Larger area of resistance

Pull-out strength direction of screw

Parallel direction of
screw insertion

Multi direction of
screw insertion

Improved stability
LHSP
(Locking Humerus Spoon Plate)
70 y, F.
pseudarthrosis

fx
d
e
t
u
n
i
m
m
Co
ne
o
b
c
i
t
o
r
o
p
Osteo

1year after inj.

83y. F.11-C2.

Just after op.

5 months after op.

22monthsafterinj.

LHSP Bonegraft4weekslater

51y.Female.RA.11A3 nonunion

3monthsafterreoperation

51y.Female.RA.11A3
nonunion
RA.

Severe Osteoporotic cases

Distal humerus
locking plates

LCP Metaphyseal

Advantages of locking plate

1. Improved stability

ty
i
l
i
b
a
t
S
r
a
l
Angu

2. Accurate plate contouring unnecessary

3. Less disturbance of periosteal blood supply
4. Less screw loosening

Accurate plate contouring unnecessary

Conv PInternal Fixator

LP

Advantages of locking plate

1. Improved stability

y
t
i
l
i
b
a
t
S
r
Angula

2. Accurate plate contouring unnecessary

3. Less disturbance of periosteal blood supply
4. Less screw loosening

Less disturbance of periosteal blood supply

Periosteal blood
disturbance due to
plate compression

Conv P

LCP

Advantages of locking plate

1. Improved stability

ty
i
l
i
b
a
t
S
r
a
l
Angu

2. Accurate plate contouring unnecessary

3. Less disturbance of periosteal blood supply
4. Less screw loosening

Less screw loosening

Load

Conv P

LP

Less screw loosening

Conv P

LP

Less screw loosening

ConvDual
P

Single

LP

98y.Female.

5monthsafter

Asian PFNA
Unstable Trochanteric Fractures
Osteoporotic bone
Suitable for Asian structure
Anti-rotation
Optimal stability
One single element

Stable Fixation --- PFNA Blade

Excellent fit through bone compaction
Less bone removal compared to a screw

Stable Fixation --- PFNA Blade

Bone removal (DHS) versus bone compaction (PFNA)
A=81.3 mm2

Segment 2

A=26.7 mm2

Segment 2

Stable Fixation --- PFNA Blade

Borderline thread

Edge of helical blade

1 mm

Asian PFNA
Requirement

Bending point should be high

Lateral side edge should be

smooth circular arc

Proximal diameter should be

thin down

Improvement of Nail
Lateral cut
Protect lateral wall
Proximal bending point
Lateral bending angle 5

PFNA

Asian PFNA

Improvement of Nail

Bending point

Lateral bending angle

PFNA 6 Asian
PFNA
5

Improvement of Nail
Blade end
PFNA
Asian PFNA

Blade end
1.5mm shorter : Reduce a protrusion
at the lateral cortex

Distal locking option

Static oblique

Static transverse

Dynamic

88y. F. unstable Fx.

2 months after op.

of PFNA

106y. F

10 w

Tensionbandwiring
Goodindication:
Proximalhumeralfractures.Distalhumeralfractures
Utilizesofttissues:Notinfluencedbybonequality
Fixationstrength:Notsostable

77Y. Female. C3

Tension band wiring

Just after operation

One year after operation

11-C3
68y. Female
Fracture-dislocation + greater tuberosity fracture

Displaced head

Reduction

Just after operation

One year later

84y. Female. 13-A2

First operation

12weeks after the operation

Tension band wiring & Bone graft

Buttress Plate
Support
Against the axial loading

13-B1

Articular surface - 3.5mm screw

Metaphysis - buttress plate

13-B2

4 weeks after operation

Bone graft + Buttress plate

84y, F. Hoffa fractures

Just after injury

81y . Male

Just after op.

6 months after op.

81y . Male

Just after injury

90y . Female

Locking plate+ Posterior buttress plate

90y . Female

Bone Cement for Screw Fixation

Enhanced plate fixation strength to the bone
Dont use fracture site
After drilling and tapping, inject the bone cement
Before hardening the cement, insert screws.

Loosening of implant

75y. F. Peri-TEA fracture

3.5mm
reconstruction plate
(double plate)
Bone cement

Bone union(+)

1 year after op.

Trochanteric Fractures treated by

DHS with Ca Phosphate Paste Bone Cement

Neck Fractures treated by

CCHS with Ca Phosphate Paste Bone Cement

Stress Distribution
From the view of Biomechanical aspect
Stress concentration
Breakage of the Fixation
New other Fractures

73y, Female
Non-union

Just after op. 6months after op.

91y. F. 33-A2

91y. F. 33-A2

10 Days after op.

91y. F. 33-A2 Re-Fixation

Conclusions
Fractures with severe osteoporosis are still now
unsolved problems.
Choose a proper method according to the type of injury.
Only one method can not solve all fractures.