Locked plates confer angular stability across fusion sites, and as such are more rigid than either screws or intramedullary nails. This gives the advantage of reducing motion to enhance union rates and potentially allowing early weight bearing. The Philos plate (Synthes) is a contoured locking plate designed to fix humeral fractures but which also fits the shape of the hindfoot and provides strong low profile fixation. Its successful use for tibiotalocalcaneal (TTC) arthrodesis has been reported. Our aim was to prospectively evaluate the use of the Philos plate in hindfoot arthrodesis Twenty-one hindfoot arthrodeses were performed using the Philos plate between Oct 2008 and Jan 2010. Patients were followed up for a minimum of 1 year and had preoperative and 6 monthly AOFAS hindfoot scores and serial radiographs until union. Overall there were 15 ankle fusions, 5 tibiotalocalcaneal fusions and 1 subtalar fusion. At 6 months there were 13 unions and 9 non-unions (4 ankle, 5 TTC) giving a non-union rate of 38% overall and 25% for ankle fusions in isolation. Mean AOFAS scores at 6 months were 74/100 for the union group and 47 for non-unions (chi squared p < 0.001). No patient in the non-union group went on to fuse within a year without further surgery. Both groups had similar case mixes including osteoarthritis, AVN of the talus and failed arthroplasty. They also had similar co-morbidities, rates of smokers and bone grafting. Our conclusion is that the high non-union rates are probably due to the lack of compression conferred across the join by the Philos plate as there is no compression hole and we did not supplement the fixation with a lag screw. We recommend using locked plates for hindfoot arthrodesis only with additional compression

Aim: The operative management of proximal humerus fractures is still viewed as an unsolved question.

Surgical treatment aims at restoring anatomical elements to a condition stable enough, to allow early mobilization to avoid secondary displacement. The blood supply of the humeral head should not be damaged, so the risk of avascular necrosis will be minimal.

This work offers a new surgical technique that dramatically reduces the need for dissection of soft tissues while using a new locked plate.

Material and Method: This prospective study was carried out between August 2002 and March 2004. 47 fractures of the humerus proximal were operated on 47 patients aged 63 as an average. There were 9 four part fractures, 18 three part and 17 two part fractures.

The two arms of this Y shaped plate embrace the humeral head. The anterior arm overbridges the biceps longus tendon and fixes the lesser tuberosity, with a locked screw in the head. The posterior arm fixes the greater tuberosity with an another locked screw. These two screws cross each other at nearly right angle thus giving optimal fixation in the head.

Results: Fourty four patients (44 shoulders) were later re-examined with 10,3 months mean delay. Re-education was made immediate for 85% of the cases. The final evaluation was made with the functional Constant score and X ray control.

The main complications were 3 algodystrophies, 1 hematoma, 4 failures of fixation, 2 nonunions and only one necrosis.

Conclusion: This first clinical experience with this new implant is stimulating, since it provides a reliable fixation, even into the osteopenic bone.

Purpose of the Study: We evaluated the complications of proximal humeral fractures, which are treated with locked plates.

Materials and Methods: 103 patients (70 female, 33 male) with proximal humeral fractures with an average follow-up time of 19 months (2 weeks– 43 months) and an average 62,1 (21–90) years of age are treated with open reduction and internal fixation from September 2005 to April 2009 in our clinic. Internal fixation was performed with PHILOS plate in 93 patients and S3 Humeral plate in 10 patients. Early and late complications that are encountered during the follow-up time is presented.

Results: Complications occurred in 10 patients (7 females, 3 males) with an average age of 67,1 (41–89) years from which 5 of them had varus inclination, 5 had inter-joint screw penetration, 1 had fixation failure, 1 had breakage of the implant and 1 had infection. Complication rate (10 of the 103 patients) was 9.7%. The rates of varus inclination (5 of the 103 patients) and the rates of screw penetration (5 out of 103) were both 4.85%. During the follow-up time 3 of the 5 patients with varus inclination (60%) had progression (displacement of varus). 4 of the 5 patients with varus inclination (80%) had screw penetration. All of the 4 patients (100%) with varus displacement had screw penetration. The average Constant Murley shoulder score of the complication group were 67.8 (50–90).

Conclusion: Surgical treatment of the proximal humeral fractures has a high rate of complications. Screw penetration rates of the patients with varus inclination is 60%. Accurate indication, protection of the head’s inclination angle with an appropriate surgical approach and a proper technique, fine calculation of the screw lengths are needed for a successful functional result. In our study, where we have found fewer rates of complications than the literature, we have pointed out the reasons of the complications and we have stated the noteworthy precautions to lower the rates of these

Background

Treatment of aggressive benign bone lesions with curettage, burring, cementation and plate augmentation is a widely accepted treatment. We have used the above method using a locked plate (rather than conventional), facilitating stability and early mobilisation. We hypothesise that this is an alternative to megaprosthetic joint replacement, and provides acceptable functional outcomes at follow-up.

Purpose: To compare the functional outcome and quality-of-life following a displaced extra-articular proximal humerus fracture treated with open reduction and locking plate fixation versus non-operative management. To provide preliminary data for a subsequent prospective clinical trial.

Method: Eligible subjects were identified through retrospective searches of a large emergency department admission database and the orthopaedic trauma database. All subjects ages ³ 55 treated for a proximal humerus fracture between 2002 to 2005 were invited to participate. The Disabilities of Arm, Shoulder, and Hand (DASH), Health Utilities Index Mark 3 (HUI), Euroqol-5D (EQ-5D), and the SF-36 questionnaires were mailed to all eligible subjects. Initial radiographs were reviewed using the AO/OTA classification system. Only patients with A3, B1, B2, or B3 fractures were included.

Results: Thiry-four subjects were included: 15 were treated with sling immobilization and 19 with locked plate ORIF. The non-operative group was approximately seven years older (mean age 74 versus 67, p = 0.046). DASH scores were similar between the groups: ORIF 26.6 ± 24 and Sling 26.5 ± 20. The 95% CI surrounding the 0.01 point difference (−16.0 to 15.9) slightly exceeds the 13 point cutoff for the instrument’s measurement error (minimal detectable change). Using univariable analysis, no statistically significant differences in health state values were detected. The mean HUI value for the ORIF group was 0.68 versus 0.75 for the sling (p=0.48). Mean EQ-5D values were 0.77 for the ORIF group and 0.80 for the sling group (p=0.73). The SF-36 PCS scores were also similar between the two groups: ORIF 41.1 versus Sling 39.8 (p=0.77). When controlling for age and pre-injury function, a 0.09 point difference in HUI values was detected favouring the sling treatment (p=0.036). No differences in DASH, EQ-5D, or SF-36 PCS scores were detected using regression models.

Conclusion: The results of this small cohort suggest, for extra-articular fractures, the functional and quality of life outcomes may be similar between the two interventions. No trial comparing locked plate fixation and non-operative management has been reported. A total of 96 subjects will be needed for a prospective clinical trial comparing the two treatments (DASH difference 15, 80% power, 0.05 two-sided alpha).

Sacroiliac screw fixation is the method of choice for the definitive treatment of unstable posterior pelvic ring injuries; however this technique is demanding and associated with a high risk of iatrogenic neurovascular damage. We therefore evaluated the outcome, complications, surgical and fluoroscopy time for unstable posterior pelvic ring injuries managed with a transiliac locked compression plate.

23 patients were managed with a transiliac locked compression plate for unstable posterior pelvic injuries at a Level I Trauma Center. 21 patients were available for follow up after an average of 30 months and outcome evaluation was performed with the Pelvic Outcome Score, which is composed of a clinical, radiological, and social integration part.

The overall outcome for the pelvic outcome score was excellent in 47.6% (10 patients), good in 19% (4 patients), fair in 28.6% (6 patients) and poor in 4.8% (1 patient). 15 out of 21 patients (71.4%) returned to their normal life, 3 patients (14.3%) were limited at work, and 3 patients (14.3%) were not able to return to work due to their disabilities. The social status was unchanged to the preinjury status in 19 patients (90.5%). 13 patients (62%) stated no changes in spare time and sports activities; 4 patients (19%) had minor and another 4 patients (19%) had major restrictions. The average operation time was 101 min and intraoperative fluoroscopic time averaged 74.2 sec. No iatrogenic neurovascular injuries were observed.

Posterior percutaneous plate osteosynthesis may be a good alternative to sacral screw fixation because it is quick, safe, and associated with a good functional outcome.

Purpose: To evaluate the use of locked Compression Plate (L.C.P.) in metaphyseal long bones fractures, and report our preliminary results.

Materials and Methods: 23 patients 14–82 years old with long bones metaphyseal fractures underwent surgery with the use of L.C.P. between January 2004 and August 2004. Four patients were adolescents.

7 patients had Supracondylar femoral fracture. One of them had the fracture at the tip of IMN. 11 patients had distal Tibia, one had proximal+midshaft tibia and 4 had distal humerus fractures. All plates were prebended to fit the area of the fracture using a skeleton model. The plates were inserted percutaneously with reduction of the fracture.

Partial weight bearing started after 6 weeks and full weight bearing started after 12 weeks.

Results: Unuion was seen in x-ray after 6 to 12 week in 95% of patients. 20 patients regained full range of motion of the adjacent joints at 3 months follow-up.

Complications: One patient developed compartment Syndrome in a high energy tibial fracture. One patient developed deep infection at the site of fibular plate not affecting the L.C.P. at the tibia. One patient developed temporary weakness of extensor Hallucis longus.

Conclusions: L.C.P. proved to be effective in fixation of meta-epiphyseal zones which are difficult in IMN fixation. The use of this plate enables fixation of long bones in adolescents with open growth plate. The locking system enables good fixation of osteoporotic bones and in periprosthetic fracture. The high primary stability in combination with newly developed minimal-invasive techniques (MIPO = minimal invasive plate osteosynthesis) are the bases for a rapid bony consolidation, a low complication rate and good functional results.

Purpose of the study: Locked plating is an attractive alternative to external fixation for the fixation of distal shaft fractures of the radius, particularly in cases with metaphyseal comminution. The purpose of this study was to assess prospectively outcome with locked anterior plate fixation in a series of 43 complex fractures of the distal radius treated between October 2003 and November 2004.

Material and methods: The AO LCP 3.5 plate (Synthes) was used. The series included 27 women and 15 men, mean age 55.5 years (range 17–83 years). We included fractures with major metaphyseal comminution according to the M.E.C classification established by Laulan (18 M2, 14 M3, and 9 M4). According to the AO classification, there were nine extra-articular fractures (eight A3 and one A2) and 35 articular fractures (ten B3, two C1, four C2, and seventeen C3). Posterior displacement was noted for 22 fractures. In eight cases plate fixation was a second intention procedure due to secondary displacement occurring on average eight days (range 3–21 days) after trauma for a fracture initially treated with infrafocal pinning. An epiphyseal locking screw was used in all cases. An antebrachiopalmar immobilization orthesis was worn for six weeks on average (range 3–9 weeks). The first-intention anterior plating was combined with an intrafocal posterior pin for 13 patients and with an external fixator in one. Radiographic outcome was reported in terms of joint congruency and using the SOFCOT symposium criteria for the 41 patients reviewed at bone healing.

Results: Anatomic restitution was achieved in 23 patients (55%). There were two purely intra-articular calluses due to failure of the primary reduction, both measured less than 2 mm. Fifteen moderate misalignements (36%) were noted, most (84.7%) involving moderate sagittal inclination, the distal radioulnar index being preserved. Two major misalignments (5%) were related to early disassembly of the osteosynthesis.

Conclusion: Locked anterior plating has provided promising results for maintaining radial length in distal radial fractures with major metaphyseal comminution. There remains a certain number of cases with a moderate and persistent posterior inclination and a few cases of defective intra-articular reduction.

Medial Displacement Osteotomy (MDO) of the os calcis is used to correct the hind foot valgus in a flat foot deformity. Screw fixation is commonly used although contemporary locking plate systems are now available. This study tested the hypothesis that a 10mm MDO would support a higher load to failure with a locked step plate than with a single cannulated screw.

Prevalence. Periprosthetic fractures around a total knee are uncommon but not rare; various large database studies suggest 0.3–2.5%. Patients at highest risk are typically older patients and those with poor quality bone from various etiologies. Supracondylar femur fractures are often associated with a high stress zone at the metaphysis/diaphysis junction near the superior edge of femoral component. Etiology. Low energy trauma is the most common preceding event as most of these occur in patients with poor bone quality. Elderly patients are at particular risk because standing-height falls generate enough energy to create fractures. Given the durable nature of most modern TKA designs the prosthesis is usually fixed well. Goals. The goals of treatment are typically fracture union, avoidance of infection, avoidance of stiffness, and maintenance of overall limb alignment. Recent gains in knowledge indicate the need to attain maximal distal fragment fixation in order to achieve the surgical goals. Correct alignment, length and rotation are often best assessed with a combination of radiographic images and intra-operative clinical inspection. Modern internal fixation principles emphasise the need to minimise stripping/devascularization of comminuted zones. Options. Three major treatment options exist for supracondylar fractures. Retrograde nails have advantages in that they are tissue-friendly and are mechanically advantageous in the face of medial comminution. Difficult to use with most posterior stabilised TKA (box). There are limited distal fixation options and malalignment is often hard to avoid. With plating the distal fixation can be maximised and there is less risk for malalignment. Typically requires more soft tissue dissection. Locked plates provide good coronal plane stability and 2nd generation locked plates allow variable screw angles such that far distal fixation is possible. Revision TKA is required when implants are loose. Revision may be more reliable than fixation options in very elderly with badly comminuted bone. Be aware that a hinged tumor type implant may be needed in many cases

Introduction: Surgical fixation of intra-articular distal femoral fractures has been associated with nonunion & varus collapse. The soft tissuestripping associated with this fracture andthe surgical exposure have been factors associated with delayed union & infection. The limited soft tissue exposure has been lauded the as a solution to this fracture. However, it has occurred with the new fixation as well.(Locked Plate). Aims: This study is an attempt to look at the fixation. Does the LISS system improve the results of this difficult fracture? Is there truly a difference in the outcome of this fracture utilizing the Locked plate system or is the percieved difference due to the surgical mini invasive approach. Patients & Methods: One hunderd & forty patients were screened, only 53 were randomized and fixed in six academic centers over 5 years. All C3 fractures were excluded as they were felt not to be treatable by the DCS device, but they were treated appropiately. 35 females and 18 males were included in the study and randomized appropiatley. Results: Fifty-three patients were randomized, 28 had the LISS implant and 25 had the DCS utilized. There were 3 nonunions in the LISS group plus two patients with early loss of reduction that required reoperation in the early post operative period. One patient developed arthrofibrosis requiring arthroscopic release and subsequently the implant failed necessitating refixation. In the DCS group, only one nonunion reported & required second surgery. This translated to a reoperation rate of 21% in the LISS group compared to 4% with DCS. Conclusion: This prospective randomized multicentre trial showed a difference when comparing the LISS to the DCS in the supracondylar distal femur fractures

Fractures of distal tibia are common and often present with dilemma of appropriate and safe management. The use of locking plates has changed the way these fractures have been managed as it avoids extensive soft tissue dissection and periosteal stripping. The aims of this study were to look at the results of stabilization and analyse the complications of fractures of distal tibia treated with Locked plates. We carried out a retrospective study of patients who underwent surgical treatment for distal tibial fractures using MIPO (Minimally invasive Percutaneous Osteosynthesis) technique. The data was gathered from theatre data base. We studied a period between Nov 2006 to May 2009. We collected patient demographics as well as the type of fractures, mechanism of injury, radiological union and associated complications. There were no open fractures in the study. The limb was splinted for two weeks after surgery in a back slab. The patients were followed up at 6 weeks, 3, 6, 9 and 12 months after surgery. There were 45 patients in the study with 29 males & 16 females between ages of 20 – 87 (avg. 49 yrs). 24 patients sustained injury due to a fall, 12 were involved in RTA and the remaining 9 were sports related injuries. The mean time to surgery was 3.15 days (1 – 7) and surgery was carried either by the consultant or their direct supervision. The mean hospital stay was 7 days (2 – 35) and mean time to radiological evidence of callus was 9 weeks. All patients eventually returned to their preinjury employment. 76% showed radiological union at 6 months and 90% at 9 months. There were 3 superficial wound infections, 2 deep infections whilst 2 needed bone grafting and 1 implant failure. 2 patients developed mild form of CRPS which resolved at 12 months. 11 patients had metal discomfort of which 9 had removal of hardware. All these patients had the tip snapped off. MIPO with LCP is a reliable and reproducible technique in treatment of closed unstable fracture of distal tibia. Patients must be counselled about implant removal after fracture union. Avoid snapping the tip of the LCP

Purpose: Proximal humeral fractures are a commonplace injury, especially in the elderly population. Management is not always straightforward, and is particularly challenging when bone quality is poor. In recent years, locking plates have become available for the internal fixation of many types of fractures, including those of the proximal humerus, and a growing trend in their use has been noted. This is a randomized biomechanical study to evaluate the mechanical stability in simulated osteoporotic bone of three fixation plates, two locking and one conventional, for unstable two-part proximal humeral fractures. Method: Eighteen synthetic left humeri were plated with six bones in each of three groups: Synthes Cloverleaf Plate, Synthes Locked Compression Plate Proximal Humerus, and Smith and Nephew Periarticular Locking Plate for Proximal Humerus. Screw holes were overdrilled to simulate osteoporotic purchase. The distal humeral condyles were potted in autobody cement in polyvinylchloride tubes. An eight millimeter osteotomy gap was made at the base of the greater tuberosity to simulate an unstable two-part fracture. Cyclic axial compression testing was done in the vertical plane in 20 degrees of abduction to simulate physiologic loading. Measurements of plastic deformation of the construct were quantified by comparing RSA images taken before and after loading. Following cyclic axial compression testing, quasi-static torsion testing was done in the horizontal plane until construct failure. Failure was defined as the point where the linearity of a load-displacement curve is lost or where visible failure of the fixation occurs. Results: No plates were loaded to failure. The locked plates were significantly stiffer in axial compression and torsion than the Cloverleaf plate. There was no difference between locked plates. The maximum total point motion seen on the RSA analysis was more than 4 times greater in the Cloverleaf group relative to either locked construct and no difference between the Synthes and Smith and Nephew locked plates was again seen. The majority of the motion in the Cloverleaf construct appeared to be in rotation about the anteroposterior axis (lateral rotation). Conclusion: This study supports that locked plates, regardless of manufacturer, are stiffer in axial compression and torsion than Cloverleaf plates and result in less displacement in an unstable fracture pattern in an osteoporotic bone model

Since the early nineties clinical experience were gained with locking plates to stabilize long bone fractures. Firstly with a Point Contact Fixator, a device making the step from a conventional plate to an internal fixator, than with pure precontured internal fixators for the periaticular regions or nowadays with plates giving the option for the placement of locking or conventional cortical screws and are so called Locked Compression Plate (LCP). Almost every new development for extraarticular fracture stabilization reflects this development. Despite today’s broad, worldwide acceptance of the fixation technique, someone should be very clear about the benefits and the underlying concept to avoid failures, complications and unnecessary costs. Clear clinical benefits have been proven in complex fractures of the metaphysis and joints, furthermore the fixation of highly osteoporotic and/or periprosthetic fractures became more reliable. Also the technique of minimally invasive plating – the so-called biological plating –, where the fracture zone is only bridged and therefore the fracture often is not exposed any more, was facilitated with the new internal fixators. However, the process should not be overused, particularly in cases of insufficient surgical experience, because the technical demanding minimally invasive procedures can have detrimental effects on the fracture alignment and therefore on the later outcome. Not to forget the extended use of intraoperative x-ray exposure to control the reduction and implant fixation. Applying locking plates, the surgeon should never forget that bone healing requires still prerequisites in respect to stability and, of course, of other biological stimuli. This reflects the ongoing discussion, how a simple long bone fracture, should be optimal stabilized with an internal fixator, the amount of bone/implant fixations contacts and the timing for necessary further operations in present of delayed healing. The opportunity to combine both stabilization options – conventional screw and locking screw placement – within one implant needs a clear understanding of the underlying fixation issues and requires a clear teaching concept to avoid unfavorable combination of the different screws. In this lecture a broad, critical overview about the worldwide impact of locking plates in long bone fracture treatment will be given including proven advantages as well as discussing detected disadvantages using literature evidence and clinical examples

We have reviewed the management and outcome of ununited fractures of the humerus in a specialist limb reconstruction unit. A retrospective study conducted at Kings College Hospital, including referrals during the period September 1994 to present. There were 47 cases of humeral non-union, (14 proximal, 25 diaphyseal and eight distal). The time of referral from injury ranged from two months to eight years, with one patient referred after 37 years. 38 of the 47 patients had undergone an average of 1.08 operations prior to referral. Treatment aimed to achieve alignment, stability and stimulation. Methods were as follows: Proximal fractures [14]: nine Locked Compression Plate (LCP), five Dynamic Compression Plate (DCP). Autologous bone graft alone [eight], Bone Morphogenic Protein (BMP – Osigraft) alone [three], both bone graft and BMP [three]. 13 have united. One is under treatment. Mean time to union was six months. Diaphyseal fractures [25]: 12 LCP, four DCP, five Intramedullary (IM) nail, one Ilizarov frame and one required observation only. Autologous bone graft alone [17], BMP alone [two], both bone graft and BMP [three]. 23 have united. One patient awaits surgery. One patient declined surgery. Mean time to union was four months. Distal fractures [eight]: four LCP, two DCP, two Ilizarov frames. Autologous bone graft alone [seven], both bone graft and BMP [one]. Seven have united. One is under treatment. Mean time to union was seven months. Open reduction and appropriate stabilisation, together with the stimulus of autologus bone graft and/or BMP consistently resulted in healing of ununited fracture of the humerus. Many treatment methods were employed. It is not clear whether it was the treatment method or the accumulated experience of the Limb Reconstruction Unit, which was responsible for a high success rate comparable to, or better than, published results