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Thomas F. Higgins, MD; Sean E. Nork, MD;
James P. Stannard, MD; and Philip J. Kregor, MD
Created October 2006 and Revised October 2011
Locked Plating
Locked Plating
Definition
Locked plating, for the purposes of this talk,
is a screw and plate construct for the
purposes of osteosynthesis, in which the
screw engages the plate with a mechanism
which secures a fixed angle between the
two.
HistoryLocked plating, improvised in various ways
for years, and in development for many
years, came into widespread commercial
availability and clinical use in the United
States between 1998 and 2002.
Five stages of new Medical Technology
1. Experimentation
2. Skepticism
3. Fevered enthusiasm / overuse
4. Complications and despair
5. Judicious use
Like much new medical technology, the
employment of locked plating was
complicated by a lack of a thorough
understanding of indications and
mechanism of action
The ideal recipe for implant and construct
stiffness is still not fully understood.
Where maximizing construct stiffness was once
the ultimate goal, locked plating has likely
created some situations where constructs have,
in fact, become TOO stiff.
The correct employment of locked plating
techniques necessitates understanding the
following:1. Mechanism of action of locked plating2. Differences from non-locked plating3. Indications for locked plating4. Contra-indications / misuses of locked
plating
Recommended Reading
Gauthier et al, Injury 2003,
Vol 34 Supplement 2, pp. B63-76
Mechanics of locked plating
Traditional (non-locking) plates rely on
friction between the plate and the bone
achieved by terminally tightening of
screws passed through the plate to the
bone.
Locked plating does not require that the
plate be compressed to the bone, as the
interface between the plate and screw is
secured without this plate-bone
compression
With non-locking fixation, failure of
fixation may initiate with toggle between
the screw and plate, subsequent loss of
compression between the plate and bone
Correct and incorrect sequencing in the application of locked
plating
Surgical Technique Reduce the joint (if applicable)
LAG First (Lag, then Lock)
Re-confirm alignment
Lock
After the second locked screw, no change
can be made
The next twelve slides should be viewed as a
“slide show”. The screws with green “x”’s
represent locking screws, and the screws
without “x”’s are non-locking.
Lab Exercise
Metaphyseal Fixation
Lab Exercise
Metaphyseal Fixation
Lab Exercise
Metaphyseal Fixation
Lab Exercise
Metaphyseal Fixation
Reduction of Shaft
Lab Exercise
Metaphyseal Fixation
Reduction of Shaft
Metaphyseal Fixation
Reduction of Shaft
Metaphyseal Fixation
Reduction of Shaft
Metaphyseal Fixation
Reduction of Shaft
Metaphyseal Fixation
Reduction of Shaft
Metaphyseal Fixation
Reduction of Shaft
Metaphyseal Fixation
Reduction of Shaft
Metaphyseal Fixation
Reduction of Shaft
Locked Plating Advantages
Increased rigidity
Decreased toggle
Potential use as a reduction tool
May permit fixation with less stripping of
soft tissues
May be helpful in osteoporotic bone
Locked Plating Disadvantages Very expensive Constructs may be too rigid Some percutaneous applications be self-
drilling– That must be unicortical or strips near cortex
No tactile feedback on bone purchase They “allow you to stop thinking”
– Reduction must still be achieved, it is not magically achieved by locking implant
List ofIndications for Locking
(Framework)
Indications for Locking Biological Fixation
– Spanning Comminution (bridging)– Percutaneous Techniques in selected indications
Implant as reduction tool
Metaphyseal / Bicondylar Articular Fractures– Short Articular Segment – Periprosthetic Fractures
Osteoporosis
Biological FixationWithout necessitating compression of the
plate to the bone to achieve fixation, locked
plating may be applied percutaneously, or
with less damage to the vascularized tissue
immediately adjacent the bone.
Obese 33 yo female with bilateral open femur fractures
I&D, Spanning external fixation
Locking plate is secured to the peri-
articular segment, the metaphyseal is not
disturbed or dissected, and then the plate is
secured to the diaphysis.
Both the nailed and
plated fractures heal
with callus
Percutaneous Techniques are a form of “biological
plating”
(in selected indications)
15 y.o. male
This is a functions like a nail:Secondary healing, Relative stability
Percutaneous / Submuscular Plating
Metaphyseal / Bicondylar Articular Fracture
36 y.o. male skier
36 y.o. male skier
With bicondylar involvement, and very small
articular segment, locking fixation allows us
to secure the joint surface back to the
diaphysis in the correct orientation
4 months out
Long Standing 6 months
Use of Locked Plate as Reduction Tool
1. Lock plate to articular segment in correct
alignment
2. Provisionally affix plate to diaphysis
3. Confirm alignment
4. Secure plate to the diaphysis with non-
locking or locking screws
Obese 47 y.o. female Open Distal femur fracture
Reduce Joint
Reduce jointm then
set the correct
orientation of the
plate on the
articular fragment
(as with this jg)
Make sure it is not
flexed or extended
on the lateral view
(done in this case
with jig)
After joint reduction,
make sure that the plate
is correctly aligned to
the articular segment.
Then connect to
diaphysis.
Connect reduced joint to Diaphysis
Short Articular Segment
Open Femur Fracture
27 y.o. male
Motorcycle vs. flatbed truck, then guard rail
Open L femur with segmental loss,
Segmental L tibia
Very small remaining articular segment
ORIF and cement spacer in metaphysis
Well healed after subsequent bone grafting
35 y.o. vs. tractor
Femoral neck fracture plus intertrochanteric
fracture equals short articular segment
Periprosthetic Fractures
(This is also a form of a short
articular segment)
Obese 64 y.o. female
72 y.o. male TAAPeriprosthetic Fracture
“Periprosthetic” = Short Articular Segment
Osteoporosis
74 y.o. diabetic female
Locking Plate Principles
Locking plate is an IMPLANT, not a
technique
There are unique techniques
Beware the siren call of M.I.S. (Mal-
aligned Implant Surgery)
Locking Implants Still Require Reduction
Unclear Indications/ Non-indication
Compression plating in healthy diaphyseal bone
does not require locking
16 y.o. male, healthy bone, non-locking fixation
18 y.o. female, diaphyseal injury. Locking fixation not necessary
Partial Articular Fractures “B-type fractures”
require buttress, not locking.
24 y.o. male Snowboarder vs. Half-Pipe
Beware “too rigid” construct
72 y.o. Rheumatoid female on multiple cytotoxic medications. Ground level fall. Repaired with this
locking construct
The experience over the last ten years with
locking fixation has demonstrated that we
now have the ability to make a construct “too
strong” or “too stiff”
Particularly in
1.Comminuted metaphyseal fractures, or
2.Very simple transverse or spiral patterns
rigid immobilization of the fracture may
obliterate all motion, and prevent the
formation of callus, leading to non-unions.
In these patterns, the correct answer may be a
wider spread of our fixation, allowing more
motion around the fragments, and the
formation of a more vigorous healing
response
Failed varus
nonunion revised to
this, allowing more
motion in the
metaphysis and a
callus response.
One other potential response to the problem of excess stiffness in locking constructs has been so called “far cortical locking”. This entails over-drilling the near cortex and then placing a screw that engages the far cortex and locks in the plate (see diagram, next slide).
This may theoretically allow more motion in the construct, and reduce strain at the screw – plate interface.
At the time of this publishing, this technology has not been proven clinically, but may have some promise in the future.
“Far cortical locking”
Locked Plating Mechanics Summary
1. Understand the biomechanical difference
from conventional plating
2. Understand the limitations
3. Reduce and lag before locking
Locked Plating Indications Summary
Biological Fixation
Plate as a reduction tool
Metaphyseal / Articular Fractures
Short articular segments / periprosthetics
Osteoporosis
Locked Plating Huge advance in plating
Must understand biomechanics and what the
various constructs accomplish
Need to know and understand the new “rules”
of locked plating, as we understand them, and
not just apply locked plating blindly
Return to General/Principles
Index
E-mail OTA about
Questions/Comments
If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to [email protected]
Thank You
Return to General/Principles
Index
E-mail OTA about
Questions/Comments
If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to [email protected]