Techniques in Orthopaedics 22(3):151155 2007 Lippincott Williams & Wilkins, Inc.

Biomechanics of Locked Plate Fixation

Dirk W. Kiner,
M.D.,

Varqa Rouhipour,

M.D.,

James F. Kellam,

M.D.

Summary: Standard compression plating techniques have been tremendously successful approach in the operative stabilization of many fractures. Shortcomings of these approaches appeared as their application became more widely used. The shortcomings were usually during uses where the plate and screw construct were forced to bear an inordinate burden of force that lead to screw loosening and failure. This lead to a design change whereby the biomechanical interface was shifted from the bone plate interface, utilizing a friction fit for stability, to a threaded plate/screw interface that formed its own mechanical fit of the components without friction to the bone. These locked plates have become more widely used in recent years. The biomechanics literature is sporadic in most areas, with the only real consensus appearing in the proximal humerus literature. The majority of the literature fails to discredit the use of these plates while showing increased utility in a limited number of applications. Key Words: BiomechanicsLocked platingReviewLocking plates.

Essentially all fixation methods act as stabilizing devices, or splints, to bear some of the forces across the bone while it attempts to heal thereby resuming its function of self-stabilization. All invasive fixation devices rely on some form of mechanical interface between the device and the bone to hold the construct together. The traditional DC plates and the later LCDC plates used a friction fit between the plate and the bone. Using a different concept of stabilization, the external fixator relies instead on a mechanical fit between the pins and the bars by way of the clamps. The idea of a locked screw plate, or internal fixator, came about in an attempt to extract the benefits from each of these systems and ideas whereas avoiding their less desirable attributes. This became necessary because of the poor performance of standard implants in the realm of minimally invasive fracture work as well as bridging fixation. The threaded screw concept of locked plating devices is designed to use a mechanical interface between the plate and the screw, rather than a friction fit between the plate and the bone, to bear the loads and stabilize the construct (Fig. 1). As the screw is ad-

vanced the final 3 to 4 turns, the male threads on the screw mate with the female threads on the plate to form a mechanical lock between the two (Fig. 2). The idea for this locking design concept being that this construct will provide axial and angular stability and therefore not permit screw back out, screw toggle, or many of the causes of hardware failure in osteosynthetic applications.5 Additionally, because compression between plate and bone is not required, there will be less disruption to the cortical blood supply.79 DESIGN As mentioned, these screws intend to impart angular and axial stability. Therefore, shearing and bending forces, those acting perpendicular to the screw and parallel to the plate, represent the majority of resistible stress. These forces concentrate at the bottom of the screw plate interface, that is to say the neck of the screw. Because of these new mechanics, the screw itself needed to be modified to tolerate the new force vectors. The screws were created with a slightly larger total diameter and significantly larger core diameters as well as a finer thread pitch to meet the new demands placed on them (Fig. 3).30 As opposed to compression screws where all screws will individually align to the direction of force and 151

From the Carolinas Medical Center, Charlotte, North Carolina. Address correspondence and reprint requests to James F. Kellam, Carolinas Medical Center, Charlotte, NC. E-mail: james.kellam@ carolinashealthcare.org

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FIG. 1. (A) Compression of the standard plate to the bone creates a friction fit to hold the 2 together. This construct requires bicortical screws to stabilize the fragment to the plate. (B) Locked screw construct relies on the mechanical threaded interface between plate and screw to provide stabilization. Does not require bicortical fixation to achieve stability. Stability may occur in the complete absence of a bone. (Copyright by AO Publishing, Davos. Taken from Wagner/Frigg, Internal Fixators, 2006.)

therefore allow for loosening and toggle, the locked interface functions to mechanically unite all of the screws to the plate and form a unit, or single beam, to resist forces en bloc (Fig. 4).12,30 This effect is even enhanced by placing the locked screws at varying insertion angles, either divergent or convergent.30 BIOMECHANICS OF LOCKING SCREWS The biomechanical principles of conventional plates and screws have been touched on previously and are well described in the orthopaedic literature1,2,11,13,15,16,20 22 and will only be expanded on here for the purposes of comparison. Locked plates, because of their single beam construction, convert shear to compressive stress at the screw/ bone interface. This characteristic common to fixed angle devices allows loads to be borne almost entirely by the construct in circumstances of bridge plating (Figs. 5 and 6). Thus, they act as internal, external fixators. The greatly increased rigidity versus external fixators is because of the much shorter distance from bone to side bar (plate) as well as various material properties. This theoretically allows for an environment where fracture site strain is optimized. Initial designs of locked plates used unicortical screws

only. This was done because it was thought that the second cortex of purchase was only useful to prevent screw toggle in unlocked systems by compressing the plate to the bone; an undesirable event in this model.19

FIG. 2. Diagram of threaded mechanical fit between locked screw and plate. (Copyright by AO Publishing, Davos. Taken from Wagner/ Frigg, Internal Fixators, 2006.)
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FIG. 3. (A) Superimposition of standard screw on a new design locked screw. (B) Standard compression screw showing smooth head for compression into LC-DC plates. Note smaller inner and outer core diameters, deeper thread pitch and less turns per inch. (C) Newer design locking screw with threaded heads for mating with the threads on a locking plate. Note larger inner and outer core diameters, finer thread pitch and greater turns per inch. (Copyright by AO Publishing, Davos. Taken from Wagner/Frigg, Internal Fixators, 2006.)

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nately mixing these 2 completely different concepts of fracture fixation risks creating a doomed construct if not carefully planned.19 22

CLINICAL BIOMECHANICS AND LITERATURE Early clinical results using locked plates and a minimally invasive technique were very promising. Numerous authors have documented good clinical results using the LISS plating system (Synthes, Paoli, PA).3,24 26,30 Most of these were the results of the initial AO investigators and all were level IV evidence. Other studies by authors outside of the design group were less favorable with higher malalignment rates, but still comparable or better than historical controls. A recent study from the University of Iowa showed a much higher complication rate using the LISS than previously documented for tibia fractures; again it was only level IV evidence.23 A recent true biomechanical study compared a locking condylar plate (LCP) construct to the traditional Dynamic Condylar Screw (DCS) system in the distal femur. This study found the LCP to be stronger in both cyclic loading as well as ultimate load to failure than the DCS in a nonarticular unstable fracture pattern.10 Literature support of the biomechanical advantages of diaphyseal use of locked plate designs is both less voluminous and less consistent. A study by Leung et al.17 showed no significant difference in any measurable benchmark after plating diaphyseal forearm fractures with either a locked or conventional plate though an identical approach in a randomized, prospective study design. The notable point of this study was that it was a randomized, controlled, level I evidence investigation that failed to reveal a difference with a study of 125 fractures. A study performed at our institution (submitted for publication) showed no significant difference in the torsional, bending, or axial loading rigidity of a locked plate construct versus an unlocked construct of the same size in either a stable or unstable fracture gap model in a humeral diaphyseal model. Our data further showed that a large fragment unlocked plate construct was significantly more rigid than either of the small fragment constructs and was

FIG. 4. (A) Standard LC-DCP/unlocked construct on diaphyseal bone. (B) Failure of LC-DCP in lateral bending because of sequential screw toggle and pullout. (C) Locked plate/screw construct on diaphyseal bone. (D) Failure of locked construct because of simultaneous cut-out of all screws distal to the lateral force. Behaves as a single beam. Note maintenance of screw/plate relationship as well as the area of bone cut through to bring about the failure. (Copyright by AO Publishing, Davos. Taken from Wagner/Frigg, Internal Fixators, 2006.)

Studies, both laboratory and clinical, have shown that the strength of unicortical locked screws exceeds conventional plate/screw constructs at physiologic loads.14,18 Further refinements in the design allowed for bicortical screw placement in circumstances where torsional forces are anticipated to exceed what unicortical screws can absorb.5 More recent designs allow for bicortical screw placement as well as the use of hybrid fixation; utilizing both locked and unlocked screw constructs. Indiscrimi-

FIG. 5. Locking construct bridging an area of comminution. Arrows indicate force transfer from bone to screw/plate construct as the comminution is bypassed. (Copyright by AO Publishing, Davos. Taken from Wagner/Frigg, Internal Fixators, 2006.)
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D. W. KINER ET AL. REFERENCES

1. Borgeaud M, Cordey J, Leyvraz PE, et al. Mechanical analysis of the bone to plate interface of the LC-DCP and of the PC-FIX on human femora. Injury 2000;31(supp3):C29 C36. 2. Cordey J, Borgeaud M, Perren SM. Force transfer between the plate and the bone: relative importance of the bending stiffness of the screws friction between the plate and bone. Injury 2000; 31(supp 3):C21C28. 3. Cole PA, Zlowodzki M, Kregor PJ. Less Invasive Stabilization System (LISS) for fractures of the proximal tibia: indications, surgical technique and preliminary results of the UMC Clinical Trial. Injury 2003;34(supp 1):A16 A29. 4. Edwards SL, Wilson NA, Zhang LQ, et al. Two-part surgical neck fractures of the proximal humerus. A biomechanical evaluation of two fixation techniques. J Bone Joint Surg 2006;88: 2258 2264. 5. Egol KA, Kubiak EN, Fulkerson E, et al. Biomechanics of locked plates and screws. J Ortho Trauma 2004;18:488 493. 6. Fulkerson E, Egol KA, Kubiak EN, et al. Fixation of diaphyseal fractures with a segmental defect: a biomechanical comparison of locked and conventional plating techniques. J Trauma 2006;60:830 835. 7. Farouk O, Krettek C, Miclau T, et al. Effects of percutaneous and conventional plating techniques on the blood supply to the femur. Arch Orthop Trauma Surg 1998;117:438 441. 8. Farouk O, Krettek C, Miclau T, et al. Minimally invasive plate osteosynthesis and vascularity: preliminary results of a cadaver injection study. Injury 1997;28(supp 1):A7A12. 9. Farouk O, Krettek C, Miclau T, et al. Minimally invasive plate osteosynthesis: does percutaneous plating disrupt femoral blood supply less than the traditional technique? J Ortho Trauma 1999; 13:401 406. 10. Higgins TF, Pittman G, Hines J, et al. Biomechanical analysis of distal femure fracture fixation: fixed-angle screw-plate construct versus condylar blade plate. J Ortho Trauma 2007;21:43 46. 11. Hofer HP, Wildburger R, Szyszkowitz R. Observations concerning different patterns of bone healing using the Point Contact Fixator (PC-FIX) as a new technique for fracture fixation. Injury 2001; 32(supp 2):SB15SB25. 12. Gautier E, Perren SM, Cordey J. Effect of plate position relative to bending direction on the rigidity of a plate osteosynthesis. A theoretical analysis. Injury. 2000;31(supp 3):C14 C20. 13. Gautier E, Perren SM, Cordey J. Strain distribution in plated and unplated sheep tibia an in vivo experiment. Injury 2000; 31(supp 3):C37C44. 14. Gautier E, Sommer C. Guidelines for the clinical application of the LCP. Injury 2003;34(supp 2):B63B76. 15. Kregor PJ, Hughes JL, Cole PA. Fixation of distal femoral fractures above total knee arthroplasty utilizing the less invasive stabilization system (LISS). Injury 2001;32(supp3):C64 C75. 16. Kregor PJ, Stannard J, Zlowodzki M, et al. Distal femoral fracture fixation utilizing the less invasive stabilization system (LISS): the technique and early results. Injury 2001;32(supp3):C32C47. 17. Leung F, Chow SP. A prospective, randomized trial comparing the limited contact dynamic compression plate with the point contact fixator for forearm fractures. J Bone Joint Surg 2003;85:23432348. 18. Marti A, Fankhauser C, Frenk A, et al. Biomechanical evaluation of the less invasive stabilization system for the internal fixation of distal femoral fractures. J Ortho Trauma 2001;15:482 487. 19. Perren SM. Evolution and rationale of locked internal fixator technology. Introductory remarks. Injury 2001;32(supp 2):B3B9. 20. Perren SM. Evolution of internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing anew balance between stability and biology. J Bone Joint Surg 2002;84: 10931110. 21. Perren SM. Point contact fixator: Part I. Scientific background, design and application. Injury 1995;22(supp 1):110. 22. Perren SM, Cordey J, Rahn BA, et al. Early temporary porosis of

FIG. 6. Finer detail of force distribution across gap fracture borne by the locked construct. This characteristic is unique to locked constructs. (Copyright by AO Publishing, Davos. Taken from Wagner/Frigg, Internal Fixators, 2006.)

the only construct type that limited torsion and bending to a range compatible with secondary bone healing. Our findings are nearly directly challenged by the findings of Fulkerson et al.6 that found significant improvements in cycles to failure and cantilever bending rigidity with bicortical locked plate constructs. The one region of the body where there is a reasonable amount of, as well as a fair consensus in, the literature concerns the proximal humerus. Numerous different authors have biomechanically and clinically demonstrated an increased rigidity and clinical utility of locked plates.4,27,28,30,31 When compared with more traditional methods of fixation in this difficult region, locking plate designs have been consistently shown to outperform their nonlocked equivalents biomechanically as well as clinically.

SUMMARY AND CONCLUSIONS True biomechanical literature on locked plate constructs is rare. Those that apply that data clinically are even more so. The early engineering from the plate companies and their designers suggested improved resistance to pullout and cut out than with conventional plate fixation, but the later data are not as obvious. Although the proximal humerus literature is both consistent and of a high quality, this is the exception to the rule at this time. The early data from our institution would seem to suggest that these potential biomechanical advantages are not realized in the diaphyses of long bones, and do not translate into increased clinical healing potential. In summary, in the majority of applications the most that can be definitively stated is that locked plates are not biomechanically inferior to standard plating and that we are not harming our patients in their use, but good data does not exist on the myriad of current, or future, uses for this technology.
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bone induced by internal fixation implants. A reaction to necrosis and not to stress protection? CORR 1988;232:139 151. Phisitkul P, McKinley TO, Nepola JV, et al. Complications of locking plate fixation in complex proximal tibia injuries. J Ortho Trauma 2007;21:8391. Schutz M, Kaab MJ, Haas N. Stabiliazation of proximal tibia fractures with the LIS-system: early clinical experience in Berlin. Injury 2003;34(supp 1):A30 A35. Schutz M, Muller M, Kaab M, et al. Less invasive stabilization system (LISS) in the treatment of distal femoral fractures. Acta Chir Orthop Traumatol Cech 2003;70:74 82. Schutz M, Muller M, Krettek C, et al. Minimally invasive fracture stabilization of distal femoral fractures with the LISS: a prospective multicenter study results of a clinical study with special emphasis on difficult cases. Injury 2001;32(supp3):C48 C54. Seide K, Treibe J, Faschingbauer M, et al. Locked versus unlocked

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plate osteosynthesis of the proximal humerus: a biomechanical study. Clin Biomech 2007;22:176 182. Siffri PC, Peindl RD, Coley ER, et al. Biomechanical analysis of blade plate versus locking plate fixation for a proximal humerus fracture: comparison using cadaveric and synthetic humeri. J Ortho Trauma 2006;20:547554. Stannard JP, Wilson TC, Volgas DA, et al. Fracture stabilization of proximal tibial fractures with the proximal tibial LISS: early experience in Birmingham, Alabama (USA) Injury 2003;34(supp1):A36 A42. Wagner W, Frigg R. Internal Fixators Concepts and Cases Using LCP and LISS. c2006. AO Publishing; Davos, Switzerland. Weinstein DM, Bratton DR, Ciccone WJ, et al. Locking plates improve torsional resistance in the stabilization of three-part proximal humerus fractures. J Shoulder Elbow Surg 2006;15: 239 243.

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