Locked Plating

Sean E. Nork, MD;

James P. Stannard, MD;
and Philip J. Kregor, MD
Created October 2006

LOCKED PLATING

INDICATIONS

BIOMECHANICS

SURGICAL SEQUENCES
AND
TRICKS

Theoretical Advantages

Improved metaphyseal screw purchase in

osteoporotic bone

Need for fewer screws

Easier percutaneous plating

Less re-fracture, especially with the use of

unicortical screws

LOCKED PLATING DOES NOT

SUBSTITUTE FOR
POOR REDUCTION
OR
POOR SURGICAL APPROACH

REASONS NOT TO USE INTERNAL

FIXATORS

LACK OF COMPRESSION AT THE

ARTICULAR SURFACE

PLATE DOES NOT AID IN THE

DIAPHYSEAL / METAPHYSEAL REGION

COST

RELATIVE CONTRAINDICATIONS
FOR LOCKED PLATING

TRANSVERSE DIAPHYSEAL FRACTURES

PARTIAL ARTICULAR INJURIES

SITUATIONS WHERE PLATE CONTOURING

HELPS REDUCE THE FRACTURE
MOST ANKLE FRACTURES

COST: 4.5 MM PLATE

8 HOLE 4.5 LCDCP
TOTAL:

$181

SCREW:
PLATE:

$13

$101

8 HOLE 4.5 LCP

TOTAL:

$1028

SCREW:

$111

PLATE:

$362

COST: 3.5 MM PROXIMAL

TIBIAL ARTICULAR PLATE

NON-LOCKING: $ 939
LOCKING: $ 1729

28 year old Female

Water-skiing Accident

PARTIAL ARTICULAR INJURY

VISUALIZATION

OF JOINT
COMPRESSION OF ARTICULAR
SURFACE
ANTI-GLIDE PLATE

TIBIAL PLATEAU FRACTURES:

INDICATIONS FOR LOCKED
INTERNAL FIXATORS

BICONDYLAR TIBIAL PLATEAU

FRACTURE WITH MINIMAL ARTICULAR
INVOLVEMENT

SIGNIFICANT METAPHYSEAL /
DIAPHYSEAL MEDIAL COLUMN
INVOLVEMENT

NOT WITH
SCHATZKER I-IV
TIBIAL PLATEAU FRACTURES

GENERALLY NOT WHEN A SEPARATE

MEDIAL INCISION IS NEEDED

ADVANTAGE OF A
NON-LOCKED PLATE
UTILIZATION OF THE PLATE /
SCREWS TO COMPRESS THE
ARTICULAR SURFACE AND
DECREASE TIBIAL PLATEAU WIDTH

K.W. 00.09.18

K.W. 01.09.12

CASES FOR LOCKED FIXATOR

N.S. 00.01.22

N.S. 00.01.22

N.S. 00.06.21

L.I.S.S.
PROVEN CLINICAL
ADVANTAGE

TREATMENT OF DISTAL FEMUR FRACTURES

USING THE LESS INVASIVE STABILIZATION SYSTEM
(L.I.S.S.):
Surgical Experience and Clinical Results in
One Hundred and Three Fractures

Philip J. Kregor, M.D.

James P. Stannard, M.D.
Michael Zlowodski, M.D.
Peter A. Cole, M.D.

Univ. of Mississippi Med Center

and
Univ. of Alabama-Birmingham Med Center
J. Ortho Trauma September 2004

Femur LISS: Complications

96/103 (96%) healed

Nonunions: 2

Acute Infections: 3

Loss of Proximal Fixation: 5

Loss of Distal Fixation: 0

Malreductions: 6

Mean ROM of Knee: 0-109 degrees

WHERE IT REALLY HELPS

MULTIPLANE, COMPLEX ARTICULAR

INJURY

SHORT DISTAL SEGMENT, ESPECIALLY IN

SETTING OF OSTEOPOROSIS

FRACTURES ABOVE TOTAL KNEES

PROXIMAL FEMUR

M.J. 04/10/28

MJ 10/28/2004

M.J. 04/10/28

WATSON-JONES APPROACH

MJ 10/29/2004

M.J. 04/10/29

M.J. 05/10/24

M.J. 05/10/24

NO NEED FOR PLATE

CONTOURING

ADVANTAGE AND
DISADVANTAGE

LOCKED INTERNAL FIXATORS

CANT SOLVE ALL THE

PROBLEMS
DONT FORGET THE BASICS

CONCLUSION

LOCKED PLATING IS HELPFUL IN 10-15 % OF

CLINICAL CASES

SIMPLE DIAPHYSEAL AND ARTICULAR

INJURIES RARELY BENEFIT FROM LOCKED
PLATING

LOCKED PLATING

OSTEOPOROSIS,

SHORT SEGMENTS OF BONE, AND

TO PREVENT VARUS COLLAPSE AROUND

THE KNEE

Locking Plates: Definitions

Angled Blade Plate

Stable fixation
Technique challenging
Single fixed angle
Requires impaction into

Locked

Plates

Stable fixation
Technique simplified
Multiple fixed angles
Bone impaction avoided

Locking Plates: Definitions

Low Profile Internal External Fixators

TERMS:
FixedPosition
FixedAngle
LockingScrew
LockingPlate

Locking Screw-Plate Constructs

Locking head screw

Threaded plate hole

Different Biomechanics

Conventional Plates
Modes of Failures

Background

Screw plate interface allows

toggle of the screw

Instability results when the applied

load (patient forces) exceeds the
plate bone
frictional force

Conventional Plates
Modes of Failures

Frictional Force
Patient Load

Purchase in
bone

If Patient Load is exceeds the Frictional Force, the

construct is UNSTABLE

Pullout of regular screws

By bending load

Pullout of locking screws

Pullout of locking screws

Pullout of locking screws

Larger area

By bending load

Why Unicortical Screws???

Difficulty with measuring depth to opposite cortex

(design issue for percutaneous applications)

Coupling of pitch and screw advancement

(becomes an issue when opposite cortex engaged)

Angular stability may partially offset the need and

biomechical advantages of bicortical purchase

Biomechanics - Theory
Unicortical Fixation

Screws have single

point of fixation
Small
Load

Conventional
Plating

Screws have two

points of fixation
Small
Load

Locked Plating

Locking Screws vs Cortical Screws

5.0 mm Locking Screw

4.4mm Core Dia.

Creates Fixed Angle

4.5 mm Cortical Screw

3.5mm Core Dia.

Generates
Friction/Compression

Plate long, locked screws, bicortical fixation

Summary

Conventional Plates

Requires good purchase of

screws into the bone
Stability is gained through
compressing the plate to
the bone

Unicortical screws are

very unstable

Locked Plates

Stability does not rely on

screw purchase into bone
Stability obtained by
locking screws to plate

(fixed angle)

Unicortical fixation
similar to conventional
bicortical fixation

Summary

Are Locking plates really better?

Biomechanically advantageous in certain circumstances

Clinical advantages completely unknown

Mode of failure different

Biomechanical properties similar to external fixators

Long locked plates with good biomechanical characteristics

Unicortical locked screws with good biomechanical characteristics

What is known?

Screw position is important

No loss of fixation, high axial load to failure with the LISS

Bicortical locked screws may be advantageous in osteoporotic bone

Locked Plating:
Rules, Tips, and Tricks

Rules, Tips, and Tricks

General

rules

MIPPO

Locked Plating rules

Combination

locked and
unlocked rules

General Rules
LISS Locked Plating

MIPPO technique with minimal damage to

vascularity
Unicortical versus bicortical locking screws
Bicortical stronger, ? If clinically necessary

Ability to place lag screws, etc

Other systems have percutaneous options

Peri-Loc

General Rules
1.

LISS Locked Plating

2.

Lag before you lock

Articular Surface Compression

Metaphyseal
Fixation

Metaphyseal
Fixation

Order of Attack
1.

Reduce and fix the articular portion of the

fracture standard rules

2.

Affix the plate to the articular block

3.

Reduce the shaft to the articular block

4.

Stabilize shaft segment

5.

Medial plate (RARE) in tibial plateau

Order of Attack
1.

Reduce and fix the articular portion of the

fracture standard rules

2.

Affix the plate to the articular block?

3.

Reduce the shaft to the articular block?

4.

Stabilize shaft segment

5.

Medial plate (RARE) in tibial plateau

Possibly the order of #2 and #3 should be

reversed???

Incision - Type C

Fix the Articular Portion

Order of Attack
1.

Reduce and fix the articular portion of the

fracture

2.

Affix the plate to the articular block

3.

Reduce the shaft to the articular block

4.

Stabilize shaft segment

5.

Medial plate (RARE) in tibial plateau

Apply Plate

Clamp the plate onto the

condyles

Open versus percutaneous

Locking screws will not

provide plate/bone
compression

Best fit of the precontoured plate

Reduction & Fixation

Beware of hardware crowding

You must consider the location

of your plates and the path of
any fixed angle (locking) screws

The path of locking screws

cannot be varied - PLAN

Locked Plating
Pitfalls

Proximal screws

Do not block the path

of your critical
locking screws with
other screws that can
be placed elsewhere

Planning Fix The Joint

Planning Fix The Joint

Reduction & Fixation

Lag Screw outside of the

plate

Guide wires & cannulated or

conventional screws

Hold plate or dummy plate

against the bone to determine
placement of screws

Use k-wires temporarily with

limited screws until plate is
in place

LAG BEFORE LOCK

Order of Attack
1.

Reduce and fix the articular portion of the

fracture

2.

Affix the plate to the articular block

3.

Reduce the shaft to the articular block

4.

Stabilize shaft segment

5.

Medial plate (RARE) in tibial plateau

Order of Attack
1.

Reduce and fix the articular portion of the

fracture

2.

Affix the plate to the articular block

3.

Reduce the shaft to the articular block

4.

Stabilize shaft segment

5.

Medial plate (RARE) in tibial plateau

Order of Attack
1.

Reduce and fix the articular portion of the fracture

2.

Affix the plate to the articular block

3.

Reduce the shaft to the articular block

4.

Stabilize shaft segment

5.

Medial plate (RARE) in tibial plateau

Depends on medial fragment size

Locking Plates
Pitfalls

Plate alignment

The screws go at a fixed

angle

You will miss bone or get

a transcortical screw if
plate is eccentric

Locking Plates
Pitfalls Transcortical Screws

MIPPO Locked Plating Tip

Do not place any locked screws through the fixator

until you are completely happy with your reduction

Screws are placed as the last step

Use threaded wires and whirlybirds to obtain your

reduction

Supplement with bump under knee

Complications
Posterior Screw Placement

Know your
system!

Complications
Posterior Screw Placement

D is for DANGER

Easy to occur

Risk to vascular
structures

Good lateral view

Place with knee in

flexion

Complications
Posterior Screw Placement

Combination Plate Rules

Apply Plate

Secure plate position on

bone with wires and/or
whirlybirds

If you are only placing

unlocked screws, you
may place them prior to
finalizing all aspects of
reduction

1
2

Insert Screw

When do you use a Locking Screw?

Remember
Cost = 10X

5.0mm Cannulated
Locking Screw

Insert Screw

When do you use a Conical or conventional Screw?

SCREW SELECTION
Joint Reduced?

NO

Reduce the articular

Surface.

YES

Which Screw?

What Effect?

SCREW SELECTION
IFC

PBC

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

Huge advance in plating

Must understand biomechanics and what the

various constructs accomplish

Fixed angle screws are best in poor bone

Need to know and understand the new rules of

locked plating

If you would like to volunteer as an author for

the Resident Slide Project or recommend updates

E-mail OTA

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