A biomechanical evaluation of locked plating for distal fibula fractures in an osteoporotic sawbone model

BackgroundSupination external rotation (SER) injuries are commonly fixed with a one third tubular neutralization plate. This study investigated if a combination locked plate with additional fixation options was biomechanically superior in osteoporotic bone and comminuted fracture models.MethodsUsing an osteoporotic and a comminuted Sawbones model, SER injuries were fixed with a lag screw for simple oblique fibula fractures, and either a one third tubular neutralization plate or a locking plate. Samples were tested in stiffness, peak torque, displacement at failure, and torsion fatigue.ResultsThere was no statistically significant difference in biomechanical testing for fractures treated with a lag screw and plate. For comminuted fractures, locked plating demonstrated statistically significant stiffer fixation.ConclusionA combination locked plate is biomechanically superior to a standard one third tubular plate in comminuted SER ankle fractures. There was no biomechanical superiority between locked and one third tubular plates when the fracture was amenable to a lag screw.     

Comparison of Locking Versus Nonlocking Plates for Distal Fibula Fractures

Locking plates might offer a biomechanical fixation advantage for distal fibula fractures with comminution or osteoporotic bone. In January 2011, our unit introduced a bone-specific locking plate for the distal fibula. The aim of the present study was to compare it against more conventional plating system implants for lateral malleolar fixation in terms of outcomes, crude costs, and complications. We retrospectively reviewed a consecutive cohort of patients with closed ankle fractures who presented within a 24-month period. The clinical and radiographic outcomes were compared among conventional plating using a one-third semitubular plate, a 3.5-mm limited-contact dynamic compression plate, and a 2.7-mm/3.5-mm locking compression distal fibula plate. A total of 145 patients with ankle fractures underwent surgical fixation: 87 (60.0%) with the semitubular plate, 22 (15.2%) with the limited-contact dynamic compression plate, and 36 (24.8%) with the locking compression distal fibula plate. A greater proportion of patients with established osteoporosis or osteoporosis risk factors were in the locking compression distal fibula plate group (27.8% versus 2.3% and 0%). Four patients (2.8%) required washout for infection. No significant differences were found between the sex distribution within the 3 groups (p?=?.432). No significant difference was found in the complication rate (p?=?.914) or the reoperation rate (p?=?.291) among the 3 groups. Although costing >6 times more than a standard fibula fixation construct (implant cost), bone-specific locking compression distal fibula plates add to the portfolio of implants available, especially for unstable fractures with poor bone quality.     

Comparison of different locking plate fixation methods in lateral malleolus fractures

BackgroundSeveral fixation methods may be used for displaced lateral malleolar fractures. We aimed to compare clinical and radiologic outcomes associated with use of locking one third tubular plate vs. anatomical distal fibula locking plate in lateral malleolar fractures.MethodsA total of 62 orthopedic patients operated for lateral malleolus fracture were included in this retrospective study. Patients were divided into two groups regarding the plate used for fixation as locking one third tubular plate (group I; n = 37) and locking anatomical distal fibula plate (group II; n = 25). Data on Danis–Weber ankle fracture classification (Type A, Type B), duration of follow up, clinical outcome [ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) score], radiological outcomes (adequacy of reduction, loss of alignment), time to fracture healing and complications were recorded in study groups.ResultsNo significant difference was noted between groups in terms of AOFAS score [87.0 (73–100) vs. 85.0 (71–100), respectively (p = 0.339)] and no patients had severe restriction in sagittal and hindfoot motion in both groups. The two groups showed similar healing time [9.0 (7–13) weeks vs. 10.0 (8–13) weeks, respectively (p = 0.355)] and complication rate [0.0% vs. 4.0%, respectively (p = 0.403)].ConclusionsThis study revealed no significant difference between use of locking one third tubular plate and locking anatomical distal fibula plate in lateral malleolar fixation, in terms of clinical and radiological outcomes, complication rates and fracture healing time.     

Fibula pro-tibia vs standard locking plate fixation in an ankle fracture saw bone model

BACKGROUNDLocking plate fixation in osteoporotic ankle fractures may fail due to cut-out or metalwork failure. Fibula pro-tibia fixation was a technique prior to the advent of locking plates that was used to enhance stability in ankle fractures by achieving tri or tetra-cortical fixation. With locking plates, the strength of this fixation construct can be further enhanced. There is lack of evidence currently on the merits of tibia-pro-fibula augmented locking plate fixation of unstable ankle fractures.AIMTo assess if there is increased strength to failure, in an ankle fracture saw bone model, with a fibula pro-tibia construct when compared with standard locking plate fixation.METHODSTen osteoporotic saw bones with simulated supination external rotation injuries were used. Five saw bones were fixed with standard locking plates whilst the other 5 saw bones were fixed with locking plates in a fibula pro-tibia construct. The fibula pro-tibia construct involved fixation with 3 consecutive locking screws applied across 3 cortices proximally from the level of the syndesmosis. All fixations were tested in axial external rotation to failure on an electromagnetic test frame (MTS 858 Mini-Bionix test machine, MTS Corp, Eden Praire, MN, United States). Torque at 30 degrees external rotation, failure torque, and external rotation angle at failure were compared between both groups and statistically analyzed.RESULTSThe fibula pro-tibia construct demonstrated a statistically higher torque at 30 degrees external rotation (4.421 ± 0.796 N/m vs 1.451 ± 0.467 N/m; t-test P = 0.000), as well as maximum torque at failure (5.079 ± 0.694N/m vs 2.299 ± 0.931 N/m; t-test P = 0.001) compared to the standard locking plate construct. The fibula pro-tibia construct also had a lower external rotation angle at failure (54.7 ± 14.5 vs 67.7 ± 22.9).CONCLUSIONThe fibula pro-tibia locking plate construct demonstrates biomechanical superiority to standard locking plates in fixation of unstable ankle fractures in this saw bone model. There is merit in the use of this construct in patients with unstable osteoporotic ankle fractures as it may aid improved clinical outcomes.     

A contoured locking plate for distal fibular fractures in osteoporotic bone: a biomechanical cadaver study

ObjectiveFixation of ankle fractures in elderly patients is associated with reduced stability conditioned by osteoporotic bone. Therefore, fixation with implants providing improved biomechanical features could allow a more functional treatment, diminish implant failure and avoid consequences of immobilisation.Materials and methodsIn the actual study, we evaluated a lateral conventional contoured plate with a locking contoured plate stabilising experimentally induced distal fibular fractures in human cadavers from elderly. Ankle fractures were induced by the supination-external rotation mechanism according to Lauge-Hansen. Stage II fractures (AO 44-B1) were fixed with the 2 contoured plates and a torque to failure test was performed. Bone mineral density (BMD) was measured by quantitative computed tomography to correlate the parameters of the biomechanical experiments with bone quality.ResultsThe locking plate showed a higher torque to failure, angle at failure, and maximal torque compared to the conventional plate. In contrast to the nonlocking system, fixation with the locking plate was independent of BMD.ConclusionFixation of distal fibular fractures in osteoporotic bone with the contoured locking plate may be advantageous as compared to the nonlocking contoured plate. The locking plate with improved biomechanical attributes may allow a more functional treatment, reduce complications and consequences of immobilisation.     

A comparison of bone union and complication rates between locking and non-locking plates in distal fibular fracture: Retrospective study of 106 cases

BackgroundAnkle fractures represents the third most frequent fracture in elderly patients. There is a current tendency to fix long bones fractures with locking plates. However, we rarely find published accounts about the use of locking plates in distal fibula fractures, except for biomechanical ones, studying human cadaveric fibula.ObjectivesThe main objective was to compare radiographic bone union rates at 6 and 12 weeks of follow up, then wound complications and hardware removal rates, and construct cost.Study Design & MethodsWe retrospectively analyzed 105 patients who underwent surgery with locking plates or non-locking plates over a two-year period, out of which 42 patients were treated with non-locking plates (VIVES™ - Stryker^Ⓡ) and 63 with locking plates (VariAx™ - Stryker^Ⓡ,). We analyzed bone union on anterior posterior and lateral X-rays of the ankle. We collected data of wound complications and hardware removal from patient records. Multiple linear regression techniques were performed after identifying dependent variables.ResultsThere was no significant difference between non-locking and locking plates in the radiographic bone union rate of distal fibula, respectively at 6 and 12 post-operative weeks (85.71% vs. 81%; p = 0.525 and 97.62% vs. 96.83%; p = 1). No significant difference was found in the wound complication rate between the two groups (11.9% vs. 11.12%; p = 0.9). No significant differences were found in the hardware removal rate, either with or without operative site's infection (respectively: 30.95% vs. 39.68%; p = 0.361 and 21.42% vs. 38.09%; p = 0.071). Cost efficiency is in the favor of non-locking plates.ConclusionNon-locking constructs are as effective as locking constructs in the treatment of displaced distal fibula fractures at a substantially lower cost. High-quality randomized controlled trials are needed in the future to verify the finding of this study.     

Complications after open reduction and internal fixation of ankle fractures in the elderly

BackgroundOpen reduction with internal fixation for unstable ankle fractures is relatively predictable with excellent outcomes. However, the management of ankle fractures in the elderly remains less predictable secondary to the various co-morbidities associated with advanced age.MethodsA retrospective chart review of 216 patients over the age of 60 that sustained an ankle fracture, was performed to determine the incidence of complications after ORIF of ankle fractures in an elderly population in the perioperative course. Secondly, the incidence of complications in patients that had locking plate fixation compared to those that had non-locking plate fixation was determined. Lastly, the effect of early weight bearing on the incidence of complications was analyzed.ResultsThere was not a statistically significant difference in the complication rates between the group with co-morbidities (19.01%) and those without (11.96%). The postoperative complication with the highest incidence was wound dehiscence (9.7%), and only diabetes significantly predicted wound dehiscence. The fixation construct and weight-bearing protocol failed to significantly predict any of the indexed complications.ConclusionsOverall, the results suggest that surgical treatment of unstable ankle fractures in the elderly is fairly predictable with an acceptable complication rate. The complication rates are higher with increased age and diabetes, but they failed to reach statistical significance. Conventional plating appears to provide adequate stability without increased risk of hardware failure. In addition patients that were allowed to walk within the first 2 weeks postoperatively did not experience a higher rate of hardware failure.     

Complications after fibula intramedullary nail fixation of pilon versus ankle fractures

BackgroundIntramedullary nail (IMN) fixation of the fibula in malleolar ankle fractures has been shown to result in less wound complications then plate fixation. Therefore, IMN fibula fixation may also be associated with lower rates of wound complications when used for higher-risk pilon fractures. The purpose of this study was to compare complications of fibula IMN fixation in pilon versus malleolar ankle fractures.MethodsA retrospective cohort comparison was performed at an urban level one trauma center involving fibula fractures in 47 patients with AO/Orthopaedic Trauma Association (OTA) type 43 fractures and 48 patients with AO/OTA type 44 fractures being treated with fibula IMN fixation. Complications, fibula-specific complications, revision surgeries, and implant removals were reviewed.ResultsThere was no detectable difference in complications (27% vs. 23%, 95% confidence interval of the odds ratio (CIOR) 0.5 to 3.2), fibular-specific complications (6% vs. 10%, CIOR 0.1 to 3.5), revision surgeries (4% vs. 4%, CIOR 0.1 to 7.5), or symptomatic fibula implant removals (13% vs. 21%, CIOR 0.1 to 1.6) between pilon and ankle fracture groups, respectively. There was one (2%) fibular nonunion and one wound complication (2%) in each of the fracture groups.ConclusionFibula IMN fixation of pilon versus ankle fractures resulted in a similar number of complications. Comparative studies of fibula IMN and plate fixation are necessary to determine if the benefits of fibula IMN in ankle fractures extends to pilon fractures.Level of evidenceLevel III, retrospective cohort.     

Locking plates in distal humerus fractures： study of 43 patients

Objective:The treatment of multifragmentary,intraarticular fractures of the distal humerus is difficult,even in young patients with bone of good quality.Small distal fragment,diminished bone mineral qu...     

锁定钢板国外应用进展

锁定钢板技术为骨质疏松性骨折和关节周围粉碎性骨折提供了较好的固定方法。与普通非锁定固定技术相比,锁定螺钉增加了固定的稳定性,推动了微创骨折固定技术的运用。锁定钢板的操作比普通钢板要求高,使用锁定钢板要求间接复位骨折块,锁定螺钉必须沿着螺孔的轴线小心地拧入螺钉孔,并确保拧紧。钢板的长度也要仔细选择。随着老年患者骨质疏松性骨折和年轻患者高能量严重创伤后骨折的增加,锁定钢板的使用很可能越来越广泛。     

Comparative analysis of fixation configurations and their effect on outcome after medial open-wedge high tibial osteotomy

PurposeThe purposes of this study were to analyze and compare 1) the postoperative fixation configurations, and 2) radiological and clinical outcomes between the new conceptual fixation device (LCfit) and the conventional locking plates.MethodsRetrospective comparative analysis of 304 cases who underwent open-wedge high tibial osteotomy with four different locking plate systems including the LCfit system was conducted. In analyzing the fixation configuration of each locking plate system, the plate position, the gap between plate and bone, screw angle, and screw length were evaluated from postoperative CT scans. The clinical outcomes and radiological parameters of four patient groups corresponding to the four locking plate systems were also compared.ResultsIn the analysis of the fixation configurations, the LCfit system showed more posteromedial plate position, decreased gap between plate and bone, reduced screw angle, and longer screw length compared to the other three locking plates. However, there were no significant differences in clinical outcomes and radiological parameters such as hip-knee-ankle angle, weight-bearing line position, medial proximal tibial angle, and posterior slope between the four groups.ConclusionThe newly designed fixation system (LCfit) for open-wedge high tibial osteotomy showed fixation configurations that have theoretical mechanical advantages over conventional anatomical locking plates. However, there were no significant differences in clinical outcomes and radiological parameters between LCfit and the other locking plate systems.Level of evidenceLevel III, retrospective cohort study.     

Increased rates of wound complications with locking plates in distal fibular fractures

Introduction

There is a growing use of locking compression plates in fracture surgery. The current study was undertaken to investigate the wound complication rates of locking versus non-locking plates in distal fibular fractures.

Patients and methods

During a 6-year study period all consecutive, closed distal fibular fractures treated with either a locking or a non-locking plate were included and retrospectively analysed for complication related to the fibula.

Results

A total of 165 patients received a one-third tubular plate and 40 patients were treated with a locking plate. The two groups were comparable with respect to patient characteristics (age, gender, smokers and diabetics), injury characteristics (affected side, fracture dislocations, number of fractured malleoli and classification) and operation characteristics (surgical delay and duration, use of a tourniquet and plate length). The wound complication rate was 5.5% in the conventional plating group, and 17.5% in the locking plate group (p = 0.019). This difference was largely due to an increase in major complications, for which removal of the plate was necessary (p = 0.008).

Conclusion

There is a significant increase in wound complications in distal fibular fractures treated with a locking compression plate. In light of the current study, we would caution against the application of the currently used locking compression plates in the treatment of distal fibular fractures.     

Working length and proximal screw constructs in plate osteosynthesis of distal femur fractures

BackgroundThe study purpose is to evaluate the working length, proximal screw density, and diaphyseal fixation mode and the correlation to fracture union after locking plate osteosynthesis of distal femoral fractures using bridge-plating technique.MethodsA four-year retrospective review was performed to identify patients undergoing operative fixation of distal femur fractures with a distal femoral locking plate using bridge-plating technique for the metadiaphyseal region. Primary variables included fracture union, secondary surgery for union, plate working length, and diaphyseal screw technique and configuration. Multiple secondary variables including plate metallurgy and coronal plane fracture alignment were also collected.ResultsNinety-six patients with distal femur fractures with a mean age 60 years met inclusion criteria. None of the clinical parameters were statistically significant indicators of union. Likewise, none of the following surgical technique parameters were associated with fracture union: plate metallurgy, the mean working length, screw density and number of proximal screws and screw cortices. However, diaphyseal screw technique did show statistical significance. Hybrid technique had a statistically significant higher chance of union when compared to locking (p = 0.02). All proximal locking screw constructs were 2.9 times more likely to lead to nonunion.ConclusionsPlating constructs with all locking screws used in the diaphysis when bridge-plating distal femur locking plates were 2.9 times more likely to incur a nonunion. However, other factors associated with more flexible fixation constructs such as increased working length, decreased proximal screw number, and decreased proximal screw density were not significantly associated with union in this study.     

Displaced ankle fractures in the geriatric population: Operative or non-operative treatment

In the current study we retrospectively reviewed the outcome and complications of 118 patients over 70 years of age, with displaced ankle fractures. Six patients had open ankle fractures, all treated with open reduction and internal fixation (ORIF). The complication rate of these patients was very high: two below knee amputations and one death due to sepsis. From the 112 patients with closed ankle fractures included in the study, 72 were treated with ORIF and 40 patients were admitted for manipulation under anaesthetic (MUA) and application of cast. The latter had 27.5% failure rate (patients requiring surgery at a later stage) and a 17.2% re-intervention rate (patients requiring re-manipulation to maintain fracture reduction).We report a 4.1% minor wound complication rate (delayed wound healing) and a similar rate of major wound complication (one below knee amputation and two wounds breakdown) in the group treated operatively. One patient in this group developed a non-union of the fracture, requiring arthrodesis of the ankle. Return to pre-injury mobility level was higher (72% versus 47%, p < 0.005) for the patients treated with ORIF. The results of our study indicate that open reduction and internal fixation of ankle fractures in geriatric patients is efficacious and safe in selected patients and age alone should not dictate the treatment of the ankle fractures in geriatric population.     

术后初次颈干角对锁定钢板治疗肱骨近端骨折疗效的影响

目的 :探讨术后初次颈干角对锁定钢板治疗肱骨近端骨折的疗效。方法 :自2014年6月至2016年9月采用锁定钢板治疗62例肱骨近端骨折患者,男29例,女33例;年龄34~74(55.95±9.48)岁。根据术后初次颈干角不同,将患者分为内翻组(颈干角127°,n=15),正常组(颈干角127°~145°,n=36)和外翻组(颈干角145°,n=11)。比较3组患者的手术时间、骨折愈合时间及并发症情况,并在末次随访时采用疼痛视觉模拟评分(VAS)和Neer肩关节功能评分进行疗效评价。结果:62例患者均获得随访,时间12~38个月,平均17.2个月。内翻组手术时间(2.37±0.59)h,正常组(2.60±0.49)h,外翻组(2.75±0.39)h;内翻组骨折愈合时间(3.99±0.48)个月,正常组(3.78±0.49)个月,外翻组(3.82±0.42)个月;内翻组VAS评分3.67±2.02,正常组3.22±2.06,外翻组4.09±1.58;3组患者在手术时间、骨折愈合时间和VAS评分方面比较,差异无统计学意义(P0.05)。Neer肩关节功能评分,正常组(87.14±6.48)分和外翻组(84.31±9.05)分,均优于内翻组(75.93±9.77)分,差异有统计学意义(P0.05)。内翻组4例出现并发症,正常组2例出现并发症,外翻组未出现明显并发症。结论:术后初次颈干角127°对于锁定钢板治疗肱骨近端骨折可以减少并发症,提高患者术后肩关节功能,获得更满意的术后疗效。     

Innovative techniques for the osteosynthesis of distal humeral fractures

Adequate restoration of the mechanical alignment, anatomic reduction of the articular surface, and stable fixation allowing early motion of the elbow joint are the primary goals in the treatment of distal humeral fractures.The purpose of our study is the comparison of the effectiveness between distal humeral locking compression plates (LCP) and conventional reconstruction and one third tubular plates.Between January 2008 and January 2009, 11 consecutive patients (4 men and 7 women) with distal humeral fractures were treated with plates in our hospital; eight patients were treated with LCP distal humeral plates and three cases were fixed with a combination of 1/3 tubular plates and reconstruction plates. They were all followed up for 12 months using the functional score of Cassebaum and radiologically with standard X-rays.Good to excellent results were obtained in 6/11 patients with a mean range of motion of 115°. At this small cohort of patients no significant differences between the two fixation methods was identified regarding clinical outcome, complications and function of the affected limb.     

Ankle fractures: High implant cost is not associated with better patient reported outcomes

IntroductionAnkle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries.Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture.MethodsAll ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost.ResultsThere was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [−411.8, −54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [−74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48).ConclusionsThe utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.     

Lower reoperation rate with locking plates compared with conventional plates in Vancouver type C periprosthetic femoral fractures: A register study of 639 cases in Sweden

AimTo investigate demographics and outcomes of Vancouver type C periprosthetic femoral fractures (PPFF) treated with open reduction and internal fixation.MethodsPatient data were obtained from medical charts of cases reported to the Swedish Hip Arthroplasty Register and/or from the National Patient Register. Vancouver type C fractures undergoing surgery between 2001 and 2011, in patients who had received their primary THR between 1979 and 2011, were included. Any further reoperation performed between 2001 and 2013 and related to the PPFF constituted the primary outcome.ResultsA total of 632 patients with 639 Vancouver type C fractures were identified. The majority of the patients were women (84%) and they had a fracture distal to a cemented stem (95%). The mean age at the time of fracture was 72 years. Treatment was performed with a locking plate (363 cases), a conventional plate (184 cases), an intramedullary nail (62 cases), or with double plating (30 cases). The overall reoperation rate was 17%, and mortality within one year of the operation was 16%. Locking plates had a significantly lower reoperation rate than conventional plates (p<0.001) and intramedullary nailing (p = 0.005). Interprosthetic femoral fractures did not have a statistically different outcome compared with non-IPFFs.ConclusionsThe lowest reoperation rate was observed using locking plates in Vancouver type C fractures when compared with conventional plates or intramedullary nailing. The presence of an ipsilateral knee prosthesis did not influence the outcome of the surgical treatment.     

Minimally invasive fixation with modified palm tree technique for proximal humerus fractures: Outcomes in a series of 132 patients

IntroductionVarious surgical techniques and implants are available for surgical treatment of significantly displaced proximal humerus fractures. We describe a minimally invasive technique using 3 curved wires, inserted in a retrograde fashion into the humeral head. These are aimed to diverge within the humeral head to provide three separate 3-point fixations to achieve good stability. We present the results of proximal humerus fractures managed with the modified palm tree technique.MethodsA retrospective analysis of data collected prospectively including demographics, radiographs, clinical outcomes, complications and revision surgery for patients treated with the palm tree technique was performed.ResultsBetween 1998 and 2017, 132 patients underwent fixation with this technique. Average age was 61.8 years. Fifty-Eight fractures were 2 part, 46 were three part and 28 were four part. Average follow up was 26 months. In three to four part fractures, a bone graft substitute block was used behind the humeral head fragment for structural support. There were 11 early revisions (8.3%). In 7 cases the fixation failed early and was revised to other implants like angular & locking plates (4), hemiarthroplasties (2) and reverse arthroplasty (1). In 4 cases the construct was revised to achieve better positioning of the wires. From the 125 remaining patients, 120 achieved union(96.8%). There were 3 painless fibrous non-unions and 2 painful non-unions requiring revision. The mean final Constant score was 75.5 and subjective shoulder value was 7.8/10. Nine patients (6.8%) developed avascular necrosis of the humeral head of which three patients were revised later to an arthroplasty.ConclusionThis technique is a simple, minimally invasive technique which can be used for two, three and four part fractures with good functional outcomes and high union rates. No metalwork remains in the proximal humerus should another procedure like arthroplasty be required in case of avascular necrosis of the humeral head or fracture sequela.     

Difficulties encountered removing locked plates

INTRODUCTION

Locked plates are commonly used to obtain fixation in periarticular and comminuted fractures. Their use has also gained popularity in repairing fractures in osteoporotic bone. These plates provide stable fixation and promote biological healing. Over the last 3 years, we have used over 150 locked plates with varying success to fix periarticular fractures involving mainly the knee and ankle. In this study, we report our clinical experience and the difficulties encountered when removing locked plates in adult patients with a variety of indications including implant failure, infection, non-union and a palpable symptomatic implant.

METHODS

A retrospective analysis was performed of patients enrolled prospectively into a database. Included in the study were 36 consecutive adult patients who each underwent the procedure of locked plate removal in a single inner city level 1 trauma centre. Data collected included primary indication for fixation, indication for implant removal, time of the implant in situ, grade of operating surgeon and difficulties encountered during the procedure.

RESULTS

Implant removal was associated with a complication rate of 47%. The major problems encountered were difficulty in removing the locked screws and the implant itself. A total of ten cold welded screws were found in eight cases. Removal was facilitated by high speed metal cutting burrs and screw removal sets in all but one case, where a decision was made to leave the plate in situ.

CONCLUSIONS

The majority of studies investigating implant removal and problems encountered in doing so report a relatively high complication rate. With the advent of locking plates and their growing popularity, difficulties are now being seen intra-operatively when removing them. There is a paucity of data, however, specifically directed at locking plate removal. We recommend that surgeons should be aware of the potential complications while removing locked plates. Fluoroscopic control and all available extra equipment (mainly metal cutting burrs and screw removal sets) should be available in theatre.