Effects of hybrid plating with locked and nonlocked screws on the strength of locked plating constructs in the osteoporotic diaphysis.

BACKGROUND: Hybrid plating (HP) may improve fixation strength of locked plating (LP) constructs by combining the use of locked and nonlocked screws within a bone segment. This biomechanical study evaluated whether a hybrid bridge plating construct provides greater fixation strength than an all-locked construct in the osteoporotic diaphysis. METHODS: LP and HP constructs were applied to a validated surrogate of the osteoporotic femoral diaphysis in a bridge plating configuration. In LP constructs, plates were applied with three locking screws on each side of the fracture gap and remained 1 mm elevated. In HP constructs, plates were applied with two conventional screws complemented by a single locked screw on each side of the fracture. Constructs were tested under dynamic loading to failure in bending, torsion, and axial loading to analyze construct strength and failure mechanism in each loading mode. RESULTS: Compared with the LP construct, the HP construct was 7% stronger in bending (p = 0.17), 42% stronger in torsion (p < 0.001), and 7% weaker in axial compression (p = 0.003). In bending, constructs failed by periprosthetic fracture. In torsion, LP constructs failed by screw breakage, and HP constructs failed by periprosthetic fracture or breakage of the locking screw. In axial compression, all constructs failed by screw migration. CONCLUSIONS: HP delivered similar bending strength and higher torsional strength than an all-locked bridge plating construct, while causing only a small decrease in axial strength. It may therefore provide an attractive alternative to an all-locked construct for plate fixation in the osteoporotic diaphysis.

Does locked plating of periprosthetic supracondylar femur fractures promote bone healing by callus formation? Two cases with opposite outcomes.

Contemporary locking plates promote biological fixation through indirect reduction techniques and by elevating the plate from the bone. They have improved fixation strength in osteoporotic bone. Periarticular locking plates are rapidly being adopted for bridge plating of periprosthetic femur fractures. When these plates are used for indirect reduction and bridge plating osteosynthesis, fracture union occurs by secondary bone healing with callus formation which is stimulated by interfragmentary motion. In two patients with similar periprosthetic femur fractures treated with periarticular locking plates one fracture healed by ample callus formation while the other resulted in a non-union and had no callus formation six months post-operatively. The case, which progressed to secondary bone healing with callus formation, exhibited varus migration as a result of loss of fixation. The non-union case retained stable fixation. The difference in outcome may indicate that callus formation was promoted by interfragmentary motion secondary to loss of fixation. Conversely, in absence of fixation failure, callus formation was suppressed by stable fixation with a stiff locking plate construct which reduced interfragmentary motion. These observations suggest that locked plating constructs should be sufficiently flexible when applied for bridge plating of comminuted fractures to promote callus formation.

Locked plating of distal femur fractures leads to inconsistent and asymmetric callus formation.

OBJECTIVES: Locked plating constructs may be too stiff to reliably promote secondary bone healing. This study used a novel imaging technique to quantify periosteal callus formation of distal femur fractures stabilized with locking plates. It investigated the effects of cortex-to-plate distance, bridging span, and implant material on periosteal callus formation. DESIGN: Retrospective cohort study. SETTING: One Level I and one Level II trauma center. PATIENTS: Sixty-four consecutive patients with distal femur fractures (AO types 32A, 33A-C) stabilized with periarticular locking plates. INTERVENTION: Osteosynthesis using indirect reduction and bridge plating with periarticular locking plates. MAIN OUTCOME MEASUREMENT: Periosteal callus size on lateral and anteroposterior radiographs. RESULTS: Callus size varied from 0 to 650 mm2. Deficient callus (20 mm2 or less) formed in 52%, 47%, and 37% of fractures at 6, 12, and 24 weeks postsurgery, respectively. Callus formation was asymmetric, whereby the medial cortex had on average 64% more callus (P=0.001) than the anterior or posterior cortices. A longer bridge span correlated minimally with an increased callus size at Week 6 (P=0.02), but no correlation was found at Weeks 12 and 24 postsurgery. Compared with stainless steel plates, titanium plates had 76%, 71%, and 56% more callus at Week 6 (P=0.04), Week 12 (P=0.03), and Week 24 (P=0.09), respectively. CONCLUSIONS: Stabilization of distal femur fractures with periarticular locking plates can cause inconsistent and asymmetric formation of periosteal callus. A larger bridge span only minimally improves callus formation. The more flexible titanium plates enhanced callus formation compared with stainless steel plates.

A computational technique to measure fracture callus in radiographs.

Callus formation occurs in the presence of secondary bone healing and has relevance to the fracture's mechanical environment. An objective image processing algorithm was developed to standardize the quantitative measurement of periosteal callus area in plain radiographs of long bone fractures. Algorithm accuracy and sensitivity were evaluated using surrogate models. For algorithm validation, callus formation on clinical radiographs was measured manually by orthopaedic surgeons and compared to non-clinicians using the algorithm. The algorithm measured the projected area of surrogate calluses with less than 5% error. However, error will increase when analyzing very small areas of callus and when using radiographs with low image resolution (i.e. 100 pixels per inch). The callus size extracted by the algorithm correlated well to the callus size outlined by the surgeons (R2=0.94, p<0.001). Furthermore, compared to clinician results, the algorithm yielded results with five times less inter-observer variance. This computational technique provides a reliable and efficient method to quantify secondary bone healing response.