Locked Plating and Advanced Augmentation Techniques in Osteoporotic Fractures

Augmented osteosynthesis in fragility fracture

Due to poor bone quality and complexity, some fractures are difficult to treat, with high risk of failure. Moreover, general health is often poor in elderly patients with multiple comorbidity and poor compliance, necessitating perfect first-line management to avoid re-operation. The armamentarium comprises specific internal fixation implants and also complementary methods such as autologous, homologous or heterologous bone graft or bone substitutes with varying mechanical and biological characteristics. Associating these options is what is mean by "augmented fixation". The present review of augmented osteosynthesis addresses the following questions: What are the characteristics of fragility fractures? Fragility fracture is caused by low-energy trauma on bone with poor structural quality and low mineral density. Treatment aims to enable early mobilization and weight-bearing while avoiding mechanical failure of fixation. Prolonged bedrest, loss of mobility and surgical revision are aggravating and sometimes fatal factors in these fragile patients. What are the biological techniques of fixation augmentation in fragility fracture? Autologous or homologous bone graft are the most widely used biological augmentation techniques. They fill spaces and promote osteoconduction and consolidation. Some bone-like phosphocalcic structures are opening up promising lines of research. What are the non-biological techniques of fixation augmentation in fragility fracture? Hydroxyapatite, phosphocalcic cement and acrylic cement are the most widely used synthetic materials. Biological and mechanical effects are variable according to composition, requiring specific implementation. What are the mechanical techniques of fixation augmentation in fragility fracture? There is at present no consensus as to the augmentation techniques to be applied in fragility fracture. Cerclage or complementary plating, or external fixation associated to internal fixation are possibilities. However, the literature consists only of small series reporting surgical techniques specific to a given surgeon or team. When and how should osteosynthesis for fragility fracture be augmented? The choice of augmentation depends on fracture location, comminution, available material and local experience. The more severe the fracture, the more complex the fixation. The approach needs to be adapted to the preoperative planning and the associated mechanical means (plate, complementary cerclage) and prosthetic replacement should be considered in certain joint fractures or fractures close to load-bearing surfaces. LEVEL OF EVIDENCE: V; expert opinion.

Application of Finite Element Analysis Combined With Virtual Computer in Preoperative Planning of Distal Femoral Fracture

Background

Distal femoral fractures are increasing with an aging population. The computer-assisted preoperative planning has great potential, but there are no preoperative plans to determine appropriate fixation methods for distal femoral fractures on an individual basis. The aims of this study are: (1) to describe the technique of finite element analysis combined with computer-assisted preoperative planning to determine a fixation method for distal femoral fractures and (2) to evaluate the intra-operative realization of this technology and the clinical outcomes based on it for distal femoral fractures.

Materials and Methods

Between January 2017 and January 2020, 31 patients with distal femoral fractures treated by open reduction and internal fixation were included and randomly divided into two groups based on preoperative planning methods: conventional group (n = 15) and computer-assisted group (n = 16). Firstly, how to determine the most appropriate plate and screw length and placement in the preoperative planning of distal femoral fractures was described. The time taken for preoperative planning for different fracture types in the computer-assisted group was then analyzed. Finally, intraoperative and postoperative parameters were compared between the conventional and computer-assisted groups, assessing operative time, intraoperative blood loss, number of intraoperative fluoroscopies, days of hospital stay, Visual Analog Scale for Pain Score (VAS), and Knee Society Score (KSS).

Results

Mean total planning time for 33-A, 33-B, and 33-C fractures in computer-assisted group were 194.8 ± 6.49, 163.71 ± 9.22, and 237 ± 5.33 min, respectively. Compared with the conventional group, the patients in the computer-assisted group had less blood loss, fewer fluoroscopic images, and shorter operation time (p < 0.05). However, there was no significant difference in the hospitalization days, KSS score and VAS score between the two groups (p > 0.05).

Conclusions

The results of this study show that finite element combined with computer-assisted preoperative planning can effectively help surgeons to make accurate and clinically relevant preoperative planning for distal femoral fractures, especially in the selection of appropriate plate length and screw positioning.

[Current status and progress of locking plate in the treatment of distal femoral comminuted fracture]

OBJECTIVE

To review the current status and progress of locking plate for the treatment of distal femoral comminuted fractures.

METHODS

The related literature was extensively reviewed to summarize the current status and progress in the treatment of distal femoral comminuted fracture with locking plate from four aspects: the current treatment situation, the shortcomings of locking plate and countermeasures, the progress of locking technology, locking plate and digital orthopedic technology.

RESULTS

Treatment of distal femoral comminuted fractures is challenging. Locking plates, the most commonly used fixation for distal femoral comminuted fractures, still face a high rate of treatment failure. Double plates can improve the mechanical stability of comminuted fractures, but specific quantitative criteria are still lacking for when to choose double plates for fixation. The far cortial locking screw has shown good application value in improving the micro-movement and promoting the growth of callus. The biphasic plating is a development of the traditional locking plate, but needs further clinical examination. As an auxiliary means, digital orthopedic technology shows a good application prospect.

CONCLUSION

The inherent defect of locking plate is a factor that affects the prognosis of distal femoral comminuted fracture. The optimization of locking technology combined with digital orthopedic technology is expected to reduce the failure rate of treatment of distal femoral comminuted fracture.

Biomechanics of Osteoporotic Fracture Care: Advances in Locking Plate and Intramedullary Nail Technology

Osteoporotic fractures are extremely common and will continue to increase. Methods of internal fixation must address challenges presented by architectural changes of weakened bone. The goals of surgery are to provide mechanically stable internal fixation with minimal biologic insult that provides rapid rehabilitation and early mobilization. Novel techniques and technology that reinforce preservation of periosteal blood supply and utilization of biomechanically stable constructs diminish failure rates. Advents in locking plate technology, intramedullary nail designs, bone augmentation, and multiple implant constructs maximize strength while mitigating axial, torsional, and bending failure modes to provide optimal patient outcomes.

Bicortical versus unicortical fixation of plated clavicular fractures: A biomechanical study

PURPOSE

To compare the biomechanical properties of three plate stabilization techniques for midshaft clavicle fractures: anatomical bicortical locking construct, anatomical unicortical locking construct, and reconstruction bicortical locking construct.

METHODS

We analyzed superior plating of the clavicle using an anatomical clavicle plate (Acumed) with both bicortical or unicortical screw fixation and a locking reconstruction plate (DePuy-Synthes). Twenty-one fourth generation composite clavicles were used for non-destructive stiffness testing in axial loading, bending, and torsion. Fifteen composite clavicles and 17 foam clavicles were used for cyclic failure testing using a combined loading method that included all three loading modes.

RESULTS

No significant differences were found between the three constructs in torsional stiffness nor in vertical bending loading. In axial loading, the anatomical bicortical locking construct was significantly stiffer than either anatomical unicortical locking construct or the reconstruction bicortical locking construct. The unicortical fixation was also significantly stiffer than the reconstruction bicortical locking construct. Regarding failure testing, there was not a significant difference between the bicortical and unicortical anatomical locking constructs; however, both were significantly stronger than bicortical screw fixation in the reconstruction plate.

CONCLUSION

Based on the biomechanical performance of these constructs, unicortical locked plate fixation may be a reasonable option in the treatment of displaced midshaft clavicle fracture fixation.

Case Report: Locking Plate for Cubitus Varus Correction in a 7-Year-Old Girl With Osteogenesis Imperfecta

Background: Cubitus varus deformity is a common complication of untreated elbow fractures in children. However, cubitus varus in osteogenesis imperfecta (OI) children is a rare but challenging situation. To the author's knowledge, this is the first study discussing the correction of cubitus varus deformity in patient with OI. Case Presentation: Here we report a case of a 7-year-old OI girl with cubitus varus deformity due to a supracondylar fracture of humerus 3 year ago. The patient's parent gave a history of supracondylar fracture of left humerus in 2015. Without medical intervention, the patient was admitted into our institution for corrective surgery with the diagnosis of osteogenesis imperfecta and cubitus varus deformity in the left arm. Result: Medications including calcium, vitamin D and bisphosphonates were administered before the corrective surgery of cubitus varus, and a single locking plate was used to fixate the osteotomy. After the surgery, the appearance and range of motion (ROM) of the left arm was almost normal. Combined with gradual rehabilitation, the ROM of the left arm was normal without pain during daily use within the 1-year follow up. The hardware was removed as the nailing of the forearm fractures was performed at the same time. In the latest follow-up in September 2021, the appearance and ROM of the left arm was normal. Conclusion: Cubitus varus is a common deformity in children with elbow injuries, but it presents a challenging situation in compound fractures in OI patients. Locking plate combined with meticulous pharmacological intervention provides a good option for corrective surgery of cubitus varus in patients with OI.

Conical coupling angular stable plate fixation: a retrospective study

Backgrounds.

Conical coupling represents an alternative to screw coupling on angular stable plate fixation. Aims of the present study was to evaluate clinical effectiveness and ease of plate removal of conical coupling locking plates into different scenario regarding quality of bone, type of fracture and operative technique.

Methods.

From May 2013 to December 2017, 198 patients with 206 fractures underwent open reduction and internal fixation with conical locking plate. In most cases fixation involved wrist (38%) and clavicle (24%) fractures but a varied type of fractures and bone were included in the study.

Results.

Ten complications related to plate fixation were observed (5,1%). Two case of intra-articular positioning of screws of wrist plate. One case of loss of reduction and breakage of wrist plate due to an inappropriate proximal fracture fixation. Five cases of complications involved clavicle fixation: three cases of non-union, one case of peri-implant fracture, one screw loosening. One non-union of distal tibial fracture, one non-union in olecranon fracture were finally observed. Thirty-four patients that have symptoms that could be traceable to the implants in-situ underwent plate removal. No complications were observed during surgical plates removal. Conical coupling angular stability plate represents an actractive alternative to threaded angular stability plate. Bush titanium insert, eliminating the problems of cold welding and cross-threading, simplifies surgical screws and plate removal

Minimally invasive posterior locked compression plate osteosynthesis shows excellent results in elderly patients with fragility fractures of the pelvis

Purpose

Fragility fractures of the pelvis (FFP) are common in older patients. We evaluated the clinical outcome of using a minimally invasive posterior locked compression plate (MIPLCP) as therapeutic alternative.

Methods

53 Patients with insufficiency fractures of the posterior pelvic ring were treated with MIPLCP when suffering from persistent pain and immobility under conservative treatment.

After initial X-ray, CT-scans of the pelvis were performed. In some cases an MRI was also performed to detect occult fractures. Postoperatively patients underwent conventional X-ray controls. Data were retrospectively analyzed for surgical and radiation time, complication rate, clinical outcome and compared to the literature.

Results

Patients (average age 79.1 years) underwent surgery with operation time of 52.3 min (SD 13.9), intra-operative X-ray time of 9.42 s (SD 9.6), mean dose length product of 70.1 mGycm (SD 57.9) and a mean hospital stay of 21.2 days (SD 7.7).

13% patients (n = 7) showed surgery-related complications, such as wound infection, prolonged wound secretion, irritation of the sacral root or clinically inapparent screw malpositioning. 17% (n = 9) showed postoperative complications (one patient died due to pneumonia 24 days after surgery, eight patients developed urinal tract infections).

42 patients managed to return to previous living situation. 34 were followed-up after a mean period of 31.5 (6–90) months and pain level at post-hospital examination of 2.4 (VAS) with an IOWA Pelvic Score of 85.6 (55–99).

Conclusion

We showed that MIPLCP osteosynthesis is a safe surgical alternative in patients with FFP 3 and FFP 4. This treatment is another way of maintaining a high level of stability in the osteoporotic pelvic ring with a relatively low complication rate, low radiation and moderate operation time and a good functional outcome.

The Few Who Made It: Commercially and Clinically Successful Innovative Bone Grafts

Bone reconstruction techniques are mainly based on the use of tissue grafts and artificial scaffolds. The former presents well-known limitations, such as restricted graft availability and donor site morbidity, while the latter commonly results in poor graft integration and fixation in the bone, which leads to the unbalanced distribution of loads, impaired bone formation, increased pain perception, and risk of fracture, ultimately leading to recurrent surgeries. In the past decade, research efforts have been focused on the development of innovative bone substitutes that not only provide immediate mechanical support, but also ensure appropriate graft anchoring by, for example, promoting de novo bone tissue formation. From the countless studies that aimed in this direction, only few have made the big jump from the benchtop to the bedside, whilst most have perished along the challenging path of clinical translation. Herein, we describe some clinically successful cases of bone device development, including biological glues, stem cell-seeded scaffolds, and gene-functionalized bone substitutes. We also discuss the ventures that these technologies went through, the hindrances they faced and the common grounds among them, which might have been key for their success. The ultimate objective of this perspective article is to highlight the important aspects of the clinical translation of an innovative idea in the field of bone grafting, with the aim of commercially and clinically informing new research approaches in the sector.