Year : 2022 | Volume
: 1 | Issue : 1 | Page : 8--14
Plate osteosynthesis: Newer tools and recent updates
Ganesh Singh Dharmshaktu, Ishwar Singh Dharmshaktu, Naveen Agarwal, Anant Agarwal
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani - 263 139, Uttarakhand
Plate osteosynthesis involves open reduction and internal fixation of fractures with plate application abiding various principles of fixation. The conventional plates currently in widespread use are dynamic compression plate, tubular pates, and locking compression plates. There have always been modifications and advancements in implant development and the plates have also undergone various updates. Many of these developments are in vogue but many are in their primary stages. The newer technical developments and newer implants enrich the surgical armamentarium and address a critical issue in their usage and application. As part of the continuous professional development, working knowledge of key recent advances and new implant development is important for a relevant orthopedic practice.
|How to cite this article:|
Dharmshaktu GS, Dharmshaktu IS, Agarwal N, Agarwal A. Plate osteosynthesis: Newer tools and recent updates.J Uttaranchal Orthop Assoc 2022;1:8-14
|How to cite this URL:|
Dharmshaktu GS, Dharmshaktu IS, Agarwal N, Agarwal A. Plate osteosynthesis: Newer tools and recent updates. J Uttaranchal Orthop Assoc [serial online] 2022 [cited 2023 Apr 1 ];1:8-14
Available from: http://www.juoa.org/text.asp?2022/1/1/8/368392
Open reduction and plate osteosynthesis is a common surgical procedure to manage fractures of not only long bones but few flat bones like scapula and pelvis. Plates are widely used for various indications and have their merits and demerits compared to other implants. Various new types of plates have arrived whereas many of older types are obsolete now. The dynamic compression plate (DCP), locking compression plate (LCP), reconstruction plate (Recon plate), and site-specific anatomical precontoured plates are widely used in current orthopedic practice. Limited contact DCP and LCP have certain advantages over conventional DCP as these interfere less with the native periosteum. LCP, on the other hand, working as an “internal fixator,” can be used through minimal invasive plate osteosynthesis and has revolutionized contemporary fracture management since its launch. Overall, plates have proved their efficacy and safety and work well if the procedure is performed in a standard manner for appropriate indication. Various developments and newer advances are frequently seen in implant development and innovation in plates is not an exception. A few notable updates in the field of plate osteosynthesis are described briefly here. Readers are encouraged to search and read medical literature regarding any of these updates for advanced understanding and comprehensive knowledge. The list is a succinct and topical revision of various updates in the field of plate osteosynthesis.
Variable-Angle Locking Plates
Variable-angle LCPs (VA-LCPs) are now widely available and these have screw holes with different designs as compared to conventional LCP. VA-LCPs have variable-angle holes to accommodate the screw trajectory as per the requirement during surgical fixation. The screws are fastened in a conical “locus of vectors” manner and are ultimately rotated at the plate/screw interface. These variable-angle screws thus inserted are useful to check joint surface penetration, avoid preexisting implants and provide better hold in poor-quality bone. As these plates become increasingly popular; there, however, is a potential risk of rotational strains on an off-axis screw much higher compared to the conventional locked screw. Despite theoretical risk, how much clinical relevance does this difference makes is not fully understood. Surgeon discretion, therefore, is advocated in the usage of VA-LCP system for particular fractures weighing all the pros and cons. These plates have been used extensively in distal radius fractures and better interfragmentary reduction and accurate fixation of distal radius articular fractures have been noted.
Fragment-specific fixation of fractures distal to the watershed line (like volar rim fractures) can also be managed better with VA-LCP as compared to its fixed angle counterpart. Complication rates also were found to be low in the usage of these poly-axial screw plates in a comparative study to fixed angle plates. The complications, however, were found more in distal femur metaphyseal fractures when compared to traditional locking plates and authors advocated a cautious approach in their usage in those subsets of fractures. VA-LCP curved condylar plate by Synthes, however showed a good outcome with comparable fracture healing to standard distal femoral locking plates but offers versatility in screw placement with no early mechanical damages. Similarly, no difference in stiffness of construct in stress-strain curve while using VA-LCP as compared to fixed counterparts was noted in biomechanical testing in distal humerus comminuted fracture models. There was also no screw breakdown or failure at plate–screw interface thus making it an alternative implant in selected cases.
Fractures with bone defects are problematic cases with risk of nonunion and implant failure when managed by single-plate fixation. A helical plate idea to bridge the fracture and supplement the preexisting plate by increasing stiffness and balanced load-sharing. Femoral fractures are very prone to these complications and studies with helical plates on bone models are promising and studies conclude that additional helical plate increases torsional stability and axial stiffness in demanding situation when gaps or defects with fractures make single-plate construct less sturdy.
Biomechanical study demonstrates increased torsional and axial construct stiffness in synthetic bones and overall well-balanced load sharing. It is ideal for challenging fractures with gap/defect where single plate may prove inadequate and may lead to nonunion or implant failure.
The above plate should not be confused with PHILOS plate used for proximal humerus fractures that are twisted to form a helical plate to minimize the risk of radial nerve injury during surgery. This helical plate-making method is well described and requires further evidence to support its usage. Similarly, a plate contoured in helical fashion is also used for humerus diaphysis fractures by placing plate in proximal-lateral and distal-anterior positions. The future study shall reveal more evidence regarding helical plates for routine use.
Catering to diverse demands and therapeutic challenges posed by distal femur fractures, a new concept in plating, the biphasic plate (BP), was conceptualized and manufactured by joint collaboration of AO Research Institute, Davos, Switzerland, and Queensland University of Technology, Brisbane, Australia. The work started in 2018 and is now a CE-certified device with aim of earlier healing and weight bearing. This effort of biphasic anatomical plate development is also supported by AO Development Incubator which will also collect clinical evidences regarding its usage. BP due to its design allows specifically defined motion at fracture site but at the same time avoids implant overloading. The plate has a characteristic slot within distal portion and has proven mechanical benefits in lab testing and preclinical experiments. The plate has garnered appreciation in global platforms but it will take some time before it is widely available in the international markets for generalized use. Comparative studies of BP with distal femoral LCP (DF-LCP) revealed BP providing more consistent interfragmentary movement over a wider loading range and adequate flexibility and implant strength.
Patella fractures are common injuries mostly managed by tension-band wiring (TBW), but the procedure is not without complication. TBW is technically difficult in certain fracture types like comminuted fractures and wire impingement-related problems are not uncommon. Patella plates are now offered by many companies to be used in simple or comminuted factors claiming superior stability. Studies on anatomical knee models also conclude superior construct stability provided by anterior locked plating compared to TBW. Variable angle (VA) locking anterior patella plate (2.7 mm) by Synthes are among various other plating systems available today. Improved performance and extension with decreased implant problems are noted with angle-stable patella plate due to increased mechanical stability. Locking titanium mesh plates are also being used in the treatment of patella fractures and show promising results. For difficult fractures, multilayer fixation is key to better stabilization, and cage plate fixation is also used for improved healing.
Some other forms like titanium anatomical curved plating have also been developed with thin profile and two hook-like blocks at both ends for respective screws. Complication rates of 13% (5 out of 38 cases) in a series were noted like reactive prepatellar bursitis, chronic infection, and loss of reduction on account of pole fragment dislocations in three cases. Mesh plating for intra-articular fractures and a mini-plate shaped like a basket (basket plate) for inferior pole fractures is also used and as per the recent systematic review, plating records better clinical outcome, fewer complications, and high union rates as compared to TBW.
Blunt chest trauma is mostly managed conservatively but many cases face serious morbidity and in certain cases mortality if not managed appropriately. Surgical stabilization and rib fixation or rib plating is gaining acceptance and adoption for symptomatic rib fractures and complex thoracic cage injuries. Its advantage in flail chest in reducing hospital stay, decreasing mortality, and need for further complication is well established. The rib plating has also been performed utilizing video-assisted thoracoscopic surgery. Contoured side-specific and rib-specific plating in a muscle-sparing, however, is preferred method. Lateral approach is used in majority of cases with a curvilinear incision over the affected rib and usually third to eight ribs are plated. The plating may be supplemented with polymer-cable circle in conditions like longitudinal fractures, osteoporotic ribs, and fractures near spine. Furthermore, plating has been found to be superior to wiring in cases of rib and sternal fractures. Hardware failure has also been found to be rare and often asymptomatic and does not require re-operation in rib plating cases.
PEEK/Carbon Fiber-Reinforced PEEK Plates
Carbon fiber-reinforced polyether ether ketone (PEEK) has an elastic modulus similar to human cortical bone and it can be used in places where implant rigidity may be one cause of implant failure. Proximal humerus fractures pose similar challenges and a comparative study of PEEK plates and titanium locking plates in the management of unstable two and three-part fractures was done. This cadaveric biomechanical study revealed PEEK plates having lower fixation strength and thus increased motion at bone–implant interface. The absence of artifacts in computed tomography (CT) or Magnetic resonance imaging (MRI) imaging and the absence of corrosion or cold-welding are added advantages. Carbon fiber plates reinforced with PEEK are composite radiolucent devices and have been widely used in distal radius fractures. Better appreciation of articular reduction during surgery has been cited as one advantage, especially in multi-fragmentary fractures. Good results of PEEK reinforced-carbon fiber composite radiolucent plates were noted in a long series of 64 cases. A recent systematic review concluded that CFR-PEEK plates have high union rates in extremity fractures compared to conventional plates and very low or comparable rate of complications, making these viable alternatives. PEEK allergies, plate failures are also reported and increased cost may be associated with decreased usage in low- and middle-income countries. Implant breakage, local tissue complications, and tendon damages may be limiting factors in their widespread use. Robust clinical studies and evidence are warranted for comprehensive knowledge regarding safety, complication, and long-term outcome of these implants.
3D Printed Plates
3D printing or rapid prototyping or additive manufacturing, has revolutionized many sectors and the bespoke implant manufacturing is an emerging arena. 3D printers convert images into physical models on 3D digital imaging and communication in medicine format data abstracted from CT or MRI through additive manufacturing. Cost-effective manufacturing of patient-specific implants can be made and are instrumental in planning and execution of complex surgeries. Plating of various anatomical sites in challenging situation has been frequently reported. A word of caution regarding increased susceptibility of 3D-printed titanium plates to bacterial adhesion and biofilm formation has been recently noted and caution regarding post-production processing in this regard is advocated. The personalized plates or P-plates, developed for joint fusion surgeries, have been instrumental for simplifying the complex procedure. Finite element analysis combined with 3D printing of plates with design, fabrication method, and evaluation methods has been developed for one tibiotalocalcaneal arthrodesis.Apart from these 3D printed templates for precontouring plates have also been used for various sites like acetabulum.
As the price of 3D printers is decreasing and widespread availability is noted, 3D printing shall be a viable alternative for low-cost implants. It shall also be extremely useful in developing countries and military or disaster units. Apart from fractures, these plates can also be used in deformity correction surgeries like hallux valgus. Combination of 3D printing and PEEK material is another arena that may in future produce PEEK plates for complex cases that are made for specific purpose.
Adjuncts Plates for Periprosthetic Fractures
Various modified LCP constructs are available for specific use in periprosthetic femur fractures (PFF) around well-fixed native femoral stems. Important ones are described briefly below-
Cable plates/cerclage cables integrated into plate
The cerclage done for PFF is technically challenging and is not stable in some cases as it can be displaced or loosened over the desired placement site. Various tools to hold the wire in desired position with the plate are available now. Cable anchoring devices to make its attachment into the plate makes them reliable and stronger. Cable anchoring devices can be mounted on unused plate holes or the drive recess of the screws and the cerclage can then be anchored into the plate. Cerclage buttons fitting into screw head recess to resist pull out of screw-plate construct or the cerclage positioning pins fitting into empty plate holes to maintain the position of cable with respect to the plate are few notable innovations. Crimp positioning pins are other options that fit directly over locking holes to maintain cable position relative to the plate.
Locking attachment plate
Locking attachment plate (LAP) is a recent addition in the armamentarium of managing periprosthetic femur fractures from the house of Synthes (Depuy-Synthes, Warsaw, IN). LAP is a fixed-angle construct that aims to put anterior and posterior screws (2 screws each) around the intramedullary implant and it can be installed on a LCP or VA-LCP. LAP-LCP construct allows a bicortical screw placed laterally to prosthesis stem. Biomechanical superiority of LAP compared to cerclage-LCP system has been demonstrated. Promising results at 1-year follow-up were noted when used around a well-fixed stem in periprosthetic femoral shaft fractures. Low failure rate and adequate fixation was noted in a large series of 28 cases of PFF around well-fixed stem. The authors also concluded that failure was due to plate breakage and not due to failure of fixation at plate-stem overlap.
Dedicated periprosthetic fracture plates
Various different plate systems from various companies exist to tackle the challenges of PFF. Various modifications like multiple screw options, screws at various planes (offset holes), VA screw options, and variability of screw diameter within the same plate holes are notable features. A greater trochanter-specific plate or extensions are additional options in selected cases. NCB® (Non-Contact Bridging) Periprosthetic Femur System by Zimmer displays various plate designs like proximal femur plate, distal femur plate, curved femoral shaft plate, and a trochanteric plate that can be assembled with proximal femur plates.
Suture plates for proximal humerus (Humerus SuturePlate™) and patella (SuturePlate II Patella fracture repair system™) by Arthrex company are plate systems with provisions for suture or cable incorporation within plates for enhanced fixation., Multiple chamfered holes along the plate margin are handy to pass FiberWire® suture in plates with variable-angle screw holes for added stability.
Radial Column Plates
Radial styloid fractures are managed both conservatively and operatively and the operative fixation is mostly done by K-wires. Radial styloid fractures are also difficult to hold by volar locking plates applied for associated distal radius fractures. In recent years concept of radial column with appropriate management of radial column management has gained momentum, especially in comminuted, displayed fractures and those with associated carpal injuries. Dedicated radial column plates are now available that are precontoured and have variable-angle screw holes for diverse fixation. The plates are slided underneath the first compartment and radial column is held provisionally with K-wires before plate application which then buttresses the fracture against shear forces. In cases of associated distal radius fracture, radial styloid plate in addition to volar distal radius plate acts as buttress and provided rigidity by orthogonal fixation of both injuries. A few modifications like Radial Column Pin Plate™ (by TriMed Wrist Fixation System) are also available where pins (two 1.1 mm K-wires) are used as part of fixation construct for radial column.
Bioresorbable plates are being used in orthopedic surgeries and are promising innovations to avoid the removal of implant and second surgery. Sports surgeries have heavily benefitted by using bioresorbable implants like interference screws, pins, suture anchors, meniscal repair implants, and mini-plates. Their usage in major long bone fractures is also under evolution. The less mechanical strength as compared to metal plates and reports of complication in few cases has been a limiting factor apart from availability and cost. These have been extensively used in maxillofacial surgeries and in pediatric cases with mostly absorbable pins used. Biomechanical testing revealed promising but inferior results to conventional volar distal radius LCP and their usage is recommended in good bone-quality cases. Similarly, for unstable metacarpal fracture models, strength and stiffness was found good for 8 weeks, but gradual loss of strength over a period of 12 weeks was noted warranting further studies for adequacy of usage of these plates. As the perception of a patient with these implants is good regarding its resorbing feature but many have apprehension regarding the strength of implant or novelty of the technology. Robust studies are required for better insights and long-term data.
Shape Memory Alloy Plate
Nickel-titanium (NiTi) or nitinol shape memory alloy (SMA) are promising implant materials manufactured by laser cutting and welding of thin, commercially available 0.5–1.0 mm thickness NiTi sheets. Resistance to corrosion, biocompatibility, MRI compatibility, shape memory, and pseudoplastic properties are some advantages of these materials. The inherent property of material causes NiTi devices to undergo induced mechanical deformation and regain of the shape by mechanics or thermal unloading. SMA staples, wires, or arched shape-memory-connector (ASC) are mostly manufactured and used in orthopedic surgeries. These materials are under development for human use but the plates made by SMA have been used in veterinary cases. In vitro experiments to use plates based on nitinol in human diaphyseal fractures have been attempted. It is early to comment on long-term data, safety, and success of these plates.
Titanium Fiber Plate
Titanium is the preferred material of plate osteosynthesis but owing to the difference in its Young's modulus from the native bone, stress shielding is not uncommon leading to bone embrittlement. Researchers from Shinshu University (Japan), molded titanium fibers into plate while simultaneously compressing at normal room temperature and procured material similar to bone in elastic modulus. Apart from it, titanium fibers are porous structures attracting cell adhesion for enhanced bone repair., These are promising developments and further studies shall bring newer insights into these plates.
Screw Modifications within Plate Constructs
Far cortical locking screw construct
LCP construct provides rigid stability and high stiffness which at times can interfere with interfragmentary motion. Most fractures require flexible fixation for secondary healing and callus formation. Rigid locking screws also lead to uneven stress distribution and are responsible for complications like stress fracture at the end screw or stress shielding under the plate. The concept of far cortical locking (FCL) construct was developed in the year 2005 and FCL screws have threads at tip and the head locking into the plate and far cortex respectively. Besides it, screws have shaft with reduced diameter allowing movement at the near cortex as a result of increased working length. It has several advantages like flexibility of fixation (reducing stiffness of plate construct by 80%–85%), progressive stiffening (due to near cortex support of FCL screw), and parallel interfragmentary motion (by S-shaped flexion of FCL screw). Union rates have been found to be higher in FCL construct as compared to bicortical locking groups for fractures of proximal humerus in a comparative study. Its usage in periarticular knee fractures also shows promising results with uniform callus formation and minimal complication rates. Periprosthetic femur fractures are another area where utility of these plates can be instrumental. Various advantages make the FCL an attractive option for selected cases but availability and cost seem to be a problem in their widespread use in developing countries.
Dynamic locking screw
Dynamic locking screw, is a new modification of locking screw which includes an outer sleeve engaging with the bone cortex and an inner pin that lies within the sleeve and locks into the plate. This system, thus serves as a combination of locking construct and dynamic motion. This arrangement also decreases axial construct stiffness and increases interfragmentary motion at the near cortex to promote secondary healing.
The plating of the fractured bone is an important orthopedic surgery and the procedure results in predictable fracture healing if done in standard fashion for an appropriate indication. Various aspects of fixation principles like compression, bridging, buttress, or biological fixation can be achieved by techniques of plate osteosynthesis as per the personality of the fracture. Newer modifications and advancements aim to better implant performance and ultimately the positive outcome. Keeping abreast of the latest developments in the field of implant development is an important part of continuous professional development.
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Conflicts of interest
There are no conflicts of interest.
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