Locked Plating in

Orthopaedic Trauma:
A Clinical Update

George J. Haidukewych, MD
William Ricci, MD

Dr. Haidukewych is Orthopedic

Traumatologist, Florida Orthopaedic
Institute, Tampa, FL. Dr. Ricci is
Associate Professor of Orthopaedic
Surgery, Washington University School
of Medicine, St. Louis, MO.
Dr. Haidukewych or a member of his
immediate family has received royalties
from and serves as a consultant to or is
an employee of DePuy. Dr. Ricci or a
member of his immediate family has
received research or institutional
support from AONA, Synthes, and
Smith & Nephew; has received royalties
from Smith & Nephew; and serves as a
consultant to or is an employee of Smith
& Nephew, Wright Medical Technology,
and OrthoVita.
Reprint requests: Dr. Haidukewych,
Florida Orthopaedic Institute, 13020 N
Telecom Parkway, Tampa, FL 33637.
J Am Acad Orthop Surg 2008;16:347355
Copyright 2008 by the American
Academy of Orthopaedic Surgeons.

Volume 16, Number 6, June 2008

Abstract
Locked plating for fracture fixation has enjoyed widespread
popularity despite a paucity of published data on outcomes.
Anatomically precontoured locked plates that allow fixation in
various anatomic regions are widely available. New technologies
incorporate subchondral support locking pegs, polyaxial bushings,
and locking washers to improve intraoperative versatility.
However, limited data are available on the efficacy of these new
implants. The clinical performance of locked plates generally has
been good. However, several unique complications have been
noted, such as difficulty with implant removal, malalignment,
fracture distraction, and loss of diaphyseal fixation, especially with
percutaneous techniques and unicortical screws. The expense of
locked plate constructs is a concern. This technology typically
costs three times more than similar unlocked constructs. Locked
constructs should be reserved for problematic fractures that have
demonstrated poor outcomes with unlocked constructs.

Innovations in Locked
Plate Design and
Surgical Techniques

he first commercially available

locked plate designed for periarticular fracture fixation, the Less Invasive Stabilization System (LISS;
Synthes, Paoli, PA), has been in use
in the United States for nearly a
decade. This titanium alloy, fixedtrajectory locking plate with instrumentation optimized for percutaneous insertion demonstrated a clear
advantage over traditional plates
with regard to union rates without
secondary surgery and improved
end-segment fixation.1 The LISS system relies on unicortical shaft fixation and self-drilling, self-tapping
screws. Published data have been en-

couraging. However, malalignment

is not infrequent, even when used by
experienced surgeons2-9 (Figure 1).
Many locked plating designs are
now available. In general, the designs
fit into two broad categoriesthose
with fixed-trajectory locking screws
and those that allow variable axis
screw locking. Most locking plate
systems provide instrumentation to
facilitate percutaneous insertion, allow traditional open techniques, provide the option of inserting either
unlocked or locked screws through
the same plate hole, and allow unicortical or bicortical screw placement. Because many surgeons prefer
to use these plates in conjunction
with traditional open exposures,
most, if not all, newer designs allow
the optional use of a targeting jig.
347

Locked Plating in Orthopaedic Trauma: A Clinical Update

Figure 1

Figure 2

Figure 3

Anteroposterior radiograph demonstrating malalignment of a distal femoral fracture treated percutaneously.

Anteroposterior radiograph
demonstrating proximal unicortical
screw fixation failure in an osteopenic
patient, resulting in nonunion.

Intraoperative anteroposterior
fluoroscopic view of a bicondylar tibial
plateau fracture. Note the multiplanar
lag screws used for articular fixation.
Obstacles to proximal end-segment
fixation can include previously placed
lag screws, fracture planes, and
fracture comminution. Such obstacles
can make placement of fixed-trajectory
locking screws difficult.

Unicortical screw fixation for the

diaphyseal portion of periarticular
plating, popular in first-generation
locked plates, has been an area of
concern, primarily because such
constructs exhibit weakness in torsion, especially in patients with very
thin cortices10 (Figure 2). Kregor et
al6 demonstrated proximal fixation
problems in 5% of patients when
unicortical screws were used to
manage distal femur fracture. Proximal fixation failure was extremely
rare with traditional plates, but distal fixation failure was common. Interestingly, there were no distal fixation failures in the series by Kregor
et al.6 This unique complication of
first-generation locked plates has
driven the development of plates
with screw holes that accept a variety of screw types. Currently, locking screws typically are inserted
after predrilling holes. This allows
tactile confirmation of bicortical
purchase, which may assist the surgeon in confirming plate position on
the diaphysis. No shaft fixation failure has been reported with the use of
bicortical fixation.11
348

Fixed-trajectory locked plates offer the advantages of excellent midterm results as well as a reproducible
surgical technique.8,12-14 However,
obstacles to screw placement can occur, such as when treating periprosthetic fractures, and fractures with
complex multiplanar fracture lines
or previously placed lag screws12,15-17
(Figure 3). In these situations it may
be difficult, if not impossible, to
achieve long screw fixation in periarticular segments, since the screw
trajectory is determined by the manufacturer. The surgeon would have
to either place a shorter screw or
angle the screw within a fixedtrajectory locking hole, resulting in
cross-threading. Even at small
degrees of angulation (5), crossthreading has been demonstrated
biomechanically to significantly decrease the fixation strength at the
screw-plate interface.18
As a result, some manufacturers
have introduced plates that allow
screws to be angled, then locked at
end-point tightening. Most of these
designs rely on some sort of hoop

stress and an additional interface between the screw head and the plate.11
However, few data exist regarding
their mechanical strength and clinical outcomes. Any fixation that relies
on an additional interface between
the screw and the plate rather than
simply on a corresponding threaded
hole likely will not provide equivalent mechanical strength.
To date, no published comparative biomechanical studies exist regarding the various types of locked
plates. Only one clinical series of
fractures treated by variable axis
locked plating exists. Haidukewych
et al,11 in a multicenter series, reported on 56 fractures of the distal
femur and proximal tibia that were
treated with a polyaxial plate. Notably, no varus collapse due to bushing
failure was noted, despite a high percentage of high-energy, unstable injuries. More data are needed on these

Journal of the American Academy of Orthopaedic Surgeons

George J. Haidukewych, MD, and William Ricci, MD

new devices, however, as they may

have their own unique complications that are yet undefined.
Although the great majority of
locking plates have been specifically
anatomically designed for problematic periarticular fractures, such as
those of the distal femur, proximal
tibia, proximal humerus, and distal
radius, locking small- and largefragment straight plating sets are
now available. The indications for
these plates remain undefined. Fractures that have historically been
treated successfully with traditional
plates (eg, humeral shaft, both-bone
forearm, lateral malleolus) require
locked fixation only in very osteopenic patients or those with segmental loss or short end segments as
a result of comminution.19-21
The expense of a locked plating
construct is substantially higher than
that of an equivalent unlocked construct. Much of the cost of such constructs is due to the locking screws
themselves, not the plates.12,20 Most
systems now offer the surgeon the
choice of inserting a locked or unlocked screw through the same hole;
thus, the cost of various screw
choices should be considered. Often,
traditional screws can be used to
compress fractures and pull the
plate down to bone, facilitating reduction. Locking screws can be used to
further stabilize the construct. This
hybridization of locked and unlocked technologies was not available
with first-generation locking plates,
which likely accounted for some of
the difficulties with achieving proper
compression, plate position on the diaphysis, and fracture alignment.
It is prudent to reserve locked
plating for problematic fractures for
which unlocked plates have demonstrated an increased rate of mechanical failure (eg, proximal humerus,
distal radius, distal femur, proximal
tibia). General recommendations for
the use of locked plates are summarized in Table 1.
Volume 16, Number 6, June 2008

Table 1
Indications for Locked Plating
Fractures for Which There Are Published Data Supporting the Use of
Locked Plating
Intra-articular fracture of the distal femur, proximal tibia, distal radius1-44
Short, extra-articular metaphyseal fracture12,13,25,36
Proximal humerus fracture, especially in the osteopenic patient28-35,37
Periprosthetic fracture below THA12,16,45
Periprosthetic fracture above TKA5,12,15,17,38,43
Nonunion of the humerus10,20
Fractures for Which There Are Little or No Clinical Data to Support the
Routine Use of Locked Plating
Diaphyseal fracture of the forearm
Diaphyseal fracture of the humerus
Fractures of the clavicle
Pediatric femur fracture
Fibula (ankle) fracture
Fracture of the distal tibia and pilon fracture
Unicondylar (type B) fracture of the distal femur and proximal tibia
Intertrochanteric or subtrochanteric fracture
THA = total hip arthroplasty, TKA = total knee arthroplasty

Locked Plating of
Fractures of the Upper
Extremity
The relative advantages of locked
platingimproved fixation of endsegment (metaphyseal) fractures that
are prone to collapse and improved
fixation in osteoporotic bonemake
fractures of the proximal humerus
and distal radius the upper extremity
fractures most suited to benefit from
the application of locked plating technology. Not unsurprisingly, locked
plating of these two fracture types has
been studied most thoroughly among
upper extremity fractures.
Distal Radius Fracture
Locked plate fixation of distal radius fractures is associated with fewer complications than is locked plating of proximal humerus fractures.
Mechanical failures have been rare
because of the reduced loads about
the wrist,22-25 although minor
amounts of settling of the distal fragment have been reported. Orbay and
Fernandez22 reported settling in 3 of

24 fractures, resulting in 1 to 2 mm
of shortening without further angular deformity. The authors noted the
importance of placing distal locked
pegs directly beneath the subchondral bone to provide support and
thereby limit this type of fracture
collapse. Musgrave and Idler23 also
found slight fracture settling, with
an average loss of length of 1 mm
(range, 0 to 3 mm) and an average
loss of radial inclination of 1 mm
(range, 0 to 5 mm) in 23 patients
treated with locked volar plates
alone. In the subset of 9 patients
treated with supplemental radial
styloid plating, loss of length and radial inclination was lower. Smith
and Henry24 retrospectively reported
on 22 patients treated with volar
locked plating and compared their
results with those of 18 patients
treated with external fixation. The
authors found a significant difference in final ulnar variance between
the locked plate group and the external fixation group, in favor of the
locked plate group. However, they
did not provide any additional data
349

Locked Plating in Orthopaedic Trauma: A Clinical Update

erage DASH score of 16 and an average grip strength of 75%.

Locked plating of the distal radius
appears to offer stable fixation, even
for comminuted fractures, allowing
early ROM. This treatment is associated with high union rates, low complication rates, and satisfactory clinical outcomes (Figure 4). Multiple
published studies of unlocked volar
plating demonstrate similarly good
results.26,27 Prospective comparative
studies are required to determine the
true advantage of locked plating for
the management of distal radius
fractures. These preliminary results
show little to no complications or
disadvantages to locked plating other than cost.

Figure 4

Anteroposterior (A) and lateral (B) radiographs of an unstable distal radius fracture
in a 50-year-old man. Anteroposterior (C) and lateral (D) postoperative radiographs
following internal fixation with a volar locking plate. The fracture united without
complications.

on the magnitude of the difference.

In general, union rates and time
to union have been satisfactory for
locked plating of distal radius fractures. Average time to union has
been reported to be between 7 and 8
weeks.23,25 Only 1 delayed union was
reported among 32 patients.23 Alignment at union and range of motion
(ROM) also have been generally satisfactory after locked plating of distal radius fractures. One of the reported benefits of locked plating for
distal radius fractures is the safety of
early ROM owing to the improved
stability of the locked construct.
This is true even for comminuted
fractures. In their study, Wright et
350

al25 began gentle active and passive

wrist ROM between postoperative
days 1 and 3, reporting an average
wrist ROM that was slightly better
at follow-up than that seen in the
group treated with an external fixator that spanned the wrist.
Satisfactory results for locked plating of distal radius fractures have been
observed using other measures of
functional outcome, as well. Orbay
and Fernandez22 reported an average
Disabilities of the Arm, Shoulder, and
Hand Questionnaire (DASH) score of
8.3 (range, 0-100; the lower the score,
the better) and average grip strength
of 77% compared with the contralateral side. Wright et al25 reported an av-

Proximal Humerus
Fracture
The large range of methods (eg,
plating, nailing, tension band fixation, arthroplasty) used for the management of proximal humerus fractures is a testament to the lack of
clear superiority of any one method.
Furthermore, the large variation in
fracture type (two-part, three-part,
four-part, and head-split, each with
or without associated dislocation)
also makes it difficult to generalize
and recommend any specific method
as the treatment of choice. These
factors and the disparity in outcome
measures used in published reports
make interpretation of results challenging.
Locked plates designed specifically
for the proximal humerus have in
common multiple fixed-angle points
of fixation into the humeral head.
Each screw acts as a miniature blade
plate, with the added benefit of providing fixed-angle support in multiple planes (Figure 5). In theory, the
risk of varus collapse should be lower
with these devices than with unlocked plate-and-screw fixation.
However, construct failure has been
reported with locked plates from mechanical failure of the locking mechanism, and from collapse of the osteoporotic humeral head around

Journal of the American Academy of Orthopaedic Surgeons

George J. Haidukewych, MD, and William Ricci, MD

Figure 5

Unstable proximal humerus fracture treated with a locking proximal humerus plate in a 70-year-old woman. A, Anteroposterior
injury radiograph. B, Postoperative anteroposterior radiograph demonstrating multiple points of proximal fixation. C, Postoperative lateral radiograph. Note that all screw holes in the plate do not need to be filled.

fixed-angle locked screws, much like

a hot knife through butter.28
Recently, the importance of inferomedial screw placement in minimizing
varus collapse has been demonstrated.29
When satisfactory fixation of the
locked screws is achieved in the humeral head, stresses may become
concentrated at other areas of the
construct. Locked screws may fracture at the plate interface. Without
proximal failure, stresses can become concentrated over the working
distance of the plate in the zone of
the surgical neck, where fracture
comminution often prevents screw
fixation.30,31
Despite these multiple potential
modes of failure, evidence suggests
that locked plating offers improved
fixation relative to other methods of
internal fixation. Failure of fixation
of locked plates has been reported to
occur in 3% to 12% of cases,31-34 and
in <10% of cases in all but the series
by Fankhauser et al.30 Nonunion has
been reported only by Bjrkenheim
et al32 (2 of 72 patients). Other complications following locked plating
Volume 16, Number 6, June 2008

of proximal humerus fractures (eg,

impingement30,32) have been infrequent. Infection rates are reported to
be <8%.28,30-34
The relatively low rates of fixation failure, nonunion, and other
complications following locked plating of proximal humerus fractures
would be of little benefit were they
not associated with satisfactory clinical outcomes. Average shoulder
outcome scores have generally been
good and have been remarkably consistent after locked plating. Several
studies each reported average Constant scores of between 72 and 77 (on
a 100-point scale) for their entire cohorts.28,30,32,33
In only one study has locked plating been directly compared with other treatment methods for proximal
humerus fracture. In 2003, Lungershausen et al34 retrospectively reviewed 51 patients with Neer types
2, 3, and 4 proximal humerus fractures treated with locked plating.
The authors compared the results of
the 24 patients available for followup with those of 32 patients treated
with conventional open reduction

and internal fixation without locking. Overall, the Neer outcome score
was 72 in the patients treated with
locked plates and 66 in those treated
with conventional methods. The
only significant difference was a better Neer score for patients with
three-part fractures (81 versus 68;
P < 0.05). Secondary displacement
occurred in two patients in the
locked group and in seven in the unlocked group.
The risk of osteonecrosis is often
cited as a relative indication for
shoulder arthroplasty in the patient
with a three- or four-part proximal
humerus fracture. No direct comparisons have been done of locked plating with hemiarthroplasty in this
group of patients. However, indirect
comparisons reveal favorable results
for locked plating. Osteonecrosis has
been reported to occur in none to
16% of patients with three- and fourpart fractures treated with locked
plating.28,31 Despite these moderate
rates of osteonecrosis, functional results after locked plating of threeand four-part fractures compare favorably with results of hemiarthro351

Locked Plating in Orthopaedic Trauma: A Clinical Update

Figure 6

Locked Plating of
Fractures of the Lower
Extremity
Obtaining and maintaining end-segment fixation is challenging in fractures of the lower extremity (eg,
distal femur, proximal tibia, periprosthetic), especially in osteopenic
patients with comminuted fractures. Given the additional loads inherent to lower extremity function,
it is not surprising that locked plating has essentially replaced conventional plating for these injuries.

Anteroposterior radiograph of a
periprosthetic femur fracture below a
well-fixed femoral component treated
with a locked plate in a 65-year-old
woman. Note the combined use of
unicortical locking screws and cables
proximally. No allograft strut graft was
necessary.

plasty. Average Constant scores following hemiarthroplasty for threeand four-part proximal humerus
fractures are reported to be between
46 and 68.35-37 Locked plating for the
same subset of patients has been reported to result in average Constant
scores of between 57 and 78.28,30-32
High-level-of-evidence studies and
even lower-level comparative studies
have yet to validate a clear advantage
of locked plating over conventional
means. However, early cohort series
indicate consistent and good results
with this method. These findings,
combined with the relative technical
ease and intuitive good sense of a
locked construct for the proximal humerus, have rapidly elevated locked
plating to a standard method of treatment for these fractures.
352

Femoral Periprosthetic
Fracture
High union rates have been
achieved with a combination of minimally invasive submuscular plating and the use of locked plates for
fixation of periprosthetic fractures
above total knee arthroplasty (TKA)
and below total hip arthroplasty
(THA).15,17,38,45 This is likely the result of favorable biology and improved mechanical stability through
the use of locked unicortical screws
in combination with cerclage cables.
Because these plates provide such excellent stability, anteriorly and medially applied allograft struts are less
commonly used. Multiple case series
have reported favorable results using
locked plates for periprosthetic fractures above TKA.15,17,38 The ability to
obtain multiple points of fixation
around the lugs and cement mantle
of a TKA improves distal fixation,
which has led to higher union rates
and lower rates of secondary surgery
compared with historical controls. A
comparative biomechanical study
demonstrated better stability with
retrograde nailing in the presence of
long segments of comminution.38
However, clinically, there must be
enough distal bone stock to achieve
distal fixation with a nail and locking screws. Often, this is not present.
Some of the highest union rates reported have involved the use of
locked plates.
When treating periprosthetic frac-

tures below a THA, some combination of screws and cerclage cables is

typically preferred.16 Screws placed
around a stem are typically unicortical; thus, locked screws are recommended. Cables control bending and
torsion to some extent, and the
locked screws can control length (ie,
axial displacement). With the advent
of locking plates, proximal fixation
has improved, leading to higher
union rates. It is now possible to insert a unicortical locked screw and a
cable in the same plate hold using
buttons that fit into the screw
head. This ability to optimize fixation by using a cable and a locked
unicortical screw at the same level
around stems may obviate the need
for orthogonally placed allograft
struts in many patients (Figure 6).
However, such treatment should be
individualized based on bone quality and construct stability. The longterm effects of drilling and inserting
screws into the cement mantle
around a femoral component are unknown.
Distal Femur Fracture
Of all of the fracture types treated
with locked plating, distal femur fracture has the most reported results and
the longest follow-up.5-9,11-13,15,38-44
Most studies have demonstrated excellent union rates and an acceptably
low complication ratemost notably,
less fixation failure and varus collapse
compared with previously used techniques.11 Problems encountered with
first-generation locked plates included valgus malalignment of the
distal fragment, plate malposition on
the femoral shaft, proximal fixation
failure resulting from unicortical
shaft fixation, and fracture site distraction. These complications have
been minimized with more modern
implant designs and reduction instruments.11,46,47 In most centers, locked
plating has become the procedure of
choice for intra-articular fractures of
the distal femur.
In a recent series, Vallier et al48 reported a 15% rate of nonunion or

Journal of the American Academy of Orthopaedic Surgeons

George J. Haidukewych, MD, and William Ricci, MD

plate failure with a stainless steel

locked plate used in conjunction with
cannulated distal locking screws (Figure 7). Such complications were not
as common with the LISS, a titanium
alloy plate with solid screws.47 Theoretically, the superior fatigue life and
modulus of elasticity of titanium alloy should make it more suitable than
stainless steel for periarticular fixation. It is important to be cautious of
implant improvements until clinical data are available.46-48
Proximal Tibia Fracture
Locked plating is rapidly replacing
traditional plating for complex fractures of the proximal tibia and tibial
plateau. High-energy unstable fractures, such as Schatzker type V and
VI fractures and some type IV fractures, appear to have benefited from
locked plating technology3,4,11,20 (Figure 8). Multiple series have demonstrated excellent union rates. However, infection is a concern with
higher-grade open injuries, even following a period of soft-tissue recovery.
The utility of locked plating in
obtaining proximal fragment fixation has led some authors to use
such constructs for extra-articular
fractures that have historically been
very difficult to nail. These short,
extra-articular fractures often require alternative nail starting points,
larger surgical approaches, and the
use of blocking screws, external fixators, small plates, or other reduction aids. With the development of
percutaneous insertion and screwtargeting aids, plating has become an
attractive alternative to nailing.
Insertion site knee pain is not a
concern when plating these fractures. When such fractures are plated, the plate is inserted with the
knee in full extension. This negates
the pull of the quadriceps muscle
and minimizes extension deformity
of the proximal fragment. The plate
is applied laterally under fluoroscopic control, making valgus deformity
very unlikely as long as there is apVolume 16, Number 6, June 2008

Figure 7

Anteroposterior radiograph
demonstrating locking plate fixation in
a multiply operated distal femur fracture
in a 75-year-old woman.

propriate surgical vigilance.

In all but the most osteopenic patients, locked plating likely offers
little or no advantage when treating
lower-energy unicondylar fractures
(ie, Shatzker type I, II, III, many type
IV). These fractures can be treated
effectively with traditional plates,
which reduces cost. The problem,
however, is that most modern lowprofile precontoured periarticular
plates are manufactured as locking
plates. Because most of the cost is
due to the screws, appropriate use of
locking screws is financially prudent. Additionally, many bicondylar
fractures have coronal medial components and require posteromedial
plating. Locked constructs probably
offer little benefit in fractures that
are double-plated.
Calcaneus and
Foot Fracture
Locking plates are available for
the management of calcaneus fractures. Theoretically, these plates
provide better coronal plane stability of the tuberosity, and they may
provide more robust support of the

Figure 8

Anteroposterior radiograph of a
comminuted bicondylar tibial plateau
fracture in a 45-year-old man treated
with a lateral polyaxial locking plate.
The fracture united without
complication.

reconstructed articular surface. Although biomechanical data have

demonstrated the superior stability
of locked plates, no clinical data are
available documenting superior outcomes compared with conventional
plates. The plates are thicker, and
plate bulk laterally may cause difficulty with the tenuous soft tissues,
which may irritate the peroneal tendons.

Summary
Locking implants for complex fractures have undergone many innovations during the past decade, and their
relative advantages and indications
are increasingly understood. The theoretic advantages of improved stability offered by locked constructs and
the biologic advantages afforded by
muscle-sparing insertion have generally been borne out, with reported
higher union rates. Malalignment,
353

Locked Plating in Orthopaedic Trauma: A Clinical Update

nonunion, implant failure and fracture, and a steep learning curve still
present challenges, but most recent
series demonstrate lower complications with greater surgeon experience
and better instrumentation. Future
constructs likely will improve subchondral supports, improve the
strength of screw angulation and
locking ability, and further facilitate
fracture reduction with specialized instruments.
In general, locked constructs
should be reserved for fixation in osteoporotic patients and for problematic fractures that have demonstrated
high failure rates with conventional
platingmost notably, comminuted
metaphyseal fractures. Early data on
newer polyaxial designs and various
anatomically designed plates are encouraging, but further research is
needed to define the role of these
new technologies.

4.

5.

6.

7.

8.

9.

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