locking compression plate in fractures of osteoporotic bones 2012 -article

7/31/2019 Locking Compression Plate in Fractures of Osteoporotic Bones 2012 -Article

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LOCKING COMPRESSION PLATE IN

FRACTURES OF OSTEOPOROTIC BONES

BY

DR.YOGESH SHIVMURTI KHANDALKAR

M.B.B.S.,D.ORTHO,M.Ch(ORTHO)(USAIM)


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INTRODUCTION

LIFE IS MOVEMENT, MOVEMENT IS LIFE

Life is defined here is said to be present only if active movement is there. To

put this principle into practice is what every orthopedic surgeon concerned

about.

To achieve full movement at a particular joint after a fracture is most

important is early mobilization. This has to be pain free mobilization to have

full support from patients side. Mobilization restores rapid return of blood

flow to bone and soft tissues and also prevents fracture disease.

Plate is an implant which is fastened to the bone for the purpose of fixation.

It can be protection or neutralization or tension band plate. The shape of

plate is an adaptation of plate to the local anatomy and does not denote

any function.

THE AIM OF ANY SURGICAL FRACTURE TREATMENT IS TO RECONSTRUCT

THE ANATOMY AND RESTORE THE FUNCTION.

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OSTEOPOROSIS AND FRACTURES

Osteoporotic fracture treatment remains a challenge for the surgeon, often

with unpredictable outcomes. In this series of cases highlights current

aspects of these fractures and focuses on advances in implant design and

surgical techniques. Osteoporosis is a skeletal disorder characterized by

compromised bone strength, predisposing to an increased risk of fracture in

the clinical setting, it can be defined as a reduction in bone mass of > 2.5 SD

below the mean for the young adult.1-4

This is confirmed in this study by

DEXA SCAN.

More than 40% of women and 14% of men over the age of 50 years will

experience fracture due to osteoporosis.4

Globally approximately 200

million people are at risk of sustaining an osteoporotic fracture each year.5

It is expected that osteoporosis will become epidemic to come as a result of

the increasing number of elderly people.

6

By 2012, 25% of the Europeanpopulation will be over the age of 65 years and by 2020, 52 million people

will be over this in United States.

The most frequent osteoporotic fractures seen in men arise in the spine,

and wrist.7

In women the common fracture sites include the wrist, spine,

humors femur and ribs. In the rising incidence of proximal fracture of the

femur represents the most important socio-economic impact of

osteoporosis.8

In 2000, there were approximately 424000 hip fractures

worldwide and 1098000 in women. Based upon altering demographics and

the increase in life expectancy is estimated that by 2025 there will be an

increase of 89% in men, resulting in 800000 hip fractures per year, and in

women the numbers will rise by 69% to 1.8 million.8

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Osteoporosis is characterized by thinner cross- linking connections within

trabecular bone.9

Endosteal diaphyseal restoration and medullary

expansion are common in both men and women changes in diameter of the

inner and outer cortices affect the bending and torsional characteristics of

the entire bone and predispose to low-energy fractures, which often have a

complex pattern at tissue level, there is a decrease in the cancellous bone

mineral density.10,19

There is also a decrease in the density of cortical bone,

because of an increase in porosity, which can affect the holding of screws.11

The healing of a fracture in osteoporotic bone passes through the normal

stages and concerned with union of the fracture although the healing

process is prolonged.12

There is evidence of animal models. Namkung-

Matthail et al.13

, showed a 40% reduction of callus in the cross-sectional

area and a 23% reduction in bone mineral density in the healing femur of an

osteoporotic bone (postoophorectomy and low calcium diet). Similar results

demonstrating that healing took longer in rats, and both stiffness and

strength remain below the values of controls, where found Meyer et al.14

The major technical problem facing the surgeon is difficult secure fixation,

less corticocancelleous screw purchase leading to decrease pull-out

strength of implants. BMD correlates linearly with holding power of the

screws

15-16

. In osteoporotic bone microfracture and loosening of implant,resorption of the bone is due to reduced strength tolerance.

17-18The

operative treatment of metaphyseal fractures in the elderly is associated

with an increased rate of complications; and implant failure occur in 2% to

10% of fractures, malunion in 4% to 40% and re-operation to 23%.19-24

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The high rate of complications has encouraged extensive research into the

development of which can improve the bone-implant interface by

preventing high stress and distributing the load transmitted to bone in a

load-sharing, rather than load-bearing way.

Techniques of the internal fixation which aim to provide absolute stability

with lag screws are usually inappropriate in Buttress-plate fixation of

metaphyseal fractures is effective in osteoporotic bone as it avoids strains

at a single screw while the implant provides a large contact area at the

bone-implant surface again reducing strain.22

Fixed-angle devices, such as the angled blade plate, are very useful as they

resist angular deformation and torsion, and the strain is reduced because

the blade has a large surface and initial success with fixed- angle implants

such as the blade plates23-24

has led t the development of screws which are

rigidly fixed to the plate. This was first achieved by adding Schuhli nuts (S

Paoli, Pennsylvania) to standard plates and, more recently, with threaded

holes incorporated into the plate, the so-called LOCKING COMPRESSION

PLATED (LCP)25-26

. Plated with locking- head screws also produced a fixed-

angle device and have similar mechanical properties. The holding power of

implant can be increased further by having locked screws at multiple fixed

angles.27

Thus LCP has achieved the purpose of angle stability and bone to

plate interface and secured fixation in fractures of osteoporotic bones. Thus

LCP is a plate of new era. An early example of this tried was the pint contact

fixator.28 4


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The main advantage of the locking-plate device is the mechanical couple

between the screw and the plate (fixed-angle device) so that even if the

screw-bone interface fails, the screw plate interface remains intact.

Complete failure of fixation is still possible, and is seen in very severe

osteoporosis, but all screws on one side of the fracture fixation must fail

simultaneously. The implants such as the locking compression plate and the

less invasive stabilization system significant advantages in osteoporotic

bone.22

Comparison between conventional and locking plated have been

conducted in distal29

and diaphyseal30

fractures of the humans and were to

be better suited to provide stable and reliable fixation. A review of the

available literature in the field of plate osteosynthesis31

came to the same

conclusion. Similar developments to include principle of angular stability in

intramedullary nails are now underway.32-33

The treatment of unstable

fractures of the proximal humerus using the se nails has demonstrated thata stable osteosyntheis is achievable in very old patients.

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LOCKING COMPRESSION PLATE:35-36

It is equivalent to external fixator, which is shifted close to the bone. The

Combination hole present in the LCP was designed by Mr. Michael Wagner

& Mr. Robert Frigg in order to incorporate a threaded hole alongside a

dynamic compression unit. A LCP-combination hole has two parts:

1. DCP unit- for cortical and cancellous screws2. Conical thread unit- for L.H.S. (Locking Head Screw)5

THUS LCP IS A NEW ERA IN THE TREATMENT OF FRACTURES OF

OSTEOPOROTIC BONES.

It is an advantageous in patients with severe osteoporosis.

For treating fractures with open reduction and internal fixation. ASIF

(Association for Study of Problems in Internal Fixation) have propounded a

1. Accurate and anatomical reduction.2. Rigid internal fixation3. Atraumatic technique on bone soft tissues. Working hypothesiscomprising of four principles.

4. Early pain free active mobilization especially during first tenpostoperative days.


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AIMS AND OBJESCTIVES:-

1)To study efficacy of L.C.P. as a treatment modality in case of fractures ofosteoporotic bones.

2)To evaluate the progression of fracture healing in osteoporotic bones.

3)To study effects of fixation fractures by locking compression plate .


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MATERIALS AND METHODS

During the period from Aug 2007 to Dec 2010, 35 cases of osteoporoticfractures confirmed by DEXA scan were selected and prospective study has

done.

Type of study Prospective

Sample Size 35 Patients included in the study

Study Duration 40 Months

Selection of Patients:

Any patient with # of osteoporotic bones was included in the study.

Compound Grade 1; 1/ Gustillo Andersons # type and closed # were also

treated. According to the requirement of the patient the surgical procedure

was done as:

- Open reduction & Int. Fix.OR

- Minimally invasive plate osteosynthesis (MIPO)

Individual case study

X-rays classified all #s according to type & BMD (Bone Mineral Density)

Confirmed by DEXA machine.

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DEXA MACHINE

Each patient underwent a detailed history taking, clinical examination

and assessment of # site. (As per attached proforma)

Fractures were classified whether intraarticular or extraarticular.

8

MANAGEMENT:-


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a)Management in causality:-

On admission, the detailed history was asked regarding mode of injury, time

since injury, any primary treatment taken, and any significant past history.

Patient was thoroughly assessed clinically. Patients vital parameters were

checked, associated-head, chest, abdominal injuries were looked for.

On local examination skin condition, presence of Haemarthrosis, instability

at joint and any distal neurovascular compromise was looked. Any other

associated limb or bone fracture was checked.

Depending on the vital parameters and general condition, an intravenous

access was sought for and intravenous fluids were given whenever

necessary. All other injuries and associated fractures were immobilized and

taken appropriate care.

If associated contused, lacerated wounds were present, they were given a

thorough wash and cleaned with savlon, hydrogen peroxide, normal saline,

betadine and dressing was applied.Bolus dose of intravenous broad-spectrum antibiotic was given when

associated wounds. Intravenous/ Intramuscular NSAIDs were given after

systemic injuries were ruled out.

Anteroposterior, lateral, and oblique, views radiographs of affected part

were taken.

9

b) Management thereafter:-


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As required, the patients with Haemarthrosis, associated dislocation,

compartment syndrome, were subsequently taken to operation theatre.

In patients with associated unclean wounds, at other sites, surgical

debridement under appropriate anesthesia was done. The wound was

cleaned with savlon, hydrogen peroxide, normal saline, betadine and

dressed. Broad-spectrum antibiotic covering gram positive, gram negative

and anaerobes were started. Tetanus toxoid and antitetanus serum were

given.

Investigation:

The patients who were admitted and were subsequently operated had

following investigation done

a) Routine Investigations:Hemoglobin %, Bleeding time, Clotting time,Peripheral blood smear, Urine- routine and microscopy.

b) For operative point of view:Blood sugar level, blood urea level, serum electrolytes, electrocardiogramand chest skiagram were done.

Radiographs of affected part in anteroposterior and lateral view formed a

major part in deciding the modality of treatment for a particular fracture.

The following questions arose:

Q. What was the type and degree of comminution of fracture?

Q. Was the depression anterior of posterior/

Q. Will bone grafting be required?

Q. Were the collateral and cruciate ligaments avulsed in case of knee injury

and ankle injury?

Answer the above questions and you will be on the right path

10

INSTRUMENTS AND IMPLANT:-


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- Full Swiss AO- synthes instrumentation and implant set- Screwdrivers having a torque limiting devices that avoids stripping of thescrew heads after they are locked in the plate.

- Plates also permit standard self tapping titanium screws which can beused in normal compression mode with all the advantages of compression

technique.

- Minimal invasive technique required image intesifier and radiolucentoperation table. All the operations were performed in operating room of

high standards.

INSTRUMENTS:-

A.O.Standard instruments were used as follows:

1. Guide sleeve

2. A.O. drill bit

3. A.O. depth gauge

4. A.O. drill guid

5. A.O. torque limiting screw driver

6. A.O. quick coupling system

7. A.O. plate bender

8. A.O. standard screw driver

11


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STANDARD A.O. (LARGE FRAGMENT) SET


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STANDARD A.O. (SMALL FRAGMENT) INSTRUMENT

Diagnosis of osteoporosis:

Diagnosis of osterporosis was confirmed by DEXA machine scan. Patient

selected for study was screened for osteoporosis.

12

OPERATIVE PROCEDURE:-


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Preoperative planning:

It was done for every patient managed by this technique. Preoperative

roentgenogram of affected part was taken in anteroposterior, lateral and if

required oblique views.

These roentgenograms were assessed to determine type of fracture

amount of displacement or depression present, probable length of screws

required for particular case; particular direction of the screw insertion

required to achieve compression at fracture site and to avoid neurovascular

damage.

Preoperative planning in each case was helpful in minimizing intra operative

decision-making, shortens the operative time and hence improves the

results. Preoperative PHYSICIAN check up was done in every case.

Anesthesia:-

The operative procedure was performed under spinal anesthesia, I.V.regional anesthesia or general anesthesia depending up on patients

physical fitness and requirement under pneumatic tourniquet control.

Positioning the patient:

Patient was in supine position. The image intensifier was placed on the

opposite side of the table and positioned perpendicular to the table.

Patients Preparation:-

Preoperative scrubbing with savlon and 7.5% povidine iodine scrub for at

least 10 min was done and mopped off with spirit and painting was done

with 10% povidines iodine and spirit.

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Appropriate surgical approach for affected fracture part was made

depending upon upper or lower extremity bone under all aseptic

precautions. Whenever necessary MIPPO technique was used, otherwise

fracture site was exposed.

As tissue respect is important in every surgery tissue handling was kept to

minimum. periosteum was stripped only from the site where the LCP was

to be applied. Open reduction was achieved using bone holding forceps and

LCP was fixed on the reduced fragment with plate holding device.

Whenever necessary few k wires were used to maintain the reduction

Anatomical reduction again confirmed under Image-Intensifier- A.O.

Principle. Drilling done using standard A.O. drill for LCP. Now 3.5 or 4.5 mm

depending upon type of the plate screws are inserted in combihole of LCP.

There was no need of tapping A.O. titanium screws as they are self tapping

screws. Closure was done using vicryl 1-0 and Ethilon 2-0. Negative suction

drain was kept depending upon need and site of fracture.Dressing done on 5

th, 9

th& 11

thpost operative day.

Alternate sutures were removed on 9th

and all sutures removed on 11th

post

operative day. Every patient was taught post operative exercises.

For lower limb walking without weight bearing with the aid of crutches was

started a few days afterwards. Exact timing of beginning of partial and full

weight bearing was judged individually but generally this was not before 6-8

weeks. Follow up with detailed objective assessment was carried out.

Radiographs were taken at 6, 12, 14, 16, 24, 48, 72 weeks. Early and late

complications were recorded and adequately managed.

Pain assessment of each patient done with VISUAL ANAGLOUGUE SCALE &

grading done according as excellent, good, fair, poor.

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Range of movement compared with previous normal movement with each

patient and graded as excellent, good, fair, and poor.

VISUAL ANALOUGE SCALE

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OBSERVATIONS AND RESULTS

Total number of cases were - 35

Table No.1

Age in years No. of cases Percentage

60-70 25 71.42

70-80 08 22.86

80-90 02 5.72

Most of cases were old age group of 60 to 70 years.

Table No. 2

Sex- Male 09 25.72

Sex- Female 26 74.28

Female predominated as commonly involved in home activity and had fall.

16

Table No. 3


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Bone involved No. of cases Percentage

Femur 06 17.14

Humerus 12 34.28

Radius-Ulna 14 40.00

Tibia- Fibula 03 08.58

Total 35 100

Table No. 4

Type of fracture No. of cases Percentage

Transverse 20 57.15

Oblique 11 31..42

Comminuted 04 11.43

Total 35 100

Transverse fractures were most suitable for compression. For comminuted

fractures with large fragments fixation done with interfragmentary screws.

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Table no.5

Type of fractures No. of cases Percentage

Simple fracture 31 88.58

Compound fractures 04 11.42

Gustilo- Anderson

type I

03

Gustilo- Anderson

type II

01

Type I & Type II compound fractures were primarily treated with

debridement under anesthesia. These patients were temporarily

immobilized with slab support or external fixator and antibiotics were

administered. These were taken for definitive surgery after wound healing.

Table No. 6

Mechanism of injury

Type of injury No. of cases Percentage

Vehicular accidents 04 11.43

Fall 31 88.57

From stair-case 14

Fall in bathroom 13

Fall on road 04

Patients predominantly had fall.

18

Table No. 7


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Fractures in upper

limb

23 65.72%

Fractures in lower

limb

12 34.28%

Upper limb fractures predominated compared to lower limb.

Table no. 8

Radiological features considered

1. Anatomical reduction2. Compression3. Position of plate4. Placement of screws5. Interfragmentary compression6.

Primary union

7. Presence/ Absence of infective changes8. Disuse osteoporosis9. Implant complications

Table No. 9

No. of cases Percentage

Screw loosening 00 00

No screw loosening 35 100

19

Table no. 10

Minimum cortices secured in plating different bones


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Humerus 6

Radius 5

Ulna 5

Femur 7

Tibia 6

Fibula 5

Table No. 11

No. of cases Percentage

Postoperative

immobilization

07 20

No immobilization 28 80

Patients having comminution and compound injuries were immobilized

temporarily.

20

Table No. 12


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Weight bearing in lower limb fracture

Early - 10th

post operative day 6 50

Delayed - 10th

day of 5 weeks 3 25

Late - More than 6 weeks 3 25

Table No. 13

Post operative stiffness in adjacent joints

Restriction upto 10 deg. Mild 04

Restriction upto 30 deg. Moderate 02

Restriction more than 30

deg.

Severe 02

Table No. 14

Stiffness in UL 05

Stiffness in LL 03

Postoperative stiffness: It was observed in (10%) cases. Two cases had

ipsilateral fractures of femur, tibia and patella.

21

Table No. 15

UNION

Metaphysis


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No. of weeks 0-2 2-6 6-

12

12-14 14-16 16-18

No. of cases 00 00 00 19 00 00

Percentage 54.28

Diaphysis

No. of weeks 0-2 2-6 6-

12

12-14 14-16 16-18

No. of cases 00 00 00 00 16 00

Percentage 45.72

Healing in 12-14 weeks for metaphyseal and 14-16 for diaphyseal fractures

is considered as excellent.

22

Table no. 16

Infection No. of cases Percentage

Superficial 03 8.58

Deep 01 2.86

Table No. 17


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Complications

1) Postoperative stiffness 08

2) Infection Superficial 03

Deep 01

3) Delayed union

4) Malunion

5) Nonunion

6) Implant failure

7) DNVC

8) Re-fracture

23

Table no. 18

BMD Scores

T-SCORE No. of patients

-2.5 to -3.5 21

-3.5 to -4.0 14

Table No. 19

Range of movement compared to previous level


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Range of movement Excellent

(75%)

Good

(50-

75%)

Fair

(25-

50%)

Poor

(


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25

DISCUSSION

The objective of fracture management is the restoration of optimal pre-

injury status by safes and most reliable method. Early mobilization and

return to pre-injury environment also provides a psychological stimulus to

healing.

Every fracture leads to a complex tissue injury involving the bone and

surrounding soft tissue envelope. Immediate after fracture and during the

repair phase, the following are evident:

1. Local circulatory disturbances,2. Local inflammation,3. Pain,4. Reflex immobilization/ adjustment of joints and surrounding muscles.


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These factors lead to development of fracture disease which is described

by Lucas-Championniere in 1907.

Fracture disease is evident clinically as chronic edema, soft tissue injury and

patchy osteoporosis. Edema, per se, induces intermuscular fibrosis and

atrophy. These fibrotic process cause muscle to develop unphysiological

adhesions to bone and fascia and therefore joint stiffness and contractures.

In case of osteoporotic bones internal fixation of fractured bone is

challenge with regular implant due to weal holding capacity. There is

loosening of screws of back firing of screws. There may be loosening of

plate also. But LCP has revolutionized the treatment by giving angular

stability in internal fixation of fractures and locking head screws.

26

LCP while fixed to bone acts as monoblock unit so chances of implant

loosening are very less as with previous plates.Blood supply of bone beneath the LCP is well maintained as it acts like

internal ex-fixator and plate is well away from bone surface which is very

important in case of osteoporotic bones. So it does not hamper local blood

healing of fixed fractures of osteoporotic bones which is confirmed in our

series of 30 cases so also helps in early pain free mobilization of operated

fractures of osteoporotic bones.

LCP is made up of titanium which is a tuff material and resistant to

corrosive effect. This reduces chances of implant failure and infection due

to stresses across the plate and even after fall after fixation in case old

people. So cost of resurgery and stress of resurgery is avoided in case old

osteoporotic people. Titanium is also resistant to infection and this

important fact proved in our series with cases of two superficial and one


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deep infection. Thus LCP is ideal implant in compound fractures of

osteoporotic bones. So also added advantage of this material is it does not

interfere with investigation like M.R.I. study in case of elderly patients with

fractures of osteoporotic bones.

LCP is bio-friendly and body-friendly material is it can be kept in body

lifelong. So cost of resurgery, stress of resurgery and stress of implant

removal in osteoporotic bones is avoided. Thus it has helped to avoid

socioeconomic burden in our community.

Significant factors which affect union are initial displacement,

communication, associated soft tissue wounds, infection and distraction.

Lambotte (1907), Dannis (1949), Kuntscher (1935), Charnley (1948) and

others have already demonstrated importance of compression and its

tolerance by bone. 27

Muller (1963), Willenger, Bagby and others have advocated use of rigid

internal fixation of diaphyseal fracture.

The significant factors which affect union of fracture are displacement,

comminution, associated soft tissue injuries, infection, and distraction of

fracture fragments and adequacy of blood supply.

By treating these patients with LCP it was possible to mobilize then early

and reduce the changes of fracture diseases. By early rehabilitation, good

physiotherapy these patients could return to their work early and could

ones again start their earning. This not only helps patients and their family

financially but psychologically also. The patient is much happier and

satisfied. In the present series treatment of fractures in these patients with


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LCP was of immense benefit as it facilitated early pain free post operative

mobilization of the patients, without a cumbersome plaster. This prevented

joint stiffness and muscle wasting to a large extent and helped nursing care

and prevention of bedsores and plaster sores.

At operation, when dealing with the fracture, the most important aspects

taken into consideration were perfect anatomical reduction.

This was relatively easy in short oblique and transverse fractures. For

comminuted fractures, perfect anatomical reduction was difficult, but could

be achieved with the help of interfragmentary screws in cases with large

butterfly fragments.

28

The technique of applying a LCP is quite an exacting technique, Requiring

considerable technical skill and a well equipped instrument trolley.

Operating time required was shortened as more experience was gained.

The results of our study were quite comparable with the standard series,

where the average period required for union of the fracture was 12 weeks.

In case of primary union, where no callus is seen it is difficult to assess

union. Minimal callus was seen in few cases mainly due to periosteal

strapping, and did not take part in consolidation of the fracture.

Follow up X-rays were also looked up carefully for presence of infective

changes, osteoporosis and implant complications.

The signs of nonunion, such as increasing fracture gap on roentgenograms

and pain on walking were not encountered in the present series. Also no

case of stress fracture of the plate was seen.


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In present series 35 cases were included.

Most of patients in our series were females from 60-70 years age group;

from low socio economic and middle class family; some of them were dailywedge earners. Period of immobilization and hospitalization mattered a lot

for them from economic point of view as well.

Most commonly involved bones were humerus and radius-ulna.

Mostly transverse and oblique fractures predominated in our series.

Compression can be easily applied to these fractures after achieving good

anatomical reduction. 29

As against that is comminuted fractures compression is difficult to achieve

unless comminution is restricted to only one or two butterfly fragments. In

case of bad comminution we used MIPO technique which shows good

results.

88.58% were simple fractures and 11.42% were compound fractures. These

were Gustilo-Anderson type I and II compound fractures which were

initially treated with debridement, suturing, temporary immobilization and

antibiotics. After complete wound healing, on an average after 7-10 days

these were taken for LCP fixation. Most of cases were fall i.e. 31 of which 14

had fall in bathroom, 13 over stair-case and 04 on road. There were 04

cases of RTA who had fracture due to minor trauma because of

osteoporosis as later on confirmed by DEXA scan.

Because of post operative pain and inflammation response to

physiotherapy was poor in the first 3 days. But later on relative pain free

mobilization could be started in these patients. 07 patients were required


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immobilization for 4-6 weeks due to comminution of fracture and

associated ipsilateral injuries.

65.72% patients had fractures in upper limbs and 34.28% in lower limbs.After rigid fixation of fractures with LCP active mobilization is very easily

isolated and single limb fractures.

30

Important fractures considered:

Plate was positioned on tension side of fractures so as to convert tension

forces into compression forces whenever possible.

Interfragmentary compression could be achieved with separate screws as

well as passing through the plate with over drilling of proximal cortex.

Radiological union is said to exist when the fracture line was totally

obliterated. In case of primary union where no callus was seen it is difficult

to access the union. Minimal callus was present in many cases which was

mainly due to periosteal stripping and did not take part in consolidation of

the fracture.

Follow up X-rays were looked at carefully for presence of infective changes,

osteoporosis and implant complications.


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Radiological union was seen after a period of average 12 weeks for

metaphyseal fractures and 14 weeks for diaphyseal fractures. Total

obliteration of fracture line was taken as radiological union.

Superficial infection was observed in 03 patients. This was restricted to

suture tracts only and could be taken care of easily with proper wound care

and use of antibiotics. 01 case of deep infection was seen in patients who

had compound injury graded as Gustilo-Anderson type II. They were initially

treated by through debridement followed by antibiotics and internal

fixation after wound healing.

31

Post operative stiffness was observed in 08 cases which were put on

physiotherapy and subsequent gain of good range of movement achieved.

The complications can be avoided in case of fractures of osteoporotic bones

by observing following points learned over period of two years-

1) Proper selection of patients2) Thorough post operative preparation3) Aseptic and atraumatic operative technique4) Selecting proper size screws and plates


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32

SUMMARY & CONCLUSIONS

Our series included 35 cases of fractures of osteoporotic bones.

Osteoporosis was confirmed by DEXA machine.

Most of the patients were female.

Common age group of patient was 60-80 years.

All patients were without plaster after surgery which was a problem with

previous implants but not in case with LCP.

All patients had pain free, early and effective mobilization after surgery.

LCP provides optimum hold and stability in case of osteoporotic fractures as

LCP gives angular stability with locking head screws. It acts as monoblock

construct. Locking minimizes the compressive forces exerted by the plate

on the bone.


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As LCP has combination hole, depending upon fracture situation, it can be

used in either a conventional technique (compression principle), bridging

technique (internal fixator principle), or a combination technique

(compression and bridging principles).

Thus LCP has improved patient compliance in case of fractures of

osteoporotic . bones.

33

In the modern day Orthopedic practice with widened indication of internal

fixation LCP is an excellent device in osteoporotic bone. Moreover it

decreases morbidity in old osteoporotic patients.

As function of affected limb is very much important in old people, LCP

offers early mobility and union by fracture site compression compared to

other devices. It does not require post operative external support hence

increases patients compliance.

It has following advantages:

1) Less surgical exposure2) Rigid internal fixation3) Interfragmentary compression4) Early post operative mobilization5) Less chances of infection6) Less chances of stiffness7) Early and good post operative pain relief8) Less chances of delayed union, nonunion, and malunion9) Decrease hospital stay


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10) Early occupational rehabilitation

11) Implant can be kept for life long unless complication

12) Body friendly material

THUS LOCKING COMPRESSION PLATE IN FRACTURES OF OSTEOPOROTIC

BONES IS THE BEST MODALITY OF TREATMENT AT PRESENT TIME. 34


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Recent Advances

1)Failure of proximal Femoral LCP with open reduction and internal

fixation,

2)Good use in periprosthetic fracture Vancouver B1 femoral

fracture- JBJS SEPT.2007 89(9) 1964-9

3)Elbow arthrodesis using two LCP Sept.2007 vol.8 issue 3 page 141

to 146-Techniques in elbow & shoulder surgery

4)Free vascularised fibular bone grafting combined with LCP for

massive bone defects in lower limbJournal of international

orthopaedics 26 jan.2012

5)FUTURE DEVELOPEMENT FEB.2012= POLYAXIAL LOCKING

COMPRESSION PLATES TO FIX SCREWS IN VARIOUS DIRECTIONS.


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39

Proforma

Name:

Age: Sex:

Case No.:

Date of admission:

Date of discharge:

Chief complaints:

History:

Mode of injury

Whether case of polytrauma

Hypovolemia

History of head injury

On exam:

Inspection Compound/Closed

Deformity/Scar/Sinuses/Swelling

Palpation

Abnormal bony mobility

DNVC

Rom at adjacent joint

Pain at # Site

Osteoporosis + / -


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Post operative management:

Period for which pt- immobility 40

Period for which pt is on antibiotic

Suture removal

Mobilization of adjacent joint

Weight bearing

Post operative observations:

Wound healing.

Edema of part.

Changes of sudeck osteodystrophy.

Joint and complications.

41


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Shoulder Stiffness

Painful arc syndrome

Active abductionElbow Stiffness

Myositis Ossificans

Range of flexion

Range of extension

Wrist Stiffness

Deformity

Dorsiflexion

Palmer flexion

Sudeck dystrophyHip Stiffness

Active flexion

Active abduction

Active adduction

Active internal rotation

Active external rotation

Knee Swelling

Stiffness

Flexion deformity

Active extension

Effusion

Crepitus

Patellar tap

Ankle Stiffness

Sudeck dystrophy

Deformity

Active plantar flexionActive dorsiflexion

Deformity- Equinus

42


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Pre operative x -ray

Intra-operative MIPO Technique


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post operative X-RAY

Pre-operative x-ray fracture proximal end ulna


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Intra - operative


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Post operative x-ray


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Post operative ROM

locking compression plate in fractures of osteoporotic bones 2012 -article

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