Therapeutic study, level V (expert opinion). See Guidelines for Authors for a complete description of levels of evidence.

Locked plate technology has evolved in an effort to overcome the limitations associated with conventional plating methods, primarily for improving fixation in osteopenic bone. The development of screw torque and plate-bone interface friction is unnecessary with locked plate designs, significantly decreasing the amount of soft tissue dissection required for implantation, preserving the periosteal blood supply, and facilitating the use of minimally invasive percutaneous bridging fixation techniques. The locked plate is a fixed-angle device because angular motion does not occur at the plate screw interface. The use of locked plate technology allows the orthopaedic surgeon to manage fractures with indirect reduction techniques while providing stable fracture fixation. The secure 'feel' of locked plates, ease of application, and the low incidence of complications noted in early clinical reports have contributed to the proliferation of this technology. Along with reports of clinical successes, as the use of fixed angle/locked plates has increased, clinical failures are being noticed. This review will focus on the biomechanics of locked plate technology, appropriate indications for its use, laboratory and clinical comparisons to conventional plating techniques, and potential mechanisms of locked plate failure that have been observed.

Locked plating constructs were stiffer than the Ogden construct in axial loading and torsion. Although no differences in loads to failure during torsion were noted, locked plating constructs exhibited catastrophic failure not observed with the Ogden construct.

The volar locked fixed-angle plate maintained a greater percentage of its initial stiffness after cyclic loading compared to the dorsal nonlocked plate. Also, the volar locked plate was stiffer than the dorsal nonlocked plate for all loading configurations tested except when subjected to a dorsally applied eccentric load.

Popliteal block provides equivalent postoperative pain control to general anesthesia alone in patients undergoing operative fixation of ankle fractures. However, patients who receive popliteal blocks do experience a significant increase in pain between 12 and 24 hours. Recognition of this "rebound pain" with early narcotic administration may allow patients to have more effective postoperative pain control.

There was no significant difference in the overall construct stiffness between the four fixation constructs. Fixation constructs with a raft of subchondral screws were more resistant to local depression loads. This supports the use of a raft construct when a central depression is a significant component of the overall fracture pattern. Condylar tilt data showed a persistent weakness in the postfixation lateral plateau regardless of fixation construct when compared with the intact specimen. This supports the current clinical practice of delayed weight-bearing for ten to twelve weeks.

Mr W, an 89-year-old veteran, arrived in the emergency department after fallling. He had a history of congestive heart failure, chronic kidney disease, obstructive sleep apnea, asthma, gastroesophageal reflux disease, benign prostatic hyperplasia with urinary incontinence, sensorineural hearing loss, depression, and mild cognitive impairment. He also had a vitamin D deficiency and chronic low back pain from lumbar spinal stenosis, despite a laminectomy. Prior to his hip fracture, he ambulated with a 4-wheel walker and had no history of falls.At the occurrence of the hip fracture, Mr W was standing-he twisted suddenly and subsequently lost his balance. He fell onto a hard floor, landing on his left hip and was brought to the hospital by his family. His medications at that time included furosemide, bupropion, citalopram, trazodone, finasteride, terazosin, oxybutynin, albuterol inhaler, loratidine, omeprazole, vitamin D, calcium, senna, acetaminophen, and acidophilus. Prior to the hip fracture, Dr H, his geriatrician, tried on several occasions to reduce the number of medications, but Mr W resisted.On admission, a radiograph of his left hip revealed a minimally displaced femoral neck fracture. The next morning, following medical optimization, Mr W underwent a pinning, in situ while under spinal anesthesia, with 4 screws placed under fluoroscopic guidance. On postoperative day 1, he had escalating pain in his left hip and was administered morphine intravenously and oxycodone orally. Over the next few hours, he became delirious and was transferred to the intensive care unit for bradycardia and hypotension. Mr W continued to have a fluctuating level of alertness for several days. By postoperative day 4, he was able to participate in physical therapy. On day 6, he was discharged to a skilled nursing Author Affiliations are listed at the end of this article.

Both ORIF and EF appear to be comparable for treatment of OTA type 43C (pilon) fractures with regard to final range of ankle motion, development of arthritis and hindfoot scores.