Orthogonal Double Plate Fixation for Long Bone Fracture Nonunion

Abstract

PURPOSE Of THE STUDyThe treatment of long bone diaphyseal fracture-nonunion is challenging. While taking into account biological needs, a stable mechanical environment is pertinent for fracture healing. This work aims at evaluating the surgical management of stubborn ununited fractures using orthogonal double plating of diaphyseal fractures with limited periosteal stripping and soft tissue dissection. PATIEnTS AnD METHODSRetrospective analysis in a level I trauma center. Between the years 2007-2009, 22 patients were treated with double plating due to nonunion of long bone fractures. Long bones included three clavicles, six humeri, three femora, seven ulnae, two tibiae and one radius. The mean period between index procedures (if existed) and revision procedures was 53.35 weeks (range 6 months-3 years). The same surgical technique, independent on the anatomical location was utilized. Perioperative intravenous antibiotics were withheld until intraoperative cultures were obtained in all patients. An approach to the fracture site was performed with removal of all previous existing hardware, including aggressive debridement of the nonunion site while keeping stripping to the necessary minimum. After primary plate fixation of the fracture with adequate compression, a second plate, with at least two well spaced screws on each side, was placed at a ninety degree angle to the primary plate. Autologous bone graft or bone graft substitute was placed in most, but not all cases. All procedures and assessment of union were done by fellowship trained trauma surgeons. In the infected cases, culture specific intravenous antibiotics were administered for six weeks. Quality of life measures included DASH score of the upper extremity, lower extremity functional score (LEfS) for the lower extremity and Short from 12 (Sf-12) for all patients. RESULTSUnion was achieved in all patients, with an average time to union of 5.8 months (range 2-24 months). One patient healed after a repeat double plating, since the first procedure was unsuccessful. Tissue culture were positive in 11 out of 22 patients. One clavicular plate was removed, due to irritation. no hardware failure was noted in these cases. Mean LEfS was 59%, quick DASH score -18.5 20 and Sf-12 MCS and PCS were 50.37 15.22 and 49.96 8.5 receptively. COnCLUSIOnDouble plating is a biomechanically sound option for treating long bone fracture nonunion with reasonable results, provided adequate biological conditions are met including eradication of infection.

Management of feline tibial diaphyseal fractures using orthogonal plates performed via minimally invasive plate osteosynthesis

“…Dual-plate fixation for treatment of fractures has been described both biomechanically and clinically in the veterinary and human literature. 7,[12][13][14]17,16,50,51 Orthogonal plating of the tibia provides greater construct stiffness during mediolateral bending and a higher failure load in axial compression when compared with single plating and plate-rod constructs. 16 This may account for the absence in the current study of the complication of plate bending, as reported in a recent study of similar fractures.…”

“…Robust fixation may involve dual-plate fixation, which has been used in the human field for many years, [12][13][14] often as an option for revision of non-union fractures. 14,15 The success of a dual-plate construct has been ascribed to high axial and rotational stiffness, and therefore longterm stability, despite a high-strain environment.…”

“…Robust fixation may involve dual-plate fixation, which has been used in the human field for many years, [12][13][14] often as an option for revision of non-union fractures. 14,15 The success of a dual-plate construct has been ascribed to high axial and rotational stiffness, and therefore longterm stability, despite a high-strain environment. 7,[15][16][17] Dual-plate fixation for the initial repair and for the revision of failed plate osteosynthesis in feline diaphyseal tibial fractures has been documented.…”

Surgical stabilization of a distal tibial fracture in a jungle cat (Felis chaus) using orthogonal double plating

“…Double plating provides more resistance to binding and torsion than a single plate, but suboptimal dissection and implant techniques can cause soft tissue disruption and slow bone healing (Meeson, 2017). The orthogonal double plating method is commonly employed for the treatment of long bone fractures (El Haj et al., 2013). This method of fixation provides firm stabilization.…”

Application of autologous cortical bone grafts for femoral non‐union fractures in two dogs

“…The orthogonal double‐plate method has been reported to be an effective procedure for the management of long bone fracture non‐union 21. However, it is better to avoid placing the plate on the cranial aspect of the femoral diaphysis, considering the movement of the quadriceps muscle on this aspect of the femur.…”