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Results of Polyaxial Locked-Plate Fixation of Periarticular Fractures of the Knee
George Haidukewych, MD1; Stephen A. Sems, MD2; David Huebner, MD3; Daniel Horwitz, MD4; Bruce Levy, MD5
1 Orthopaedic Trauma Service, Florida Orthopedic Institute, 13020 Telecom Parkway, Temple Terrace, FL 33637. E-mail address: docgjh@aol.com
2 Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
3 New West Sports Medicine and Orthopaedic Surgery, 3219 Central Avenue, Suite 2, Kearney, NE 68847
4 Orthopaedic Center, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108
5 Regions Hospital, 640 Jackson Street, St. Paul, MN 55101
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (DePuy). Also, a commercial entity (DePuy) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.
Investigation performed at the Orthopedic Trauma Service, Florida Orthopedic Institute, Temple Terrace, Florida; the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota; New West Sports Medicine and Orthopaedic Surgery, Kearney, Nebraska; Orthopaedic Center, University of Utah, Salt Lake City, Utah; and Regions Hospital, St. Paul, Minnesota

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Mar 01;89(3):614-620. doi: 10.2106/JBJS.F.00510
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Abstract

Background: Locked-plate fracture-fixation techniques and designs continue to evolve. Polyaxial locking plates that allow screw angulation and end-point locking have become available; however, there are no clinical data documenting their strength and efficacy, to our knowledge. The purpose of this study was to evaluate the clinical performance of a variable-axis locking plate in a multicenter series of periarticular fractures about the knee.

Methods: Between 2003 and 2005, fifty-four patients with a total of fifty-six fractures were treated with a polyaxial locked-plate fixation system (DePuy, Warsaw, Indiana). There were twenty male patients and thirty-four female patients with a mean age of fifty-seven years. There were twenty-five distal femoral fractures and thirty-one proximal tibial fractures. Twelve of the fractures were open. Clinical and radiographic data, including changes in alignment, hardware breakage, or other mechanical complications of the device, were retrospectively reviewed. Function was assessed with use of the Knee Society scores. One patient with a bilateral fracture died less than three months postoperatively, and two patients were lost to follow-up prior to union. Fifty-two fractures in fifty-one patients were followed to union or for a minimum of six months; the mean duration of follow-up was nine months (range, six to twenty-five months).

Results: Forty-nine (94%) of the fifty-two fractures united. There were no mechanical complications. Most importantly, there was no evidence of varus collapse as a result of polyaxial screw failure. There were three deep infections and one aseptic nonunion. No plate fractured, and no screw cut out.

Conclusions: The variable-axis locking plates performed well, with a high rate of fracture union and no evidence of varus collapse due to failure of the polyaxial screw fixation, in a series of complex fractures about the knee. Complication rates were similar to those for historical controls treated with fixed-trajectory locking plates. Polyaxial locking plates offer more fixation versatility without an apparent increase in mechanical complications or loss of reduction.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    George J. Haidukewych, MD
    Posted on May 01, 2007
    Polyaxial Locked Plating for Complex Knee Trauma
    Florida Orthopedic Institute, Tampa, FL

    We would like to thank Dr. Lovisetti and colleagues for their letter regarding our publication evaluating the performance of a polyaxial locked plate for complex knee trauma. We agree that long standing hip to ankle radiographs are generally more accurate in determining limb alignment after bicondylar tibial plateau fractures. We also agree that diaphyseal translation can influence limb alignment.

    We chose to measure the alignment of tibial fractures utilizing a line drawn parallel to the tibial joint line and one perpendicular to the tibial shaft to compare pre and post operative alignment. This method avoided the additional expense (and radiation) of full length films, and we felt that it was adequate to compare alignment CHANGE and to evaluate for varus drift. The comminuted tibial plateau case we chose for a figure was selected because of its highly comminuted meta-diaphysis and the presence of interference screws which necessitated angulation of the locking screws to gain medial purchase. The case also demonstrated indirect reduction and excellent healing despite the high energy nature of the injury.

    We concede that this can be considered a minor malalignment due to some shaft translation. It is not angular, but nevertheless, some shift in limb axis would be inevitable. Nevertheless, the take home point of the study was the fact that no CHANGE in alignment occurred due to bushing failure and that polyaxial technology appears to strong enough to manage such complex fractures.

    Giovanni Lovisetti, M.D.
    Posted on April 25, 2007
    Radiographic Assessment of Lower Extremity Alignment
    Menaggio Hospital via Casartelli 22017 Menaggiio Como, ITALY

    To The Editor:

    We read with great interest the article "Results of Polyaxial Locked -Plate Fixation of Periarticular Fractures of the Knee"(1). In the Results section, the authors reported that "No fractures were seen to be malaligned on the postoperative radiographs, and only two demonstrated malalignment at the time of the last follow up". In support of their statement, they presented radiographic images of a bicondylar tibial plateau fracture (Fig.3 A to E) described as "demonstrating excellent alignment" and "fracture healing without loss of reduction". However, we believe the images show a small but real lateral shift of the diaphysis with consequent valgus malalignment.

    The authors defined a malalignment as an angulation greater than 5° in any plane, and measured tibial alignment by lines drawn along the tibial shaft and parallel to the tibial articular surface. This method may be inaccurate when there are compression fractures of the articular surfaces that can make the articular line less evident (as with the lateral tibial plateau of the case presented). It also does not take into account the malalignment resulting from translation of the tibial shaft. We believe that lower limb alignment can be better assessed using bilateral panoramic x-rays of the entire lower extremities.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    Reference:

    1. Haidukewych G, Sems SA, Huebner D, Horwitz D, Levy B. Results of polyaxial locked-plate fixation of periarticular fractures of the knee. J Bone Joint Surg Am 2007;89:614-620.

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