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Indications and Contraindications for Bone Plate Fixation
The selection of bone plate fixation is guided by strict clinical criteria. For patients with flail chest, surgical stabilization with bone plates (SSRF) is universally recommended to restore thoracic stability and reduce mortality. Similarly, patients with multiple severely displaced fractures (double-cortical displacement) or those who fail conservative treatment should be considered for SSRF. A 2021 consensus highlights that pulmonary contusion or traumatic brain injury (TBI) should not be absolute contraindications; instead, personalized assessments are critical. For instance, patients with spinal injuries may require delayed SSRF until spinal stabilization is achieved to avoid exacerbating neurological damage during positioning.
In lumbar spine surgery, cortical bone trajectory (CBT) screws are indicated for osteoporotic patients with lumbar degenerative diseases, including spondylolisthesis and spinal stenosis. CBT’s unique entry point near the midline reduces paraspinal muscle dissection, making it advantageous for obese or elderly patients. However, patients with severe osteoporosis (T-score < -3.5) or active infections at the surgical site are contraindicated for CBT due to increased risks of screw loosening or implant failure.
Surgical Techniques and Innovations
Minimally Invasive Approaches
Minimally invasive plate osteosynthesis (MIPO) has become a cornerstone for long bone fractures, such as femoral or tibial shaft fractures. By inserting plates through submuscular tunnels, MIPO preserves soft tissue and blood supply, reducing infection rates by 40% compared to open reduction. For example, in distal femur fractures, MIPO combined with locking plates achieves stable fixation while minimizing periosteal stripping, which is crucial for fracture healing.
In thoracic surgery, SSRF traditionally involves open approaches, but advancements in thoracoscopic-assisted techniques are emerging. While thoracoscopic SSRF theoretically offers better visualization of posterior fractures, challenges remain in achieving adequate reduction and fixation. Current evidence does not support routine thoracoscopic SSRF, but hybrid approaches combining limited open exposure with thoracoscopic guidance are being explored for select cases.
Biomechanical Optimization
The design of bone plates has evolved to enhance biomechanical stability. CBT screws, for instance, utilize a medial-to-lateral trajectory that increases cortical bone contact, improving pullout strength by 30% in osteoporotic vertebrae. Similarly, locking plates in long bones distribute stress across multiple screws, reducing the risk of fixation failure in comminuted fractures. For pelvic fractures, precontoured anatomical plates that mimic the natural curvature of the iliac wing improve screw placement accuracy, enhancing stability by 25% compared to manual contouring.
Postoperative Management and Complication Prevention
Antibiotic Prophylaxis and Infection Control
Infection prevention is paramount in bone plate fixation. For SSRF, preoperative antibiotics (e.g., cefazolin) are administered within 60 minutes of incision, with intraoperative redosing if surgery exceeds two half-lives of the drug. Vancomycin is preferred for patients with methicillin-resistant Staphylococcus aureus (MRSA) risk factors. In lumbar surgery, CBT’s reduced soft tissue dissection lowers infection rates to 2–3%, but strict aseptic techniques remain essential.
Pain Management and Rehabilitation
Early postoperative mobilization is critical to prevent complications such as deep vein thrombosis (DVT) and muscle atrophy. For SSRF patients, multimodal analgesia (e.g., non-opioid medications, regional nerve blocks) reduces opioid consumption by 50%, facilitating earlier coughing and deep breathing exercises to prevent pneumonia. In lumbar surgery, CBT’s minimal muscle disruption allows patients to ambulate within 24 hours, with physical therapy focusing on core strengthening to support spinal stability.
Hardware Removal Considerations
The timing of hardware removal depends on fracture healing and patient symptoms. For SSRF, plates are typically removed 12–18 months postoperatively to reduce refracture risk, especially in patients under 50. In lumbar surgery, CBT screws may be left in place indefinitely unless they cause irritation or require revision. A 2025 study found that delayed removal (>24 months) increased the risk of screw breakage during extraction, emphasizing the importance of timely follow-up.
Special Considerations for Complex Cases
Osteoporotic Fractures
Osteoporosis complicates bone plate fixation by reducing screw purchase. In lumbar surgery, CBT screws are preferred over traditional pedicle screws for osteoporotic patients due to their superior biomechanical properties. For proximal humerus fractures, locking plates with unicortical screws in the humeral head improve stability while minimizing the risk of screw penetration into the glenoid.
Open Fractures
Open fractures require urgent debridement and stabilization to prevent infection. The ERAS (Enhanced Recovery After Surgery) protocol recommends SSRF within 24 hours for Gustillo Type III open fractures, combined with aggressive soft tissue coverage (e.g., free flaps) within 7 days. In long bones, MIPO is avoided in severely contaminated wounds; instead, external fixators are used initially, followed by delayed plate fixation once the wound is clean.
Pediatric Fractures
While bone plates are less commonly used in children due to growth plate concerns, they are indicated for select cases such as supracondylar humerus fractures with vascular compromise or pelvic fractures requiring stable fixation. Precontoured plates that accommodate growth plates are preferred, and screws are placed away from the physis to minimize growth disturbance.