SUPPLEMENT ARTICLE
Absolute Versus Relative Fracture Fixation: Impact on
Fracture Healing
Brent L. Norris, MD,* Gerald Lang, MD,† Thomas A. (Toney) Russell, MD,‡ David L. Rothberg, MD,§
William M. Ricci, MD,k and Joseph Borrelli, Jr, MD, MBA¶
Summary: The goals of all orthopaedic surgeons treating fractures
are, and will remain, obtaining union of the fracture with a well-
aligned and functional limb while minimizing the risk of complica-
tions. This requires us to understand how the biomechanical
environment of the fracture affects healing and to be able to discern
which mechanical environment is preferred over another. Under-
standing the spectrum of stability imparted by our current surgical
devices is paramount to giving our patients the best opportunity to
heal and recover from their injury. Gone are the simplistic views of
plates and screws being applied for absolute stability and nails and
external fixators being applied for relative stability. This review
sheds new light on how the use of different implants provides the
appropriate stability to encourage fracture healing and limit the risk
of complication and loss of function.
Key Words: absolute, relative, stability, osteoporosis, fracture fixa-
tion, healing
(J Orthop Trauma 2018;32:S12–S16)
INTRODUCTION
The perfect fracture treatment regimen has yet to be
developed, which would successfully address each of the
fracture types that occur. Fractures come in a wide variety of
settings, including open and closed, diaphyseal, metaphyseal,
epiphyseal and in combinations of all 3. Fractures also come
in a variety of fracture patterns from simple transverse to
complex comminuted intra-articular and segmental fractures.
Fractures occur in a variety of different systemic environ-
ments, including in young, healthy individuals and older, less
Accepted for publication December 11, 2017.
From the *Division of Orthopaedic Surgery, Department of Surgery, Univer-
sity of Oklahoma School of Medicine, Tulsa, OK; †Department of Ortho-
pedic Surgery, University of Wisconsin, Madison, WI; ‡Department of
Orthopedic Surgery, Campbell Clinic/University of Tennessee Center for
Health Sciences, Memphis, TN; §Division of Orthopaedic Trauma, Depart-
ment of Orthopaedics, University of Utah, Salt Lake City, UT; kThe
Hospital for Special Surgery, Weill College of Medicine, New York,
NY; and ¶Orthopedic Surgery, BayCare Medical Group, St. Joseph’s
Hospital-North, Lutz, FL.
The authors report no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.jorthotrauma.
com).
Reprints: Joseph Borrelli, Jr, MD, MBA, BayCare Medical Group, 4211 Van
Dyke Road, Suite 200, Lutz, FL 33558 (e-mail: jborthodoc58@gmail.com).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000001124
S12 | www.jorthotrauma.com
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
healthy individuals, and everything in between. Fractures
occur in bone with altered mechanical properties (osteopo-
rotic/fragility fractures), strong stiff bones and those in
environments where their ability to heal is compromised. In
addition, as the world’s population ages and as a direct result
of more and more total joint arthroplasties being implanted
each year, orthopaedic surgeons are seeing more and more
patients with periprosthetic fractures and the unique chal-
lenges these fractures present. Fracture fixation methods have
evolved over the past 100 years and with an ever-improving
understanding of the mechanisms by which fractures heal,
techniques for treating fractures have evolved, and for the
most part improved. Currently, implants for the treatment of
fractures include plates/screws, intramedullary (IM) nails,
external fixators, and, when indicated, prosthetic joint replace-
ment. In general, these implants are used to facilitate fracture
healing by providing fracture stability while complimenting
the biological and mechanical environments of the fracture.
This review will outline the means by which plates can be
used to treat fractures, review why IM nails are currently the
mainstay of diaphyseal and diaphyseal/metaphyseal fracture
treatment, as well as the pros and cons of plate fixation in
osteoporotic bone and for the treatment of periprosthetic frac-
tures, and if bone grafting is necessary to aid healing.
PLATES: ALTERNATIVE FIXATION METHODS
AND THEIR INFLUENCE ON FRACTURE HEALING
There are many variables that affect fracture healing.
These variables often influence the biological and mechanical
factors at the fracture site itself. If there is adequate blood
supply and soft tissue coverage at the fracture site, the
mechanical environment influences the fracture healing
greatly. When treating fractures, one should remain very
mindful of the mechanical environment one is trying to
achieve with the fixation construct. Plate fixation can create
a broad spectrum of stability in conjunction with the fracture
characteristics (configuration and location), and dependent on
fixation/fracture stability, the fracture can heal either by direct
healing or by “secondary” healing or a combination of these 2
mechanisms.
SPECTRUM OF STABILITY
Although we like to quantitate the conditions of
construct stability, it may be best to conceptualize stability
along a spectrum. Absolute stability is at one end of the
J Orthop Trauma  Volume 32, Number 3 Supplement, March 2018
J Orthop Trauma  Volume 32, Number 3 Supplement, March 2018
spectrum, with instability at the other; relative stability being
somewhere in the middle. We can greatly influence where on
that spectrum of stability the fracture is found, and ultimately,
how the fracture heals based on our choices of implants and
methods of fixation (see Fig. 1, Supplemental Digital Con-
tent 1, http://links.lww.com/JOT/A286).
STRAIN THEORY
The strain therapy as put forth by Perren1 involves the
concept of fracture strain or the amount of deformity or
motion that occurs at a fracture gap as a result of the stability
of the fixation construct. Strain can be calculated by compar-
ing the original length of the fracture gap to the size of the gap
under stress (Strain = ΔL/L). If the fracture strain is #2%,
conditions of absolute stability are met, which leads to pri-
mary bone healing. If the fracture strain is between 2% and
10%, this will lead to a condition of relative stability, and
fracture healing will likely proceed by secondary bone heal-
ing, involving a cartilage intermediary. If the strain at the
fracture site is .10%, fibrous tissue will likely form and lead
to a nonunion. If the fracture is stabilized by a means, which
provides “absolute stability” and adequate apposition of the
fracture fragments is created in an appropriate biological envi-
ronment, primary bone healing will occur. Conditions of
absolute stability are obtained surgically by generating com-
pression at the fracture site using lag screws, compression
plates, tension band constructs, and buttress plates. Areas
where small gaps (,1–2 mm) exist under conditions of
absolute stability will be bridged by appositional bone growth
(gap healing) (see Fig. 2, Supplemental Digital Content 2,
http://links.lww.com/JOT/A287).
In fractures stabilized where some interfragmentary
motion occurs between fracture fragments, conditions of “rel-
ative stability” have been achieved. Conditions of relative
stability are typically created with casting, bridge plating,
IM nails, or application of external fixators. These methods
of fixation are most appropriate for metaphyseal and diaphy-
seal fractures (see Fig. 2, Supplemental Digital Content 2,
http://links.lww.com/JOT/A287).
PREOPERATIVE PLANNING
Preoperative planning should include a detailed assess-
ment of the patient and an accurate assessment of the fracture
pattern and the conditions of the surrounding soft tissues.
During preoperative planning, one must decide which type of
fracture healing is most desirable, what reduction strategies
and fixation methods can be used to create the preselected
spectrum of stability, and how best to create a fixation
construct to best achieve it. Simple fracture patterns can
usually be treated with anatomic reduction and compression
plating, which will achieve absolute stability and encourage
primary bone healing. Simple fractures treated with an IM
nail, however, generally heal by secondary bone healing, as
the nail generally provides only relative stability. Commi-
nuted fractures, treated with an IM nail or a bridge plate,
where relative stability is provided also generally heal by
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Absolute Versus Relative Fracture Fixation
secondary bone healing (see Fig. 3, Supplemental Digital
Content 3, http://links.lww.com/JOT/A288).
PROBLEM AREAS
Leaving a fracture gap of greater than 1–2 mm under
conditions of absolute stability often leads to a delay in
healing or nonunion of the fracture. Another problem area
encountered is having too little motion (strain ,2%) or too
much motion (strain .10%) while attempting to create con-
ditions of relative stability. This can lead to inadequate
amounts of callus formation or instability that can lead to
a nonunion even with significant callous formation. Although
somewhat counterintuitive, achieving relative stability in
a simple fracture pattern can lead to high strain (larger ΔL and
smaller L) and an increased risk of nonunion. This may help
us understand why we see an occasional simple diaphyseal
fracture treated with relative stability (either with a bridge
plate or with an IM nail) that is slow to heal progressing to
a nonunion. In the metaphyseal area of bone, particularly at
the proximal tibia and distal femur, IM fixation may lead to
inadequate stability, which can contribute to difficulties in
healing. All the preoperative planning based on biomechanics
will not overcome severe shortcomings in the biological
environment of the fracture. Maintaining and maximizing the
healing capacity of a fracture is always considered when
formulating a preoperative plan.
PLATE-SPECIFIC ISSUES
Plates for fracture fixation can provide multiple func-
tions. Plates can be used to generate compression to create
conditions of absolute stability. They can also provide
a buttressing effect to stabilize fractures under conditions of
absolute stability. When lag screws are used to generate
compression across a fracture site, plates can be used in
a neutralization mode to protect the lag screws that are
producing a condition of absolute stability. Plates can also
function in a bridge mode that produces a condition of
relative stability. The stability produced with a bridge plate
can vary widely depending on the degree of fracture
comminution, length of plate, and size of screw clusters at
either end. Bridge plating can be accomplished with both
locking and nonlocking plates. Use of nonlocking plates
relies on generating friction between the surface of the bone
and the surface of the plate with the screws to maintain
stability and axial length. Use of locking plates for the
technique of bridge plating much more resembles that of an
external fixator.2
SUMMARY
Fracture stability can be modified using plate fixation.
The function of a plate can vary widely, creating a variable
amount of stability at the fracture site. Fracture type, quality
of fracture reduction, and choice of implants and how they are
applied all contribute to construct stability, which has a direct
impact on the type of fracture healing that ultimately occurs.
Simple fractures treated with anatomic reduction and
www.jorthotrauma.com | S13
Norris et al J Orthop Trauma  Volume 32, Number 3 Supplement, March 2018
interfragmentary compression tend to heal with direct bone
healing. More comminuted fractures treated by means to
achieve relative stability tend to heal by secondary bone
healing involving callus.
Preoperative planning is essential for assessing the type
of fracture and helping to identify the most appropriate type
of fracture healing desirable for the fracture and the host.
Once this stability target has been determined, the surgery
should be executed with the desired construct stability in the
mind. Maintaining biological integrity of the fracture envi-
ronment is of the upmost importance. Advancement in
surgical techniques (biologically friendly indirect fracture
reduction, submuscular and percutaneous plating) and
implant design (low contact and locking plates) has certainly
decreased the biologic insult to the bone associated with plate
fixation.
INTRAMEDULLARY FIXATION FOR DIAPHYSEAL
AND METADIAPHYSEAL FRACTURES
Diaphyseal and metadiaphyseal fractures of long bones
are relatively common and usually require surgical stabiliza-
tion to restore length, alignment, and rotation. Over the past
100 years, IM fixation has evolved to become the most
prevalent means of stabilizing diaphyseal and metadiaphyseal
fractures of the long bones.
The use of IM fixation for long bone fractures can be
traced back to the late 1800s when German physicians Heine
and Bircher used ivory pegs to stabilize fractures. In the early
1900s, a Belgian surgeon Lambotte introduced metal IM
implants. An English surgeon Hey-Groves used open surgical
techniques to place short solid IM rods to maintain the
alignment of diaphyseal fractures. Open nailing was used
sporadically for the next few decades, but it was not until the
German surgeon Gerhard Kuntscher pioneered closed IM
fixation of long bone fractures in the 1940s that IM nailing
really started to evolve as an acceptable treatment of
diaphyseal fractures.3
As IM nailing became more accepted, several advances
occurred with the advancement of the technology regarding
IM nails. The nail design changed from an open cloverleaf to
a closed cannulated curved nail. IM reaming was developed
to allow for the placement of larger and stronger nails.
Interlocking screws were introduced to help control shorten-
ing and rotational alignment. Finally, third-generation nails
were introduced allowing for cephalomedullary nailing and
retrograde femoral nailing. All these changes advanced the
science of IM nailing of long bones and the acceptance of the
technique to promote stabilization and union of these
fractures. The clinical results of IM fixation of the femur in
the 1980s ushered in the acceptance of this technique over
external fixation and plates and screws.4,5 IM fixation of tibia
fractures quickly followed with excellent results from English
surgeons in the early 1990s.6 Upper extremity long bones
have not had the same success/outcomes when treated with
IM fixation as in the lower extremities, for reasons which are
still unclear. Although probably multifactorial, the lack of
weight bearing on the upper extremities likely plays a role
in the union rate difference that has been observed.
S14 | www.jorthotrauma.com
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The science behind healing of long bone fractures is
centered on the use of indirect techniques that preserve the
all-important blood supply to the injured bone. The initial
hematoma formation at the fracture site is left undisturbed,
and the process of endochondral ossification (secondary bone
healing) is promoted. In addition, comminuted fractures that
would be very difficult to anatomically align without
significant injury to the surrounding blood supply could be
left alone and essentially bypassed with the advent of IM
fixation. In addition, because the material science behind IM
nails is well known, early weight bearing, even on commi-
nuted fractures, is encouraged and likely promotes bone
healing.
Finally, pushing the envelope of nailing into stabilizing
metadiaphyseal fractures has been ongoing for several years.
When moving from the diaphysis to the meta-diaphysis, the
IM nail loses the ability to use the restricted canal size to
obtain and maintain fracture alignment and relative stability.
To accommodate for this nail-to-canal mismatch, innovative
surgeons have come up with the use of “pollar” or blocking
screws.7 These screws are placed in the expanded metaphy-
seal region of the bone directing the nail into a much tighter
corridor. This technique has been very helpful in obtaining
and maintaining the alignment of metadiaphyseal fractures.
This technique is coupled with the IM nails being placed
using a closed method, assists in the preservation of the rich
blood supply of the metaphysis, and promotes early fracture
healing. A known risk of treating metadiaphyseal fractures
with IM nails is the lack of stability that can be obtained with
the use of conventional locking screws (screws placed in the
coronal plane), particularly with short segment fractures.
When short segment fractures are treated with IM nails, the
risk of malunion increases. The advent of angle stable locking
screws has helped this, but the risk remains, especially in
osteoporotic patients.
In summary, IM fixation of diaphyseal and metadia-
physeal fractures restores length, alignment, and rotation
better than external fixators and can be performed with less
soft tissue striping than when plates and screws are used. In
addition, IM fixation promotes early functional recovery,
including earlier weight bearing, and predictable fracture
union and has evolved over time to become the mainstay of
treatment of most diaphyseal and metadiaphyseal fractures.
PERIPROSTHETIC FRACTURE FIXATION: TO
GRAFT OR NOT TO GRAFT?
Periprosthetic femur fractures continue to increase in
frequency, as the general population is living longer and
people are remaining active long after undergoing total joint
arthroplasty. There may be several additional reasons for the
increase in periprosthetic fractures including more common
use of noncemented components and joint replacements being
done later in life in active patients with poorer quality bone.
The treatment goals for the treatment of periprosthetic
fractures are to restore limb length, alignment, and rotation;
to provide sufficient fracture stability to support timely union
while preserving blood supply to the fracture; to assure
a stable prosthesis; and to allow for early mobilization of the
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 32, Number 3 Supplement, March 2018
limb and of the patient all in an effort to return the patient to
his/her prefracture level of function. Treatments of peripros-
thetic fractures generally include open reduction and internal
fixation (ORIF) with or without bone grafts, revision total
joint arthroplasty, or a combination of both. Critical factors in
decision making are the stability of the prosthesis, the
location of the fracture relative to the prosthesis, the quality
of the fractured bone, and patient factors, including age,
accompanying comorbidities, and their prefracture functional
abilities.
The Vancouver classification system is a very useful
system for guiding periprosthetic fracture treatment. Vancou-
ver B fractures are the most common and include fractures
that occur at the tip of the femoral component; these fracture
types are further stratified into Vancouver B1 fractures that
have a stable implant and no bone loss, B2 fractures that
occur in combination with a loose femoral component, but
with satisfactory bone stock, and B3 fractures that occur in
combination with a loose femoral component and inadequate
bone stock. Type B1 fractures are generally treated with
anatomic ORIF with plates and screws and occasionally
circumferential cables. In each case, attempts should be made
to maximize soft tissue attachments to the fracture fragments
in an effort to maximize blood supply vital to bone healing.
The need for adjuvant bone grafting in the treatment of B1
type fractures, either in the form of allograft strut grafts or as
corticocancellous autograft, is being debated. In a recent
study, Ricci et al8 described 41 patients with B1 fractures
prospectively treated with biologically friendly ORIF with
a single lateral plate and no allograft struts or other bone
grafts. Of note, the surgeons involved in the care of these
patients were experienced fracture surgeons and well versed
on the biologically friendly means of fracture reduction and
stabilization. Each of these 41 patients healed (100%) after
the index procedure. It is clear from this study when biolog-
ically friendly techniques are used with precise ORIF, auto-
graft and allograft strut bone grafting is not necessary for the
successful treatment of periprosthetic femur fractures associ-
ated with a stable implant without bone loss.
Interprosthetic femoral fractures, fractures occurring
between ipsilateral total hip arthroplasty and total knee
arthroplasty, are also becoming increasingly more common
and represent an even more challenging problem for ortho-
paedic surgeons. Ricci et al reported on the success of the
treatment of these fractures using a treatment protocol that
included the use of a single lateral plate to span the
interprosthetic zone, using modern soft tissue preserving
reduction techniques without adjuvant bone grafts.9 All 20
fractures healed after the index procedure. These modern bio-
logic plating techniques showed reliable union rates (100%)
without the use of adjuvant bone graft while maintaining limb
alignment and implant survival.
Vancouver type B2 fractures, those fractures in combi-
nation with a loose femoral component, generally are treated
with revision arthroplasty, using a long noncemented stem
prosthesis that bypasses the fracture in addition to stable
ORIF.10–13 Depending on the fracture morphology and sta-
bility after arthroplasty revision and fixation with a lateral
plate that spans the entire femur, bone grafting, as with B1
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Absolute Versus Relative Fracture Fixation
fractures, is generally unnecessary. In a recent study reported
by Joestl et al, the authors sought to compare the functional
and radiographic outcomes in 2 patient cohorts with Vancou-
ver B2 periprosthetic femoral fractures after primary total hip
arthroplasty.14 Patients were treated either with ORIF with
locking compression plate (LCP) fixation alone or by revision
arthroplasty using a noncemented long femoral stem. All
fractures treated with LCP fixation alone healed uneventfully,
and there were no signs of secondary stem migration, mala-
lignment, or plate breakage. According to the results of this
study, the authors concluded that the use of LCP fixation
alone can be a sufficient option for the treatment of Vancou-
ver B2 periprosthetic femoral fractures correspondingly with
femoral stem loosening.
Type B3 fractures are very complex, as they are
associated with a loose implant and bone loss. Successful
treatment of these fractures generally requires revision
arthroplasty or on occasion a proximal femoral replacement.
In general, periprosthetic fractures with stable implants
(Vancouver B1) or with unstable implants but without bone
loss (Vancouver B2), when treated with modern, soft tissue
friendly techniques and anatomic reduction of the fracture and
stable fixation, generally do not require adjuvant bone
grafting.
PROS AND CONS OF PLATES AND SCREWS IN
OSTEOPOROTIC BONE
Osteoporotic fractures are increasingly more common
with the aging of the United States’ and world’s populations.
Although many surgeons are adopting a strategy of IM nail
fixation for the treatment of most diaphyseal fractures, partic-
ularly in the setting of osteoporosis, plate and screw con-
structs continue to be the mainstay of treatment when such
fractures are located in the metaphyseal and epiphyseal seg-
ments. Improved understanding of the indications of plates
and screws allows for the successful treatment of osteoporotic
fractures.
Osteoporotic bone includes both microscopic and
macroscopic changes that influences its response to certain
injuries and treatment. On a cellular level, there typically are
an abundance of osteoclasts relative to osteoblasts, which bias
bone homeostasis toward negative bone balance resulting
over time in bone loss. On a macroscopic level, the trabeculae
within the cancellous portions of bone are generally poorly
interconnected; more commonly are rod shaped as opposed to
plate-like; and poorly mineralized when compared with
normal bone. In addition, there is more cortical thinning than
in normal bone. All these changes are the result of aging,
certain diseases, certain medications, and disuse. As bone
mineralization decreases and the bone quality (ie, trabecular
architecture) worsens, so does the holding power of screws. A
conventional screw/plate construct relies on the friction
created between screw threads and bone and the ability to
maintain compression between the plate and bone to maintain
fracture reduction and stability during healing. An inability to
obtain or maintain a stable plate/screw construct as a result of
poor bone strength (bone strength = bone mineral density +
bone quality) increases the likelihood of fixation failure and
www.jorthotrauma.com | S15
Norris et al J Orthop Trauma  Volume 32, Number 3 Supplement, March 2018
fracture complications. In addition, obtaining and maintaining
fracture fixation in osteoporotic bone is further influenced by
the presence of comminution and the loss of innate fracture
stability after reduction. Locking plate and screw fixation
allows for construct stability without screw-bone and plate-
bone friction, instead, locking screw plate constructs act more
like an I-beam bridging and stabilizing the fracture with
screws that work together as a unit.15
Anatomically designed locking plates allow for the
treatment of very proximal as well as very distal periarticular
and even intra-articular fractures. When placed well with
screws configured correctly, these implants also allow the
surgeon to create absolute or relative stability constructs and
can also be used to aid in fracture reduction. Fractures with
short articular segments are very difficult to treat with IM
devices, and locking plates offer an effective alternative for
their treatment. Understanding the design of many locking
plate contours and how they relate to the local boney anatomy
allows for these plates to be used as a reduction and a fixation
tool.
To mitigate the risk of failure when using locking plates
and screws, certain principles of fracture fixation must be
followed. Locking screw failure, plate breakage, and bending
are implant failures that generally occur as a result of fatigue
when surgeons have failed to adhere to biologically friendly
treatment principles, resulting in delayed fracture healing.
Generally, if the construct fails with screw “pull-out,” this is
commonly the result of poor bone strength and/or poor
implant placement/utilization. The guiding principle should
be to balance the fixation construct that diminishes the failure
force on the plate and screws, while providing the appropriate
strain across the fracture site to encourage fracture healing. In
other words, one wants to create relative or absolute stability
as dictated by the personality of the fracture and fixation
construct and combine this with the optimal biomechanical
environment to encourage fracture healing.
In a comminuted supracondylar distal femur fracture,
for example, one should consider a plate several times the
length of the fracture to allow approximately 8 cortices of
fixation in each fragment. Ricci et al showed that plates with
.9 holes fared better than the shorter plates regarding failure
in the treatment of supracondylar fractures, illustrating the
need for balancing construct strength and stiffness.16 In the
ideal setting, a locked plate 2–3 times longer than a commi-
nuted fracture, with .4 cortices per fragment, ,0.5 screws
per hole in the plate, and an empty hole space of at least 3
holes, bridges a comminuted segment.17 Understanding these
principles, along with minimizing insult to the surrounding
soft tissues from stripping, allows for the design of constructs
that are both stable and allow for micromotion at the fracture
S16 | www.jorthotrauma.com
Copyright Ó 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
site in an effort to win the race between fracture healing and
implant failure.
Locked plate fixation is quickly becoming the mainstay
of osteoporotic fracture treatment, as it allows for a balance of
fixation stability and bone healing through the preservation of
micromotion (strain) at the fracture site. Adherence to simple
principles during the treatment of osteoporosis-related frac-
tures would help mitigate the use of the locked plating
technology in osteoporotic bone by mitigating both the forces
on the bone–implant interface and the fracture itself.
REFERENCES
1. Perren SM. Physical and biological aspects of fracture healing with
special reference to internal fixation. Clin Orthop Relat Res. 1979;138:
175–196.
2. Beltran MJ, Collinge CA, Gardner MJ. Stress modulation of fracture
fixation implants. J Am Acad Orthop Surg. 2016;24:711–719.
3. Kuntscher G, Maatz R. Technik de Marknagelung. Leipzig, Germany:
Thieme Publishers; 1945.
4. Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedullary nail-
ing of femoral fractures. A report of five hundred and twenty cases. J
Bone Joint Surg Am. 1984;66:529–539.
5. Brumback RJ, Uwagie-Ero S, Lakatos RP, et al. Intramedullary nailing of
femoral shaft fractures. Part II: fracture-healing with static interlocking
fixation. J Bone Joint Surg Am. 1988;70:1453–1462.
6. Bone LB, Johnson KD. Treatment of tibial fractures by reaming and
intramedullary nailing. J Bone Joint Surg Am. 1986;68:877–887.
7. Krettek C, Miclau T, Schandelmaier P, et al. The mechanical effect of
blocking screws (“Poller screws”) in stabilizing tibia fractures with short
proximal or distal fragments after insertion of small-diameter intramedul-
lary nails. J Orthop Trauma. 1999;13:550–553.
8. Ricci WM, Bolhofner BR, Loftus T, et al. Indirect reduction and plate
fixation, without grafting, for periprosthetic femoral shaft fractures
about a stable intramedullary implant. J Bone Joint Surg Am. 2005;87:
2240–2245.
9. Mamczak CN, Gardner MJ, Bolhofner B, et al. Interprosthetic femoral
fractures. J Orthop Trauma. 2010;24:740–744.
10. Joestl J, Hofbauer M, Lang N, et al. Locking compression plate versus
revision-prosthesis for Vancouver type B2 periprosthetic femoral frac-
tures after total hip arthroplasty. Injury. 2016;47:939–943.
11. Egol KA, Kubiak EN, Fulkerson E, et al. Biomechanics of locked plates
and screws. J Orthop Trauma. 2004;18:488–493.
12. Ricci WM, Streubel PN, Morshed S, et al. Risk factors for failure of
locked plate fixation of distal femur fractures: an analysis of 335 cases. J
Orthop Trauma. 2014;28:83–89.
13. Gautier E, Sommer C. Guidelines for the clinical application of the LCP.
Injury. 2003;34:63–76.
14. Joestl J, Hofbauer M, Lang N, et al. Locking compression plate versus
revision-prosthesis for Vancouver type B2 periprosthetic femoral frac-
tures after total hip arthroplasty. Injury. 2016;47:939–943.
15. Egol KA, Kubiak EN, Fulkerson E, et al. Biomechanics of locked plates
and screws. J Orthop Trauma. 2014;18:488–493.
16. Ricci WM, Streubel PN, Morshed S, et al. Risk factors for failure of
locked plate fixation of distal femur fractures: an analysis of 335 cases. J
Orthop Trauma. 2014;28:83–89.
17. Gautier E, Sommer C. Guidelines for the clinical application of the LCP.
Injury. 2003;34(suppl 2):B63–B76.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.