Injury, Int. J.

Care Injured 34 (2003) S-B31S-B42

General principles for the clinical use of the LCP

Michael Wagner Klinik fr Trauma and Sportmedizin, Wilhelminenspital Wien 1171 Wien, Austria

Summary1
The basic principles of an internal fixation procedure using a conventional plate and screw system (compression methode) are direct, anatomical reduction and stable internal fixation of the fracture. Wide exposure of the bone is usually necessary to gain access to and provide good visibility of the fracture zone to allow reduction and plate fixation to be performed. This procedure requires pre-contouring of the plate to match the anatomy of the bone. The screws are tightened to fix the plate onto the bone, which then compresses the plate onto the bone. The actual stability results from the friction between the plate and the bone. Anatomical reduction of the fracture was the goal of conventional platingtechnique, but over time a technique for bridging plate osteosynthesis has been developed for multifragmentary shaft fractures that, thanks to a reduction of vascular damage to the bone, permits healing with callus formation, as seen after locked nailing. Since the damage to the soft tissues and the blood supply is less extensive, more rapid fracture healing can be achieved. The newly developed, so-called locked internal fixators (e.g. PC-Fix and Less Invasive Stabilization System (LISS)), consist of plate and screw systems where the screws are locked in the plate. This locking minimizes the compressive forces exerted by the plate on the bone. This method of screw-plate fixation means that the plate does not need to touch the bone at all, which is of particular advantage in so-called Minimal Invasive Percutaneous Osteosynthesis (MIPO). Precise anatomical contouring of a plate is no longer necessary thanks to
1

Abstracts in German, French, Italian, Spanish, Japanese and Russian are printed at the end of this supplement.

these new screws and because the plate does not need to be pressed onto the bone to achieve stability. This prevents primary dislocation of the fracture caused by inexact contouring of a plate. The LISS plates are precontoured to match the average anatomical form of the relevant site and, therefore, do not have to be further adapted intraoperatively. The development of the locked internal fixator methode has been based on scientific insights into bone biology especially with reference to its blood supply. The basic locked internal fixation technique aims at flexible elastic fixation to initiate spontaneous healing, including its induction of callus formation. This technology supports what is currently known as MIPO. The development of the Locking Compression Plate (LCP) has only been possible based on the experience gained with the PC-Fix and LISS. With reference to the mechanical, biomechanical and clinical results, the new AO LCP with combination holes can be used, depending on the fracture situation, as a compression plate, a locked internal fixator, or as an internal fixation system combining both techniques. The LCP with combination holes can also be used, depending on the fracture situation, in either a conventional technique (compression principle), bridging technique (internal fixator principle), or a combination technique (compression and bridging principles). A combination of both screw types offers the possibility to achieve a synergy of both internal fixation methodes. If the LCP is applied as a compression plate, the operative technique is much the same as conventional technique, in which existing instruments and screws can be used. The internal fixator method can be applied through an open but less invasiv or an MIPO approach. An indirect

00201383/$ see front matter # 2003 Published by Elsevier Ltd. doi:10.1016/j.injury.2003.09.023

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closed reduction is necessary when using the LCP in the internal fixator methode bridging the fracture zone. A combination of both plating techniques is possible and valuable, depending on the indication. It is important to command a knowledge of both techniques and their different features. Keywords: Locking Compression Plate (LCP), combination hole, Dynamic Compression Unit (DCU), conventional plating technique (compression principle), bridging plate technique (internal fixator principle), Minimal Invasive Percutaneous Osteosynthesis (MIPO) Injury 2003, Vol. 34, Suppl. 2 2) Biological bridge plating: Indirect, closed or open but less invasive (no touch technique) reduction and biological bridge plating (LC DCP, DCS, DHS etc.), greater relative stability. [2, 3]. 3) MIPO-technique: Indirect, closed reduction and sub muscular / subcutaneous sliding techniques. Bridging the fracturezone, internal fixator method (with angular stable implants/locked screws PC Fix, LISS), greater relative stability. [6, 7, 8, 10, 11] Indirect, closed reduction and bridging of the fracture zone with locked internal fixators (LIF) were often seen as a solution to the problems of ORIF. Plate and screw systems, where the screw can be locked in the plate, form one stable system and the stability of the fracture depends on the stiffness of the construct. No compression of the plate on the bone is required to suppress the risk of primary loss of reduction and preserve the bone blood supply. Locking the screw into the plate to ensure angular as well as axial stability eliminates the possibility for the screw to toggle, slide or be dislodged and thus greatly reduces the risk of postoperative secondary loss of reduction. Based on the experiences gained with the PC-Fix system, the LISS DF and LISS PLT systems were developed and have shown very promising clinical results. Preconditions for internal fixation by MIPO: Indirect closed reduction without exposure of the fracture. Small incisions for the insertion of the implants. Elastic bridging of the fracture zone with a locked internal fixator (e.g., LISS, LCP). Implants with minimal bone contact. Slightly elevated plate from the bone surface to eliminate any mismatch of the precontured plate to the anatomy of the bone. Self-drilling and self-tapping locking head screws for mono- or bicortical insertion. Only for LISS: Ageometrical correlation between aiming handle and plate for closed application. Relative stability (elastic fixation) increases callus formation. Note: The same technique may be used by the less experienced with an open, but less invasive approach. [6] Some years ago, we expressed the desire to have a 1plate system with the possibility for the surgeon to choose pre- or intraoperatively, whether or not to use it with conventional screws, locked screws or with a combination of both screws. This desire led to the development of the combination hole of the LCP. [1, 12, 13]

Introduction
The AO has developed techniques and defined the basic principles of internal fixation. There are currently various methods and techniques for plate osteosynthesis:

Conventional plating technique

1) Open reduction and internal fixation (ORIF): Direct, open, precise reduction and stable internal fixation (conventional technique, compression methode principle greater absolute stability) with plates and screws has established itself as a standard and successful technique for treating bone fractures. Standard plates produce compression between the implant and the bone and only work, if they are pressed to the bone. However, some problems in internal fixation with plates (DCP) and screws remain unsolved. Two of which were implant related and therefore technical issues: primary and secondary loss of reduction leads to misalignment and instability, and the third leads to compression of the periosteum, which causes a disturbance of the bone blood supply. The biological shortcomings of direct open reduction and conventional compression plating are damage to the blood supply to the bone, which can lead to biological complications. Compression plating needs good bone quality and precise, anatomical reduction. In multifragmentary shaft fractures, precise anatomical reduction is often not possible without a great risk of an iatrogenic soft tissue trauma. [4, 9] The total injury of the bone and the surrounding softtissue is caused by trauma and by the operative injury (iatrogenic injury). The operative injury = damage caused by reduction + approach + fixation of fracture. Additional surgical damage can be reduced by adjusting the surgical technique e.g., a change in soft-tissue handling, reduction, and fixation techniques (insertion and choice of implant). New methods that bear a minimal risk for treating problematic fractures were developed to accelerate bone regeneration and bone healing. [6]

Different methods, different techniques, and different biomechanical principles to use the LCP
The LCP with combination holes allows applications as a conventional compression plate as well as an internal

M. Wagner: General principles for the clinical use of the LCP

fixator with locking head screws. Under certain circumstances, the two principles may be incompatible. Therefore, it is advisable to use only one of the two techniques in one fracture zone, either conventional or as internal fixator. The LCP with combination holes can be used for the following fracture situations: Conventional technique (compression methode principle of absolute stability > primary fracture healing). MIPO technique (internal fixator methode principle of relative stability > secondary fracture healing). Combination of both (compression and bridging with LIF).

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1) LCP in a conventional plating technique (compression method, principle of absolute stability): Simple fractures in the diaphysis and metaphysis (if precise, anatomical reduction is necessary for the functional out come/Simple transverse or oblique fractures with low soft tissue compromise) Articular fractures (buttress plate). Delayed or non-union. Closed-wedge osteotomies. 2) LCP in a MIPO-technique bridging the fracture zone (internal fixator method, principle of relative stability): Multifragmentary fractures in the diaphysis and metaphysis. Simple fractures in the diaphysis and metaphysis (if a non-precise reduction is enough for the functional outcome. The strictly/following of the biomiechanical principles of strain tolerance are important). Open-wedge osteotomies (e.g., proximal tibia: TomoFix). Peri-prosthetic fractures. Secondary fractures after intramedullary nailing. Delayed change from external fixator to definitive internal fixation. Tumor surgery. 3) LCP in a combination of both methods (compression method and internal fixator (bridging) method) using one plate: Articular fracture with a multifragmentary fracture extension into the diaphysis: anatomical reduction and interfragmentary compression of the articular component, bridging of the reconstructed joint block to the diaphysis.

Different indications
Choosing to use a LCP depends on a number of factors: 1) Clinical stand point: Fracture location and configuration. Soft-tissue conditions. Condition of the patient (polytrauma, ISS). 2) Other factors: Presence of other implants. Im-nail? Borderline indication: metaphyseal zone, size of the medullary canal, etc.? Personal experience and preference. Availability of implants (i.e., LCP), instruments, and intraoperative imaging. There are different indications to use the LCP for different techniques and biomechanical principles (Table 1):

Specific indications for the different techniques

Compression Simple diaphyseal fractures Simple metaphyseal fractures Multifragmentary diaphyseal fractures Multifragmentary metaphyseal fractures Osteotomies Articular fractures Articular fractures with multifragmentary metaor diaphyseal fracutres Segmental fractures with two different fracture patterns + + + No bridging! + + + Bridging (+)* (+)* + + + No compression! No compression! Combination

Table 1: Specific indications for the different techniques in plate osteosynthesis. Newer clinical experience has shown an uneventful bone healing also after bridging of simple fractures with internal fixator principle.

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Segmental fracture with two different fracture patterns (one simple and one multifragmentary): conventional technique, compression principle for the simple and bridging technique, internal fixator principle for the multifragmentary fracture. The term combination describes the combination of two biomechanical principles: use of a combination of interfragmentary compression and the internal-fixator method (bridging). Note: Acombination technique does not mean combining different types of screws! This hybrid use of both types of screws are recomented some times for the reduction of a fragment onto the bone or to correct the malaligment of the plate on bone axis.
On the femur and tibia, the LCP is indicated as an alternative method to intramedullary nailing and other fixation techniques, especially in cases of: Extension of the fracture into the joint. Multifragmentary shaft and metaphyseal fractures. Narrow as well as very large medullary canals. Pr e-existing bone deformity. Shaft fractures in children. Polytrauma, severe brain or thoracic injury. Simple shaft and metaphyseal fractures with soft tissue compromise.

Notes for the different surgical techniques

The LCP with combination holes can be used, depending on the fracture situation, in a conventional technique (compression methode). The surgical technique and instruments are similar to conventional plating with the DCP or LC DCP. After open, direct, precise reduction and preshaping of the plate, the interfragmentary compression is achieved by eccentric cortical screw setting in the DC part of the combination hole of the LCP (Fig. 1). Fracture compression can also be accomplished with a tnsion device. Interfragmentary compression can also be accomplished with insertion of a plate lagging screw either to compress a simple fractureline in the meta- or diaphyseal segment or an intra-articular fracture. The additional cortical screws are again used to increase the friction between the plate and the bone. In cases of good bone quality and through an open approach (accurate plate contouring possible), conventional screws may be inserted. The additional stability with the LCP is achieved with locking head screws. These locking screws are supporting reduction and compression created by the lag screws without creating uncontrolled forces by pressing the

Fig.1a: AP. and lateral view, open (1) shaft fracture of the forearm, 19-year-old femal, fall from the high.

Fig.1b: Stabilisation of the ulna shaft fracture with an 8-hole 3.5 LCP, conventional technique compression principle. Two cortex screws (placed eccentrically in the DC part of the combination hole) are used to compress the fracture. The radius shaft fracture was fixed with an elastic intramedullary nail. FU 1 year after operation shows solid bone healing of both fractures.

Fig. 1c: AP and lateral view after removable of the hardware.

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Fig. 2: If the LCP is used in a compression mode, two cortex screws (placed eccentrically in the DC part of the combination hole) are used to compress the fracture. The operative technique is much the same as in conventional plating (anatomical reduction, inter-fragmentary compression), whereby conventional instruments and screws are used. In case of good bone quality, the additional cortex screws add to the stability of the construct by increasing the friction between plate and bone. Three bicortical conventional screws (not locking head screws) on each side of the fracture are effective. In osteoporotic bone, the stability is increased by using locking head screws: In osteoporotic bone, locking head screws should be used because they increase the stability of the bone-implant-interface; three LHS on each side of the fracture are advised, whereby at least one bicortical LHS should be used (a minimum of four cortices on either side of the fracture). By using monocortical locking head screws, the opposite cortex is not weakened (no drill hole), hence reducing the risk of refracture after implant removal.

Fig. 4: When using a tension device to achieve compression, cortex screws are inserted to maintain the induced interfragmentary compression. The fixation of the fracture is considered stable, if the friction forces eliminate all motion at the fracture site. The LCP with locking head screws allows optimal purchase of the plate on the bone. The fracture is compressed with the tension device. This compression is maintained by locking head screws. The stability of the fixation is however not relying on the friction between plate and bone, but rather on the angular stable construct thanks to the locking head screws (LHS are advised in osteoporotic bone).

Fig. 3: If the LCP is used as a neutralization plate, fracture reduction and interfragmentary compression are achieved by the lag screws (1 & 2). In case of good bone quality, the additional cortex screws add to the stability by increasing the friction between plate and bone. In osteoporotic bone, additional stability is achieved by inserting locking head screws. Locking head screws help to maintain reduction and compression without additionally pressing the plate against the bone surface.

Fig. 5: LCP for plating of intra-articular fractures in conventional technique; buttress plate. This picture illustrates one possibility to fix an intra-articular fracture using the LCP in the conventional way by reducing the fracture to the plate. Depending on the fracture pattern, the anatomical reconstruction of the joint surface can also be achieved with plateindependent lag screws. In case of bone loss or osteoporosis, locking head screws will help to maintain angular stability while the standard cancellous bone screw provides interfragmentary compression of the articular components.

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Fig. 6a: AP and lateral radiographs of a tibial head fracture.

plate to the bone surface. In osteoporotic bone, locking head screws are preferred because there is no primary loss of reduction if the plate is not adequately contoured and there is better stability in bones of poor quality (Fig. 2). If the plate is used as a neutralization plate, the fracture reduction and the inter-fragmentary compression is achieved by the lag screws (Fig. 3, 4, 5, 6). The LCP with combination holes can be used, depending on the fracture situation, in a bridging technique (internal fixator method). The bridge-plating technique (i.e. pure splinting) can be applied through an open or an MIPO approach. An indirect closed non-precise reduction is necessary using the LCP in a bridge-plate technique. A long plate and adequate spacing between the locking screws must be used. The longer the bridging plate,

Fig. 6b: possibility to fix an intra-articular fracture using the LCP in the conventional way by reducing the fracture to the plate buttress plate. Depending on the fracture pattern, the anatomical reconstruction of the joint surface can also be achieved with plate-independent lag screws. In case of osteoporosis, locking head screws will help to maintain angular stability while the standard cancellous bone screw provides interfragmentary compression of the articular components.

the better. The biomechanical behavior of a bridging plate (i.e. pure splinting) with locking screws can be compared to that of an external fixator. (Fig. 7) In bones of good quality, the use of monocortical locking head screws is sufficient, however, at least three screws should be inserted on either side of the fracture, in each main fragment. It is important to avoid stress concentration at the fracture site, 2 or 3-plate holes in the fracture zone without screws lead to stress distribution.

Fig. 7: Biomechanic of Locked internal fixator (LIF): bridging technique - internal fixator principle. The plate and screws form on stable system and the stability of the fracture is dependant on the stiffness of the construct. The biomechanical behaviour of the LCP used as a bridging plate with locking screws can be compared to that of an external fixator. A long plate and adequate spacing between the locking screws must be used. Basic rule in multifragmentary shaft fractures: indirect closed reduction main attention to: axis, length, rotation, bridging of the multifragmentary fracture with an locked internal fixator focus on fixation above and below only, relative stability > induction of callus formation.

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Fig. 8 ae: 83-year-old woman, hit by car, polytrauma and severe osteoporosis. Complex fracture of the proximal tibia, type 41-C2. Stabilization of the fracture: 1. After closed reduction of the articular fracture, fixation with two separate 4.5 mm cannuiated lag screws (with washers). 2. Bridging of the comminuted metaphyseal fracture zone with an 8-hole LCP T-plate 4.5/5.0 after closed alignment of length, axis, and rotation. Fig. 8b: The separate medial and anterior wedges were not touched; Fig. 8c: FU 4 weeks post-operative, beginning of callus formation; Fig. 8d: 4 months FU; Fig. 8e: bone healing after one year.

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Fig 9: 65-year-old woman with fracture of the distal radius, type 23-C3, after fall (a). Stabilization of the fracture with an oblique angled 3-hole LCP T-plate 3.5 (b).

c)

Fig. 10a e: a) 59-year-old woman, accident: fall on the street, distal tibial fracture type 42B1 fracture with fractured third of the proximal fibula ap and lateral view b) post-operative radiographs, ap and lateral: closed, indirect reduction and fixation with an 11-hole 4.5/5.0 LCP (MIPPO), bridging technique internal fixator principle c) follow-up after 6 weeks, ap and lateral view good callus formation visible d) follow-up after one year, good bone healing e) after implant removal, good functional result

M. Wagner: General principles for the clinical use of the LCP

M. Wagner: General principles for the clinical use of the LCP

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Fig. 11ad: a) 9-year-old male, Judo, tibia shaft fracture, Type 42-A2. b) Closed reduction and briding of the fracture with a 9-hole 4.5/5.0 LCP, intra-operative view. c) FU 6 weeks postoperative, beginning of the callus formation. d) Removal of the plate after 10 months, solid bone healing

In osteoporotic bones, the use of locking head screws is strongly recommended with at least three screws in each main fragment, on either side of the fracture, of which at least one must be inserted bicortically. To apply the device as an internal fixator, temporary space holders can be screwed into several of the conical holes of the plate. These space holders maintain a minimal distance between the plate and the bone. The space holders may be replaced by screws during the operation or may be removed once plating has been completed. This procedure offers the advantage that the plate will not touch the bone at any point, thus minimizing the damage to the bone vascularity.

Biomechanical and clinical benefits

The main biomechanical and resulting clinical benefits of these locked internal fixators are: The plate and screws form one stable system and the stability of the fracture depends on the stiffness of the construct. No compression of the plate on the bone is required; this suppresses the risk of primary loss of reduction and preserves the bone blood supply. Locking the screw into the plate to ensure angular as well as axial stability, eliminates the possibility for the screw to toggle, slide or be dislodged and thus strongly reduces the risk of postoperative loss of reduction.

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Multiple angle stable screw fixation in the epi- metaphyseal fragments enables the fixation of many fractures that are not treatable with standard types of devices. Improved stability in multifragmentary, complex fractures with loss of medial/lateral buttress or bone loss. The locked screw/plate interface provides fixed angle stability, which avoids subsidence in the metaphyseal areas. It also allows medial or lateral fixation without reconstructing the medial or lateral vis--vis buttress or without double plating, and without the use of primary bone graft. There is no need to precisely contour the plate. As the stability does not rely on compression between the plate and the bone, the plate does not need to be anatomically contoured. This is especially true for metaphyseal areas where the shape of the bone can be quite complex, which facilitates the surgical procedure. This point is important when using the MIPO technique. Improved biology for healing. Locked internal fixators do not compress the periosteal blood supply, thereby causing less interference of the fracture hematoma and fracture healing. The elastic fixation of a locked internal fixator acts more like an IM- nail or external fixator, allowing for bridge plating with callus formation. Improved fixation and biology lead to better clinical outcome and faster healing. Elderly people with an osteoporotic bone and patients with multifragmentary fractures particularly benefit from these advantages. Better fixation in osteoporotic bone, especially near the joint: In osteoporotic bone, locking head screws have better resistance against bending and torsion forces with less pull out of the screw. Divergent of convergent locked screws improve the pull out ressistance of the hole construct (e.g. LPHP for the proximal humerus or an individual multiple slightly bended plate (so-colled multiple waves plate). The locked screws do not compress the plate to the bone, so the plate/bone interface is not loaded along the screw axis, which reduces the tendency to strip the thread in the bone. These locked screws have a higher core diameter to resist cantilever and bending forces at the screw/cortex junction. Fixed angle devices are not subject to the toggling (windshield wiper effect) seen with unlocked screws, which improves fixation in the osteoporotic bone. No or less need of primary bone graft. The main clinical benefits (and arguments) for using the LCP are in these following situations: Epi-/metaphyseal fractures (short articular block, little bone mass for purchase, angular stability, angular blade plate). (Fig. 8 and Fig. 9). In situations where the MIPO technique is indicated or possible; because accurate contouring of the plate is not possible and also not necessary when using locking head screws; there is no loss of initial reduction (Fig. 10). MIPO with indirect reduction and minimal-invasive submusculare/subcutaneous plate insertion and fracture stabilization with locked internal fixator minimize the surgical devascularsation and the implant-related vascular insult to the bone and the soft tissues. Fractures with severe soft-tissue injuries. Fractures in osteoporotic bone (because there is better resistance against bending and torsion force, and less pull out of the screw-plate construct, no stripping of the bone thread during insertion of the screw, and therefore no over tightening of the screw is possible). Shaft fractures in children (Fig. 11). No or less need of primary bone graft. Wider range of indications

Special and anatomically pre-shaped plates:

Special metaphyseal plates in different sizes and length are now available, as well as plates for opening and closing osteotomies on the distal femur and proximal tibia TomoFix. There are strong demands for anatomically preshaped plates. Some pre-shaped plates are currently available for anatomical regions: 2.4 mm distal radius plates, different olecranon plates, and plates for the proximal humerus (Fig. 12) and distal humerus. Also for the distal femur and proximal lateral Tibia are preshaped plates available The advantages of anatomically pre-shaped plates are: No intraoperative shaping of the plate required. Plate helps achieve the anatomical reduction. Aiming blocks help to insert the locking head screws. Clear indications for a given implant. Defined placement for a given implant. Clear rules of how to use the given implant.

Final comment
An internal fixator is a construct in which the screws (pins/bolts) are locked in the plate (frame). Forces are transferred from the bone to the fixator across the screwplate threaded connection. No compression of the fixator on the bone is therefore required to achieve stability. Locking the screw in the fixator increases stability and the risk of loss of reduction due to toggling of the screw is therefore eliminated. Furthermore, the blood supply to the bone under the fixator is preserved intact as no contact between the fixator and the bone is needed [1, 6]. The locked internal fixator technique allows but does not generally require precise reduction. Non-compressed plates, nails, and fixators are splints. This new

M. Wagner: General principles for the clinical use of the LCP

technology of internal fixators behaves in a similar way to the external fixator in that it gives way elastically and is thus a forgiving technology. [1, 6, 7, 13] Locking internal fixation is a new technology that aims to preserve biology. Its application is similar to that of the external fixator. It is inherently simple but requires an open minded approach to this new methode and philosophy. The locked internal fixator methode is an approach that optimizes internal fixation. It aims at simple and safe handling, optimizing biological conditions for soft and hard tissues and at being universally applicable. This device resembles a plate but functions like an external fixator that is fully implanted. This procedure supports biological internal fixation, that is, a type of internal fixation that gives priority to biology over mechanics.

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Fig. 12 ac: a) 72-year-old man, fall while playing tabletennis. Subcapital proximal fracture of the left humerus, type 11-A 3. b) Open plate osteosynthesis, indirect reduction by manual distraction. (non touch technique). Fixation was obtained using the LPHP. Intraoperative x-rays in different planes show the reduced fracture and the correct positioning of the plate, no subacromial impingement (90 abduction). The 5-hole LPHP was proximally fixed with five and distally with three locking head screws (distally one LHS was inserted bicortically, the other two monocortically). c) Postoperative control after 6 weeks.

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The internal fixation of bone fractures or osteotomies with the LCP system will be the new standard for fixation with plates and screws from the AO/ASIF. This new plate and screw system uniquely combines the benefits of both the conventional technique (compression methode) and of the bridging the fracture zone in the MIPO technique. (internal fixator methode) [1, 12, and 13]. Using the LCP in the conventional technique (compression methode pincipiple of absolute stability), it is similar to the technique using standard plate and screw system. In the bridging , we use the LCP in the internal fixator method (principle of relative stability) with locking head screws. Using these different principles of fracture treatment leads to different types of fracture healing. Choosing to use a LCP depends on bone quality, fracture situation, anatomical region and the surgeons preference. The LCP combines two methods and techniques in one implant. By making the correct decision in using the LCP in specific cases, one can significantly contribute to the improvement of the clinical outcome of the operative treatment of bone fractures. Promising early clinical results have already been published.

References
1. Frigg R. Locking Compresssion Plate (LCP). An osteosynthesis plate based on the Dynamic Compression Plate and the Point Contact Fixator (PC-Fix). Injury. 2001;32(suppl 2):63-66. 2. Gautier E, Ganz R. Die biologische Plattenosteosynthese [The biological plate osteosynthesis]. Zentralbl Chir. 1994;119:564-572. 3. Leunig M, Hertel R, Siebenrock K, Balmer F, Mast J, Ganz R. The evaluation of indirect reduction techniques for the treatment of fractures. Clin Orthop. 2001;375:7-314. 4. Perren SM, Russenberger M, Steinemann S, Mller ME, Allgwer M. A dynamic compression plate. Acta Orthop Scand. 1969;125(suppl):31-41. 5. Perren SM, Schlegel U. Surgical aspects of implants and infections. Arch Orthop Trauma Surg. 1990;109:330-333. 6. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002;84-B:1093-1110. 7. Perren SM. Evolution and rational of locked internal fixator technology. Introductory remarks. Injury. 2001;32 (suppl 2):S-B3-9. 8. Perren SM. Point contact fixator: part I. Scientific background, design and application. Injury. 1995;22(suppl 1):1-10. 9. Redi TP, Murphy WM, eds. AO Principles of Fracture Management. Stuttgart-New York: Thieme; 2000. 10. Schandelmaier P, Stephan C, Reimers N, Krettek C. LISS osteosynthesis for distal fractures of the femur. Trauma Berufskrankh. 1999;l:392-397. 11. Tepic S, Perren SM. The biomechanics of the PC-Fix internal fixator. 1995;26(suppl 2):5-10. 12. Wagner M, Frigg R. Locking Compression Plate (LCP): Ein neuer AO-Standard. OP-Jurnal. 2000;16(3):238-243. 13. Wagner M, ed. LCP: Locking Compression Plate. [AO teaching series on CD-ROM]. Davos, Switzerland: AO International; 2002.

Correspondence address: Prof. Michael Wagner Klinik fr Trauma and Sportmedizin, Wilhelminenspital Wien, Montleardstr. 37, 1171 Wien, Austria e-mail: michael.wagner@unf.wil.magwien.gv.at