ORIGINAL ARTICLE
Reducing Fracture Risk Adjacent to a Plate With an
Angulated Locked End Screw
Jeffrey B. Peck, MD,* Paul M. Charpentier, MD,* Brian P. Flanagan, MD,* Ajay K. Srivastava, MD,*
and Patrick J. Atkinson, PhD
Objectives: Locking screws often are used in the treatment of
osteoporotic fractures. Studies show that locking screws can increase
bone stresses at the plate end, which increases the possibility of peri-
implant fracture. This study evaluates whether the technique used to
insert the end screw is related to the fracture tolerance adjacent to the
plate.
Methods: Twelve groups of plate constructs were evaluated using
a bular diaphyseal surrogate with mechanical properties similar to
osteoporotic bone. All inboard screws were nonlocked with only the
end screw xation differing among groups. The end screws were
inserted either perpendicularly to the plate or at an angle of 30 degrees
for 6- and 12-hole plates. For both orientations, the end screws were
inserted nonlocked, locked, or by a locked overdrilling technique,
resulting in 6 groups per plate length. The perpendicular nonlocked
screws represented a control group. The constructs were tested to failure
in 4-point bending to determine peak load, failure energy, and stiffness.
Results: All constructs failed by peri-implant fracture along a plane
through the 2 cortical holes of the end screw. Compared with the
control group, an angulated locked screw at the plate end signi-
cantly increased the peak bending moment and energy required
to produce a fracture for both plate lengths (6-hole, P = 0.008,
P , 0.001; 12-hole, P = 0.006, P , 0.001).
Conclusions: The use of an angulated locked end screw may
enhance the resistance of osteoporotic bone to peri-implant fractures
caused by bending forces.
Key Words: periplate fracture, fracture risk
(J Orthop Trauma 2015;29:e431e436)
INTRODUCTION
In 2000, 10 million people had osteoporosis in the
United States, a number expected to increase 40% by 2020.1
Accepted for publication June 22, 2015.
From the *Department of Orthopaedic Surgery, McLaren Flint, Flint, MI; and
Department of Mechanical Engineering, Kettering University, Flint, MI.
Presented as a poster at the 2014 MOS Annual Scientic Meeting, June 12
14, 2014, Mackinac Island, MI.
The authors report no conict of interest.
After review by the McLaren Health Care IRB, it was determined that this
project did not qualify as human subject research and is not subject to
oversight by the McLaren Health Care IRB.
Reprints: Jeffrey B. Peck, MD, Department of Orthopaedic Surgery, McLaren
Flint, 401 South Ballenger Highway, Flint, MI 48532 (e-mail:
jeffreypeck2007@u.northwestern.edu).
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma
Volume 29, Number 11, November 2015
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In 2010, within the European Union, it was estimated that
27.5 million people had osteoporosis and approximately 3.5
million fragility fractures occurred.2 As the number of pa-
tients with osteoporosis increases, optimizing treatment for
these difcult fractures is crucial.
Although plate xation commonly is used to treat
osteoporotic fractures, the implant design plays an important
role in treatment success. Conventional nonlocked plates are
prone to failure because of loosening and loss of reduction.35
Failure typically occurs by sequential screw loosening and
pullout,3 beginning at the end screw.6 Locked plating is one
option for stabilizing osteoporotic fractures and minimizing
sequential screw failure.3,7 Particularly in osteoporotic bone,
locked implants improve xation.8,9 However, locked con-
structs are prone to stress shielding10 and implant fatigue
failure11 with nonunion of fractures.11,12 Additionally, less
load is required to create a peri-implant fracture at the plate
end for all-locked constructs when compared with nonlocked
or hybrid designs.13,14 Bottlang et al13 explained these nd-
ings by showing that a locked end screw caused a focused
load transfer through the end screw, which led to an increased
risk of fracture adjacent to the plate end. Peri-implant fracture
at the end of a plate has been a recognized problem for many
years,1519 and recent investigations have continued to evalu-
ate this complication.13,14,2022
Far cortical locking (FCL) may improve the bone
fracture tolerance when using a locked end screw. The FCL
technique was designed to increase interfragmentary axial
motion, while maintaining a toggle-free screw-to-plate union.
Bottlang et al explored this technique to address stress
shielding and implant fatigue failure.10,20,2325 FCL uses spe-
cialized locking screws, which are free of threads at the near
cortex,20 creating clearance between the screw shaft and the
near cortex bone. A near cortex overdrilling technique26
with standard locking screws may simulate these effects
by providing similar clearance. Mathematical models show
that FCL reduces stresses in the near cortex at the screw-to-
bone interface, which is especially apparent at the end
screw.23,24 Although FCL may reduce the likelihood of
peri-implant fracture, research regarding this theory has
not appeared in the literature.
Another alternative to modify the performance of plate
constructs is to create a hybrid construct, combining non-
locked and locked screws.14,27 Doornink et al14 found that
a hybrid conguration with a nonlocked end screw demon-
strated improved fracture tolerance. An additional strategy
that may reduce bone stresses further is angulating the end
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 Peck et al J Orthop Trauma
Volume 29, Number 11, November 2015

screw such that the near and far cortex holes are offset,
increasing the amount of bone between the holes and decreas-
ing the concentration of stress. This construct may increase
the energy required to cause a fracture. Although Stoffel et al28
found that angulating the end screw increased energy to con-
struct failure in 3-point bending using a solid polyurethane
foam model, an angulated end screw has not been evaluated
relative to peri-implant fracture risk.
This study was designed to identify if fracture tolerance
could be increased with different combinations of the
variables described above. It was hypothesized that a locked,
angulated, and overdrilled end screw would provide the
greatest resistance to fracture. Nonlocked perpendicular end
screws acted as a control construct.
MATERIALS AND METHODS
The methods used were adapted from the litera-
ture.13,20,29 A synthetic bula model with osteoporotic prop-
erties (r = 0.169/cm3, modulus = 58 MPa, model 1127-26;
Pacic Research Laboratories), used in previous literature,22
was used. A synthetic bone substitute was used because it has
less intersample variability than cadaver bone.29 The number
of tests (n = 5) per group followed prior peri-implant fracture
studies using bone surrogates13,14,20 and was conrmed with
power testing. A perpendicular fracture plane was simulated
by cutting the bone model 7 cm proximal to the distal end,
which was intended to represent a Weber C/OTA 44-C1-
equivalent fracture.30 Six- and 12-hole plates were centered
on the fracture, attached with different screw congurations
(described below).
Twelve different platebone constructs were evaluated
for a total of 60 specimens. The plates (3.5 mm low contact)
and screws were stainless steel and consisted of 20 stock and
40 custom designs (VOI; models 3.506 LCCP, 3.512LCCP,
and custom; Florida). All holes in the 20 stock design plates
were nonlocked (Fig. 1) with the end screw inserted perpen-
dicularly to the plate or angulated 30 degrees away from the
fracture. The remaining 40 plates were custom prepared by
the manufacturer and had an end locking hole. This locked
end hole was perpendicular to the plate in 20 constructs and
angled 30 degrees away from the fracture in 20 constructs.

FIGURE 1. Six- and 12-hole plates were

attached to an osteoporotic fibular bone
model with 2 or 3 screws, respectively.
Only the end screw insertion technique
varied for 6 different groups per plate
length; all inboard screws were nonlocked
and perpendicular. Only one-half of the
plate is shown. The 6 groups evaluated
different end screw orientations: either
perpendicular (groups A, C, E, G, I, and K)
or 30 degrees angulated (groups B, D, F,
H, J, and L) with a nonlocked (groups A, B,
G, and H), locked (groups C, D, I, and J),
or overdrilled-locked (groups E, F, K, and
L) technique.

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 J Orthop Trauma
Volume 29, Number 11, November 2015
Consideration was given to testing inward screw angulation;
however, the study by Charpentier et al31 demonstrating
weaker xation strength with inward screw angulation dis-
suaded investigation into this approach. Screws were placed
in 2.5 mm pilot bone holes for nonlocked screws and in 2.8
mm pilot bone holes for the locking screws as per prior lit-
erature32 and manufacturers recommendations. In an over-
drilled group, the pilot holes were created using the locking
drill sleeve followed by overdrilling the near cortex to 4.1
mm, 0.6 mm greater than the screw diameter, using freehand
technique. Different plate lengths were evaluated to determine
if plate length inuenced results as reported by Stoffel et al.28
For the 6- and 12-hole plates, 2 and 3 screws were used,
respectively, on either side of the fracture.
For all groups, all inboard screws (ie, all screws other
than the end screw) were identical (nonlocked, perpendicular)
to isolate the effect of the end screw. All inboard screws were
inserted to 100 N$mm, which was 75% of the minimum tor-
que necessary to strip screws during xation.31 The non-
locked perpendicular end screw groups for each plate length
(groups A and G; Fig. 1) represented a control construct. This
type of construct has been studied previously,13,21 which pro-
vides a means for interstudy comparison. Five test construct
groups were evaluated for each plate length by changing the
end screw implantation parameters: 30-degree angle non-
locked, perpendicular or 30-degree angle locked, perpendic-
ular or 30-degree angle overdrilled locked. Thus, there were 6
groups per plate length. For the hybrid groups, the nonlocked
screws were inserted rst.
The constructs were evaluated in 4-point bend-
ing,13,14,20,21 using a materials testing machine (Test Resour-
ces 8304, Shakopee, MN). Clinically, bending is a common
mode for direct loading of leg33 and has been used in previous
biomechanical testing of the bula.3436 Additionally,
Bottlang et al13 demonstrated that altering the end screw sig-
nicantly inuenced peri-implant fracture tolerance in bend-
ing but not in torsion or axial loading. The bone substitute
served as one fragment and was secured in room temperature
curing epoxy (Fig. 2). The plate bridged the bone substitute
and a rigid bar, which stabilized the opposite plate end. The
rigid bar ensured the fracture occurred in the diaphysis. The
fracture gap was 10 mm.13,14,20,21 The unsupported bone span
was 30 mm. The load was applied at 0.1 mm/s37 with a ramp
load to failure.22,28,3840 Failure was dened as the instant
when fracture occurred with a concurrent rapid drop in bend-
ing moment. Load and machine actuator displacement (reso-
lution = 1 N and 0.005 mm, respectively) were recorded at
FIGURE 2. The proximal end of the
fibula (right side of the figure) was
secured in epoxy, and the distal end of
the plate was attached to a rigid block.
There was a fracture gap of 10 mm (*)
between the bone and block. This
method was adapted from Bottlang
et al13,20 and ensures that bone failure
occurs in the diaphysis over the
unsupported 30 mm span (#) during 4-point bending. The bending was delivered remote to the 30 mm span (4 black arrows).
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Reducing Plate End Fracture Risk
a sampling frequency of 30 Hz. Constructs were inspected
after failure to characterize failure mode.
The following data were determined from the bending
machine actuator displacement measurements: peak bending
moment, bending stiffness, and failure energy, which is the
energy required to produce a fracture. Stiffness was the slope
over the linear range (R2 . 0.99 for all curve ts). Energy was
dened as the area under the curve from the start of loading
until the peak bending moment. Data from the 6-hole and
12-hole plate groups were compared within plate length cate-
gories only (SigmaStat; SPSS, San Jose, CA) using analysis of
variance with Student-Newman-Keuls post hoc testing (a =
0.05) after conrmation of data normality. Each plate length
was analyzed separately for 2 reasons. First, the bular models
diameter varied along its length, thus causing the peri-implant
fracture to occur across different cross-sectional amounts
of synthetic bone depending on the plate length. Second, the
12-hole plate used 3 screws, whereas the 6-hole plate used 2
screws. If normality could not be afrmed, analysis of variance
on ranks (SNK post hoc testing) was used.
RESULTS
All failures were peri-implant bone fractures along the
end screw by the screws path. Thus, the fractures were either
perpendicular or angulated 30 degrees to the transverse plane
(Figs. 3A, B). For the 6- and 12-hole plates, the angulated
locked end screw groups exhibited the greatest fracture resis-
tance (Table 1). For the 6-hole plates, the locked angulated
end screw (group D) peak bending moment was signicantly
greater than that of all other 6-hole plate groups (P = 0.008).
Similarly, the peak bending moment of the locked angulated
end screw in the 12-hole plates (group J) tended to be greater
than that of all other groups, although this nding was only
signicant when compared with perpendicular nonlocked and
overdrilled groups (groups G and K; P = 0.006). Failure
energy for the locked angulated groups for both plate lengths
(groups D and J) was signicantly greater than that of all
other groups for a given plate length (P , 0.001 for both
comparisons). More specically, when comparing the angu-
lated locked groups (groups D and J) with the control con-
structs (groups A and G), there were 12% and 40% increases
on average in peak bending moment for groups D and J,
respectively. Furthermore, groups D and J absorbed approx-
imately twice the energy to failure when compared with
groups A and G, respectively. Although there were variations
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 Peck et al J Orthop Trauma
Volume 29, Number 11, November 2015

FIGURE 3. All constructs failed by peri-implant fracture along

the end screw bone hole. Therefore, fractures were transverse
(A) or angulated 30 degrees (B).

in stiffness between groups, the differences were inconsistent
and not signicant.
DISCUSSION
This study explored the effect of angulating, locking,
and/or overdrilling the end screw on peri-implant fracture risk
at the plate end in a synthetic osteoporotic model when
subjected to bending. It was hypothesized that an angulated,
locked, and overdrilled end screw would enhance xation. To
isolate the effect of the end screw, inboard screws were
nonlocked for all groups.
This study showed that an angulated locked end screw
signicantly enhances the resistance to peri-implant fracture
of a boneplate construct. This implant exhibited the greatest
peak bending moment and failure energy. There are likely
multiple reasons for this performance. First, angulating the
end screw led to peri-implant fracture along the angulated
end screw path. Conversely, all perpendicular screws failed
in a perpendicular orientation. Therefore, the angulated failure

TABLE 1. Bending Moment and Test Machine Displacement Data Were Reduced to Identify 3 Parameters That Describe the
Performance of 12 Different Plate Constructs: Peak Bending Moment, Bending Stiffness, and Failure Energy
Stiffness (Moment/mm of Actuator Failure Energy (Moment mm of
Plate Length Group Peak Bending Moment (N$mm) Displacement) Actuator Displacement)
6-hole plate groups A 1729 6 306* 249 6 53 6707 6 1395*
B 1435 6 102* 173 6 4 6240 6 555*
C 1622 6 271* 209 6 62 6974 6 1035*
D 1946 6 235 168 6 35 11,828 6 3213
E 1329 6 195* 182 6 27 5005 6 684*
F 1560 6 200* 182 6 4 7183 6 2071*
12-hole plate groups G 1618 6 53 245 6 9 6249 6 657k
H 2133 6 569 298 6 107 9570 6 2404
I 1929 6 506 307 6 76 7116 6 2515k
J 2307 6 182 267 6 18 13,868 6 3027
K 1395 6 146 222 6 36 4911 6 591k
L 2044 6 257 249 6 18 11,130 6 2475
For the 6- and 12-hole plates, groups D and J exhibited the greatest number of signicant differences when compared with other constructs of the same plate length. See Fig. 1 for
details regarding the implantation technique for each group.
*Signicantly different versus group D.
Signicantly different versus group E.
Signicantly different versus group A.
Signicantly different versus group J.
kSignicantly different versus group L.
Signicantly different versus group K.

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 J Orthop Trauma
Volume 29, Number 11, November 2015
required a greater amount of bony tissue to fracture; thus,
more energy and load typically were required. Second, the
locked screw allows the plate to serve, in part, to decrease
implant-to-bone toggle and augment implant stability.
Although the overdrilling technique used in this investigation
was anticipated to improve fracture tolerance, this hypothesis
was not supported. Bottlang et al24 conrmed that FCL re-
duces bone stresses, an effect that was anticipated to lead to
elevated fracture tolerance. The overdrilling technique was
used because it is readily applied to any locked plate. How-
ever, the increased hole size used in this study for overdrilling
likely weakened the cortex and increased the stress in the
vicinity of the hole. Additionally, overdrilling in only the
end screw does not achieve the controlled motion FCL aims
to achieve when used in all holes. Furthermore, the FCL
technique screws have thinner shafts, which are hypothesized
to allow for even distribution of load and were not used in the
overdrilling technique. Therefore, overdrilling the end hole is
unlikely to provide peri-implant fracture resistance.
The results of this study are consistent with the ndings
of Stoffel et al.28 Stoffel et al concluded that a 30-degree
angle angulated end screw enhanced resistance to plate con-
struct failure in an osteoporotic analog. However, that study
did not investigate locked screws, and the test method by
Stoffel et al consistently led to failure by screw pullout or
plate bending. Thus, it was not possible for Stoffel et al28 to
evaluate peri-implant fracture risk. Bottlang et al13 and Door-
nink et al14 used 4-point bending to evaluate factors inuenc-
ing peri-implant fracture when all screws were inserted
perpendicularly to the plate in an osteoporotic model. They
reported that all-locked constructs are at greater risk of peri-
implant fracture in 4-point bending when compared with
hybrid constructs. However, none of their hybrid constructs
locked the end screw. In this study, all inboard screws were
nonlocked; only the implantation technique of the end screw
varied. Thus, these hybrid plates with locked end screws add
data to the ndings of Bottlang et al and Doornink et al when
considering the optimal use of screws in osteoporotic bone.
Additionally, although not always signicant, the locked, an-
gulated, overdrilled groups tended to have higher failure ener-
gies compared with all groups other than the locked angulated
groups. This nding suggests the important role of a locked
screw engaging the far cortex beyond the end screw hole.
This study has several limitations. First, this study used
a bone surrogate to represent an osteoporotic bula.22 This
model was selected to avoid the high variability in strength in
cadaver specimens.29 The uniformity in synthetic bone allows
the inuence of the end screw implantation technique to be
isolated and statistically signicant differences in xation
strengths to be demonstrated more readily. The bular model
has material properties consistent with osteoporotic bone and
has been used previously to evaluate biomechanical perfor-
mance.22 Recent investigations of periplate fracture13,14,20,21
and screw angulation28 also have used synthetic bone models.
Thus, although bone surrogates are an imperfect replication of
cadaver bone, there are signicant advantages to using them.
Another limitation is that a unimodal single load to failure test
was used in the current experiment, while in vivo loading is
more complicated and multidirectional. However, the bending
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Reducing Plate End Fracture Risk
method represents an important failure mode and has been
used by others to evaluate the strength of plated con-
structs.13,14,20,21,28,3840 Further testing in torsion and axial
loading would provide additional useful data. Also, one
aspect of in vivo loading is cyclic loading. Therefore, future
evaluation in fatigue loading would be benecial. Addition-
ally, this study tested largely nonlocked constructs. Fully
locked constructs also are used widely in fracture xation,
and testing with an angulated end screw in an all-locked
construct would be revealing. Finally, although the current
design evaluated a surrogate bula, the mechanical behavior
of the platebone construct likely would be transferable to
plates ending in the diaphysis of other bones, such as the
femur, humerus, or radius.
Although many studies have investigated osteoporotic
fracture xation, peri-implant fractures after plate xation,
and hybrid plate use, none have evaluated peri-implant
fracture risk using angulated locked end screws. This study
demonstrates that an angulated locked end screw signicantly
decreases the risk of peri-implant fracture to bending load.
Peri-implant fractures are a signicant and severe complica-
tion of plate xation, and using an angulated locked end
screw should be considered in an attempt to minimize the risk
of such an outcome.
ACKNOWLEDGMENTS
The authors thank Dan Boyse for his assistance with
fabricating the test xture and testing support, as well as
Brandon Liphardt and James Lince for their assistance in
manuscript support and construct assembly. Finally, the
authors would like to thank Nancy Offutt for her assistance
in nal manuscript preparation.
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