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Failure of LCP Condylar Plate Fixation in the Distal Part of the Femur.
A Report of Six Cases
Heather A. Vallier, Theresa A. Hennessey, John K. Sontich and Brendan M. Patterson
J Bone Joint Surg Am. 2006;88:846-853. doi:10.2106/JBJS.E.00543

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Failure of LCP Condylar

Plate Fixation in the
Distal Part of the Femur
A REPORT OF SIX CASES
BY HEATHER A. VALLIER, MD, THERESA A. HENNESSEY, MD, JOHN K. SONTICH, MD, AND BRENDAN M. PATTERSON, MD
Investigation performed at MetroHealth Medical Center, Cleveland, Ohio

T
he treatment of comminuted, intra-articular distal fem- condylar plate for a distal femoral fracture during a thirty-six-
oral fractures (Orthopaedic Trauma Association [OTA] month period at our hospital, and we identified six implant
classification1 33-C3) is challenging. Many of these inju- failures. Fracture care was provided by fellowship-trained
ries are the result of high-energy trauma, which generates severe traumatologists at a level-I trauma center. Information on
soft-tissue damage and articular and metaphyseal comminu- these patients can be found in Table I and the Appendix. Indi-
tion. Bone loss resulting from open fracture and poor bone cations for the use of this implant included a coronal plane
quality may decrease the stability of fixation. Traditional devices fracture, osteopenia, and/or extensive distal fracture commi-
for internal fixation have included the 95° condylar blade-plate, nution precluding insertion of a conventional 95° condylar
the dynamic condylar screw with a 95° side-plate, and in- blade-plate or a dynamic condylar screw.
tramedullary nails. However, coronal fractures or extensive dis- All forty-six patients underwent assessment and resus-
tal comminution may preclude the use of these devices. In such citation according to Advanced Trauma Life Support (ATLS)
cases, a lateral buttress or neutralization plate may be used. The guidelines17. Open wounds were inspected, and dressings were
condylar buttress plate was the first implant designed to serve applied. Intravenous antibiotics and tetanus prophylaxis were
this function. Unfortunately, when this device is applied in the administered. Closed reductions were performed, and splints
presence of medial comminution or bone loss, failure of fixa- were applied. Open fractures were managed with urgent dé-
tion and varus collapse may eventually result2,3.
Recent advances in technology for the treatment of dis-
TABLE I Information on Patients Treated with the LCP
tal femoral fractures include the Less Invasive Stabilization Condylar Plate at Our Hospital
System (LISS; Synthes, Paoli, Pennsylvania) and the Locking
Compression Plate (LCP) condylar plate (Synthes)4-15. Each of Implant Failure All Cases
these implants offers multiple points of fixed-angle contact Mean age (yr) 62.2 (range, 36-88) 60.0 (range, 21-88)
between the plate and screws in the distal part of the femur, Men 2 19
theoretically reducing the tendency for varus collapse that is
Women 4 27
seen with traditional lateral plates. The LISS differs from the
LCP condylar plate in composition, shape, and placement. Mechanism of injury
Early clinical studies of the LISS have demonstrated a high fre- Automobile acc. 4 26
quency of fracture union with low rates of malalignment7-9,15. Motorcycle acc. 1 11
Few cases of failure of the LISS have been reported11,12,16. To our High-energy fall 1 5
knowledge, there have been no published studies focusing Low-energy fall 0 3
specifically on the LCP condylar plate and no reported cases of Crush 0 1
failure of this implant in the distal part of the femur. The pur- Open fracture 4 25
poses of this report were to describe and critically examine six Closed fracture 2 21
cases of failure of the LCP condylar plate and to discuss the
OTA classification*
limitations of this implant for the treatment of distal femoral
fractures. The patients were informed that data concerning 33-A3 0 5
the cases would be submitted for publication. 33-C1 0 5
33-C2 0 9
Materials and Methods 33-C3 6 27
e retrospectively reviewed the cases of all forty-six pa-
W tients who had been treated primarily with the LCP
*OTA = Orthopaedic Trauma Association.
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bridement and irrigation. At the surgeons’ discretion, open

fractures were either treated primarily with open reduction
and internal fixation or managed with provisional external
fixation. Provisional external fixation was converted to inter-
nal fixation after repeat débridement and irrigation within
twenty-four to forty-eight hours. Definitive treatment con-
sisted of fixation with the LCP condylar plate. A lateral ap-
proach was used in all patients. The articular surface was
visualized, and open reduction and internal fixation of the ar-
ticular surface was performed. The articular segment was sta-
bilized to the femoral shaft with the LCP condylar plate.
Indirect reduction principles were followed. A minimum of
four locked screws were placed distally. A minimum of seven
cortices of fixation were obtained proximally. Standard
large-fragment cortical screws were used to stabilize the plate
to the femoral shaft. Range of motion of the knee was permit-
ted when adequate soft-tissue healing had occurred. The pa-
tients were instructed to remain non-weight-bearing for at
least twelve weeks postoperatively.

Results
deep infection developed postoperatively in one patient.
A She was treated with serial débridement and irrigation,
hardware removal, and intravenous antibiotics. After four-
teen months, she had a nonunion without recurrence of the
infection. Additional surgery was not planned because of
medical comorbidities and functional decline.
Three closed fractures were treated with morsellized al-
lograft bone during the index procedure. Six patients with an
open fracture underwent autogenous iliac crest bone-grafting
between six and ten weeks after fixation. After a minimum of
twelve months of follow-up, thirty-nine patients had fracture
union. The fixation failed in six patients. The initial fracture
alignment, assessed on plain anteroposterior and lateral radio-
graphs, was acceptable in all six patients.

Case Reports
ASE 1. A fifty-four-year-old man was struck by a bus
C while riding a motorcycle. His injuries included an APC
(anteroposterior compression) type-III18 pelvic ring disrup-
tion, a type-IIIA19,20 open right distal femoral fracture (OTA
33-C3), and a right ulnar fracture. The patient was hypoten-
sive on arrival at the hospital and was immediately taken to
the operating room, where he underwent internal fixation of
the pelvis, exploratory laparotomy, and débridement and irri-
gation and spanning external fixation of the open femoral
fracture. Approximately thirty-six hours later, he underwent
definitive fixation of the right distal femoral fracture with an
LCP condylar plate. The wounds healed uneventfully, and
knee motion returned to nearly normal by six months, at
which time he reported mild pain in the stance phase of gait.
At nine months, he presented with increased pain and defor-
mity. Radiographs demonstrated a femoral nonunion, varus
collapse, and implant failure. He was treated with a 95° condy-
lar blade-plate and application of iliac crest bone graft and al-
lograft. Inspection of the removed hardware showed a fracture
Fig. 1-A
Figs. 1-A through 1-D Case 2. Fig. 1-A Anteroposterior radio-
graph made after the initial fixation and placement of provi-
sional antibiotic-impregnated polymethylmethacrylate beads.
of one of the locking screws at the screw-plate interface and
impending fatigue failure of the plate. The nonunion healed
after four months. At twenty-one months, the patient had no
knee pain and could flex the knee from 0° to 115°.
CASE 2. A thirty-six-year-old, otherwise healthy man was in-
volved in a high-speed motor-vehicle accident. On the right
side, he sustained a fracture of the femoral shaft, a type-
IIIA19,20 open fracture of the patella, a type-IIIA open fracture
of the tibial plateau, a fracture-dislocation of the calcaneus,
and fractures of the radial and ulnar shafts with compartmen-
tal syndrome. On the left, there was a type-IIIA open Monteg-
gia fracture-dislocation and a type-IIIA open distal femoral
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Fig. 1-B
Figs. 1-B and 1-C Anteroposterior and lateral radiographs demonstrating the broken plate and medial collapse at the
fracture site.
fracture with extensive comminution and articular fractures
in both the sagittal and the coronal plane (OTA 33-C3).
On the day of injury, the patient underwent débride-
ment and irrigation of all of the open fractures and definitive
fixation of the upper extremities as well as the right femur, pa-
tella, and tibia. He also underwent provisional spanning exter-
nal fixation of the left femoral fracture. After forty-eight
hours, he was returned to the operating room for repeat
débridement and irrigation as well as open reduction and in-
ternal fixation of the distal part of the left femur with an LCP
condylar plate. Antibiotic polymethylmethacrylate beads were
placed into a massive metaphyseal defect (Fig. 1-A). Range-of-
motion exercise of the left knee was initiated three days after
the surgery. Seven weeks after the surgery, autogenous iliac
F A I L U RE O F LCP C O N D Y L A R P L A T E F I X A T I O N
IN THE D I S T A L PA R T O F T H E FE M U R
Fig. 1-C
crest and morsellized allograft croutons were applied at the
site of the distal femoral fracture. Cultures of intraoperative
specimens were negative, and all of the hardware appeared to
be stable. Four months after the injury, the patient had 115° of
flexion of the left knee and he was taking no pain medications.
At that time, he began progressive weight-bearing. He re-
turned to working on his farm.
Fourteen months after the injury, the patient noted the
sudden onset of severe pain and deformity in the left thigh
while he was walking in his barn. Radiographs demonstrated a
nonunion with failure of the plate in the distal femoral meta-
physis (Figs. 1-B and 1-C). He underwent a revision open re-
duction and internal fixation with a 95° condylar blade-plate,
and augmentation with iliac crest and allogenic bone graft.
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Fig. 1-D
Anteroposterior radiograph made after the revision open re-
duction and internal fixation with a 95° condylar blade-plate.
There was no evidence of infection.
Eighteen months postoperatively, the fracture appeared
healed radiographically, the patient reported no pain, and
there was 115° of knee flexion (Fig. 1-D). The patient returned
to work on his farm.
CASE 3. An eighty-eight-year-old woman was involved in a
high-speed motor-vehicle accident in which she sustained a
bilateral closed distal femoral fracture (OTA 33-C3). Before
the injury, she was capable of independent community ambu-
lation, and she had a history of obesity and type-II diabetes
mellitus. On the day of the injury, she underwent open reduc-
tion and internal fixation with an LCP condylar plate and allo-
genic bone-grafting for both fractures.
F A I L U RE O F LCP C O N D Y L A R P L A T E F I X A T I O N
IN THE D I S T A L PA R T O F T H E FE M U R
The postoperative course was unremarkable. Bilateral
range-of-motion exercise of the knee was permitted three days
after the surgery. Three months after the surgery, plain radio-
graphs demonstrated some healing bilaterally, and she was al-
lowed to start walking. Six months after the surgery, at the
time of routine follow-up, she reported no symptoms but
plain radiographs demonstrated 5° of varus deformity of the
distal part of the right femur with further evidence of meta-
physeal healing. A broken screw was noted at the distal screw-
plate interface. The findings were reviewed with the patient,
and activity as tolerated was permitted. She returned three
months later, at which time she had no clinical symptoms. Ra-
diographs made at that time suggested that both distal femo-
ral fractures were united, with 10° of varus collapse on the
right. She was able to walk outside of her home with the assis-
tance of a cane fifteen months after surgery.
CASE 4. A sixty-two-year-old woman sustained an isolated
type-IIIA19,20 open distal femoral fracture (OTA 33-C3) in a
high-speed motor-vehicle accident. She had a history of obe-
sity and type-II diabetes mellitus. She underwent débridement
and irrigation and provisional spanning external fixation of
the fracture on the day of the injury. After forty-eight hours,
repeat débridement and irrigation as well as open reduction
and internal fixation were performed. An LCP condylar plate
was used because of medial and lateral coronal plane fractures.
Knee motion was permitted two days after the surgery, and the
early postoperative course was without complications.
Twelve weeks after the surgery, some fracture-healing
was noted on plain radiographs and progressive partial
weight-bearing was begun. Eighteen weeks after the surgery,
the patient returned to the clinic and reported mild knee stiff-
ness and swelling with occasional pain that did not require
medication. Plain radiographs made at that time demonstrated
breakage of two locked screws at the screw-plate interface and
lateral displacement of another screw. Sixteen months after
the surgery, the fracture appeared united with a loss of 5° of
angular alignment, and the patient could flex the knee from 0°
to 100°. Because some of the distal screws were prominent, the
patient was considering elective hardware removal at the time
of writing.
CASE 5. A seventy-eight-year-old woman sustained a type-
IIIA19,20 open fracture of the distal part of the femur with coro-
nal and sagittal fractures of the articular surface (OTA 33-C3)
in a high-speed motor-vehicle accident. She underwent débride-
ment and irrigation as well as open reduction and internal fix-
ation of the fracture with an LCP condylar plate. She did not
have any problems with wound or soft-tissue healing. Range-
of-motion exercise of the knee was initiated three days postop-
eratively. No weight-bearing was permitted for twelve weeks.
Radiographs made at twelve weeks demonstrated some heal-
ing of the distal femoral fractures with stable alignment, and
the patient began progressive weight-bearing.
Six months postoperatively, the patient returned to the
clinic. She reported mild pain and stiffness in the knee that
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Fig. 2-A
Figs. 2-A through 2-D Case 6. Figs. 2-A and 2-B Anteroposterior and lateral radiographs made twelve weeks after fixa-
tion, demonstrating loosening of one distal screw.
did not require medication. Radiographs showed two screws
that were broken at the distal screw-plate interface and 5° of
varus collapse. Abundant medial metaphyseal callus was
present at that time. The patient subsequently had a decrease
in the pain over the following ten months with additional
healing of the fracture and no further malalignment. At the
time of final follow-up, she was using a cane for walking out-
side of her home and knee flexion was from 0° to 100°.
CASE 6. A fifty-five-year-old woman with long-standing type-I
diabetes mellitus and tobacco use fell down stairs, sustaining a
comminuted distal femoral fracture (OTA 33-C3). On the day
of the injury, she underwent open reduction and internal fixa-
tion with an LCP condylar plate. No wound complications
were noted. She was instructed to remain non-weight-bearing
for twelve weeks.
At twelve weeks, radiographs demonstrated stable align-
ment of the fracture and the implant with the exception of
loosening of one distal screw (Figs. 2-A and 2-B). Some early
fracture-healing was evident, so progressive weight-bearing
was started. The patient returned seven months postopera-
tively, at which time she was experiencing mild activity-related
F A I L U RE O F LCP C O N D Y L A R P L A T E F I X A T I O N
IN THE D I S T A L PA R T O F T H E FE M U R
Fig. 2-B
pain and swelling in the knee. Radiographs showed two screws
that were broken at the distal screw-plate interface and four
distal screws backing out of the distal part of the femur with
10° of varus collapse (Fig. 2-C). Revision open reduction and
internal fixation was performed. The malunion was corrected,
and the bone was stabilized with use of a 95° condylar blade-
plate, iliac crest bone graft, and morsellized allograft bone
(Fig. 2-D). Twenty months later, the fracture was healed, func-
tion had improved, and knee flexion was from 0° to 110°.
Discussion
igh-energy distal femoral fractures are frequently associ-
H ated with articular and metaphyseal comminution. Coro-
nal plane fractures and extensive distal comminution generally
preclude the use of traditional fixed-angle devices or retrograde
nails. Fixation of these fractures with a lateral plate alone has
historically been associated with nonunion and/or malunion
with varus collapse. Prior to the advent of locked plates, this
problem may have been addressed with dual medial and lateral
fixation, causing additional surgical insult to the local fracture
biology21,22. Reports have also described adjunctive medial exter-
nal fixation, or medial endosteal substitution with the use of in-
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cluded technical errors in plate placement and early weight-

bearing in the presence of delayed fracture union. The LISS
differs from the LCP condylar plate in composition, shape,
and placement. The LISS actually functions as an internal fix-
ator with locked unicortical fixation in the femoral shaft. LCP
implants may include locked screws or conventional screws
proximally. It has been our practice to use bicortical, non-
locked screws in the proximal portion of the LCP condylar
plate, which may improve pull-out strength compared with
that provided by the unicortical locked screws of the LISS.
Of the forty-six LCP condylar plates that were used in
the distal part of the femur at our institution over a thirty-six-
month period, and that were followed for a minimum of
twelve months, six (13%) failed. The patients in whom these
plates failed had been treated by fellowship-trained trauma-
tologists who had extensive experience with complex distal
femoral fractures and with use of the LCP device. Two patients
(Cases 1 and 2) had nonunion with plate failure. Both had
sustained the initial fractures as a result of high-energy
trauma. In the first patient, the fixation failed nine months af-
ter the injury and was successfully revised to a blade-plate.

Fig. 2-C
Anteroposterior radiograph showing varus collapse and bro-
ken screws at the screw-plate interface.

tramedullary plates, which is technically demanding and may

compromise additional reconstructive options2,3.
The introduction of plates with the option of locked
screws has provided the means to increase the rigidity of fixa-
tion in osteoporotic bone or in the presence of periarticular or
juxta-articular fractures with a small epiphyseal segment4-6,14.
There are many theoretical advantages to using a locked plate in
the distal part of the femur. The LCP condylar plate provides
multiple points of fixed plate-to-screw contact, generating
greater stability than is provided by a single lateral construct,
which potentially reduces the tendency for varus collapse. The
LISS also allows minimally invasive insertion and preservation
of vascularity to the lateral cortex. Early clinical results follow-
ing use of the LISS in the distal part of the femur have been
promising7-9,15, as have been the early results of the use of LCP
implants for other fractures13.
Kregor et al. reported a 5% prevalence of proximal
screw failure or loosening after treatment of 103 distal femoral
fractures with the LISS9. Another recent paper described fail- Fig. 2-D
ure of the LISS, with plate breakage or loss of proximal screw Anteroposterior radiograph made after the revision
fixation, in four patients (18% of their patients) treated for a open reduction and internal fixation with a 95°
distal femoral fracture16. Potential reasons for these failures in- condylar blade-plate.
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The slow appearance of callus on early postoperative radio-
graphs may have been an indication for bone-grafting after
three to six months, and this intervention may have prevented
the failure of the implant at nine months. Because function
was not limited by pain, a less aggressive approach was taken
initially. (He was observed—i.e., no surgery was anticipated.)
The second patient had implant failure at fourteen months.
He had previously undergone bone-grafting of a massive
metaphyseal defect and was functioning at a high level. We
have encountered another patient with this type of failure. She
was initially treated, at an outside hospital, with the same de-
vice. The plate was placed posteriorly on the lateral femoral
condyle with 2 cm of shortening and malalignment in external
rotation, which may have increased the potential for plate
breakage. That patient also had a history of diabetes and was
of advanced age, which may have decreased the ability of the
fracture to heal.
The remaining patients (Cases 3 through 6) all had failure
at the screw-plate interface with 5° to 10° of medial collapse. All
of these patients had metabolic factors that contribute to a di-
minished healing response, including advanced age, osteoporo-
sis, obesity, diabetes mellitus, or tobacco use. Furthermore, two
(Cases 4 and 5) had an open fracture, which may have been as-
sociated with greater disruption of the local blood supply at the
time of injury. Allograft bone was placed at the time of the ini-
tial surgery in one patient (Case 3); however, none of the others
underwent primary bone-grafting. It is possible that more judi-
cious use of bone graft or bone-graft substitutes would have en-
hanced the healing response and decreased the propensity for
mechanical failure and varus collapse. Fortunately, only one
of these four patients required revision fixation. The other
fractures united, and to date the patients have not had pain
or functional impairment that was sufficient to warrant addi-
tional surgery.
To our knowledge, this is the first report of failures of
the LCP condylar plate. Previously described failures of LCP
plates in other anatomical locations were speculated to be
secondary to technical errors, including inappropriate plate
length or size, an insufficient number of screws, or the use of
unicortical (instead of bicortical) screws23. It is possible that
additional fixation in our patients would have decreased the
risk of implant failure. Simonian et al. described angled screw
placement through the plate from the lateral metaphysis into
the medial femoral condyle as an adjunct in the stabilization
of distal femoral fractures24. In their model, the addition of a
single screw in this location more than doubled the stiffness of
the construct under an axial load, reducing the tendency for
varus collapse. Three of our patients had screw placement in
this location as part of the initial fixation, but failure still oc-
curred. Modification of the design of the LCP condylar plate
to permit locked screws to be directed obliquely, from proxi-
mal and lateral to distal and medial, could be advantageous.
Furthermore, the LCP condylar plate could be modified to
eliminate the cannulation of the locked screws. This could re-
duce the frequency of screw breakage at the screw-plate inter-
face, as solid screws may be less likely to fail over time.
F A I L U RE O F LCP C O N D Y L A R P L A T E F I X A T I O N
IN THE D I S T A L PA R T O F T H E FE M U R
In all three cases of plate fatigue (Cases 1 and 2 and the
patient treated at another hospital), the fracture occurred
through the most proximal of the locking holes in the condylar
portion of the plate. None of our patients had a screw inserted
there. We speculate that increasing the cross-sectional thickness
of the plate and/or eliminating the screw hole at that level
would improve the fatigue strength of the plate and reduce the
frequency of implant failure. Alternatively, routine placement of
a screw through that hole could be considered to reduce the me-
chanical stress in the fixation construct at that level25.
We believe that locking plates represent a valuable ad-
vancement in fracture treatment. However, the limitations of
this new technology and the indications for its use have not
been completely elucidated. Despite the introduction of new
implants, principles of fracture management remain un-
changed. Severe medial comminution necessitates the use of
indirect methods of reduction, preservation of biology, and
protected weight-bearing. Additionally, we propose that the
LCP condylar plate be used only when conventional fixed-angle
implants cannot be placed. A recent study demonstrated that
the 95° condylar blade-plate has greater stiffness than the LISS
under both axial and torsional loading26. Although no biome-
chanical studies of the LCP condylar plate have been pub-
lished to our knowledge, each of the failed implants that
required a reoperation in our series was successfully revised to
a blade-plate. Furthermore, we propose that traditional fixed-
angle devices may be more cost-effective for most distal femo-
ral fractures. In our hospital, the cost of an eight-hole, 95°
condylar blade-plate construct is $370 compared with $743
for a dynamic condylar screw with a 95° side-plate and $2089
for an LCP condylar plate of similar size.
In conclusion, the LCP condylar plate represents an evo-
lutionary approach to the surgical management of distal fem-
oral fractures, but it does not completely solve the age-old
problems of nonunion and malunion. We encountered six
cases of implant failure. Accurate reduction and fixation, judi-
cious use of bone-grafting, and protected weight-bearing, per-
haps combined with modifications in implant design, may
decrease the prevalence of these problems in the future.
Appendix
A table showing clinical details of the six cases is avail-
able with the electronic versions of this article, on our
web site at jbjs.org (go to the article citation and click on
“Supplementary Material”) and on our quarterly CD-ROM
(call our subscription department, at 781-449-9780, to order
the CD-ROM). 
Heather A. Vallier, MD
Theresa A. Hennessey, MD
John K. Sontich, MD
Brendan M. Patterson, MD
Department of Orthopaedic Surgery, MetroHealth Medical Center, 2500
MetroHealth Drive, Cleveland, OH 44109. E-mail address for H.A. Val-
lier: hvallier@metrohealth.org
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The authors did not receive grants or outside funding in support of
their research for or preparation of this manuscript. They did not re-
ceive payments or other benefits or a commitment or agreement to pro-
vide such benefits from a commercial entity. No commercial entity paid
or directed, or agreed to pay or direct, any benefits to any research fund,
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