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Objectives: To compare outcomes and costs between locking and nonlocking (NL) constructs in the treatment of bicondylar tibial plateau (BTP) fractures., Design: Retrospective cohort study., Setting: Level 1 academic trauma center., Patients: All patients who presented with complete articular, BTP fractures OTA/AO 41-C and Schatzker VI between 2013 and 2015 were screened (n = 112). Patients treated with a mode of fixation other than plate-and-screw were excluded. Fifty-six patients with a minimum follow-up of 12 months were included in the analysis., Intervention: Operative fixation of BTP fractures with locking (n = 29) or NL (n = 27) implants., Main Outcome Measurements: Implant cost, patient-reported outcomes (PROMIS physical function and pain interference), clinical, and radiographic outcomes., Results: There were no differences between the 2 groups with respect to demographics, injury characteristics, radiographic outcomes (change in alignment), or clinical outcomes (PROMIS, reoperation, nonunion, and infection). Implant costs were significantly greater in the locking group compared with the NL group (mean L, $4453; mean NL, $2569; P < 0.01)., Conclusions: This study demonstrated improved value of treatment (less cost with no difference in clinical outcome) with NL implants for BTP fractures when dual-plate fixation strategies are performed., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Thirty-three peer-reviewed studies met the inclusion criteria for the Overview. Criteria were framed by three key questions regarding indications for the use of locking plates, their effectiveness in comparison with traditional nonlocking plates, and their cost-effectiveness. The studies were divided into seven applications: distal radius, proximal humerus, distal femur, periprosthetic femur, tibial plateau (AO/OTA type C), proximal tibia (AO/OTA type A or C), and distal tibia. Patient enrollment criteria were recorded to determine indications for use of locking plates, but the published studies do not consistently report the same enrollment criteria. Regarding effectiveness, there were no statistically significant differences between locking plates and nonlocking plates for patient-oriented outcomes, adverse events, or complications. The literature search did not identify any peer-reviewed studies that address the cost-effectiveness or cost-utility of locking plates.

Locking-plate systems are believed to provide better purchase in poor quality bone and equivalent purchase with fewer screws, and also to limit screw pullout by functioning as fixed-angle devices. This retrospective study examined 25 oncologic reconstructions involving locking plates. There were 8 cases of open reduction and internal fixation for pathologic fracture or nonunion and 17 limb-salvage reconstructions. Mean follow-up was 18.2 months with 92% of constructs intact (there were 2 implant-related failures). Locking plates offer advantages that can be useful in orthopedic oncology reconstructions. The long-term performance and mechanisms of failure of these implants remains to be defined.