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S-A16

Less invasive stabilization system (LISS) for fractures of the


proximal tibia: Indications, Surgical Technique and Preliminary Re-
sults of the UMC Clinical Trial

P.A. Cole, MD1, M. Zlowodzki, MD2, P.J. Kregor, MD2

1 University of Minnesota, Department of Orthopedic Surgery, Regions Hospital, Minnesota


2 Department of Orthopedic Surgery, Division of Orthopedic Trauma, Vanderbilt University Medical Center,
Nashville

Summary1

The surgical treatment of proximal tibia fractures, with ture has a propensity for valgus and flexion (apex ante-
or without intraarticular involvement, is associated rior) deformity due to the muscular forces acting through
with well-described patterns of failure and significant the quadriceps and iliotibial band (Figure 1a–b). Fur-
complication rates. Recent surgical advances allow for thermore, there is an expected incidence of anterior knee
a minimally invasive approach to such injuries, which pain after intramedullary nailing for tibia diaphysis frac-
may improve healing times, increase union rates, and tures [1–3]. Articular fractures involving both condyles
decrease complication rates. The Less Invasive Stabi- of the tibial plateau are difficult to reduce through sin-
lization System (LISS) for proximal tibia fractures em- gle approaches, and the traditional plating technique uti-
ploys a laterally based fixed angled implant, allowing lized through a lateral approach does not prevent varus
for the placement of locking screws proximal and dis- collapse due to the lack of buttress of the medial column
tal to the fracture, which may be placed percutaneous- (Figure 2a–b). Combined or extended approaches to ad-
ly. This manuscript presents the surgical technique and dress this principle of the medial buttress are associated
indications of the Tibia LISS. A preview of the early clin- with a significant incidence of wound slough and infec-
ical results of the treatment of bicondylar tibial plateau tion [4–7]. Techniques for external fixation have also been
fractures and proximal tibia diaphysis will also be pre- proposed to prevent these complications and patterns of
sented. failure; however, these techniques may compromise
anatomical articular reduction, and are associated with
Keywords: tibial plateau, proximal tibia, Less Inva- pin track infections and septic arthritis [8–11]. Further-
sive Stabilization System, LISS, submuscular plating, more, patient dissatisfaction is high with extended times
minimally invasive using external fixation devices.
Injury 2003, Vol. 34, Suppl. 1 The Less Invasive Stabilization System method of
fracture fixation proposes the advantages of indirect
fracture reduction and percutaneous, submuscular im-
Introduction plant placement. The fixator implants and instrumen-
tation system offers a method of percutaneous place-
The surgical treatment of proximal tibia fractures, with ment of self-drilling/self-tapping screws. These screws
or without intraarticular involvement, is associated with have threaded heads to provide a fixed angle with
well-described patterns of failure and significant com- matching threaded screw holes in the fixator (Figure 3).
plication rates. Specifically, the proximal third tibia frac- Proximal placement of these fixed-angled screws in
multiple strategic locations provide capture of the ar-
ticular segment. Distally, along the stem of the implant,
1 Abstracts in German, French, Italian, Spanish, Japanese and self-drilling/self-tapping monocortical screws may be
Russian are printed at the end of this supplement. placed to achieve anchorage in the tibial diaphysis.
P. A. Cole et al.: Proximal tibial LISS S-A17

The purpose of this manuscript is to review the sur-


gical indications for use of the LISS in proximal tibia frac-
tures and to describe the surgical technique. Technical
tricks for problem fractures and specific surgical chal-
lenges will be elucidated. There will be an emphasis on
closed reduction techniques to highlight distinguishing

a) b)

Fig. 2a: Anteroposterior Fig. 2b: Anteroposterior


radiograph of a knee depict- radiograph of the knee as
ing a bicondylar proximal pictured in 2a, four weeks af-
tibia fracture after fixation ter surgery. Note the collapse
with a laterally based plate of the fracture into varus due
and screws. to the lack of a medial but-
tress.

a) b)

Fig. 1a: Anteroposterior Fig. 1b: Lateral radiograph of


radiograph of the tibia the tibia as depicted in 1a, af-
demonstrating the valgus ter fixation with an in- Fig. 3: Photograph of
deformity which occurs at tramedullary nail. Note the a 9-hole Tibia LISS
the proximal fracture due to flexion deformity which oc- fixator demonstrating
deforming forces, mainly curs at the proximal fracture the varied proximal
from the iliotibial band. site due to the deforming screw angles and
force of the quadriceps locking capability of
through the tibial tubercle. the screws.

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S-A18

a) b) c) d)

e) f)

Fig. 4:
a) Anteroposterior radiograph of a proxi-
mal one third segmental tibial shaft frac-
ture and an associated fibular fracture at
the same level. An ipsilateral pilon frac-
ture can be noted as well.
b) Lateral radiograph of the same leg pic-
tured in 4a.
c) Anteroposterior radiograph of the leg six
weeks after LISS fixation of the tibial
fracture and intramedullary nailing of
the fibular shaft.
d) Lateral radiograph of the same tibia as
pictured in 4c.
e) Anteroposterior radiograph of the ankle
in the same patient demonstrating inter-
nal fixation of the ipsilateral pilon frac-
ture.
f) Lateral radiograph of the tibia depicting
the distal LISS fixator directly lateral over
the tibia.
P. A. Cole et al.: Proximal tibial LISS S-A19

principles of the LISS from conventional plate and screw reference to the Schatzker Classification for tibial
fixation. Lastly, early results from one clinical trial of plateau fractures, the indications include Schatzker
treatment for proximal tibia fractures using the Less In- Type V & VI.
vasive Stabilization System will be presented. The LISS fixator is not specifically indicated for the
isolated midshaft tibial diaphysis fracture, however, we
have found it quite useful for segmental shaft fractures
Indications involving the proximal one-half of the tibia (Figure
4a–f), as well as ipsilateral diaphyseal and bicondylar
One of the distinguishing biomechanical advantages of tibial plateau fractures. There are other implant designs
the LISS fixator is its fixed angled nature. Since it is ap- currently available that may be utilized with minimal-
plied laterally on the tibia, it prevents varus collapse in ly invasive techniques for fractures of the tibial dia-
metadiaphyseal fractures, or fractures of the tibial physis. What role these latter fixation techniques will
plateau involving the medial condyle. play next to standard intramedullary nailing for dia-
Therefore, use of the tibia LISS is indicated for frac- physeal fractures remains to be defined. Other less
tures of the proximal tibia that involve both the medial common circumstances where the tibia LISS has been
and lateral columns. These include AO/OTA Type utilized, includes pathological lesions with impending
41-A2, A3, C1, C2, C3, and all proximal Type 42’s. With fracture of the proximal tibia (Figure 5a–d).

a)

Fig. 5:
a) Anteroposterior
radiograph of a knee
depicting a lytic le-
sion of the proximal
tibia.
b) Lateral radiograph of
the same knee
demonstrating the im-
pending fracture.
c) Anteroposterior
radiograph of the tib-
ia after filling the de-
fect with Norian SRS
cement compound
and placement of a
9-hole LISS fixator.
d) Lateral postoperative
radiograph of the
b) c) d) same knee.

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S-A20

a) b) d) e)

c)
P. A. Cole et al.: Proximal tibial LISS S-A21

We have limited the use of the LISS fixator in the most ly; and distally, the fascial incision is taken down to the
extreme cases of lateral or medial plateau comminution periosteum over Gerdy’s tubercle. As one dissects in a
and depression where the strongest and most accurate distal direction, the anterior compartment musculature
subchondral buttress is mandatory for support. In these is reflected posteriorly, preserving the anterior com-
rare circumstances, it is best to have the subchondral partment crural fascia for repair. Emphasis should be
hardware traverse an implant which is fixed to the dis- placed on preserving periosteocutaneous flaps. At this
tal diaphyseal segment (Figure 6a–e). point, a submeniscal arthrotomy should be performed
preserving a cuff of the coronary (meniscotibial) liga-
ments to repair upon closure. The articular surface is
then appropriately visualized, reduced, and provision-
Technique
ally fixed with K-wires. We advocate the use of a femoral
distractor and headlamp for adequate visualization
during joint assessment and reduction.
Strategy and Approaches
The next step is articular fixation. Typically, 3.5 mm
One of the tenets of use of the LISS system which dis- cortical screws are used to lag articular fragments, and
tinguishes it from conventional plate and screw usage to provide a raft for mechanical support of the plateau.
is that the fracture reduction must be accomplished be- Large fragment screws may be more suitable in porotic
fore fixation takes place. This is because the screws lock bone. One should place these periarticular implants tak-
into the implant, thus making it an “Internal External ing into account the proposed direction of the LISS
Fixator”. In this sense, the LISS cannot be used to achieve screws, which have a fixed direction. Surgery then pro-
fracture reduction. ceeds with fixation of the articular block to the diaphy-
While treating tibial plateau fractures, an anatomical seal portion.
articular reduction and fixation must be accomplished Articular comminution or displacement of the medi-
prior to LISS implantation. If there is any articular al plateau must be appropriately addressed through a
stepoff or gap, an incision is made beginning proximal medial incision based on preoperative radiographic
to the joint line in the midaxial line of the femur and findings. Seldom is it necessary to place a medial but-
sweeping anterior to Gerdy’s tubercle, then gently dis- tress plate. However, when the comminution along the
tal about one centimetre off the crest of the tibia in a medial column extends very proximally, it is prudent to
“Lazy S” fashion. The iliotibial band is split proximal- place a medial buttress since the proximal LISS screws

Fig. 6:
a) Anteroposterior radiograph of the knee in a 20-year-old d) Postoperative anteroposterior radiograph demonstrating
male involved in a car crash, demonstrating extreme com- plates on both the medial and lateral columns and articu-
minution and depression of the lateral plateau. lar restoration. Note the surgeon’s preference to place the
b) Lateral radiograph of the same knee as pictured in 6a. subchondral raft of screws through, rather than above the
lateral plate. The contour of the Tibia LISS does not allow
c) An axial CT scan image, fifteen millimetres below the ar- for placement proximal enough of such a raft of screws.
ticular surface of the same knee as pictured in 6a–b. Note
the degree of metaphyseal impaction and articular de- e) Lateral radiograph of the same patient postoperatively
pression. demonstrating satisfactory alignment and articular
restoration with the subchondral raft of 3.5 mm cortical
screws.

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S-A22

a) b) c)

Fig. 7:
a) Anteroposterior radiograph of an AO 41-C3
tibial plateau fracture with extensive medial
comminution calling for adjunctive medial
fixation in addition to LISS fixation.
b) Lateral radiograph of the same tibia as pictured
in 4a.
c) CT scan of the tibial plateau
demonstrating medial involvement
and lateral articular depression.
d) Intraoperative anteroposterior
C-arm image demonstrating proxi-
mal medial fixation with a buttress
plate fixed proximally as the first
step.
e) Intraoperative anteroposterior
C-arm image demonstrating lateral
fixation with a 9–hole LISS fixator.

d) e)

f) g) h)
P. A. Cole et al.: Proximal tibial LISS S-A23

Fig. 7:
j)
f) Intraoperative an-
teroposterior C-arm
image demonstrat-
ing elevation of the
medial plateau with
a ball-spiked pusher
through the medial
plate.
g) Intraoperative later-
al C-arm image
demonstrating
anatomical articular
reduction.
h) Postoperative an-
teroposterior radio-
graph demonstrat-
ing satisfactory
k)
alignment in the
frontal plane.
i) Postoperative lateral
radiograph of the
same tibia as pic-
tured in 7h, demon-
strating adequate
alignment in the
sagittal plane.
j) Follow-up photo-
graph sixteen weeks
after surgery
demonstrating 135
degrees of flexion at
the knee.
k) Follow-up photo-
graph sixteen weeks
after surgery
demonstrating full i)
knee extension.

Fig. 8:
a) Photograph of location and size of an anterolateral inci- b) Photograph after insertion of a 5-hole LISS fixator as well
sion in relation to the LISS fixator. This approach is used as correction and maintenance of tibial length by inser-
for simple non articular fractures. tion of a Kirschner wire proximal and distal to the frac-
ture, followed by insertion of the first screw.

deployed through the fixator are not “high” enough an AO/OTAType 42 (i.e. proximal metadiaphyseal), the
(Figure 7a–k). incision need only be four centimetres in length, sweep-
The incision used for fixation of the lateral plateau is ing over the anterolateral aspect of the proximal tibia
adequate for insertion of the implant. If the fracture is (Figure 8).

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S-A24

Guide & Implant Assembly detail in the next section: Special Challenges & Technical
Tips.
The LISS fixators come in three sizes: five, nine, and thir-
teen holes corresponding to approximately 14, 22, 30 cm
lengths, respectively. There is a left and right side fixa- Implant Insertion
tor inventory. Based on preoperative templating, the ap-
The fixator should next be inserted into the surgical in-
propriate size should be chosen for attachment to the
cision and slid underneath the anterior compartment
Insertion Guide.
making sure to contact bone during slide insertion. A
Attachment to the Guide is accomplished with a Fix-
thumb on the anterior tibial crest can be used to feel and
ation Bolt placed through the A hole and into the im-
judge that the implant is in contact with the bone. An-
plant. It is then tightened into the small divots in the ex-
other method of ensuring bone contact during penetra-
terior surface of the fixator, corresponding to nipples on
tion is to follow insertion fluoroscopically. The fixator
the Guide.
should be inserted until the metadiaphyseal flare of the
bone and fixator match. Fracture reduction must be
maintained during this part of the procedure.
Fracture Reduction
In the setting of acute fractures, it is likely that closed
Implant Position
reduction can be achieved with traction by pulling on
the ankle. However, one or two “bumps”, six to ten At this juncture, the fracture should be grossly aligned
inches in diameter, strategically placed behind the and the implant should approximate the contour of the
popliteal fossa and proximal calf are necessary first. tibia. We attempt to achieve this approximation to with-
Typically, the assistant must apply traction by pulling in a few millimetres and it is quite all right for the im-
downward “into the bed”. At the same time, alignment plant not to be absolutely flush with the tibia. Intraop-
must be achieved by simple manipulation. Intraopera- erative radiography should verify that the implant is sit-
tively, the C-arm must be utilized to verify and “dial in” ting accurately on the lateral aspect of the bone proxi-
the length, alignment, and rotation. Once reduction has mally and distally.
been achieved, an assistant simply holds the position Once it has been verified in the anteroposterior C-arm
during implant placement. In certain situations, a view that the fixator approximates to the tibia and is ac-
joystick, clamp, or a femoral distractor may be used to curately placed in the lateral view (as in Figures 9a-b),
aid reduction. These clinical scenarios are covered in 2 mm threaded K-wires are placed through receiving

Fig. 9: b) Intraoperative anteroposterior C-arm c) Intraoperative anteroposterior C-arm


a) Intraoperative lateral C-arm image image demonstrating a gap between image demonstrating perfect alignment
demonstrating adequate alignment the fixator and the distal tibia frag- of the fixator and the tibia after using
of the fixator in relation to the tibia ment as indicating by the arrows. the “Whirlybird” as shown in Fig. 8b.
in the sagittal plane. A “Whirlybird” (arrow) is inserted bi-
cortically through a drill sleeve in or-
der to “pull” the tibia to the fixator.
P. A. Cole et al.: Proximal tibial LISS S-A25

holes in the Guide proximally and distally to secure the have used this option primarily in cases where other pe-
relationship between Guide-Implant assembly and tib- riarticular implants have blocked the free passage of the
ia. Furthermore, the Stabilization Bolt is placed through self-drilling self-tapping screw.
a cannula in the Insertion Guide corresponding to the
most distal hole in the fixator. This is executed through
a stab incision in the skin which is then prepared by
blunt dissection down to the bone using a trocar in the Special Challenges & Technical Tips
cannula.
A small incision distally on the lateral aspect of the Multifragmentary Fractures
leg to permit palpation down to the bone is recom- Multifragmentary fractures present a relatively difficult
mended. This allows for verification that the implant is circumstance for achieving a closed reduction. Often,
lying directly in the lateral position and it allows for pro- the intercalary segment wants to behave independent-
tection of the neurovascular bundle during distal screw ly from the proximal and distal segments over which
insertion. This step is critical for the placement of distal one has slightly more control.
screws in the 13 hole fixators based on an anatomical There are several strategies one may consider for this
dissection study [12]. problem. The first is to place strategically sized bumps
behind the popliteal fossa and proximal calf with fluo-
The Whirlybird roscopic assistance, until the intercalary fragment has
been approximately restored in terms of length and
Although manual pressure is usually sufficient to ap- alignment. Traction is always necessary through the dis-
proximate the tibia and fixator, fracture reduction can tal extremity, usually with a pair of helping hands. If
be “fine-tuned”. To fine tune the reduction or the ap- strategic bumps do not help to gain or maintain the re-
proximation of the fixator, the Whirlybird may be used. duction, a percutaneous Schanz pin can be placed
The Whirlybird is a threaded tool with a diameter of through a stab incision to achieve control of the frag-
four millimetres, which can be drilled through the In- ment. Strategically placed pressure from a pushing de-
sertion Guide, through a cannula, through one of the vice through a stab incision on the medial side may aid
screwholes, into bone. It has a sliding nut on its proxi- in this part of the reduction as well. Lastly, the LISS fix-
mal end which can be tightened against the Insertion ator may first be placed in its position in the anterior
Guide, thus approximating or docking the bone to the compartment, then one or two whirlybird approxima-
fixator. This manoeuver should be guided by antero- tor devices may be used to dock the segmental piece to
posterior fluoroscopy (Figure 9). the fixator (Figure 9).

Fracture Fixation Very Proximal Medial Comminution


Self-drilling self-tapping screws are inserted next. A In the circumstances where medial comminution ex-
guideline we have preferred during our clinical trial is tends very far proximally, sometimes to within a cen-
the placement of four screws proximal and four screws timetre of the medial tibial plateau, it is necessary to
distal to the fracture when possible. The length of the slide the LISS fixator quite far proximally, perhaps even
proximal screws is based on an estimate with reference to the lateral joint line. This directs the most proximal
to a guidewire placed across the plateau. The two most fixed angle screws, which have a 10 degree inferiorly
proximal screws diverge and are directed in an inferior directed angle, just below the medial subchondral bone.
direction to approximately ten degrees in each direction. This causes the metadiaphyseal flare of the lateral
The screws appropriate for the diaphysis may be either plateau not to match that of the fixator. Furthermore, it
18 or 26 mm in length. causes the implant to “ride off” the lateral plateau by as
Next, the Stabilization Bolt can be removed, and a much as half a centimetre or more. We have found this
screw placed through this hole. Lastly, the Insertion approach, though not visually aesthetic on radiographs,
Guide assembly, K-wires, and Fixation Bolt are all re- to be necessary for adequate support of the medial col-
moved. A screw can now be placed through the A-hole umn. Alternatively, this circumstance can be addressed
in the plate (from which the Fixation Bolt was removed) as discussed earlier and demonstrated in Figures 7a–k.
using a freehand method. Aforty millimetre screw is ap-
propriate for this hole and will be directed toward the
The Fractured Tibial Tubercle
tibial eminence and end at the level of the joint line.
When placing self-drilling self-tapping screws free- In some comminuted variants, the tibial tubercle may
hand, the surgeon has eleven degrees of freedom in each represent an independent fracture. Since the articular
direction. Beyond eleven degrees, the screw implant fixation as well as the LISS fixation in the proximal ar-
fixed-angle interface is destroyed. One other option is ticular segment does not address the tibial tubercle, it
to place conventional screws through the fixator. We will have a propensity to displace due to pull of the

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S-A26

quadriceps through the patella tendon. In this circum-


stance, independent fixation of the tibial tubercle by cor-
tical lag screws directed from anterior to posterior is rec-
ommended. One should not place these cortical lag
screws across the metadiaphyseal zone to the distal
segment. Rather, these screws should be placed in an
anterior-distal to posterior-proximal direction.

Delayed Fixation
A subset of proximal tibia fractures will not be operat-
ed on early due to prominent swelling, lack of surgical
planning and resources, or delayed transfer of the pa-
tient. We prefer a spanning external fixator across the
knee for these fractures which have a propensity to
Fig. 10: Initial provisional stabilization of a tibial plateau shorten due to the exertion of muscular forces across the
fracture with a spanning external fixator. knee (Figure 10). In cases where delayed fixation is nec-

a) b) c) d)

Fig. 11:
a) Anteroposterior radiograph of the knee demonstrating g) Intraoperative photograph demonstrating soft tissue clo-
an AO 41-C3 tibial plateau fracture and an AO 33-C3 in- sure of the quadriceps insertion and patella retinaculum.
tracondylar femoral fracture with a segmental shaft com- h) Postoperative anteroposterior radiograph of the knee
ponent. demonstrating satisfactory alignment.
b) Lateral radiograph of the same knee as pictured in 11a. i) Lateral radiograph of the same knee as pictured in 11h.
c) Anteroposterior radiograph of the knee demonstrating j) Anteroposterior radiograph of the femur demonstrating
periarticular fixation, placement of antibiotic beads and callus formation 6 weeks after surgery.
spanning external fixation for initial provisional stabi-
lization. k) Lateral radiograph of the same femur as pictured in 11j.
d) Lateral radiograph of the same knee as pictured in 11c, l) Anteroposterior radiograph of the tibia demonstrating
before placement of the beads. callus formation 6 weeks after surgery.
e) Clinical photo of the lower extremity after external fixa- m) Lateral radiograph of the knee pictured in 11 l.
tion. n) Anteroposterior radiograph of the proximal femur
f) Intraoperative photograph after placement of antibiotic 6 weeks after surgery. Note that the patient had an ipsi-
beads and LISS fixation of the femur and tibia. lateral intertrochanteric hip fracture and an acetabular
fracture as well.
P. A. Cole et al.: Proximal tibial LISS S-A27

e) h) i)

f)

g)

j) k) l) m) n)

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S-A28

essary, it is more difficult to achieve closed reduction including six Gustilo Type 3B, and five Gustilo Type 3A
due to the organization of haematoma and fracture cal- fractures.
lus, as well as contracture of surrounding soft tissues. The implants utilized for the fractures included four
In these circumstances, closed reduction is not always 5-hole plates, thirty-two 9-hole plates, and eighteen 13-
successful with manual traction and alignment alone. hole plates. The mean number of screws used to fix the
We have placed percutaneous Schanz pins, clamps or, proximal articular segment was five (R=3-7), and the
in rare circumstances, we have had to use a femoral dis- mean number of screws distal segment was five (R=3-
tractor to achieve the necessary reduction prior to fixa- 6). The average time for placement of the LISS was fifty-
tor placement. For these reasons, it is always recom- six minutes, which included the time from initial inser-
mended the definitive fixation be performed at the tion to placement of the last self-tapping screw.
safest, earliest convenience.

Open Fractures
Results and Complications
For open fractures of the proximal tibia, immediate in-
ternal fixation after thorough irrigation and debride- The mean range of motion was 1 degree (R=0-10) to 116
ment is advisable. Typically the open fracture wounds degrees (R=80-150). Two patients required quadricep-
occur medially. After the fracture has been appropri- splasty for joint ankylosis. Both of these patients had
ately addressed through this wound, it is closed pri- sustained ipsilateral Type C3 distal femoral fractures as
marily, if possible, and then attention is directed to the well as the tibial plateau fracture.
lateral side for placement of the LISS fixator (Figure 11a- The mean time to full weight-bearing in this series
n). If the open fracture wounds are not able to be closed was 13.2 weeks (R=8-16). Forty-eight patients were clin-
primarily, we favour serial irrigation and debridement ically healed when full weight-bearing commenced and
with interim antibiotic bead pouches until appropriate all but two eventually healed except one delayed union
soft tissue coverage by the microvascular team can be which responded to elective bone grafting, and one non
executed as shown in Figure 11f. union.
Postoperative malreductions included two articular
step-offs of two and three millimetres. There was a hy-
perflexion (apex anterior) deformity between five to ten
degrees in four patients, and a varus malreduction of
UMC Clinical Trial
eight degrees in one. There were no additional varus or
valgus malreductions more than five degrees. In two
Materials and Methods
cases, there was anterior translation of the proximal tib-
In November of 1998, a prospective clinical trial was be- ia fragment relative to the distal fragment of more than
gun at the University of Mississippi Medical Center for one centimetre. One required a reoperation for loss of
the treatment of proximal tibia fractures treated with the proximal fixation and the other healed uneventfully.
Less Invasive Stabilization System (LISS). Specifically, The patient with an eight degree varus malreduction
between 11/98 and 8/00, patients with AO/OTA Type was reoperated for correction of his deformity. There
41-A2, A3, C1, C2, C3, and proximal Type 42 were were no cases of late varus collapse or loss of reduction.
prospectively enrolled. Surgical, radiographic, and clin- Three patients developed wound haematomas or
ical follow-up information was entered into a trauma seromas, which responded to simple irrigation and de-
database. bridement. These three patients all had negative cul-
This trial included fifty-four fractures in fifty-three tures of their fluid accumulation. Two patients devel-
patients treated by two surgeons. The mean age of the oped infections. One patient had a superficial infection,
patients was forty-four years (R=16-82). There were fif- which occurred in an open fracture wound distant from
teen female patients and 32% of the fractures resulted the LISS insertion site. This patient responded to a sin-
from a high-energy mechanism. gle irrigation and debridement and course of oral an-
Forty-six percent of the fractures represented an tibiotics. The second infection arose four months post-
AO/OTA Type 41, and 28% represented an AO/OTA operatively and responded to implant removal, irriga-
Type 42. Twenty-six percent of the fractures were de- tion and debridement and a course of oral antibiotics.
fined as an ipsilateral Type 41 and 42. A full 54% of the There were two postoperative nerve palsies. The first
fractures in this trial had some degree of intraarticular was thought to be iatrogenic, affected the deep peroneal
involvement. nerve, and was thought to arise from distal percuta-
Thirteen percent of the fractures were associated with neous placement of screws into the 13-hole fixator. This
an ipsilateral shaft fracture, and 13% were classified as patient’s nerve palsy improved from a Grade 0/5 to a
an AO/OTA Type 41-C3 with extensive articular com- Grade 3/5 muscular strength after two years. The oth-
minution. Furthermore, 31% of the fractures were open, er palsy represented as global dyaesthesias over the tib-
P. A. Cole et al.: Proximal tibial LISS S-A29

ial and peroneal nerve distributions, and was thought References:


to be related to a tourniquet used intraoperatively. This
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Two patients underwent amputations at one year tramedullary tibial nailing. Its use in closed and type I open
fractures. J Bone Joint Surg (B) 1990;72:605.
postoperatively, related to the poor clinical outcome of
a mangled extremity. Two other patients died within 2. Keating JF, Orfaly R, O'Brien PJ. Knee pain after tibial nail-
two months of surgery due to unrelated medical causes. ing. J Ortho Trauma 1997;11:10.
3. Toivanen JA, Vaisto O, Kannus P, Latvala K, Honkonen SE,
Jarvinen MJ. Anterior knee pain after intramedullary nail-
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ized study comparing two different nail-insertion tech-
Discussion niques. J Bone Joint Surg (Am) 2002;84:580.
4. Moore TM, Patzakis MJ, Harvey JP. Tibial plateau frac-
Results from the clinical trial of the first fifty-three pa- tures: definition, demographics, treatment rationale, and
tients treated with a LISS for proximal tibia fractures in- long-term results of closed traction management or oper-
dicate that a high rate of union (96%), stable fixation of ative reduction. J Ortho Trauma 1987;1:97.
the proximal fragment with no late varus collapse or 5. Perry CR, Evans LG, Rice S, Fogarty J, Burdge RE. A new
cut-out, and an acceptable infection rate (3.7%) can be surgical approach to fractures of the lateral tibial plateau.
achieved with this technique and technology. These J Bone Joint Surg (Am) 1984;66:1236.
methods may be successfully utilized for both bi- 6. Stokel EA, Sadasivan KK. Tibial plateau fractures: stan-
condylar tibial plateau fractures and proximal one third dardized evaluation of operative results. Orthopedics
tibial fractures. 1991;14:263.
A high proportion of injuries in this series represent- 7. Young MJ, Barrack RL. Complications of internal fixation
ed the extreme end of the spectrum of fracture severity. of tibial plateau fractures. Orthop Rev 1994;23:149.
In this light, it would seem that the mean range of mo- 8. Weiner LS, Kelley M, Yang E, Steuer J, Watnick N, Evans
tion (1–116 degrees) achieved and time to weight-bear- M, et al. The use of combination internal fixation and hy-
ing (13.2 weeks) as well as the type and rate of compli- brid external fixation in severe proximal tibia fractures. J
cations are quite acceptable. It was not the goal of this Orthop Trauma 1995;9:244.
study to assess functional outcome. 9. Bolhofner BR. Indirect reduction and composite fixation
Possible disadvantages of the Less Invasive Stabi- of extraarticular proximal tibial fractures. Clin Orthop Rel
Res 1995;315:75.
lization System include difficulties with closed reduc-
tion techniques and fixator applications. Furthermore, 10. Gaudinez RF, Mallik AR, Szporn M. Hybrid external fixa-
a concern for neurovascular injury during placement of tion of comminuted tibial plateau fractures. Clin Orthop
Rel Res 1996;328:203.
the most distal screws in the 13-hole fixators is war-
ranted. 11. Bal GK, Kuo RS, Chapman JR, Henley MB, Benirschke SK,
Claudi BF. The anterior T-frame external fixator for high-
energy proximal tibial fractures. Clin Orthop Rel Res
2000;380:234.
12. Kregor P, Christensen R, Nemecek D, Gilbert S, Cole P.
Conclusion Neurovascular risk associated with submuscular fixation
of the proximal tibia: A cadaveric study. In: 17th Annual
The surgical treatment of proximal tibia fractures, with Meeting of the Orthopaedic Trauma Association; 2001; San
or without intraarticular involvement, is associated Diego, CA; 2001.
with well-described patterns of failure with significant
complication rates. The LISS can be thought of as an “in- Corresponding Author:
ternal-external fixator”. Its use in dual column proximal Peter Alexander Cole, M.D.
tibia fractures prevents varus collapse by virtue of its Associate Professor
fixed-angled screws, which offer multiple points of fix- University of Minnesota
ation in the proximal articular segment. The LISS guide Department of Orthopedic Surgery
system utilized with a percutaneous submuscular tech- Regions Hospital
nique lessens soft tissue insults common to these in- 640 Jackson Street
juries. The LISS technique and technology appears to St Paul, MN 55127
provide stable fixation (96%), a high rate of union (96%), Tel: 651-254-1513
and an acceptable rate of infection (4%) for proximal tib- Fax: 651-254-1519
ia fractures, based on our experience with the first 54
patients.

Injury 2003, Vol. 34, Suppl. 1