LISS Plate Research Articles

Operative treatment of periprosthetic fractures of the proximal femur with a contralateral, upside-down LISS plate in elderly patients

BackgroundIncreasing expectancy of life and levels of activity in the growing geriatric population lead to a rising number of prosthetic implants of the hip and consequently the incidence of periprosthetic fractures of the femur increase. The fracture pattern and the possible instability of the stem are a challenge to the orthopaedic surgeon. Treatment options are complete replacement of the implant or a solitary osteosynthesis. The goal of this study was to analyse the feasibility of the operative intervention using a contralateral reversed anatomic distal femoral LISS® locking plate and the radiological and functional outcome in a geriatric cohort.MethodsWe included all patients older than 75 years of age with a Vancouver type B fracture, which have been treated by osteosynthesis using a LISS® (contralateral reversed) plate in our institution in an interdisciplinary ortho-geriatric setting between 7/2013 and 12/2021. Perioperative morbidities, clinical and radiological outcome during follow-up were retrospectively analysed.ResultsDuring the observed time period, 83 patients (mean age: 88 years (range: 76–103), male/female: 26/57) were treated. Most fractures were Vancouver type B2 (n = 45, 54%) followed by B1 (n = 20, 24%) and B3 (n = 18, 22%). The most prevalent postoperative surgical complication was anaemia (n = 73, 88%) followed by infections (n = 12, 14%, urinary infections, pneumonia) and cardiovascular decompensation (n = 8, 10%). Clinical and radiological follow up 6–8 weeks postoperative was possible for 59 patients (70%). The majority of them did not describe pain (n = 50, 85%) and had a good or excellent radiological outcome. Three cases needed revision surgery due to infection and another three due to non-union, loosening of the stem or an additional fracture. 1-year mortality was 30%.ConclusionWe are convinced that the reversed contralateral LISS-plate is an easy-to-use implant with a small complication rate but a very successful and high healing rate in a geriatric, polymorbid cohort.

Intraoperative complications during total hip arthroplasty: a very uncommon intraoperative femur fracture occurred in a malnourished osteoporotic patient.

Intraoperative femoral fracture is a rare but growing complication of primary total hip arthroplasty. We aimed to present an uncommon related case, assessing also the role of malnutrition and osteoporosis. We discuss the case of a 49 years old male patient, malnourished and osteoporotic, with an intertrochanteric, multifragmentary, inveterate fracture, that happened three months before. During the prosthetic surgery, a supracondylar fracture occurred. We synthesized it with a 13 holes LISS plate, 7 distal screws and 3 proximal cerclage wires. The leg was immobilized to 0° for 3 weeks and the load forbidden for 3 months. Calcium, Albumine, Total Proteins, Osteocalcin and Vitamin-D levels were below the normal range. Teriparatide was administered for 6 months. Global investigation of the patient's nutritional status is recommended before joint replacement and preoperative planning is mandatory to choose the adequate implant. Osteoanabolic therapy could be advisable to favor fracture healing.

Outcome of Extra-Articular Fractures of Distal Femur: Less Invasive Stabilization on System (LISS) Plating versus Closed Retrograde Intramedullary Interlocking Nail

Objective: To evaluate the functional outcome of extra-articular fracture of distal femur, LISS plating versus retrograde intramedullary interlocking nailing. Study Design: Prospective/Randomized control trial Place and Duration of Study: Department of Orthopaedic Surgery, Ghulam Muhammad Mahar Medical College Sukkur from 1st July 2019 to 31st December 2020. Methodology: One hundred patients of both genders with ages 20 to 60 years presented with fractures of distal femur were included in this study. Patients were equally divided into two groups I and II. Group I contained 50 patients and received LISS plating and Group II contained 50 patients and received closed retrograde intramedullary interlocking nail, Pre and post-operative assessment was done. Post-operative complications were noted at 12th day. Functional outcomes were examined after 6 months by the NEERs criteria. Results: Sixty five (65%) patients were males (35 in group I and 30 in group II) and 35 (35%) patients were females (15 in group I and 20 in group II). Road traffic accident was the most common mode of injury in 62 (62%) patients. Most of the fractures were on right side 66 (66%). According to the NEER criteria, 80% patients shows excellent, 20% patients shows satisfactory with no poor results in Group I and in Group II 30% patients shows excellent, 66% patients shows satisfactory results and 4% shows unsatisfactory results. Conclusion: The LISS plating and closed retrograde intramedullary interlocking nail was safe and effective methods for extra-articular fractures of distal femur but there were less complications found in LISS plating. Keywords: Fracture of distal femur, LISS plating, Interlocking nail

Biomechanical assessment of single LISS versus double-plate osteosynthesis in the AO type 33-C2 fractures: A finite element analysis

ObjectivesIn the present study, we assessed the biomechanical advantage between the single LISS and double-plate used in AO type 33-C2 fractures with the method of finite element analysis, which will help surgeons choose the optimal therapy to the unstable distal femoral fracture. MethodsThe AO type 33-C2 fractures and the models of LISS plate and medial plate was constructed in 3-matic software and UG-NX software respectively. We then assembled the single plate and the double-plate to the fracture model separately to form the fixation models. After meshing the models’ elements, we used the Abaqus software to perform the finite element analysis. Values of peak Von Mises Stress (VMS) on the plate, maximum deformation of the models and the distance changes of the fracture gap were used to capture the mechanical factors in this study. ResultsOur results indicated that the single LISS underwent 1.2 times higher amount of stress than the double-plate (316.0 MPa VS 281.6 MPa). And the medial plate dispersed some stresses (the maximum stress is 47.4 MPa). Single-plate generated 3 times greater bending angle than double-plate (0.6° VS 0.2°). The bending angles of the single and double-fixation-fracture models are 0.9° and 0.3° respectively. The maximum distance changes of the fracture gap in the single-plate model was 2 times higher than that of double-plate model (2.6 mm VS 1.3 mm). In the torsional load analysis, peak VMS of the single and double model was 1.0 MPa and 0.8 MPa respectively. And the bending angle was 0.8° in the single model and 0.4° in the double model. ConclusionsThe double-plate is more effective scenario using in the distal femoral fractures, particular in unstable fractures with joint involvement.

Modified one-stage revision procedure for treating proximal femoral infected nonunion after intramedullary nail fixation

To explore the methods and results of modified one-stage revision procedure for treating proximal femoral infected nonunion after intramedullary nail fixation. From June 2010 to June 2015, 10 patients of proximal femoral infected nonunion after intramedullary nail fixation were treated with modified one-stage revision procedure, including 9 males and 1 female, ranging in age from 35 to 77 years old. There were 3 cases of intertrochanteric fractures, 2 cases of intertrochanteric fractures accompanied with proximal femoral fractures and 5 cases of subtrochaneric fracures. The fractures ware fixed by LISS plate after radically debridement. The bone defects were repaired by free vascularized fibular graft and autogenous cancellous bone graft mixed artificial bone containing antibiotics. Postoperatively, ambulation without weight bearing was encouraged as early as possible. Ten patients were followed up from 9 to 30 months and all nonunions healed smoothly without wound infection recurrence or internal fixation failure at the final follow-up. The time for full weight bearing was from 12 to 28 weeks. The hip joint function was evaluated by Sanders Traumatic Hip Rating Scale, the result was excellent in 7 cases, good in 2, and fair in 1 at the final follow-up. Modified one-stage revision procedure is an effective treatment with a good functional result for proximal femoral infected nonunion after intramedullary nail fixation. On the basis of radical debridement, the combination of infection control and bone healing therapeutic techniques is key for success.

A clinical study of minimally invasive percutaneous plate osteosynthesis of proximal tibial fractures using locking compression plate

Background: Proximal tibia being a prime component of knee joint, which is vital for weight bearing and mobility. Because of its superficial location and vulnerable position, proximal tibia is frequently injured, more frequently in road traffic accidents (RTA). With the better understanding of fracture healing, recent advances in tissue friendly minimally invasive techniques like MIPPO (Minimally Invasive Percutaneous Plate Osteosynthesis) and development of technically mature implant systems like LCP (Locking Compression Plate), which have shown promising results in the treatment of complex proximal tibial fractures, thus overcoming most of the drawbacks of conventional plating and other treatment modalities. The LCP is an internal fixator system, which is a hybrid of LC-DCP and LISS plate. The LCP can be applied in 3 different ways (1) As compression plate, (2) As combined compression and plating principle, and (3) As pure internal fixator (bridge plate). Material and Methods: We studied 20 patients involving proximal tibial fractures fixed with LCP using MIPPO technique. Results: We followed up all the patients for a period ranging from 16-36 weeks. The average time for union of fractures was 19 weeks ranging from 16-24 weeks. An average knee range of motion of 0-121o was achieved. In our study excellent results were achieved in 10 fractures (47.6%), good in 8 fractures (38.1%), fair in 2 fractures (9.6 %) while poor result was seen in one fracture (4.7 %). We had a total of 6 complications which included 2 knee stiffness, 1 post operative loss of reduction,1 infection, 1 varus deformity and 1 knee instability. Conclusion: The patient sample approximately reflected the regular trauma patients encountered at our setup. The fractures treated with pure bridge plating and combined principle of compression and bridge plating healed rapidly by secondary fracture union, achieving strong union across the fracture site. In addition by MIPPO technique, there is minimal soft tissue damage and minimal disruption of blood supply to fracture ends, resulting in faster healing and fracture union.

The outcome of unstable proximal femoral fracture treated with reverse LISS plates

BackgroundThe Russel-Taylor type 2B fractures compromised the trochanteric region and medial buttress of proximal femur. This fracture pattern limits the choice of implants and raises the risk of adverse outcomes. We aimed to (i) determine the outcome of Russel-Taylor type 2B fractures treated using reverse less invasive stabilization system plates (LISS-DF) and to (ii) learn what factors affected outcomes after osteosynthesis with reverse LISS plates. DesignA retrospective study SettingThe study was conducted at a Level III trauma center in Taiwan. MethodsTwenty-five consecutive patients presenting with a Russel-Taylor type 2B fracture were enrolled. All cases were treated with reverse LISS plates. A Modified Radiographic Union Scale for Femur (RUSF), Radiographic parameters, functional scores, and complications were assessed. ResultsUnion occurred in 21 cases at an average of 18.8 weeks. The average immediate postoperative neck-shaft angle was 130° (range: 122–135°) compared with 139° (range: 135–141°, p=0.05) on the contralateral side. Two cases had complications of proximal screws cutting out and two cases had broken implants. Finally, all 4 cases required repeated surgeries (16%). Malunion occurred in 4 patients and early mechanical failure (proximal screws cut out) occurred in 2. There was a significant difference in the purchase index of the proximal screws between cases with redisplacement and those without (26.4mm and 98.6mm, p=0.01). ConclusionsThe use of reverse LISS plate appeared to be an alternative procedure for the specific pattern in the present study. We recommend using this reverse locking plate to treat unstable proximal femoral fractures with meticulous techniques of placing plates. Adequate purchase of the proximal locking screws might decrease the risks of complications.

Treatment of Aseptic Hypertrophic Nonunion of the Lower Extremity with Less Invasive Stabilization System (New Approach to Hypertrophic Nonunion Treatment)

Aim. To evaluate whether aseptic hypertrophic nonunion in the long bones of the lower extremity can be treated successfully with LISS applied with closed methods without grafting. Materials and Methods. The study included 7 tibias and 9 femurs of 16 patients. All cases had hypertrophic nonunion. Initial surgical treatment was with intramedullary nailing in 14 cases, 6 of which had required an exchange of intramedullary nail. All the patients were treated with LISS plate with closed methods. Results. Union was obtained at mean 7 months in all patients. No implant loosening or breakage of the implant was observed and there was no requirement for secondary surgery. Conclusion. Cases of hypertrophic nonunion have excellent blood supply and biological potential. Therefore, there is no need for bone grafting and the addition of fracture stability is enough to achieve full union. Using a limited approach and percutaneous screw insertion, LISS provides fracture stabilization with soft tissue protection.

L’osteosintesi nelle fratture periprotesiche di ginocchio

Periprosthetic fractures are becoming increasingly common nowadays. Standard treatment includes revision of the prosthetic implant, albeit this option typically leads to complex and lengthy interventions. Removal of the prosthesis often leads to significant bleeding, which has particular relevance for elderly subjects with significant comorbidities. Osteosynthesis using plates or nails is the second choice, albeit limitedly to the femoral portion, as it may not be used in the tibial portion. Our experience has prompted us to use LISS plates for fracture reduction, which allows for better management of complex, multifragmentary fractures, even in proximity to the prosthetic implant. Retrograde nailing is not always feasible due to a number of factors, such as: type of prosthesis, presence of fragments near the prosthetic implant, loss of bone material. An increase in the incidence of fractures between the prosthetic stem and intramedullary nails has been observed. The use of nails is preferred thanks to the shorter surgical times in case of uncomplicated fractures. On the other hand, plates allow for fracture stabilisation, especially with distal fractures, with the restoration of limb length without any need for lengthy incisions or damage to periskeletal soft tissues and minimum risk of perioperative bleeding (better patients compliance). Furthermore, they allow for better control of possible axial deviations of the segment, even in case of rotary movements (not always fixed by the application of retrograde nails). On the basis of published evidence, the use of plates seems to be preferable over nailing. Lastly, there is the need to emphasise that attentive and diligent surgical techniques at the time of the prosthetic implant largely reduces the incidence of such fractures.

Errors in Treatment of Fractures of Distal Femur by LISS Method (Less Invasive Stabilization System) - Single-centre Experience.

LISS, the newest surgical method, makes it possible to completely regain knee function after knee fractures. We share our experience of the most frequently occurring errors during LISS-based treatment and ways of avoiding them. Our sample consisted of patients treated with the LISS method between 2007 and 2012 in the Department of Orthopedics and Traumatology of the 4th Military Hospital in Wroclaw, Poland. We analysed the patients' radiographic records. We analysed follow-up radiographs of 28 patients with fractures of the distal femur. We identified the following seven errors in reduction and fixation of fractures of the distal femur occurring during treatment using the LISS method: 1. Valgus or varus fracture fixation. 2. Malrotation of the fracture fragments. 3. Fixation in malrotation in the sagittal plane. 4. Non-axial placement of the LISS plate in the sagittal plane. 5. The use of K wires not recommended in the LISS method. 6. Screws penetrating into the joint. 7. Drilling holes for unicortical screws. 1. The most common errors in the treatment of fractures of the distal femur by LISS method relate to inadequate reduction of the fracture. 2. Intraoperative fluoroscopy should be used at all stages of the surgical procedure. 3. The surgical technique recommended by the creators of the LISS method must be strictly followed.

The Rotator Cuff Repair Mess

To the Editor: I reached orthopaedic surgery led by the hand of my father, Jose M. Palomo, as well as Lorenz Bohler (The Treatment of Fractures) and Sir Reginald Watson-Jones (Fractures and Joint Injuries). Soon afterward, at the faculty ofmedicine, I learnedabout Sir JohnCharnley (The Closed Treatment of Common Fractures). Until that moment, a bony fracture meant some kind of cast and traction, as well as the dictum, “Close open fractures but don’t open the closed ones.” I had to give up that knowledge to closely and religiously follow, in a successive and exclusive way, the immovable principles of Maurice Muller (AO plates and screws), Gerhard Kuntscher and Josef Ender (intramedullary nails), R. Hamilton Russell (balanced suspension skeletal traction), Augusto Sarmiento (functional casts), Klaus Klemm and Dieter Schellman (locked nails), AO LISS plates, and nowadays, MIPO locked plates. Shall theydlocked platesdremain forever or will any of the previously abandoned “obsolete” techniques return to the present time, the sameway theFoucault pendulumalways returns to its starting point? It is now nearly 30 years since I started performing arthroscopic surgery of the knee, and although it has quite progressed, that development has maintained a certain predominant direction without too many bends except for extra-articular techniques and double-bundle ACL reconstruction. Shoulder arthroscopy has evolved quite differently. For rotator cuff repair, I started my training following Gary Gartsman, and so my metallic anchors went to the lateral aspect of the humerus to send their threads in an inverted mattress stitch configuration, in a single row, to push the cuff against its footprint. I then shifted to simple stitches from doubleloaded metallic anchors inserted at the top of the footprint (a la Stephen Snyder) and to absorbable top and medial anchors (a la Stephen Burkhart) to configure double-everted mattress stitches brought to a second single row of PEEK anchors distal to the lateral edge of the greater tuberosity. Then came the triple-loaded metallic anchors, just to fight the SutureBridge configuration, polyester suture-based anchors, not to mention all the transosseous-equivalent constructs, which were followed by the anchorless real transosseous device. Modified Mason-Allen stitches and rip-stop constructs, as well as reconstructive tissue matrices, then came to close the loop.up to a few months ago. I have now returned, very much in the way the Foucault pendulum

Nailing versus plating for comminuted fractures of the distal femur: a comparative biomechanical in vitro study of three implants.

The purpose of our study was to determine the biomechanical properties of three different implants utilized for internal fixation of a supracondylar femur fracture. The retrograde supracondylar nail (SCN), the less invasive stabilization system plate (LISS) and the distal femoral nail (DFN) were tested and their biomechanical properties compared. Twenty pairs of fresh-frozen human femura were used. Each femur was osteotomised to simulate a comminuted supracondylar fracture (AO/OTA 33.A3) and then randomized to fracture fixation with either SCN (n=9) or LISS (n=9). Each contralateral femur was stabilized with DFN as a control (n=18). Two femur pairs were spent on pretesting. All femura were subjected to axial (10-500N) and torsional (0.1-14Nm) loading. Eighteen matched femur pairs were analyzed. The post-loading median residual values were 49.78, 41.25 and 33.51% of the axial stiffness of the intact femur and 59.04, 62.37 and 46.72% of the torsional stiffness of the intact femur in the SCN, LISS and DFN groups. There were no significant differences between the three implants concerning axial and torsional stiffness. All implants had sufficient biomechanical stability under physiological torsional and axial loading. All three implants have different mechanisms for distal locking. The SCN nail with the four-screw distal interlocking had the best combined axial and torsional stiffness whereas the LISS plate had the highest torsional stiffness.

Total Knee Arthroplasty in a Patient With Skeletal Fluorosis

Published reports on patients with skeletal fluorosis undergoing total knee arthroplasty are rare. Skeletal fluorosis is a chronic condition that occurs secondary to the ingestion of food and water that contain high levels of fluoride. Although fluorosis may be described as osteosclerotic and marble-like in appearance, features may also include characteristics of osteomalacia and osteoporosis. This article describes the case of a 67-year-old man with skeletal fluorosis who underwent total knee arthroplasty complicated by fracture. An intramedullary guide was used for the proximal tibia and distal femoral bone cuts intraoperatively. Following the completion of the femoral bone cuts, it was noted that the drill used to open the femoral canal had breached the medial femoral cortex. Multiple fractures were seen in both femoral condyles. A revision femoral stem was chosen to complete the total knee arthroplasty but, after further manipulation of the femur, it appeared that the fracture had displaced. A LISS plate (Synthes, West Chester, Pennsylvania) was used to ensure fracture reduction and implant stability. The remainder of the procedure was completed without complication. One year postoperatively, functional knee range of motion was limited to 70° of flexion. Radiographs showed signs of healing and satisfactory implant position. This case highlights the importance of the preoperative examination and the need to fully appreciate the bone quality of patients prior to undertaking an orthopedic procedure. Variation from the use of intramedullary guides should be considered in patients with questionable bone quality undergoing total knee arthroplasty.

Clinical comparative study between LISS and traditional anatomical plate in the treat-ment for proximal tibia complex fractures

Objective To observe the clinical efficacy compare between LISS and traditional anatomical plate in the treatment for proximal tibia complex fractures. Methods 68 cases of proximal tibia complex fractures admitted to our hospital from September 2010 to September 2011, were randomized to treatment： 34 cases in the experimental group（GE） taken LISS treatment, and other 34 cases in control group（GC） underwent traditional anatomic plate as treatment. Results after 3-9 months followed-up statistics shown that while the same in operative time, GE can significantly reduce the amount of blood loss, reduce hospitalization time, and postoperative complications, better than the GC; the difference was statistically significant （P〈 0.05）; Kotmer efficacy assessment shown that, the total effective rate of G E was 85.3%, higher than it in GC（70.6%）; difference was statistically significant （P 〈 0.05）.Conclusions LISS can be effective in reducing intraoperative blood loss, reduce hospitalization time, as well as reducing postoperative complications and the clinical efficacy should be affirmed. Key words: Minimally invasive fixation system; Anatomical plates; Comparative efficacy

A Bridge Too Far: A LISS Non-Union

A non-union of the tibia developed after the use of a LISS with a long bridging segment as a pure relative stability device for a comminuted tibial fracture. It was treated primarily by stiffening the construct which led to union. It is suggested that the non-union developed because of strain concentration and healed when this was neutralised. The case illustrates an interesting failure mode, perhaps adds light to the biomechanical features of a LISS plate and suggests the role of strain in the process of bony healing.

A subtle intra-operative complication of the IMHS that may go unnoticed

We present two cases with intra-operative complications during the placement of intra-medullary hip screw (IMHS). In both occasions, the implant accidentally breached the anterior cortex of the distal femur. Lateral view with image intensifier confirmed the perforation. This intra-operative complication has not been reported before. It is unclear how often this occurs and how often we miss these subtle complications with potentially disastrous consequences. In the event that it does occur, it is arguable whether any intra-operative or post-operative precautions should be taken. Intra-operative complications with particular reference to femoral fractures is a risk, which when occurring could drastically change the course of management. Although this can be subtle, in general, this will be easily visible on image intensifier. On the other hand, femoral shaft perforations can be a lot more subtle if they are noticed at all. If this complication is not noted and the management does not take this into account, a consequential fracture (eg. Supracondylar or peri-prosthetic) and further complications can result. Possible causes for femoral cortex breaching can be numerous. It is questionable if the breaching is noted whether it should be protected with further internal fixation, casting support or altering the weight-bearing state post-operatively. In one of our cases, the surgeon used extra-medullary device (LISS plate) and for the other, the surgeon managed this conservatively. Different surgeon different management but similar good outcome.

Biomechanical Comparison of Polyaxial-Type Locking Plates and a Fixed-Angle Locking Plate for Internal Fixation of Distal Femur Fractures

To test the stability to axial loading of 2 new polyaxial locking screw-plate designs and analyze different angles of screw insertion. The noncontact bridging (NCB) polyaxial locking plate (Zimmer) and the POLYAX plate (DePuy) were compared with a fixed-angle less invasive stabilization system (LISS; Synthes). Twenty-five synthetic femurs were divided into 5 groups and assigned fixation with the LISS plate (group I), POLYAX plate (groups IIA and IIB), or NCB plate (groups IIIA and IIIB). The polyaxial constructs were divided into parallel and crossed distal condylar screw configurations. Each construct was tested under axial loading and stressed to failure at a displacement rate of 5 mm/min with a preload of 100 N. Outcome measurements included stiffness, load to failure, peak force, and mode of failure. All LISS and POLYAX constructs failed by plastic deformation of the plate, whereas 9 of 10 NCB constructs failed by an intra-articular lateral condyle fracture. No failures occurred at the screw-plate interface in either polyaxial constructs. Load to failure of the LISS was 33% greater than the parallel POLYAX (P < 0.01) and 24% greater than the crossed POLYAX (P < 0.01). Load to failure of NCB (parallel and crossed) were 24% greater than the parallel POLYAX (P < 0.01 and P < 0.01, respectively) and 15% greater than the crossed POLYAX (P < 0.01 and P = 0.02, respectively). The POLYAX also had significantly lower stiffness and peak force compared with the LISS and NCB. There was no difference between the LISS and NCB with regard to stiffness, load to failure, and peak force. Parallel and crossed polyaxial constructs showed no difference in stiffness or failure loads. There were no failures of either polyaxial screw-plate interface despite large forces and screw angle did not affect the overall strength of these constructs, supporting the biomechanical soundness of both polyaxial device designs under axial loading. However, the POLYAX supported smaller loads compared with the LISS and NCB while under axial loading. In addition, the mode of failure of the NCB plate, creating an intra-articular fracture propagating from the distal posterior screw hole, may be of some concern. Additional testing is needed to determine the clinical importance of the demonstrated differences among these plate designs.

A biomechanical comparison of retrograde supracondylar nail with LISS plate in distal femur fractures

A biomechanical comparison of retrograde supracondylar nail with LISS plate in distal femur fractures

Computer assisted LISS plate placement: an in vitro study

Computer assisted LISS plate placement: an in vitro study

Minimally Invasive LISS Plating for Fractures Around the Knee

Minimally Invasive LISS Plating for Fractures Around the Knee