Date: Fri, 10 Sep 2004 22:02:25 +0200
From: Josep M. Muñoz Vives
Subject: LISS failure
I would like your thoughts and advice about this case.
This 40 yo male suffered a car accident on Monday. His lesions were:
On Wednesday we operated him, we used a LISS plate in either bone, when drilling we had the feeling of a 'normal' bone.
On Thursday afternoon he was alright, he is a very active man and he was moving well both knees. Later that evening he told me that while he was a little bit asleep he turned on the bed and felt pain and that the femur was loose. Here are the X-rays we took.
We are planning to reoperate him on Monday. Removing the screws from the LISS plate and drilling the medial cortex, using locking screws without the drilling tip.
Thanks in advance.
Dr. Josep M. Muñoz Vives
Hospital Universitari Dr. Josep Trueta.
Date: Fri, 10 Sep 2004 22:31:01 +0200
From: J.C. Goslings
We have had similar experiences with unicortical screws in LISS femur. In this case we would remove the LISS (can be quite difficult if screws are tightly locked in the plate), connect the two condyles with cannulated screws and re-apply LISS more distally and use the (green) bicortical screws.
Date: Fri, 10 Sep 2004 15:45:54 -0500
From: Frederic B. Wilson, M.D.
I think the problem occured because the sagittal split was not recognized and/or adequately fixed. We have had this problem also. I usually fix the condylar split with cannulted screws placed so that they will not interfere with the LISS plate. The coronal splits must also be suspected and recognized. You may want to clamp the condylar fragments with the periarticular clamp prior to reinserting the locking screws. You may also want to place a lag screw in the plate, at least temporarily.
Tyler, Texas, USA
Date: Fri, 10 Sep 2004 15:57:04 -0500
From: Anglen, Jeffrey
One option would be to abandon LISS, revise it with a locking condylar plate, longer, with bicortical screws in the shaft, and lag screws in the joint segment. You can put large or small fragment lags outside the plate, and some conical head screws through the plate, in addition to locking screws.
University of Missouri
Date: Fri, 10 Sep 2004 17:33:19 -0500
From: Andrew H. Schmidt
Although I agree with the comments of the others who have responded, I wanted to add some other information gleaned from my own experience with this device.
In this case, the fixation might have failed because of inadequate purchase of the side plate to the shaft. I say this because the initial lateral xray shows that the plate seems to be fairly anterior to the mid-axis of the femoral shaft.
Once the plate pulled off of the shaft, it continued to pull out of the distal segment. With the short unicortical screws used for shaft fixation, it is imperative that the plate be applied precisely at the midline (widest diameter) of the femur. If it is applied even slightly anterior or posterior to the midline, the screws just don t engage the cortex. You can t tell by feel, since the screws lock firmly into the plate. The only guidance that imaging provides is to visualize the plate centered exactly on the bone on a good lateral projection, which is difficult to obtain intra-operatively. I have resorted to making a 3-4 cm incision at the top of the plate so that I can verify that the plate is exactly centered over the femur at its proximal tip.
A second pearl is to place at least one or 2 lag screws between the condyles for intrafragmentary fixation before applying the LISS. Although screws were used across the coronal plane (Hoffa) fracture, I do not see any lag screws from lateral to medial. The LISS screws are designed to maintain the reduction of the distal femoral condylar mass to the shaft, but they do not function as lag screws. The intra-articular portion of the fracture demands open reduction and rigid internal fixation according to established principles; the LISS is used to then stabilize the reconstructed distal femur to the shaft.
I think that this could be revised any way that one wishes basically starting over at the beginning. The femoral condyles are first reduced and stabilized with lag screws, then whatever plate one is comfortable with could be used to bridge the metaphysis. If the LISS is used again, be sure that the plate is precisely positioned.
Date: Sat, 11 Sep 2004 10:57:26 +0600
From: Alexander Chelnokov
JMMV> We are planning to reoperate him on Monday. Removing the screws from the LISS plate and drilling the medial cortex, using locking screws without the
Considering that even with the plate in place there was significant malalignment, with the such revision the wrong axis would remain the same. However reduction of condyles is fine, so i would temporarily transfix them by few wires from medial to lateral, then remove the plate and perform closed locked nailing. For such a pattern i prefer antegrade though no superstitons about retrograde.
Pls do not include into reply the entire initial message with all attachments. Even on hi-speed line it is senseless, and on a low speed connection(i now use PDA with a mobile phone) it is painlful to downnload huge duplications.
Alexander N. Chelnokov