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

a) b)

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

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

Injury 2003, Vol. 34, Suppl. 1

 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
fixation. Lastly, early results from one clinical trial of
treatment for proximal tibia fractures using the Less In-
vasive Stabilization System will be presented.
Indications
One of the distinguishing biomechanical advantages of
the LISS fixator is its fixed angled nature. Since it is ap-
plied laterally on the tibia, it prevents varus collapse in
metadiaphyseal fractures, or fractures of the tibial
plateau involving the medial condyle.
Therefore, use of the tibia LISS is indicated for frac-
tures of the proximal tibia that involve both the medial
and lateral columns. These include AO/OTA Type
41-A2, A3, C1, C2, C3, and all proximal Type 42’s. With
reference to the Schatzker Classification for tibial
plateau fractures, the indications include Schatzker
Type V & VI.
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
involving the proximal one-half of the tibia (Figure
4a–f), as well as ipsilateral diaphyseal and bicondylar
tibial plateau fractures. There are other implant designs
currently available that may be utilized with minimal-
ly invasive techniques for fractures of the tibial dia-
physis. What role these latter fixation techniques will
play next to standard intramedullary nailing for dia-
physeal fractures remains to be defined. Other less
common circumstances where the tibia LISS has been
utilized, includes pathological lesions with impending
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.

Injury 2003, Vol. 34, Suppl. 1

 S-A20

a) b) d) e)

c)
P. A. Cole et al.: Proximal tibial LISS
We have limited the use of the LISS fixator in the most
extreme cases of lateral or medial plateau comminution
and depression where the strongest and most accurate
subchondral buttress is mandatory for support. In these
rare circumstances, it is best to have the subchondral
hardware traverse an implant which is fixed to the dis-
tal diaphyseal segment (Figure 6a–e).
Technique
Strategy and Approaches
One of the tenets of use of the LISS system which dis-
tinguishes it from conventional plate and screw usage
is that the fracture reduction must be accomplished be-
fore fixation takes place. This is because the screws lock
into the implant, thus making it an “Internal External
Fixator”. In this sense, the LISS cannot be used to achieve
fracture reduction.
While treating tibial plateau fractures, an anatomical
articular reduction and fixation must be accomplished
prior to LISS implantation. If there is any articular
stepoff or gap, an incision is made beginning proximal
to the joint line in the midaxial line of the femur and
sweeping anterior to Gerdy’s tubercle, then gently dis-
tal about one centimetre off the crest of the tibia in a
“Lazy S” fashion. The iliotibial band is split proximal-
Fig. 6:
a) Anteroposterior radiograph of the knee in a 20-year-old
male involved in a car crash, demonstrating extreme com-
minution and depression of the lateral plateau.
b) Lateral radiograph of the same knee as pictured in 6a.
c) An axial CT scan image, fifteen millimetres below the ar-
ticular surface of the same knee as pictured in 6a–b. Note
the degree of metaphyseal impaction and articular de-
pression.
Injury 2003, Vol. 34, Suppl. 1
S-A21
ly; and distally, the fascial incision is taken down to the
periosteum over Gerdy’s tubercle. As one dissects in a
distal direction, the anterior compartment musculature
is reflected posteriorly, preserving the anterior com-
partment crural fascia for repair. Emphasis should be
placed on preserving periosteocutaneous flaps. At this
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-
ally fixed with K-wires. We advocate the use of a femoral
distractor and headlamp for adequate visualization
during joint assessment and reduction.
The next step is articular fixation. Typically, 3.5 mm
cortical screws are used to lag articular fragments, and
to provide a raft for mechanical support of the plateau.
Large fragment screws may be more suitable in porotic
bone. One should place these periarticular implants tak-
ing into account the proposed direction of the LISS
screws, which have a fixed direction. Surgery then pro-
ceeds with fixation of the articular block to the diaphy-
seal portion.
Articular comminution or displacement of the medi-
al plateau must be appropriately addressed through a
medial incision based on preoperative radiographic
findings. Seldom is it necessary to place a medial but-
tress plate. However, when the comminution along the
medial column extends very proximally, it is prudent to
place a medial buttress since the proximal LISS screws
d) Postoperative anteroposterior radiograph demonstrating
plates on both the medial and lateral columns and articu-
lar restoration. Note the surgeon’s preference to place the
subchondral raft of screws through, rather than above the
lateral plate. The contour of the Tibia LISS does not allow
for placement proximal enough of such a raft of screws.
e) Lateral radiograph of the same patient postoperatively
demonstrating satisfactory alignment and articular
restoration with the subchondral raft of 3.5 mm cortical
screws.
 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-
sion in relation to the LISS fixator. This approach is used
for simple non articular fractures.
b) Photograph after insertion of a 5-hole LISS fixator as well
as correction and maintenance of tibial length by inser-
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).

Injury 2003, Vol. 34, Suppl. 1

 S-A24

Guide & Implant Assembly
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-
tor inventory. Based on preoperative templating, the ap-
propriate size should be chosen for attachment to the
Insertion Guide.
Attachment to the Guide is accomplished with a Fix-
ation Bolt placed through the A hole and into the im-
plant. It is then tightened into the small divots in the ex-
terior surface of the fixator, corresponding to nipples on
the Guide.
Fracture Reduction
In the setting of acute fractures, it is likely that closed
reduction can be achieved with traction by pulling on
the ankle. However, one or two “bumps”, six to ten
inches in diameter, strategically placed behind the
popliteal fossa and proximal calf are necessary first.
Typically, the assistant must apply traction by pulling
downward “into the bed”. At the same time, alignment
must be achieved by simple manipulation. Intraopera-
tively, the C-arm must be utilized to verify and “dial in”
the length, alignment, and rotation. Once reduction has
been achieved, an assistant simply holds the position
during implant placement. In certain situations, a
joystick, clamp, or a femoral distractor may be used to
aid reduction. These clinical scenarios are covered in
detail in the next section: Special Challenges & Technical
Tips.
Implant Insertion
The fixator should next be inserted into the surgical in-
cision and slid underneath the anterior compartment
making sure to contact bone during slide insertion. A
thumb on the anterior tibial crest can be used to feel and
judge that the implant is in contact with the bone. An-
other method of ensuring bone contact during penetra-
tion is to follow insertion fluoroscopically. The fixator
should be inserted until the metadiaphyseal flare of the
bone and fixator match. Fracture reduction must be
maintained during this part of the procedure.
Implant Position
At this juncture, the fracture should be grossly aligned
and the implant should approximate the contour of the
tibia. We attempt to achieve this approximation to with-
in a few millimetres and it is quite all right for the im-
plant not to be absolutely flush with the tibia. Intraop-
erative radiography should verify that the implant is sit-
ting accurately on the lateral aspect of the bone proxi-
mally and distally.
Once it has been verified in the anteroposterior C-arm
view that the fixator approximates to the tibia and is ac-
curately placed in the lateral view (as in Figures 9a-b),
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
demonstrating adequate alignment
of the fixator in relation to the tibia
in the sagittal plane.
image demonstrating a gap between image demonstrating perfect alignment
the fixator and the distal tibia frag- of the fixator and the tibia after using
ment as indicating by the arrows. the “Whirlybird” as shown in Fig. 8b.
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
holes in the Guide proximally and distally to secure the
relationship between Guide-Implant assembly and tib-
ia. Furthermore, the Stabilization Bolt is placed through
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
cannula.
A small incision distally on the lateral aspect of the
leg to permit palpation down to the bone is recom-
mended. This allows for verification that the implant is
lying directly in the lateral position and it allows for pro-
tection of the neurovascular bundle during distal screw
insertion. This step is critical for the placement of distal
screws in the 13 hole fixators based on an anatomical
dissection study [12].
The Whirlybird
Although manual pressure is usually sufficient to ap-
proximate the tibia and fixator, fracture reduction can
be “fine-tuned”. To fine tune the reduction or the ap-
proximation of the fixator, the Whirlybird may be used.
The Whirlybird is a threaded tool with a diameter of
four millimetres, which can be drilled through the In-
sertion Guide, through a cannula, through one of the
screwholes, into bone. It has a sliding nut on its proxi-
mal end which can be tightened against the Insertion
Guide, thus approximating or docking the bone to the
fixator. This manoeuver should be guided by antero-
posterior fluoroscopy (Figure 9).
Fracture Fixation
Self-drilling self-tapping screws are inserted next. A
guideline we have preferred during our clinical trial is
the placement of four screws proximal and four screws
distal to the fracture when possible. The length of the
proximal screws is based on an estimate with reference
to a guidewire placed across the plateau. The two most
proximal screws diverge and are directed in an inferior
direction to approximately ten degrees in each direction.
The screws appropriate for the diaphysis may be either
18 or 26 mm in length.
Next, the Stabilization Bolt can be removed, and a
screw placed through this hole. Lastly, the Insertion
Guide assembly, K-wires, and Fixation Bolt are all re-
moved. A screw can now be placed through the A-hole
in the plate (from which the Fixation Bolt was removed)
using a freehand method. Aforty millimetre screw is ap-
propriate for this hole and will be directed toward the
tibial eminence and end at the level of the joint line.
When placing self-drilling self-tapping screws free-
hand, the surgeon has eleven degrees of freedom in each
direction. Beyond eleven degrees, the screw implant
fixed-angle interface is destroyed. One other option is
to place conventional screws through the fixator. We
Injury 2003, Vol. 34, Suppl. 1
S-A25
have used this option primarily in cases where other pe-
riarticular implants have blocked the free passage of the
self-drilling self-tapping screw.
Special Challenges & Technical Tips
Multifragmentary Fractures
Multifragmentary fractures present a relatively difficult
circumstance for achieving a closed reduction. Often,
the intercalary segment wants to behave independent-
ly from the proximal and distal segments over which
one has slightly more control.
There are several strategies one may consider for this
problem. The first is to place strategically sized bumps
behind the popliteal fossa and proximal calf with fluo-
roscopic assistance, until the intercalary fragment has
been approximately restored in terms of length and
alignment. Traction is always necessary through the dis-
tal extremity, usually with a pair of helping hands. If
strategic bumps do not help to gain or maintain the re-
duction, a percutaneous Schanz pin can be placed
through a stab incision to achieve control of the frag-
ment. Strategically placed pressure from a pushing de-
vice through a stab incision on the medial side may aid
in this part of the reduction as well. Lastly, the LISS fix-
ator may first be placed in its position in the anterior
compartment, then one or two whirlybird approxima-
tor devices may be used to dock the segmental piece to
the fixator (Figure 9).
Very Proximal Medial Comminution
In the circumstances where medial comminution ex-
tends very far proximally, sometimes to within a cen-
timetre of the medial tibial plateau, it is necessary to
slide the LISS fixator quite far proximally, perhaps even
to the lateral joint line. This directs the most proximal
fixed angle screws, which have a 10 degree inferiorly
directed angle, just below the medial subchondral bone.
This causes the metadiaphyseal flare of the lateral
plateau not to match that of the fixator. Furthermore, it
causes the implant to “ride off” the lateral plateau by as
much as half a centimetre or more. We have found this
approach, though not visually aesthetic on radiographs,
to be necessary for adequate support of the medial col-
umn. Alternatively, this circumstance can be addressed
as discussed earlier and demonstrated in Figures 7a–k.
The Fractured Tibial Tubercle
In some comminuted variants, the tibial tubercle may
represent an independent fracture. Since the articular
fixation as well as the LISS fixation in the proximal ar-
ticular segment does not address the tibial tubercle, it
will have a propensity to displace due to pull of the

Fig. 10: Initial provisional stabilization of a tibial plateau
fracture with a spanning external fixator.
a) b)
Fig. 11:
a) Anteroposterior radiograph of the knee demonstrating
an AO 41-C3 tibial plateau fracture and an AO 33-C3 in-
tracondylar femoral fracture with a segmental shaft com-
ponent.
b) Lateral radiograph of the same knee as pictured in 11a.
c) Anteroposterior radiograph of the knee demonstrating
periarticular fixation, placement of antibiotic beads and
spanning external fixation for initial provisional stabi-
lization.
d) Lateral radiograph of the same knee as pictured in 11c,
before placement of the beads.
e) Clinical photo of the lower extremity after external fixa-
tion.
f) Intraoperative photograph after placement of antibiotic
beads and LISS fixation of the femur and tibia.
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
shorten due to the exertion of muscular forces across the
knee (Figure 10). In cases where delayed fixation is nec-
c) d)
g) Intraoperative photograph demonstrating soft tissue clo-
sure of the quadriceps insertion and patella retinaculum.
h) Postoperative anteroposterior radiograph of the knee
demonstrating satisfactory alignment.
i) Lateral radiograph of the same knee as pictured in 11h.
j) Anteroposterior radiograph of the femur demonstrating
callus formation 6 weeks after surgery.
k) Lateral radiograph of the same femur as pictured in 11j.
l) Anteroposterior radiograph of the tibia demonstrating
callus formation 6 weeks after surgery.
m) Lateral radiograph of the knee pictured in 11 l.
n) Anteroposterior radiograph of the proximal femur
6 weeks after surgery. Note that the patient had an ipsi-
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)

Injury 2003, Vol. 34, Suppl. 1


essary, it is more difficult to achieve closed reduction
due to the organization of haematoma and fracture cal-
lus, as well as contracture of surrounding soft tissues.
In these circumstances, closed reduction is not always
successful with manual traction and alignment alone.
We have placed percutaneous Schanz pins, clamps or,
in rare circumstances, we have had to use a femoral dis-
tractor to achieve the necessary reduction prior to fixa-
tor placement. For these reasons, it is always recom-
mended the definitive fixation be performed at the
safest, earliest convenience.
Open Fractures
For open fractures of the proximal tibia, immediate in-
ternal fixation after thorough irrigation and debride-
ment is advisable. Typically the open fracture wounds
occur medially. After the fracture has been appropri-
ately addressed through this wound, it is closed pri-
marily, if possible, and then attention is directed to the
lateral side for placement of the LISS fixator (Figure 11a-
n). If the open fracture wounds are not able to be closed
primarily, we favour serial irrigation and debridement
with interim antibiotic bead pouches until appropriate
soft tissue coverage by the microvascular team can be
executed as shown in Figure 11f.
UMC Clinical Trial
Materials and Methods
In November of 1998, a prospective clinical trial was be-
gun at the University of Mississippi Medical Center for
the treatment of proximal tibia fractures treated with the
Less Invasive Stabilization System (LISS). Specifically,
between 11/98 and 8/00, patients with AO/OTA Type
41-A2, A3, C1, C2, C3, and proximal Type 42 were
prospectively enrolled. Surgical, radiographic, and clin-
ical follow-up information was entered into a trauma
database.
This trial included fifty-four fractures in fifty-three
patients treated by two surgeons. The mean age of the
patients was forty-four years (R=16-82). There were fif-
teen female patients and 32% of the fractures resulted
from a high-energy mechanism.
Forty-six percent of the fractures represented an
AO/OTA Type 41, and 28% represented an AO/OTA
Type 42. Twenty-six percent of the fractures were de-
fined as an ipsilateral Type 41 and 42. A full 54% of the
fractures in this trial had some degree of intraarticular
involvement.
Thirteen percent of the fractures were associated with
an ipsilateral shaft fracture, and 13% were classified as
an AO/OTA Type 41-C3 with extensive articular com-
minution. Furthermore, 31% of the fractures were open,
S-A28
including six Gustilo Type 3B, and five Gustilo Type 3A
fractures.
The implants utilized for the fractures included four
5-hole plates, thirty-two 9-hole plates, and eighteen 13-
hole plates. The mean number of screws used to fix the
proximal articular segment was five (R=3-7), and the
mean number of screws distal segment was five (R=3-
6). The average time for placement of the LISS was fifty-
six minutes, which included the time from initial inser-
tion to placement of the last self-tapping screw.
Results and Complications
The mean range of motion was 1 degree (R=0-10) to 116
degrees (R=80-150). Two patients required quadricep-
splasty for joint ankylosis. Both of these patients had
sustained ipsilateral Type C3 distal femoral fractures as
well as the tibial plateau fracture.
The mean time to full weight-bearing in this series
was 13.2 weeks (R=8-16). Forty-eight patients were clin-
ically healed when full weight-bearing commenced and
all but two eventually healed except one delayed union
which responded to elective bone grafting, and one non
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
eight degrees in one. There were no additional varus or
valgus malreductions more than five degrees. In two
cases, there was anterior translation of the proximal tib-
ia fragment relative to the distal fragment of more than
one centimetre. One required a reoperation for loss of
proximal fixation and the other healed uneventfully.
The patient with an eight degree varus malreduction
was reoperated for correction of his deformity. There
were no cases of late varus collapse or loss of reduction.
Three patients developed wound haematomas or
seromas, which responded to simple irrigation and de-
bridement. These three patients all had negative cul-
tures of their fluid accumulation. Two patients devel-
oped infections. One patient had a superficial infection,
which occurred in an open fracture wound distant from
the LISS insertion site. This patient responded to a sin-
gle irrigation and debridement and course of oral an-
tibiotics. The second infection arose four months post-
operatively and responded to implant removal, irriga-
tion and debridement and a course of oral antibiotics.
There were two postoperative nerve palsies. The first
was thought to be iatrogenic, affected the deep peroneal
nerve, and was thought to arise from distal percuta-
neous placement of screws into the 13-hole fixator. This
patient’s nerve palsy improved from a Grade 0/5 to a
Grade 3/5 muscular strength after two years. The oth-
er palsy represented as global dyaesthesias over the tib-
P. A. Cole et al.: Proximal tibial LISS
ial and peroneal nerve distributions, and was thought
to be related to a tourniquet used intraoperatively. This
patient’s palsy completely resolved.
Two patients underwent amputations at one year
postoperatively, related to the poor clinical outcome of
a mangled extremity. Two other patients died within
two months of surgery due to unrelated medical causes.
Discussion
Results from the clinical trial of the first fifty-three pa-
tients treated with a LISS for proximal tibia fractures in-
dicate that a high rate of union (96%), stable fixation of
the proximal fragment with no late varus collapse or
cut-out, and an acceptable infection rate (3.7%) can be
achieved with this technique and technology. These
methods may be successfully utilized for both bi-
condylar tibial plateau fractures and proximal one third
tibial fractures.
A high proportion of injuries in this series represent-
ed the extreme end of the spectrum of fracture severity.
In this light, it would seem that the mean range of mo-
tion (1–116 degrees) achieved and time to weight-bear-
ing (13.2 weeks) as well as the type and rate of compli-
cations are quite acceptable. It was not the goal of this
study to assess functional outcome.
Possible disadvantages of the Less Invasive Stabi-
lization System include difficulties with closed reduc-
tion techniques and fixator applications. Furthermore,
a concern for neurovascular injury during placement of
the most distal screws in the 13-hole fixators is war-
ranted.
Conclusion
The surgical treatment of proximal tibia fractures, with
or without intraarticular involvement, is associated
with well-described patterns of failure with significant
complication rates. The LISS can be thought of as an “in-
ternal-external fixator”. Its use in dual column proximal
tibia fractures prevents varus collapse by virtue of its
fixed-angled screws, which offer multiple points of fix-
ation in the proximal articular segment. The LISS guide
system utilized with a percutaneous submuscular tech-
nique lessens soft tissue insults common to these in-
juries. The LISS technique and technology appears to
provide stable fixation (96%), a high rate of union (96%),
and an acceptable rate of infection (4%) for proximal tib-
ia fractures, based on our experience with the first 54
patients.
Injury 2003, Vol. 34, Suppl. 1
S-A29
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Corresponding Author:
Peter Alexander Cole, M.D.
Associate Professor
University of Minnesota
Department of Orthopedic Surgery
Regions Hospital
640 Jackson Street
St Paul, MN 55127
Tel: 651-254-1513
Fax: 651-254-1519