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Re: LISS failure
послал Josep M. Muсoz Vives 11 Сентябрь 2004, 18:49
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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.
I was teached not to put the plate in the middle of the shaft in a true lateral view of the femur, but rather slight anterior and internally rotated so the end part will adapt to the trapezoid shape of condyles, but still the screws will be in the maximum diameter of the shaft. On the post-op X-ray you can see a true lateral view of the femur (the posterior part of the condyles are aligned) but not of the plate (you can see them coming under). I can assure you that the plate was completely centered on the shaft.
You can’t tell by feel, since the screws lock firmly into the plate.
But you can tell by the drilling.
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.
On intraoperative fluoroscopy with external rotation of the thight we confirmed that the plate was completely centered in that case.
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.
I fully agree with you, we should have used lag screws between the two condyles.
Dr. Josep M. Muñoz-Vives
Hospital Dr. Josep Trueta.
Girona
Catalonia
Spain
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