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Re: LISS failure
послал Andrew H. Schmidt 11 Сентябрь 2004, 16:40
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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 don¹t engage the cortex. You can¹t 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.
Andy Schmidt
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Andrew H. Schmidt, M.D.
Faculty, Hennepin County Medical Center
Assoc. Professor, Univ. of Minnesota
Minneapolis, MN
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