Session II - Tibia

Utilization of the Less Invasive Stabilization System (LISS) Internal Fixator for Open Fractures of the Proximal Tibia: A Multi-Center Evaluation

James P. Stannard, MD¹; Christopher G. Finkemeier, MD²; Jackson Lee, MD³; Philip J. Kregor, MD⁴;

¹University of Alabama at Birmingham, Birmingham, Alabama, USA;

²Orthopaedic Trauma Surgeons of Northern California;

³University of Southern California, Los Angeles, California, USA;

⁴Vanderbilt University Medical Center, Nashville, Tennessee, USA

Purpose: We evaluated the use of the Less Invasive Stabilization System (LISS) plates and screws with open fractures involving either the tibial plateau or proximal tibia. Specifically, we wished to document the incidence of infection and skin breakdown associated with use of this internal fixation system.

Methods: Data were prospectively collected at four level I university trauma centers on patients with open fractures stabilized by using LISS "plates" on the tibia. Inclusion criteria included open fractures of either the tibial plateau or the proximal tibia with the fracture extending to within 5 cm of the knee joint. The number of superficial and deep infections encountered and outcomes of those infections were documented. Data collected included the OTA classification of fractures, the Gustillo classification of open fractures, the need for flap coverage, the timing of definitive stabilization of the tibia, and the occurrence of complications.

Results: A total of 52 patients with open fractures have been evaluated, with a mean follow-up of 16.2 months and a range of 9 to 36 months. The Gustillo classification of the patients' fractures was 3 type I, 7 type II, 26 type IIIA, 14 type IIIB, and 2 type IIIC. The OTA classification was as follows: 41A, 4; 41B, 2; 41C, 26; 42A, 3; 42B, 5; and 42C, 16. Four patients had fractures that involved the plateau and extended into the diaphysis. Fifteen patients in this study required flap coverage of their open wounds, with 13 rotational and two free flaps. The mean time from injury to stabilization with the LISS implant was 2.9 days, with a range of 0 to 17. Thirteen patients had their fracture stabilized on the day of injury and an additional 12 within the first 24 hours. Three patients developed deep infections, for an incidence of 5.8%. The incidence of infection of tibial plateau fractures was at 6.3% and tibial shaft fractures, at 4.3%. The incidence of deep infection by classification was type I and II, 0%; type IIIA, 7.7%; type IIIB, 7.1%; and type IIIC, 0%. Three additional patients developed superficial infections that resolved with antibiotics. Three patients in this series developed nonunions, one associated with an infection.

Conclusion: Plate osteosynthesis has been associated with an extremely high incidence of infection (11 to 80%) when used with open fractures of the tibia and tibial plateau. As a result, alternative methods of fixation have been adopted for many open fractures in this region. However, intramedullary nails are associated with malunion and decreased stability when fractures extend proximally, and small wire external fixators have many additional complications. Biomechanically, the LISS functions as an "internal external fixator" rather than as a plate. Whether the biomechanical differences from standard compression plates make the LISS fixators safer in open fractures is not clear. No data have been published analyzing the outcome of a large series of open tibial fractures treated with the LISS system. Our results indicate that treatment of proximal tibial fractures with the LISS system results in an infection rate that is at least as low as that of intramedullary nailing or external fixation and remarkably better than that of compression plating.

Significance: Aggressive irrigation and debridement, followed by soft tissue coverage is mandatory. On the basis of our data, the LISS system is a viable option for treating open fractures of the tibial plateau and proximal tibia.