Liss

For the bone is a plant
with its roots in the soft

tissue & what it requires for
its welfare are the skills of a
gardener rather than those
of a cabinet maker.
-Gathorne Robert
Moderators : Dr Surendra U. Kamath

Dr Preetham Raj V Salian
Presented by : Dr Vivek P Nahar
Introduction
Less Invasive Stabilization System (LISS) is

an extramedullary, internal fixation system
that has been developed to incorporate
technical Innovations (Locking plates) &
surgical techniques (Indirect Reduction).
AO Principles
Anatomical reduction of fracture fragments
Stable internal fixation designed to fulfill the

local biomechanical demands
Preservation of blood supply by means of

atraumatic surgical technique
Early active pain free mobilization of muscles

and joints
Principles Biological
Fixation
Indirect Reduction
Adequate Stabilization
Preservation of osteogenic potential
Limited bone plate contact
LISS - Main features
Atraumatic insertion technique
Minimal bone-plate contact
Locked, fixed-angle construct
Conventional Plating
Screws tighten plate to
bone-compression
Screw threads under
load applied intraop
Patient loads add to
preload on plate/screw
Locked Plating
Screws lock to the plate
Screws inserted with
minimal axial preload
No stress in the system
(bone or plate) prior to
patient loads
Indications
Proximal Tibia Fractures
Distal Femur Fractures
Periprosthetic fractures - distal femur with TKR or

hip arthroplasty
Instrumentation LISS
Tibial Set
Instrumentation LISS
AO ASIF Template
Lag Screws (Articular Reduction)
Extra-Articular - Indirect Reduction
Insertion guide & Main Component
Pull Reduction Instrument
2 mm Kirschner Wires, Screws, side specific

plates, power drill.
Pre Operative
Planning
Positioning
Usually supine on Fracture Table
Support under Knee Joint
Tourniquet if desired
Sandbag under affected side buttock
Incision over lateral aspect
Lateral or curved hockey stick incision

Start at Gerdys tubercle & extend 5cm distally
Retract tibialis anterior 3cm distally from tibial ridge
Reduction
Reduce & fix articular surface as

normal
Meta-diaphyseal reduction prior to

plate insertion
Lag screws may be medial to lateral

to avoid conflict with the plate
Reduction - Indirect
Articular : Lag Screws
Extra-articular : Ditractors, Ext. fixators,

joysticks, manual traction, Pull
Reduction Instrument
Under C Arm guidance
Correct : Varus/Valgus, Recurvatum,

Angulation
Plate Insertion
In submuscular plane
C Arm & Tactile Feedback
Plate Insertion
Insert plate b/w tibialis anterior & periosteum
Proximal end of plate against lateral plateau
When inserting 13 hole plate, BE AWARE tip

may injure superficial peroneal nerve.
If necessary distal incision to visualize
Plate Fixation
Assess Reduction : Axial rotation,Length
Assess Position of Plate on the shaft
If end of plate centered on shaft in lateral view,

insert K wire through Stabilization Bolt
Metaphyseal Screw Fixation
Plate Fixation
Diaphyseal Screw Fixation
Distal Screw Fixation LAST
Additional screws as appropriate
Minimum of 4 screws / main fragment

Use Irrigation for ALL screws
Insert using power driver
Torque limiting screwdriver for final tightening
Post Op Mobilisation
Similar to conventional fixation
Partial Weight Bearing ~ 10 Kgs
Range of Motion Exercises
Implant Removal
ONLY after complete consolidation & Canal

Remodelling
Using Insertion guide
Screws removed (Torque Limitting Driver)
Mobilise plate using guide or fixation bolt
E.g. Pre Op Xrays
E.g. Post Op Xrays
Advantages
Advantages
Minimally Invasive Metaphyseal Fixation
Absolutely accurate reduction not required
Biological Fixation Using Indirect Reduction

and LCPs
Useful for Osteoporotic bones
Disadvantages
Disadvantages
High Cost Concerns
Increased Radiation exposure to surgeon,

OT personnel & patients
Prebending not an option
Removal of implant can be difficult
References
EVOLUTION OF THE INTERNAL FIXATION OF LONG BONE

FRACTURES THE SCIENTIFIC BASIS OF BIOLOGICAL
INTERNAL FIXATION: CHOOSING A NEW BALANCE BETWEEN
STABILITY AND BIOLOGY - Stephan M. Perren ,From the AO
Research and Development Institutes, Davos, Switzerland
LISS Technique Guide Synthes Implants
Manual of Internal Fixation- 3rd edition
General Principles for the clinical use of LCP ; Michael W et al;

Injury Sept 03; vol 34; suppl 2
www.synthes.com
Thank you

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For the bone is a plant

with its roots in the soft

Moderators : Dr Surendra U. Kamath

Less Invasive Stabilization System (LISS) is

Anatomical reduction of fracture fragments

Stable internal fixation designed to fulfill the

Preservation of blood supply by means of

Early active pain free mobilization of muscles

Preservation of osteogenic potential

Limited bone plate contact

LISS - Main features

Atraumatic insertion technique

Minimal bone-plate contact

Locked, fixed-angle construct

Proximal Tibia Fractures

Distal Femur Fractures

Periprosthetic fractures - distal femur with TKR or

Lag Screws (Articular Reduction)

Extra-Articular - Indirect Reduction

Insertion guide & Main Component

Pull Reduction Instrument

2 mm Kirschner Wires, Screws, side specific

Usually supine on Fracture Table

Support under Knee Joint

Sandbag under affected side buttock

Incision over lateral aspect

Lateral or curved hockey stick incision

Retract tibialis anterior 3cm distally from tibial ridge

Reduce & fix articular surface as

Meta-diaphyseal reduction prior to

Lag screws may be medial to lateral

Articular : Lag Screws

Extra-articular : Ditractors, Ext. fixators,

Under C Arm guidance

Correct : Varus/Valgus, Recurvatum,

Insert plate b/w tibialis anterior & periosteum

Proximal end of plate against lateral plateau

When inserting 13 hole plate, BE AWARE tip

If necessary distal incision to visualize

Assess Reduction : Axial rotation,Length

Assess Position of Plate on the shaft

If end of plate centered on shaft in lateral view,

Metaphyseal Screw Fixation

Diaphyseal Screw Fixation

Distal Screw Fixation LAST

Additional screws as appropriate

Minimum of 4 screws / main fragment

Insert using power driver

Torque limiting screwdriver for final tightening

Similar to conventional fixation

Partial Weight Bearing ~ 10 Kgs

Range of Motion Exercises

ONLY after complete consolidation & Canal

Using Insertion guide

Screws removed (Torque Limitting Driver)

Mobilise plate using guide or fixation bolt

E.g. Pre Op Xrays

E.g. Post Op Xrays

Minimally Invasive Metaphyseal Fixation