title: Utilization of the less-invasive stabilization system internal fixator for open fractures of the proximal tibia: a multi-center evaluation.
abstract: BACKGROUND
  Locked plating has become popular and has clear biomechanical advantages when compared with conventional plating. When combined with minimally invasive surgical techniques, locked plating may cause substantially less iatrogenic tissue damage when compared with conventional plating. These characteristics may make locked plating an attractive option for treating open fractures of the tibial plateau and proximal tibia for which coverage over the plate can be obtained. The purpose of this study was to evaluate the use of the Less-Invasive Stabilization System (LISS) for high-energy open fractures involving either the tibial plateau or proximal tibia.
  
  
  METHODS
  This study is a retrospective evaluation of a consecutive multicenter series of 52 consecutive patients operated by seven surgeons, who used LISS plating in open proximal tibia or tibial plateau fractures seen at one of four Level I Trauma Centers. All patients were treated using a locked plating system that was implanted using minimally invasive submuscular surgical techniques. The primary outcome measure was the incidence of deep and superficial infection.
  
  
  RESULTS
  Fifty-two patients with open fractures have been evaluated, with a mean follow-up of 16.8 (12-36) months. Three patients (5.8%) developed deep infections. Two patients (6.3%) with tibial plateau and one (4.3%) of patients with a tibial shaft fracture developed deep infections. Fifteen patients required flap coverage of their open wounds. The incidence of deep infection as per Gustilo and Anderson classification was Type I and II - 0 (0%); Type IIIA - 2 (7.7%); Type IIIB - 1 (7.1%); and Type IIIC - 0 (0%).
  
  
  CONCLUSIONS
  Biomechanically, the LISS functions as an "internal-external fixator" rather than a plate. Traditional plate osteosynthesis has yielded rates of infection between 18% and 35%. Our data indicate that locked plating using minimally invasive techniques yield deep infections rates that are no worse than published series using intramedullary nails or external fixators. Technical difficulties that can be encountered with the LISS system revolve primarily around obtaining and maintaining reduction while performing a minimally invasive procedure. Additional difficulties can include "cold welding" of screws to the plate and malposition of the plate leading to failure in the diaphysis. High-energy open fractures involving the tibia shaft or plateau remain high-risk injuries, but LISS is an acceptable alternative for treatment of these fractures.
authors.affiliation: University of Alabama at Birmingham, Orthopaedic Surgery, Trauma Section, Birmingham, Alabama 35294-3409, USA. james.stannard@ortho.uab.edu
authors.forename: James P
authors.initials: JP
authors.lastname: Stannard
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Finkemeier
authors.forename: Jackson
authors.initials: J
authors.lastname: Lee
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Kregor