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LISS-Osteosynthese von distalen Femurfrakturen

LISS osteosynthesis for distal fractures of the femur

  • Leitthema
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Trauma und Berufskrankheit

In einer prospektiven, nicht randomisierten Studie wurden zwischen Februar 1997 und September 1998 29 frische distale Femurfrakturen mit dem winkelstabilen, minimalinvasiv eingebrachten System LISS (less invasive stabilization system) versorgt. Das Prinzip des LISS ist ein perkutan eingebrachtes Implantat, das anatomisch nach dem rechten und linken lateralen Femurkondylus geformt ist. LISS wird mit winkelstabilen, monokortikalen Schrauben verankert. In dieser Studie wurden 33C3- und 33C2-Frakturen mit intraartikulärer Dislokation über einen transartikulären Zugang mit lateraler parapatellarer Arthrotomie versorgt, während bei den 33A-Frakturen, 33C2- und 32B1-Frakturen ohne intraartikuläre Dislokation ein lateraler Zugang gewählt wurde. In die Nachuntersuchung wurden 29 Frakturen eingeschlossen. Das Durchschnittsalter der Patienten war 54 Jahre (20–92 Jahre). Die durchschnittliche Nachuntersuchungszeit betrug 6 Monate (1,5–16 Monate) und der durchschnittliche ISS 14,1 (9–27). Offen waren 8 Frakturen (5mal Typ I, 2mal Typ II, 1mal Typ IIIB nach Gustilo). Die durchschnittliche Operationszeit lag bei 131 min (40–300 min). Die durchschnittliche Bildwandlerzeit betrug 142 s (31–402 s). Postoperativ kam es in 1 Fall zu heterotopen Ossifikationen mit Einschränkung der Kniegelenkbeweglichkeit, in 1 Fall zu einer tiefen Beinvenenthrombose mit Lungenembolie und in 3 Fällen zu tiefen Infekten, davon 2mal als Folge offener Frakturen. In 2 Fällen kam es zu Schraubenausrissen im proximalen Plattenbereich innerhalb der ersten 2 Monate. In 1 Fall war eine Rotationsdifferenz beider Femora von 32° zu sehen. Die Zeit bis zur knöchernen Durchbauung betrug durchschnittlich 3,1 Monate (2,5–4,5 Monate), die Zeit bis zur Vollbelastung 3 Monate (1,5–5 Monate). Die Kniegelenkbeweglichkeit war in 15 Fällen, mit einer Nachuntersuchungszeit von mehr als 3 Monaten, 121° (Minimum 20°, Maximum 140°). Der Lysholm-Score konnte für 9 Patienten ermittelt werden und ergab im Durchschnitt 67,5 Punkte (48–92 Punkte), der Neer-Score 69,8 Punkte (49–88 Punkte). Die Anwendung des LISS ermöglicht eine komplikationslose Ausheilung ohne Notwendigkeit der Knochentransplantation. Besonderes Augenmerk muß auf eine achsengerechte Reposition gelegt werden, da diese am distalen Femur schwierig ist.

In a prospective, nonrandomized study conducted between February 1997 and September 1998, 29 displaced fractures of the distal femur were stabilized with an angularly stable interlocking plate system (less invasive stabilization system, or LISS) designed for minimally invasive placement. The LISS System consists of an anatomically configured plate contoured to fit percutaneously onto the lateral femoral condyles with monocortical screws which anchor into the plate , thus building an angularly stable construct. Using the AO fracture classification system, 33 group C3 fractures and 32 C2 fractures with intra-articular displacement were fixated via a transarticular approach with a lateral parapatellar arthrotomy of the knee joint and percutaneous placement of the shaft screws, while 33 group A fractures and 32 C2 and B1 fractures with no intra-articular dislocation were treated via a lateral stab incision and placement of the LISS laterally on the femoral shaft under the vastus lateralis muscle. Twenty-nine fracture cases were included in the follow-up studies. The average patient age was 54 years (range 20–92) and mean duration of follow-up was 6 months (range 1.5–16). The mean injury severity score (ISS) was 14.1 (range 9–27). Twenty-six fractures were located at the distal segment of the femur (localization 33) and further subdivided into 13 group C3, four group C2, eight type A fractures, and one type B fracture. An additional three fractures were located at the distal shaft (localization 32) and classified as subgroup B1.3. Eight fractures were open (5 type I, 2 type II, 1 type IIIB3). Mean operative time was 131 minutes (range 40–¶300). Mean image intensifier time was 142 seconds (range 31–402). Postoperative complications included one case with heterotopic ossification (HO) limiting knee motion, one of deep venal thrombosis with pulmonary embolism, and three cases of deep infection (one type IIIB open, one arterial injury, and one type II open). Implant-related complications included two cases of screw pullout in the proximal plate during the first 2 months postinjury. These cases were treated by screw exchange. In a 37-year-old female with an increased antetorsion angle of 32° (internal rotation deformity) in both femurs postoperatively, rotational correction was performed. Length of time to fracture healing averaged 3.1 months (range 2.5–4.5) in 23 cases. Length of time to full weight-bearing averaged 3 months (range 1.5–5). At the latest review of 15 cases with an average of 3 months’ follow-up, knee flexion averaged 121° (min. 20°, max. 140°). Thirteen cases displayed knee flexion of less than 120°, three of which had less than 90°. At follow-up, an extension lag of 10° was noted in two cases. The Lysholm score could be applied to nine patients and showed a mean of 67.5 points (range 48–92), and the Neer scores averaged 69.8 points (range 49–88) (one failure, three unsatisfactory, four satisfactory, and one excellent). The remaining cases were still undergoing follow-up evaluation at the time of writing. The correct use of LISS for distal femoral fractures leads to uneventful bony healing without the additional morbidity of bone grafts. However, due to demanding surgical technique in this region, special care must be taken to restore correct axial alignment.

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Schandelmaier, P., Stephan, C., Reimers, N. et al. LISS-Osteosynthese von distalen Femurfrakturen. Trauma Berufskrankh 1, 392–397 (1999). https://doi.org/10.1007/s100390050069

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  • DOI: https://doi.org/10.1007/s100390050069

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