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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 442-449

Lessinvasive stabilization system versus open reduction and internal fixation of closed proximal tibial fractures in adults


Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission11-Apr-2016
Date of Acceptance26-Jun-2016
Date of Web Publication25-Sep-2017

Correspondence Address:
Mohammed S. A. El-Hamid Arafa
Kafr Fisha Elkobra, Menoufia, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.215437

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  Abstract 

Objective
The aim of this study was to compare the clinical and radiological outcome between less invasive stabilization system(LISS) and open reduction with internal fixation(ORIF) for the treatment of extra-articular proximal tibia fractures through the lateral approach.
Background
Proximal tibial fractures present a difficult treatment challenge with historically high complication rates. ORIF has been in vogue for long time with good outcome. However, it is associated with problems, especially overlying skin conditions, delayed recovery, and rehabilitation with limited functional outcome. LISS is an emerging procedure for the treatment of proximal tibial fractures. It preserves soft tissue and the periosteal circulation, which promotes fracture healing.
Patients and methods
Thirty patients with closed proximal tibial fractures were included in this study. They were randomly divided into two groups. GroupI(n=15) patients were treated with LISS and groupII(n=15) with ORIF. Major characteristics of the two groups were similar in terms of age, sex, mode of injury, fracture location, and associated injuries. All patients were followed up at least 6months.
Results
In eachgroup, 12patients showed union, two patients showed nonunion, and one patient showed delayed union. The mean operative time in LISS patients was 79.3min, whereas in ORIF patients it was 122min. All patients of the LISS group were exposed to radiation, whereas only 40% of patients in the ORIF group were exposed to radiation. The mean time of union in LISS patients was 10.87weeks. However, in ORIF patients, the mean time of union was 21.13weeks. There was no significant difference between the two groups as regards the postoperative complications. Functional outcome was satisfactory in both groups.
Conclusion
LISS achieves comparable results with ORIF in extra-articular fractures of the proximal tibia. Although LISS potentially has the radiation hazard, it reduces the perioperative complications with a shortened operation time and minimal soft tissue dissection.

Keywords: less invasive; open reduction; proximal tibial fracture


How to cite this article:
El-Hamid Arafa MS, Shams El-Din AF, El-Mowafy HM. Lessinvasive stabilization system versus open reduction and internal fixation of closed proximal tibial fractures in adults. Menoufia Med J 2017;30:442-9

How to cite this URL:
El-Hamid Arafa MS, Shams El-Din AF, El-Mowafy HM. Lessinvasive stabilization system versus open reduction and internal fixation of closed proximal tibial fractures in adults. Menoufia Med J [serial online] 2017 [cited 2019 Sep 21];30:442-9. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/442/215437


  Introduction Top


Proximal tibial fracture is a common injury, with some of these fractures being caused by strong impact such as traffic accident and others being caused by the relatively weak impact such as a fall in elderly people[1].

These fractures represent surgical challenge because of the variety of fracture patterns and the associated soft tissue injuries. The ultimate goals of treatment are to re-establish joint stability and alignment while preserving full range of motion[1].

Nonoperative treatment using traction, casts, or braces are complicated by the loss of reduction, poor functional results, and prolonged hospital stays. Hybrid external fixation for these injuries is associated with malunion, pin tract complications, decreased knee range of motion, and poor patient satisfaction. Intramedullary nailing frequently has complications of valgus or apex anterior angulation and residual displacement at the fracture site[2],[3].

Plate osteosynthesis remains the mainstay of operative treatment of extra-articular proximal tibial fractures. Soft tissue coverage is obviously better over the lateral surface of the tibia than over the medial surface of the tibia. Plating is generally performed through an anterolateral approach. Techniques of open reduction with internal fixation(ORIF) using traditional lateral plate and screw constructs offer little resistance to varus deformity[4],[5].

Less invasive stabilization system(LISS) is an extramedullary internal fixation system developed by the Arbeitsgemeinschaft für Osteosynthesefragen(AO) group for stabilization of proximal tibial fractures. The LISS method of facture fixation proposes the advantages of indirect fracture reduction and percutaneous, submuscular implant placement[6].


  Patients and Methods Top


Thirtypatientswith proximal tibial fractures were included in this study. They were randomly divided into two groups:

  • GroupI included 15patients treated with LISS(Synthes, Paoli, Philadelphia, PA)
  • GroupII included 15patients treated with ORIF.


All patients were operated upon at Menoufia University Hospital during the period from January 2014 to October 2015.

Level of evidence

The level of evidence was II(randomized prospective comparative study).

Inclusion criteria

Inclusion criteria were as follows: skeletally mature (18–50years of age), proximal tibial fracture(only extra-articular), closed, and nonpathologic origin.

Exclusion criteria

Patients with intra-articular fractures, open fractures, porotic low-energy fractures, high-velocity gunshot injuries, pathological fractures, vascular injury, and neurological injury were excluded from the study.

GroupI: There were nine male and six female patients with an average age of 41years(range: 19–67years). The fracture was on the right side in seven cases and on the left side in eight cases. The mechanism of injury was road traffic accident in seven cases and fall from height in eight cases. Fracture was classified according to the AO classification of fracture of the proximal tibia. Eight cases were of A2 type and seven cases were of A3 type.

GroupII: There were 11male and four female patients with an average age of 36years(range: 18–65years). The fracture was on the right side in seven cases and on the left side in eight cases. The mechanism of injury was road traffic accident in eight cases and fall from height in seven cases. Fracture was classified according to the AO classification of fracture of the proximal tibia. Seven cases were of A2 type and eight cases were of A3 type.

Technique of less invasive stabilization system

Positioning and tourniquet

All patients were placed in a supine position on a radiolucent table, which allows complete imaging of the lower leg. Abump was placed under the patients' buttock to bring patella directly anterior to facilitate true anteroposterior(AP) and lateral intraoperative images. Asterile tourniquet was used in all patients[Figure1].
Figure 1: Patient positioning, tourniquet, and position of C-arm.

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Reduction

Extra-articular reduction was accomplished with traction. Reduction was performed under C-arm guidance and was assessed in both the AP and lateral views. It is important to verify that the plate is applied on the proximal tibia in the appropriate lateral position. Before locking screws were placed in each main fragment, length, rotation, varus–valgus, and recurvatum correction were achieved[Figure2].
Figure 2: Reduction of the fracture by means of traction with C-arm guidance.

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Incision

A lateral curved(hockey stick) incision was used. Skin incision started at Gerdy's tubercle and extended 50mm in a distal direction. The anterior tibialis muscle was retracted∼30mm distally, starting∼5mm from the tibial ridge[Figure3].
Figure 3: Skin incision in less invasive stabilization system patients.

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Instrument assembly for insertion

  • Proximal tibia LISS insertion guide left, or right, main component, and radiolucent extension were assembled
  • Fixation bolt was inserted through hole A of insertion guide ensuring that the knurled nut on the fixation bolt is against the head of the bolt
  • The three points of the insertion guide were aligned with the corresponding three points on the plate
  • The fixation bolt was screwed into the LISS plate using the top segment of bolt. Final tightening was completed with a quarter turn of the pin wrench
  • The nut on the fixation bolt was screwed toward the insertion guide to stabilize the attachment between guide and LISS plate. Final tightening was completed with a quarter turn of the pin wrench [Figure4].
Figure 4: System assembly.

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Plate insertion

The plate was inserted between the anterior tibialis muscle and the periosteum for the tibia under fluoroscopic control[Figure5].
Figure 5: Less invasive stabilization system plate positioning.

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Locking screw insertion

A minimum of four screws were inserted in each main fracture fragment. More screws were used in osteopenic bone[Figure6].
Figure 6: Locking screw insertion.

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Final checkup and wound closure

After insertion of the locking screws, fracture reduction, plate position, and screw lengths were checked. Finally, the proximal incision and the stab incisions were sutured after releasing the tourniquet[Figure7].
Figure 7: The final picture before wound closure.

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Technique of open reduction with internal fixation

Positioning and tourniquet

It was similar to LISS patients[Figure1].

Incision

The anterolateral approach was the approach used in all patients. The incision was based over Gerdy's tubercle and extended distally over the anterior compartment. An L-shaped incision in the origin of the anterior compartment muscles provided access to the anterolateral surface of the tibia.

Reduction

Following exposure of the fracture, the first step was reduction of the fracture. Following successful reduction and stabilization of the fracture, the locking plate was applied to the tibia. The plate was clamped to the bone and then fixed to the proximal segment. Both conventional screws and locking screws were used. Conventional screws were used to reduce the proximal fragment to the plate as well as to lag fragments together proximally. After initial stabilization of the proximal fragment to the plate, the tibia distal to the fracture was reduced and stabilized to the plate using temporary wires or conventional screws. Following this initial stabilization, the quality of reduction was assessed in all planes. If the reduction was satisfactory, locking screws were placed proximally and distally to increase the stability of the construct[Figure8].
Figure 8: Reduction of the fracture and plate insertion in case of open reduction with internal fixation.

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Wound closure

Before closure of the wound, the tourniquet was released and hemostasis obtained. Asmall drain was inserted in all cases with ORIF technique.

In both methods, the patient's leg was supported in above knee posterior plaster slab for 10–15days, postoperatively. Fourteen days postoperatively, sutures were removed; splint was removed with intermittent knee mobilization. Follow-up visits with clinical examination and AP and lateral radiography were performed monthly for 3months and then every 3months until bony union was achieved. The follow-up period ranged from 6 to 12months.

In terms of data collection, operative time, intraoperative radiation exposure, intraoperative blood loss, time to observable callus formation, union time, time for full weight bearing(FWB), postoperative complications, and knee functions were recorded. Knee function was assessed by Hospital for Special Surgery Knee-Rating Scale(HSS) score, which assesses knee range of motion, pain, instability, climbing stairs, walking, flexion deformity, and muscle strength. Operative time was defined as the time from skin incision to closure. Union was defined as the absence of pain and the presence of bridging callus in three of the four cortices on AP and lateral radiographic views of the proximal tibia. Nonunion was defined as the absence of progressive fracture union at 6months postoperatively.

Statistical analysis

These data were collected, tabulated, and statistically analyzed using an IBM compatible personal computer with SPSS statistical package(version20; SPSS Institute, Cary, North Carolina, USA). Intraoperative radiation exposure, HSS scoring, and complications of the two groups were compared using the χ2-test. Operative time and the intraoperative blood loss were compared using Student's t- test. Intraoperative radiation time, time to observable callus formation, union time, and time for FWB were compared using the Mann–Whitney test.


  Results Top


Thirty patients with extra-articular proximal tibial fractures met the inclusion criteria for this study. They were divided into two groups:

  • GroupI included 15patients treated with LISS
  • GroupII included 15patients treated with ORIF.


A highly significant relation was found between the two groups with regard to operative time(P=0.000). The mean operative time in LISS patients was 79.3±7.76min (range: 65–90min), whereas in ORIF patients it was 122±8.61min(range: 110–140min) [Table1]. As regards intraoperative radiation exposure, the relation between two groups was highly significant(P=0.0014). All patients in the LISS group were exposed to radiation, whereas only 40% of patients in the ORIF group were exposed. Ahighly significant relation was found between the two groups with regard to the intraoperative radiation time(P=0.000). The mean intraoperative radiation time in LISS patients was 73.3±8.9 s(range: 60–90 s), whereas it was 5±6.54 s(range: 10–15 s) in the ORIF group. Ahighly significant relation(P=0.000) was found between the two groups as regards perioperative bleeding; in LISS patients, the mean amount of blood loss was 92.7±15.3ml(range: 70–120ml), whereas the mean amount of bleeding in ORIF patients was 366.8±52.3ml(range: 300–450ml)[Table2].
Table 1: Operative time among the recruited patients in relation to the type of intervention using Student's t-test (n=30)

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Table 2 Amount of perioperative bleeding among the recruited patients in relation to the type of intervention using t-test (n=30)

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In LISS patients, two cases showed nonunion and were excluded from the statistical analysis with regard to time for callus formation, time for union, and time for FWB. Anonsignificant relation was found between two groups as regards time needed for callus formation(P=0.935); in LISS patients, the mean time needed for callus formation was 4.5±1.19weeks(range: 3–7weeks), whereas it was 5.1±1.13weeks(range: 4–7weeks) in ORIF patients[Table3]. According to the union time, there was a significant difference between the two groups(P=0.041). The mean time of union in LISS patients was 10.87±10.54weeks(range: 10–36weeks). However, in ORIF patients, the mean time of union was 21.13±11.12weeks(range: 10–40weeks)[Table4]. According to the time needed for FWB, there was a highly significant difference between the two groups(P=0.004). The mean time needed for FWB for LISS patients was 9.91±3.24weeks(range: 7–12weeks). However, in ORIF patients, the mean time needed for FWB was 13.13±3.07weeks(range: 9–20weeks)[Table5]. According to the HSS scoring system, there was no significant difference between the two groups(P=0.89). In the LISS group, the HSS scores were excellent in seven cases, good in five cases, and fair in three cases. In the ORIF group, the HSS scores were excellent in six cases, good in five cases, and fair in four cases[Table6].
Table 3 Time needed for callus formation among the recruited patients in relation to the type of intervention using Mann-Whitney test (n=28)

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Table 4 Time needed for full union among the recruited patients in relation to the type of intervention using the Mann-Whitney test (n=28)

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Table 5: Time needed for full weight bearing among the recruited patients in relation to the type of intervention using the Mann-Whitney test (n=28)

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Table 6: Hospital for Special Surgery scoring among the recruited patients in relation to the type of intervention using Chi square (n=30)

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On studying postoperative complications, there was a nonsignificant relation between patients of two groups as regards nonunion, delayed union, exposed plate, infection, broken plate, lost reduction, and implant-related pain[Table7].
Table 7: Complications among the recruited patients in relation to the type of intervention (n=30)

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  Discussion Top


Proximal tibial fractures typically require operative fixation to achieve an acceptable functional outcome. The objective of surgery is to achieve an acceptable reduction, stable fixation of the fracture, and to restore the mechanical axis of the limb[7]. ORIF has been in vogue for long time with good outcome. However, it is associated with problems, especially overlying skin conditions, delayed recovery, and rehabilitation with limited functional outcome. To overcome these problems, minimally invasive techniques have been developed, which are based on the principle of indirect reduction without opening the fracture site. It involves lesser incision, lesser soft tissue dissection with lesser complications, and better functional outcomes[7]. The LISS is an extramedullary internal fixation system developed by the AO group for stabilization of proximal tibial fractures[6],[7].

The current study was a prospective randomized study to compare the clinical and radiological outcome between LISS and ORIF for the treatment of extra-articular proximal tibial fractures through the lateral approach.

Zolwodzki etal. [8] treated 54 proximal tibial fractures in 53patients with LISS. The mean operation time was 56min[8]. Sharama etal.[9], in a comparative study on conventional ORIF versus LISS in the management of proximal tibial fractures, documented that 36patients were prospectively analyzed and divided into two groups. GroupI(n=20) patients were treated with conventional plating and groupII(n=16) with LISS. The mean operation time was 99.5min in groupI and 79.25min in groupII[9].

In this study, 15patients with fracture of the proximal tibia were surgically treated with LISS(groupI) and 15patients were surgically treated with ORIF(groupII). The mean operative time was 79.3min(range: 65–90min) in LISS patients and 122min(range: 110–140min) in ORIF patients, which was statistically highly significant. Themean operative time was shorter in LISS cases due to smaller incision and less soft tissue dissection. These results coincide with the results of other studies[9]. The mean operative time was slightly longer in the LISS group in this study as compared with the study by Zolwodzki etal.[8], as they documented this time as the time from the initial screw insertion to the placement of the last self-tapping screw(the time for placement of the LISS). In this study, the operative time was calculated from skin incision to skin closure and this correlates with other studies[9].

In this study, the mean perioperative blood loss was 92.7ml(range: 70–120ml) and 366.8ml(range: 300–450ml) in the LISS group and the ORIF group, respectively, which was statistically highly significant. The mean blood loss was lesser in LISS patients due to smaller incision, lesser soft tissue dissection, and lesser disturbance to the fracture hematoma.

In this study, intraoperative fluoroscopic control was used in all patients of the LISS group to assess reduction and had a satisfactory alignment because the fracture site was not exposed. The mean time of intraoperative radiation exposure was 73.3 s(range, 60–90 s). C-arm was not routinely used in the ORIF group. Intraoperative fluoroscope was used to assess reduction after fixation in some patients, especially those with intra-articular extension, with a mean exposure time of 5 s(range: 10–15 s).

Boldin etal. [10] treated 26 proximal tibial fractures in 25patients with LISS. The mean time needed for observable callus formation was 5.7weeks(range: 4–7weeks). Bony consolidation was evident after a mean of 11weeks(range; 8–25weeks). Healing was achieved in this patient after elective bone grafting[10]. Cantu and Koval [11]treated 77 proximal tibial fractures with LISS. The average time to FWB was 12.6weeks[11].

Sharama etal. [9] documented the results of two methods, ORIF and LISS, in the treatment of proximal tibial fractures. The mean fracture union time was 19.8weeks in the ORIF group and 19.5weeks in the LISS group. In the LISS group, 100% union was achieved. However, in the ORIF group, 95% union was achieved with only one(5%) case nonunited[9].

In this study, the mean time needed for observable callus formation in LISS patients was 4.5±1.19weeks (range: 3–7weeks), whereas it was 5.1±1.13weeks (range: 4–7weeks) in ORIF patients. The mean time of union for LISS patients was 10.87±10.54weeks(range: 10–36 weeks). However, in ORIF patients, the mean time of union was 21.13±11.12weeks(range: 10–40weeks). Two patients were nonunited and one patient showed delayed union in either the LISS or the ORIF group.

The mean time needed for FWB for LISS patients was 9.91±3.24weeks(range: 7–12weeks). However, in ORIF patients, the mean time needed for FWB was 13.13±3.07weeks(range: 9–20weeks). These results correlate with the results of other studies[9],[10],[11]. The time to observable callus formation, union time, and the time for FWB was longer in ORIF than in LISS due to extensive soft tissue dissection, disruption of the fracture hematoma, and iatrogenic trauma associated with interfragmentary implants as lag screws.

Zolwodzki etal. [8] documented that two patients developed infections. Boldin etal.[10]documented that no patient had a deep or superficial infection. Sharamaetal. [9] reported that early postoperative complications such as superficial infection, deep infection, hardware pain, and skin slough were more frequent in the ORIF group.

In this study, one patient developed superficial infection with exposed proximal end of the plate in the LISS group. This was managed with debridement, implant removal, and insertion of an external fixator, but the patient did not attend follow-up. In the ORIF group, two patients developed infection. They were managed with debridement; culture and sensitivity was taken, and intravenous antibiotics were given according to the culture and sensitivity results. This coincides with other studies.

Apostolou etal.[12]documented that the HSS scores were excellent in five patients, good in two patients, and fair in two patients. Cantuetal. [11] reported that the mean HSS score was 88. Sharama etal. [9] reported that 80% of patients in the ORIF group and 95% of patients in the LISS group showed excellent-to-good results according to the Neer scoring system.

In this study, the HSS score was excellent in seven(46.7%) patients, good in five(33.3%) patients, and fair in three(20%) patients in the LISS group. In the ORIF group, the HSS score was excellent in six(40%) patients, good in five(33.3%) patients, and fair in four(20%) patients. The mean score for the LISS group was 85 and that for the ORIF group was 81, and this correlates with other studies[9],[10],[11],[12].

Complicated cases

In LISS patients, one case showed delayed union. Union in this patient was achieved through protected weight bearing in a cast after 9months, but the HSS score was fair. Two cases showed nonunion. One patient had loss of reduction intraoperatively as it was one of the early cases in this study and the familiarity with the LISS technique was not established yet, and the patient refused to have another operative revision. This patient developed superficial infection with exposed proximal end of the plate. This was managed with debridement, implant removal, and insertion of an external fixator, but the patient did not attend follow-up. The other patient had broken LISS with advanced osteoarthritis knee and total knee replacement with stem tibia inserted after plate removal. Implant-related pain was found in three patients and was managed with analgesics in two patients and plate removal in one patient.

In ORIF patients, one case also showed delayed union. Thispatient had his plate exposed, the plate was removed, and the cast was maintained until complete healing, but the HSS score was fair. Two patients developed infection. They were managed with debridement; culture and sensitivity was taken, and intravenous antibiotics were given according to the culture and sensitivity results. Two patients who showed nonunion were managed with bone graft, and full union was achieved 3months postbone graft, but the HSS score was fair.


  Conclusion Top


On the basis the current study results, it was found that the time for full union and time for FWB are shorter in LISS. Although complication rates are comparable in both groups, the LISS involves smaller incision, lesser soft tissue dissection, and subsequently shorter operation time and lesser blood loss. LISS exposes the surgical team and the patient to more hazards of the radiation exposure compared with ORIF. The limitations of this study were limited number of the patients included and short time of the patient follow-up, which did not cover any possible future complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
UchidaH, MinezakiT, MochidaJ. Predictors of short-term functional outcome following proximal tibial fractures. Tokai J Exp Clin Med 2006; 31:92–94.  Back to cited text no. 1
    
2.
HohlM. Tibial condylar fractures. JBone Joint Surg Am 1967; 49:1455–1467.  Back to cited text no. 2
    
3.
AliA, BurtonM, HashmiM, SalehM. Outcome of complex fractures of the tibial plateau treated with a beam-loading ring fixation system. JBone Joint Surg Br 2003; 85:691–699.  Back to cited text no. 3
    
4.
KriegJ. Proximal tibial fractures current treatment, results and problems. Injury 2003; 34(Suppl1):A2−A10.  Back to cited text no. 4
    
5.
BonoM, LevineR, RaoJ, BehrensF. Non articular tibial fractures treatment option and decision making. JAm Acad Orthop Surg 2001; 9:176–186.  Back to cited text no. 5
    
6.
StannardP, WilsonC, VolgasA, AlonsoE. The less invasive stabilization system in the treatment of complex fractures of the tibial plateau: short-term results. JOrthop Trauma 2004; 18:552–558.  Back to cited text no. 6
    
7.
SmithT, HedgesC, SchankatK, HingC. Asystematic review of the clinical and radiological outcomes of LISS plating for proximal tibial fractures. Eur J Orthop Surg Traumatol. 2010; 20:141–150.  Back to cited text no. 7
    
8.
ZolwodzkiM, ColePA, KregorPJ. Less invasive stabilization system(LISS) for fractures of the proximal tibia: Indications, surgical techniques and preliminary results of the UMC clinical trial. Injury 2003; 34(Suppl1):A16-A29.  Back to cited text no. 8
    
9.
SharamaR, KapilaR, SinghB, SohalY. Traditional buttress plating v/s MIPO in management of proximal tibial fractures–A clinical study. Pb J Orthop 2013; XIV: 11–16.  Back to cited text no. 9
    
10.
BoldinC, FankhauserF, HoferH, SzyszkowitzR. Three-year results of proximal tibia fractures treated with the LISS. Clin Orthop Relat Res 2006; 445:222–229.  Back to cited text no. 10
    
11.
CantuR, KovalK. Minimally invasive LISS plating for fractures around the knee. Tech Knee Surg 2008; 7:131–136.  Back to cited text no. 11
    
12.
ApostolouC, PapavasiliouA, AslamN, HandleyR, WillettK. Preliminary results and technical aspects following stabilisation of fractures around the knee with LISS. Injury Extra 2005; 36:529–536.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table1], [Table2], [Table3], [Table4], [Table5], [Table6], [Table7]



 

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