Liss LC DF

Less invasive stabilization system
(LISS) for LISS and LCP DF Plates.
Surgical Technique
This publication is not intended for

distribution in the USA.
Instruments and implants

approved by the AO Foundation.
Stardrive
Hex drive
Image intensifier control
This description alone does not provide sufficient background for direct use
of DePuy Synthes products. Instruction by a surgeon experienced in handling
these products is highly recommended.
Processing, Reprocessing, Care and Maintenance

For general guidelines, function control and dismantling of m ulti-part
instruments, as well as processing guidelines for implants, please contact your
local sales representative or refer to:
http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance
For general information about reprocessing, care and maintenance of Synthes
reusable devices, instrument trays and cases, as well as processing of Synthes
non-sterile implants, please consult the Important Information leaflet
(SE_023827) or refer to:
http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance
Table of Contents
Introduction L ess invasive stabilization system (LISS) 2

for LISS and LCP DF Plates
AO Principles 4
Indications and Contraindications 5
Clinical Cases 6
Surgical Technique Preoperative Planning 8
Preparation11
Plate Insertion 17
–– Option A: Insertion of Self-Drilling, 21
Monocortical Locking Screws
–– Option B: Insertion of Self-Tapping, 26
Bicortical Locking Screws
–– Option C: Insertion of Self-Tapping Locking Screws 30
for Periprosthetic Fractures
–– Option: Pulling Device (“Whirly Bird”) 33
–– Option: Guiding Blocks 34
Implant Removal 37
Additional Information 39
Instruments for Minimally Invasive Osteosynthesis 40
Product Information Implants41
Locking Screws B 5.0 mm 42
Instruments43
Sets46
Bibliography 48
MRI Information 49
Less invasive stabilization system (LISS) for LISS and LCP DF Plates Surgical Technique DePuy Synthes 1
Less invasive stabilization system
(LISS) for LISS and LCP DF Plates.
Anatomically precontoured low Angular stability LCP combi-holes

profile plates –– May prevent screw loosening as well –– Combine a dynamic compression
–– Limited plate -periosteum contact as primary and secondary loss of unit (DCU) hole with a locking screw
–– No need for plate contouring reduction hole
–– Offers purchase in osteoporotic –– Permits an internal plate fixation
bone and in multiple fragment frac- using standard screws, locking
Precaution: Excessive and repetitive tures screws or a combination of the two
bending is not recommended as it may
weaken the plate.
Wide variety of anatomically Wide variety of screws

precontoured plates –– Self-tapping or self-drilling locking
–– Available in stainless steel and screws
titanium alloy (TAN) –– Periprosthetic locking screws with
–– LCP DF plates in eight lengths with blunt tip for periprosthetic fractures
5 to 19 holes in the shaft –– Cortex screws
–– Long LCP DF plates (15 to 19 holes) –– Available in stainless steel and
available in sterile only titanium
–– LISS plates in TAN in lengths 5,
9 and 13 holes
2 DePuy Synthes Less invasive stabilization system (LISS) for LISS and LCP DF Plates Surgical Technique
Available guiding tools:
guiding block and LISS insertion guide
The guiding block facilitates mounting The radiolucent LISS insertion guide
of the threaded LCP drill sleeves. permits a minimally-invasive surgery,
allows accurate percutaneous place-
ment of screws and facilitates the in-
sertion of the plate.
Use of cortex screws

in the plate head
LISS instrumentation for Stardrive
and Hex drive
The torque-limiting screwdriver, the
screwdriver shaft and the cleaning in-
strument are available for screws with
Stardrive and Hex drive.
The threaded holes in the plate head

also accept cortex screws to create
compression.
Note: Cortex screws are only recom-

mended in cases when compression
through the plate is needed or when
an independent cortex screw cannot
be placed. This decision depends on
patient’s history, bone quality, physio-
logical condition and compliance and
has to be made individually for each
patient.
AO Principles
AO PRINCIPLES
In 1958, the AO formulated four basic principles, which have

In 1958, the guidelines
become AO formulated four basic
for internal principles,
fixation1,2. which
have become the guidelines for internal fixation1, 2.
4_Priciples_03.pdf 1 05.07.12 12:08
Anatomic
Anatomic reduction fixation
Stable fixation
Fracture reduction
Fracture reduction and
and fixation
fixation to Fracture
Fracture fixation
fixationproviding
providingabsolute
abso- or
to restore
restore anatomical
anatomical relationships.
relationships. relative stability,stability,
lute or relative as required
as by the
prequired
atient, theby injury, and thethe
the patient, personality
injury,
1 2 of
andthethe
fracture.
personality of the
fracture.
Early,
Early, active mobilization
mobilization Preservationof
Preservation of blood
blood supply
supply
Early and
Early and safe mobilization
mobilizationand
and 4 3 Preservation
Preservationof ofthe
theblood
bloodsupply
supply
rehabilitation the injured partand
rehabilitation of the injured part to
to soft tissues and bone bygentle
soft tissues and bone by
the patient
and as a whole.
the patient as a whole. reduction techniques
gentle reduction and careful
techniques and
handling.
careful handling.
1
Müller ME, M Allgöwer, R Schneider, H Willenegger. Manual of Internal
Fixation. 3rd ed. Berlin Heidelberg New York: Springer. 1991.
2
Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management.
2nd ed. Stuttgart, New York: Thieme. 2007.
1 Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixation.

3rd ed. Berlin, Heidelberg, New York: Springer. 1991.
2 Rüedi TP, Buckley RE, Moran CG. AO Principles of Fracture Management. 2nd ed.
Stuttgart, New York: Thieme. 2007.
4 DePuy Synthes Expert Lateral Femoral Nail Surgical Technique

Indications and Contraindications
Indications
LCP DF is indicated for the stabilization of fractures
of the distal femur. These include:
– Distal shaft fractures
– Supracondylar fractures
– Intra-articular fractures
– Periprosthetic fractures
Contraindications
No specific contraindications.
Clinical Cases
Case 1
Male, 20 years old,
polytrauma, fracture 33-C3
Preoperative Follow-up after 6 weeks
Follow-up after 3 months Follow-up after 5 months
Case 2
Male, 76 years old, isolated
fracture 33-B2
Preoperative Postoperative
Follow-up after 4 weeks
Preoperative Planning
Use the x-ray templates for LCP DF (Art. No. 034.000.315 LCP Distal Femur, right
for right and 034.000.320 for left femur) to determine the E D/F A
C/G
B
length of the plate and the position of the screws.

1
2
3 4 5
Ö034.000.315öAB{ä
6 7 8 9 10 11 12 13 14 15 16 17 18 19
Preoperative planning of lag screws may be necessary.
All rights reserved Synthes is trademark of Synthes, Inc. or its affiliates

19
18
17
16
F
15
14
G
13
E
12
B
1 2 10 11
3 4 5 8 9
6 7
C
Precaution: Plate bending is not recommended as this may
© 09/2010 Synthes, Inc. or its affiliates

F E/A/B D
G C
weaken the plate and the plate-screw interface and can 0

1.10 Magnification
10 20 30 40 50 60 70 80 90 100 mm
Titanium
422.250
422.252
422.254
St. Steel
222.250
222.252
222.254
Holes
5
7
9
Length (mm)
156
196
236
422.256 222.256 11 276
compromise the targeting function of an aiming arm, if in

Caution: Due to variable magnification factors in x-rays,
this template should be used for general pre-operative planning only. 422.258 222.258 13 316
04.124.030S 02.124.030S 15 356
034.000.315 AB 30100466
For use only with the Original AO System of
04.124.034S 02.124.034S 17 396
Instruments and Implants
04.124.038S 02.124.038S 19 436
Synthes GmbH
use. However, there may be cases in which plate bending is

Eimattstrasse 3
CH-4436 Oberdorf
www.synthes.com
clinically necessary. In such cases, the plate should only be

bent to fit proximal femur anatomy and only bend the plate LCP Distal Femur, left
incrementally and between screw holes using the plate E D/F A
C/G
B
bending press (329.300), and never bend back-and-forth.

1
2
3 4 18 19
14 16 17
Ö034.000.320öABNä
5 6 7 8 9 10 11 12 13 15
Insert at least one screw distal to the bend.
Synthes is trademark of Synthes, Inc. or its affiliates

4 5 6 7 8
D
2 3 9 10
1 11
B
12
A
13
E
14
G
15
16
F
17
All rights reserved

18
19
© 06/2010 Synthes, Inc. or its affiliates

D B/A/E F
C G
1.10 Magnification Titanium St. Steel Holes Length (mm)
422.251 222.251 5 156
422.253 222.253 7 196
0 10 20 30 40 50 60 70 80 90 100 mm 422.255 222.255 9 236
422.257 222.257 11 276
Caution: Due to variable magnification factors in x-rays,
422.259 222.259 13 316
this template should be used for general pre-operative planning only.
04.124.031S 02.124.031S 15 356
30100466
For use only with the Original AO System of 04.124.035S 02.124.035S 17 396
Instruments and Implants 04.124.039S 02.124.039S 19 436
034.000.320 AB
Synthes GmbH
Eimattstrasse 3
CH-4436 Oberdorf
www.synthes.com
Preoperative screw-length selection using an AP
radiograph
To select the proper screw length for the condyle, it is possi-
ble to perform a preoperative x-ray with the 50 mm wide
calibrator and to use the table below.
1. Place the x-ray calibrator medially or laterally at the height

of the condyle.
2. Take an AP radiograph of the distal femur.
3. Measure the width of the x-ray calibrator (XRC)
on the radiograph.
4. Measure the maximum condyle width (MCW)
on the radiograph.
5. Determine the real condyle width (RCW).
50
RWC = × MCW
XRC
6. Determine the screw lengths for the screw holes A to G

using the table below. The positions A to G are indicated
on the x-ray template and on the LISS DF insertion guide.
Length of locking screws (mm)

Real condyle Hole Hole Hole Hole Hole Hole Hole
width (RCW) A B C D E F G
60–80 mm 65 40 40 55 65 65 55
81–87 mm 75 40 55 65 75 75 65
88–95 mm 75 55 65 65 75 75 75
96–110 mm 85 65 75 75 75 85 85
Preoperative Planning
Example
The length of the x-ray calibrator on the radiograph (XRC)
is 55 mm (magnification 1.10).
The maximum condyle width on the radiograph (MCW)

amounts to 91 mm.
50
RWC = × 91 = 83
XRC
The real condyle width (RCW) is therefore 83 mm.
The screw lengths are therefore:
Screw hole Screw length (mm)

A 75
B 40
C 55
D 65
E 75
F 75
G 65
Note: The proper placement of the plate on the condyle is

essential to ensure the correct screw length.
Preparation
1 Power Tools*
Prepare required sets 511.701 Compact Air Drive II
511.750 AO/ASIF Quick Coupling, for Compact Air

Instrument sets Drive and Power Drive
01.120.040 LISS Instruments and Insertion Handle, 511.790 Quick Coupling for Kirschner Wires B 0.6
for DF and PLT Plates, in Vario Case to 3.2 mm, for Compact Air Drive and
or Power Drive
01.120.041 LISS Instruments Stardrive and
Insertion Handle, for DF and PLT Plates,
in Vario Case
05.001.201 Battery Handpiece, modular,
Optional instrument set for Trauma Recon System
01.120.457 LCP Large Fragment Instruments and 05.001.202 Power Module, for Trauma Recon System
Standard Instruments in Vario Case
05.001.203 Sterile Cover, for Trauma Recon System
Plate sets
05.001.227 Lid for Battery Handpiece No. 05.001.201,
01.120.332 LCP-DF 4.5/5.0 (Stainless Steel), for Trauma Recon System
in Modular Tray, Vario Case System
or 05.001.205 AO/ASIF Quick Coupling, for Trauma Re-
01.120.334 LCP-DF 4.5/5.0 (Titanium Alloy/TAN), con System
in Modular Tray, Vario Case System
05.001.212 Quick Coupling for Kirschner Wires B 1.0
Note on long plates: The LCP DF plates with 15 to 19 holes to 4.0 mm, for Trauma Recon System
are available in sterile only and not part of a set. Therefore
05.001.216 Torque Limiter, 4.0 Nm, for Trauma Recon
these articles have to be ordered as single items (for article
System
numbers refer to page 41).
Screw sets
68.122.050 Modular Insert, for Modular Screw Rack,

for Screws B 5.0 mm, size 1⁄ 3,
without Contents, Vario Case System


68.122.054 Modular Screw Rack, with Drawer, Mea-

suring Block and Lid, length 200 mm,
height 115 mm, size ½, without Contents,
Vario Case System
* For further information refer to the instructions for use for the Trauma Recon
System (036.000.505) or the Compact Air Drive (036.000.064).
Preparation
Note: The LISS instruments are compatible with both LISS

and LCP DF plates. This technique guide shows the tech-
nique with LCP plates only. For your reference a picture of
the LISS pate is shown on the right.
2
Position the patient
Position the patient supine on a radiolucent table. The leg

should be freely movable. The contralateral leg can be placed
in an obstetric leg holder. Place the knee joint line slightly
distal to the hinged part of the table to allow flexion of the
knee during surgery.
Avoid too strong a traction and a fully extended knee, as the

forces of the gastrocnemius muscle would draw the distal
fragment into recurvatum. This does not only make the re-
duction of the fracture difficult, but also endangers the pop-
liteal artery and vein.
In very short distal fragments, it is recommended to flex the

lower leg to approximately 60°. This also reduces the trac-
tion force of the gastrocnemius muscle.
Preparation
3
Assemble the insertion instruments
Instruments
1
324.011 LISS Insertion Guide for Distal Femur,
left, radiolucent
or
2
324.012 LISS Insertion Guide for Distal Femur, 3
right, radiolucent 1 4 5 Hole A
321.170 Pin Wrench B 4.5 mm, length 120 mm 2
324.022 Drill Sleeve for LISS Insertion Guide,

length 130 mm 3
324.044 Stabilization Bolt for LISS Insertion Guide,

length 156 mm 4
324.043 Fixation Bolt for LISS Insertion Guide,

length 151 mm 5
Note: In certain cases (e.g. distal fracture treated with a

short plate) it may be advantageous to do the surgery with-
out using the LISS insertion guide and the corresponding
LISS instruments. Then, screws can be inserted by applying
the technique described in the LCP Instructions for Use
DSEM/TRM/0115/0278 (036.000.019).
Insert the fixation bolt in hole A of the insertion guide.
Place the insertion guide on the three-point locking

mechanism of the plate.
Thread the fixation bolt into the plate. Thread the nut of the
fixation bolt and lightly tighten it with the pin wrench.
For a more stable fixation of the plate on the insertion guide

during insertion, introduce the stabilization bolt with the drill
sleeve in hole B and thread it into the plate.
Hole B Hole A
Note: To prevent tissue ingrowth and facilitate implant re-

moval, the unoccupied screw holes may be filled with screw
hole inserts prior to inserting the plate. Use the torque-limit-
ing screwdriver. The optimum torque is reached after one
click.
Preparation
4
Reduce the fracture
In an intra-articular fracture, first reconstruct and stabilize

the entire joint. The figure shows the possible positioning
sites for lag screws in the condyles (in red).
Note: Make sure that these lag screws will not collide with
Possible positioning sites for lag screws (in red)
the screws inserted through the insertion guide.
The fracture can be aligned manually by traction using a

temporary knee-bridging external fixator or a distractor.
Intraoperative x-ray or image-intensifier control is recom-
mended to check the reduction.
The anteromedial insertion of a Schanz screw can be benefi-

cial in distal fragment manipulation.
5
Surgical approaches
Extra-articular fractures
Perform a skin incision from Gerdy’s tubercle about 80 mm
in a proximal direction. Split the iliotibial tract in the direction
of the fibres. Open the space between the lateral vastus and
the periost. Distally, the lateral vastus muscle inserts mainly
on the femoral ridge. There are no muscle insertions on the
lateral periost or bone. The plate can be inserted into the
space between the periost and the muscle.
Intra-articular fractures
In intra-articular fractures, an anterolateral arthrotomy pro-
viding good control of the reduction is recommended. This
arthrotomy also allows a subsequent insertion of the plate
and can be used to insert lag screws from medially.
Precaution: The incision can be extended if necessary to

improve visualization of the articular surface or lateral me-
taphysis and diaphysis. It may not always be appropriate to
use limited incisions and closed reduction techniques.
Plate Insertion
1
Insert LISS
Instruments
Assembled Insertion Guide
324.027 Trocar, length 162 mm, for No. 324.022
Use the assembled insertion guide to insert the plate be-

tween the lateral vastus muscle and the periost. Slide the
plate proximally and ensure that its proximal end remains in
constant contact with the bone. Position the distal end of
the plate against the lateral condyle. To find the correct posi-
tion, move the plate proximally and then back distally until
the plate fits the condyle. Should the proximal end of the
handle and the soft tissues impair the insertion of the plate,
it is possible to remove the radiolucent proximal part of the
handle for insertion.
Due to its weight, the insertion guide tends to tilt dorsally.

If the insertion guide points parallel to the floor with the pa-
tient in a supine position, the plate is externally rotated and
no longer lies flat up against the lateral condyle. The fixation
bolt must be oriented parallel to the patello-femoral joint.
Consequently, the insertion guide shows an internal rotation
of about 10°. This occurrence is also visible in the AP view of
an image intensifier. The plate must lie flat up against the
condyle to ensure an optimal fit on the bone.
Plate Insertion
Once the plate is properly aligned with the bone, remove the
drill sleeve and stabilization bolt from hole B. Insert the tro-
car through the drill sleeve in the most proximal hole of the
plate. Perform a stab incision and push the drill sleeve and
the trocar down to the plate. Check the correct position of
the proximal part of the plate, either with the image intensi-
fier or by direct palpation.
Secure the position of the drill sleeve with the lateral screw
on the insertion guide. Replace the trocar with a stabilization
bolt. To close the frame, thread the stabilization bolt into the
plate.
Note: Due to soft tissues around the stabilization bolt, it will

be difficult to change the position of the plate/handle as-
sembly once the bolt has been inserted.
Option: Check plate position with a Kirschner Wire
Instrument
292.699 Kirschner Wire B 2.0 mm with threaded

tip, length 280 mm, Stainless Steel
Use a Kirschner wire to check the correct position of the

proximal part of the plate on the bone.
2
Fixate LISS temporarily with Kirschner wires
Instrument

For preliminary fixation of the plate, use 2.0 mm Kirschner

wires through the fixation and stabilization bolts.
Carefully check the position of the plate and the length of

the reduced injured limb. Once the reduction has been
successfully completed and the plate has been positioned
correctly, the locking screws can be inserted.
Plate Insertion
Alternative technique
Instruments
324.048 Aiming Device for Kirschner Wires,

for LISS Insertion Guide
324.034 Centering Sleeve for Kirschner Wire,

length 184 mm, for No. 324.048

If necessary, it is possible to use 2.0 mm Kirschner wires for

the preliminary fixation along the full length of the plate. Use
the aiming device for Kirschner wires to insert the wires on
the ventral and dorsal side of the plate. Note that the dis-
tance between bone and plate should be kept as short as
possible when inserting the wires, as they are arranged in a
convergent way. After the insertion of the Kirschner wires,
the distance between plate and bone can no longer be re-
duced.
After removing the Kirschner wire sleeves and the aiming

device, proximal/distal displacement and adjustment of the
position of the plate can be carried out. At the same time,
the lateral Kirschner wires prevent the plate from migrating
into the sagittal plane. Once the correct position is deter-
mined, the plate can be locked temporarily with a Kirschner
wire through the fixation bolt.
Note: The aiming device can be used from hole 3 to hole 13.
Option A: Insertion of Self-Drilling,
Screw placement depends on the type of fracture. The

position of the screws should be chosen in accordance with
established biomechanical principles for internal fixation.
The screws should be inserted close to and remote from the
fracture gap in the main fragments. Use at least four screws
per fracture side.
Once the initial screw has been inserted in each main frag-
ment, length and rotation are defined. Ante- and recurva-
tum deformities can still be manipulated relatively well,
whereas there are only limited correction possibilities for
varus/valgus deformities. Therefore, it is recommended to
insert the first screw in the distal fragment. The distal screws
should be placed parallel to the knee joint. Then insert a
screw in the proximal fragment.
Note: If a screw has to be removed and reinserted, use the

torque-limiting screwdriver and not the power tool.
1
Make stab incision
Instruments

length 130 mm
Make a stab incision and insert the trocar through the drill
sleeve.
2
Determine screw length
The length of the condylar screws can be deduced from the

table on page 9.
Use screws of 26 mm length in the diaphyseal region.
Options:
–– In case of very thick cortex, pre-drill by using the pulling
device (324.033) or the drill bit B 4.3 mm (310.423).
–– The insertion of the initial screw tends to push the bone
medially, especially in case of dense bone and/or unstable
reductions. The pulling device helps to solve this problem
(see page 33).
Option: Determine screw length with Kirschner wire
Instruments

324.037 LISS Measuring Device for Kirschner

Wires B 2.0 mm, length 121 mm,
for No. 292.699

It is also possible to use the measuring device with a 2.0 mm

Kirschner wire, placed through the centering sleeve.
Using image intensification, insert the Kirschner wire to the

desired depth leaving at least 5 mm between the tip of the
Kirschner wire and the medial cortex. Measure the screw
length over the Kirschner wire using the measuring device
for Kirschner wires, leaving the centering sleeve in place, and
round down to the nearest screw length. This will ensure
that the tip of the screw will not protrude through the me-
dial cortex.
3
Insert self-drilling locking screws
Instruments
511.771 Torque Limiter, 4 Nm,

for Compact Air Drive and Power Drive
324.050 Screwdriver Shaft 3.5, hexagonal,

length 180 mm
or
324.250 Screwdriver Shaft Stardrive, T25,
length 180 mm
324.052 Torque-limiting Screwdriver 3.5,

self-holding, for Locking Screws B 5.0 mm 1st bulge
or 2nd bulge
314.163 Torque-limiting Screwdriver Stardrive, T25,
self-holding, for Locking Screws B 5.0 mm
324.019 Stopper for LISS Insertion Guide
To insert the locking screw using a power tool, fit a torque

limiter to the power tool and insert the screwdriver shaft into
the torque limiter.
Insert the locking screw into the plate hole through the drill
sleeve for LISS insertion guide. To insert the screw, start the
power tool slowly, increase the speed and then reduce it
again before the screw is fully tightened. Advance the screws
into the bone until the second bulge of the screwdriver dis-
appears in the drill sleeve.
Tighten the screw manually with the torque-limiting screw-
driver. After one click, the optimum torque is reached.
Insert a stopper into the LISS insertion guide after screw

insertion.
Notes:
–– To reduce the risk of stripping the screw head do not lock
the screws at full speed. This can make it difficult to re-
move the implant.
–– In order to achieve an excellent interface between screw
and bone and to prevent a medial migration of the bone,
use the power tool without high axial forces (3 to 5 kg).
–– To prevent heat necrosis, it is important to cool the screw
with saline solution during the drilling procedure through
the drill sleeve.
–– If the screw is difficult to insert or stops advancing prior to
locking to the plate, remove the screw and clean the cut-
ting flutes using a Kirschner wire. The screw can be re-
used if the socket has not been damaged.
–– Should the screwdriver be difficult to remove after inser-
tion, disconnect it from the power tool and remove the
drill sleeve. After reconnecting the screwdriver to the
power tool, withdraw the screwdriver from the screw.
Option B: Insertion of Self-Tapping,
1
Make stab incision
Instruments

length 130 mm
Make a stab incision and insert the trocar through the drill
sleeve for LISS insertion guide.
2
Predrill screw hole
Instruments
324.007 Drill Sleeve 7.2/4.3, length 130 mm, for LISS
310.423 Drill Bit B 4.3 mm, length 280 mm,

for No. 324.007
Remove the trocar and thread the drill sleeve 7.2/4.3 into the
plate hole through the drill sleeve for LISS insertion guide.
Carefully drill the screw hole using the 4.3 mm drill bit.
3
The length of the condylar screws can be deduced from the

table on page 9.
For screws in the diaphyseal region
Slide the stop ring down to the drill sleeve to make reading
easier.
Read the drilled depth directly from the laser mark on the
drill bit. Remove both drill bit and drill sleeve 7.2/4.3.
Option: The insertion of the initial screw tends to push the

bone medially, especially in the case of dense bone and/or
unstable reductions. The pulling device helps to solve this
problem (see page 33).
Option B: Insertion of Self-Tapping,
4
Insert self-tapping locking screws
Instruments
511.771 Torque Limiter, 4 Nm,

for Compact Air Drive and Power Drive

length 180 mm
or
length 180 mm

or 1st bulge
2nd bulge
Choose a self-tapping locking screw according to the mea-

sured length. To insert the locking screw using a power tool,
fit a torque limiter to the power tool and insert the screw-
driver shaft into the torque limiter.
Insert the locking screw into the plate hole through the drill
sleeve for LISS insertion guide. To insert the screw, start the
power tool slowly, increase the speed and then reduce it
again before the screw is fully tightened. Advance the screws
into the bone until the second bulge of the screwdriver dis-
appears in the drill sleeve.
Warning: If the torque limiter is unavailable, do not tighten

the screws to the plate under power. Perform final tighten-
ing by hand.
Tighten the screw manually with the torque-limiting screw-
driver. The optimum torque is reached after one click.

insertion.
Precautions:
–– To reduce the risk of stripping the screw head do not lock
the screws at full speed. This can make it difficult to re-
move the implant.
–– For long screws and thick cortical bone, ensure cooling
during insertion.
Option: Manual insertion
Instruments

or
Insert and lock the screw with the torque-limiting screw-

driver through the drill sleeve for LISS insertion guide.

insertion.
Option C: Insertion of Self-Tapping
Locking Screws for Periprosthetic
Fractures
Special screws for periprosthetic fractures have been devel-

oped for cases in which an intramedullary nail or a prosthesis
could impair the placement of screws.
These periprosthetic screws are self-tapping with a flattened,

very short tip. This ensures optimal fixation of the plate on
the diaphysis. They are available in five lengths of 8, 10, 12,
14 and 18 mm and allow the thread to engage in the near
cortex.
1
Make stab incision
Instruments

length 130 mm
Make a stab incision for plate holes requiring a periprosthetic

screw and insert the drill sleeve for LISS insertion guide and
the trocar.
2
Predrill screw hole
Instruments

for No. 324.007
Remove the trocar and thread the drill sleeve 7.2/4.3 into the
plate hole through the drill sleeve for LISS insertion guide.
Use the drill bit to pre-drill the bone under image intensifier
control. Drill as close to the prosthesis or intramedullary
implant as possible to allow for the placement of the longest
periprosthetic screw possible.
3
Slide the stop ring down to the drill sleeve to make reading
easier.
Read the drilled depth directly from the laser mark on the
drill bit. Remove both drill bit and drill sleeve 7.2/4.3.
Option C: Insertion of Self-Tapping Locking Screws
for Periprosthetic Fractures
4
Insert self-tapping locking screws for periprosthetic
fractures
Instruments

or
Choose a periprosthetic screw according to the measured

length. Insert and lock the screw with the torque-limiting
screwdriver through the drill sleeve for LISS insertion guide.

insertion.
Note: If the measured drill depth is shorter than 8 mm,

do not use periprosthetic screws.
Precaution: Never place a screw which is longer than the

measured length, as this will result in stripping of the thread
in the bone and loss of screw anchoring.
Option: Pulling Device (“Whirly Bird”)
Instrument
324.033 Pulling Device, length 240 mm, for LISS

length 130 mm
The insertion of the initial screw tends to push the bone

medially, especially in case of dense bone and/or unstable
reductions. The pulling device helps to solve this problem.
Insert the pulling device without the knurled nut through the
drill sleeve into the neighbouring hole of the first permanent
screw.
Stop the power tool before the entire screw length of the
pulling device is inserted.
Remove the power tool and the drill sleeve.
Screwing the knurled nut onto the pulling device allows the
bone to pull towards the plate. Since the tip of this instru-
ment has a diameter of 4.0 mm, replacing it with a 5.0 mm
locking screw still ensures good purchase in the bone.
Precaution: It is important to monitor the advance of the

screw tip carefully when inserting the pulling device. Stop
the power tool before the pulling device is seated on the
plate. Failure to do so may result in stripping the thread in
the bone.
Option: Guiding Blocks
Using LCP instrumentation

See technique guide LCP Locking Compression Plate
DSEM/TRM/0115/0278 (036.000.019).
Using LISS instrumentation

Use instruments as described in section plate insertion.
Using the guiding blocks for LCP DF

The guiding block facilitates mounting of the threaded
LCP drill sleeves in the head of the plate.
Instruments
312.946/947 Guiding Block for LCP DF, right/left
323.042 LCP Drill Sleeve 5.0, for Drill Bits B 4.3 mm
310.430 LCP Drill Bit B 4.3 mm with Stop,

length 221 mm, 2-flute,
for Quick Coupling
Note: If cortex screws are used they have to be inserted be-

fore mounting the guiding block and before inserting locking
screws.
Instrument assembly
1
Choose the matching guiding block and place it onto
the plate head. Make sure that the three-point locking
mechanism is positioned on the pre-contoured reference
points of the plate.
2
A
Insert a first LCP drill sleeve through the guiding block into
the central hole (A) of the plate and tighten it.
3
To lock the LCP drill sleeve tighten the locking nut of the
guiding block by turning it clockwise.
Option: Guiding Blocks
4
For preparing additional holes in the plate head insert
LCP drill sleeves in the surrounding holes.
Predrilling and screw measurement

Pre-drill with the LCP drill bit B 4.3 mm. Measure screw
length by reading the drilled depth directly from the
laser mark on the drill bit. To make reading easier shove
the stop ring down to the drill sleeve.
Screw insertion
Remove the LCP drill sleeve. Insert the locking screw through
the guiding block.
Implant Removal
Instruments
324.011 LISS Insertion Guide for Distal Femur,

left, radiolucent
or
324.012 LISS Insertion Guide for Distal Femur, right,
radiolucent

length 151 mm

length 130 mm

length 156 mm

length 180 mm
or
length 180 mm

or
Remove the implant only after complete consolidation of the

fracture. Remove it in reverse order to the implantation.
First, make the incision for the insertion guide in the path of
the old scar, and mount the insertion guide (see step 1 on
page 17).
Make stab incisions and use the torque-limiting screwdriver

to unlock all screws manually. In a second step, completely
remove all screws with a power tool.
Implant Removal
Option: Clean screw heads with cleaning instruments
Instruments
324.053 Cleaning Instrument for LISS Screw Head,

length 202 mm
or
324.253 Cleaning Instrument for Screw Head
Stardrive, T25, length 202 mm
The cleaning instrument helps to clean the recess of the

screw heads. After placing the drill sleeve, insert the cleaning
instrument carefully. Insert the stiletto with threaded tip and
turn clockwise. Remove the cleaning instrument. Unlock all
screws manually with the torque-limiting screwdriver. In a
second step, completely remove all screws with a power
tool.
If the screws cannot be removed with the screwdriver, please

consult the separate Synthes publication “Screw Extraction
Set. Instruments for removing Synthes screws.” (Art. No.
036.000.918), which explains in detail how screws with a
damaged recess as well as how broken and jammed screws
can be removed.
After removal of all screws, remove the plate. Should the

plate remain stuck when all screws have been removed, take
the insertion guide away and use the fixation bolt to loosen
the plate.
Additional Information
If the reduction of the fracture causes difficulties, insert a To ensure stability of the construct, the most proximal screw
Schanz screw antero-medially in the distal fragment, and use should be inserted last, just before removing the insertion
the screw as a joystick. The insertion of a Schanz screw or guide. Remove the stabilization bolt and insert the screw
pulling device into the proximal fragment can also be very through the drill sleeve.
beneficial. Should it still be impossible to perform a correct
reduction, improve the access by enlarging the soft-tissue If hole A is unoccupied, it must be closed with a Screw Hole
opening. Insert (422.390) to facilitate the application of the insertion
guide for removing the implant.
Precaution: Bending and twisting of the plate is not recom-

mended as it may result in a misalignment between the
holes of the insertion guide and the corresponding plate
holes.
Should the plate lie too ventral or too dorsal, the screws can-
not be centred in the medullary canal. This position may
compromise screw purchase (see illustration).
Both screwdriver shaft and torque-limiting screwdriver are Correct placement

equipped with a self-holding mechanism. Apply slight pres-
sure on pick-up to ensure that the screwdriver shaft pene-
trates the recess of the screw head.
Should the screwdriver be difficult to remove after insertion,

disconnect it from the power tool and remove the drill
sleeve. After reconnecting the screwdriver to the power tool,
withdraw the screwdriver from the screw.
Standard 4.5 mm cortex screws can be used through the in-

Compromised
sertion guide if required. Note that cortex screws cannot be screw purchase
inserted through the drill sleeve for LISS insertion guide.
Hole A serves to lock the insertion guide to the implant. This

hole cannot be used for the insertion of a screw as long as
the fixation bolt is attached. If a screw has to be inserted in
hole A, remove the fixation bolt – with the stabilization bolt
still in place – and attach it in an adjacent hole. Place the drill
sleeve in hole A (pre-drill if necessary) and insert the appro-
priate screw. If all holes are occupied by a screw, the screw
in hole A can be inserted by free-hand technique. Use the di-
rection given by the fixation bolt prior to removal of the in-
sertion guide to determine the correct direction for insertion.
Instruments for Minimally Invasive
Osteosynthesis
Hohmann Retractor Holder

The Hohmann retractor holder was developed to support
minimally invasive, percutaneous plate osteosynthesis. Its
unique design enables the easy and reliable percutaneous in-
sertion of plates. These characteristics make the Hohmann
retractor holder the ideal instrument for use in combination
with modern implant systems such as LCP and LISS.
–– The Hohmann retractor holder allows better visualization

of the inserted plate.
–– Serves as a guide for the inserted plate.
–– Ensures that the inserted plate is centered on the bone.
For additional information see the separate Synthes

publication on the Hohmann retractor holder
(Art. No. 036.000.219).
Soft Tissue Retractor

The offset blade facilitates easy preparation of the epipe-
reosteal cavity for percutaneous plate insertion.
–– Adjustable blade for free choice of insertion angle and

blade length
–– Available in two sizes: for small and large fragment plates
For additional information see the separate Synthes publica-

tion on the Soft tissue retractor (Art. No. 036.000.127).
Implants
LCP Distal Femur (LCP DF)
Stainless steel Titanium alloy Holes Length

(mm)
222.250 422.250 5 156 right
222.251 422.251 5 156 left
222.252 422.252 7 196 right
222.253 422.253 7 196 left
222.254 422.254 9 236 right
222.255 422.255 9 236 left
222.256 422.256 11 276 right
222.257 422.257 11 276 left
222.258 422.258 13 316 right
222.259 422.259 13 316 left
02.124.030S 04.124.030S 15 356 right
02.124.031S 04.124.031S 15 356 left
02.124.034S 04.124.034S 17 396 right
02.124.035S 04.124.035S 17 396 left
02.124.038S 04.124.038S 19 436 right
02.124.039S 04.124.039S 19 436 left
Note: Long LCP DF plates from 15–19 holes are available in

sterile only.
LISS Distal Femur (LISS DF)
TAN Holes Length

(mm)
422.340 5 156 Right
422.341 5 156 Left
422.344 9 236 Right
422.345 9 236 Left
422.348 13 316 Right
422.349 13 316 Left
Add suffix ”S” to article number to order sterile product.
Locking Screws B 5.0 mm
Hex Stardrive
X13.414– X12.251– self-drilling,

X13.490 X12.267 length 14–90 mm
X13.314– X12.201 – self-tapping,

X13.390 X12.227 length 14–90 mm
0X.221.458 0X.221.508 for periprosthetic

0X.221.460 0X.221.510 fractures,
0X.221.462 0X.221.512 self-tapping,
X22.402 0X.221.514 length 8–18 mm
X22.404 0X.221.518
422.390 Screw Hole Insert B 5.0 mm,

Titanium Alloy (TAN)
X = 2: stainless steel
X = 4: TAN
All screws are available nonsterile and sterile packed.
For sterile implants add suffix “S” to the article number.
Instruments
324.011 LISS Insertion Guide for Distal Femur, left,

radiolucent
324.012 LISS Insertion Guide for Distal Femur, right,

radiolucent

length 151 mm
321.170 Pin Wrench B 4.5 mm, length 120 mm

length 130 mm

length 156 mm
324.033 Pulling Device, length 240 mm, for LISS

for No. 324.007
Instruments



length 180 mm

length 180 mm

324.056 X-ray Calibrator, length 50 mm
324.053 Cleaning Instrument for LISS Screw Head,

length 202 mm
324.253 Cleaning Instrument for Screw Head

Stardrive, T25, length 202 mm
312.946 Guiding Block for LCP-DF 4.5/5.0, right
312.947 Guiding Block for LCP-DF 4.5/5.0, left
312.940 Guiding Block for LCP-PLT 4.5/5.0, right
312.941 Guiding Block for LCP-PLT 4.5/5.0, left
Optional instruments
324.048 Aiming Device for Kirschner Wires,

for LISS Insertion Guide


324.037 LISS Measuring Device for Kirschner

Wires B 2.0 mm, length 121 mm,
for No. 292.699
Sets
LISS Instruments and Insertion Handle, for DF and PLT

Plates, in Vario Case
01.120.040 Hex
01.120.041 Stardrive
68.120.040 Vario Case
LCP DF 4.5/5.0 in Vario Case
01.120.332 Stainless Steel

01.120.334 Titanium Alloy/TAN
68.120.330 Insert
Note on long plates: The LCP DF plates with 15 to 19 holes

are available in sterile only and not part of a set. Therefore
these articles have to be ordered as single items (for article
numbers refer to page 41).
Modular Large Fragment Screw Rack

for Screws B 5.0 mm, size 1⁄ 3, without
Contents, Vario Case System


68.122.054 Modular Screw Rack, with Drawer,

Measuring Block and Lid, length 200 mm,
height 115 mm, size ½, without Contents,
Vario Case System
68.122.056 Auxiliary Modular Insert, for Modular

Screw Rack, size 1⁄ 3, without Contents,
Vario Case System
68.000.128 Auxiliary Module, size 1⁄ 3, height 14 mm,

for Screw Rack, size ½
68.000.129 Auxiliary Module, size 1⁄ 3, height 28 mm,

for Screw Rack, size ½
Bibliography
Fankhauser F et al. (2004) Minimal-invasive treatment of dis-

tal femoral fractures with the LISS (Less Invasive Stabilization
System). Acta Orthop Scand 75 (1): 56–60
Haas NP et al. (1997) LISS – ein neuer Fixateur intern für

distale Femurfrakturen [LISS – a new internal fixator for distal
femoral fractures]. OP Journal 13: 340–344
Hockertz TJ et al. (1999) Die Versorgung von periprothe-

tischen Femurfrakturen bei liegender Kniegelenkprothese
mit dem LIS-System [Use of the LISS to treat periprosthetic
femoral fractures with implanted knee prosthesis].
Der Unfallchirurg 10: 811–814
Injury (2001) Int. J. Care Injured 32: S-C
Kobbe P, Hockertz TJ, Reilmann H (2006) Periprothetische

Frakturen [Periprosthetic Fractures]. OP Journal 22: 22–26
Schandelmaier P et al. (1999) LISS-Osteosynthese von dis-

talen Femurfrakturen [LISS osteosynthesis of distal femoral
fractures]. Trauma Berufskrankheiten 1: 392–397
Schandelmaier P et al. (1999) Stabilisation of distal femur

fractures using the LISS. Techniques in Orthopaedics
14 (3): 230–246
Schandelmaier P et al. (2000) Distale Femurfrakturen

[Distal femoral fractures]. Unfallchirurg 70: 428–436
Schandelmaier P et al. (2001) Internal Fixation of Distal

Femur Fractures with the Less Invasive Stabilizing System
(LISS). Orthopedics and Traumatology 9: 166–184
Schütz M et al. (2003) Revolution in plate osteosynthesis:

new internal fixator systems. Journal of Orthopedic Science
8: 252–258
MRI Information
Torque, Displacement and Image Artifacts according

to ASTM F 2213-06, ASTM F 2052-06e1 and
ASTM F2119-07
Non-clinical testing of worst case scenario in a 3 T MRI
system did not reveal any relevant torque or displacement
of the construct for an experimentally measured local spatial
gradient of the magnetic field of 3.69 T/m. The largest image
artifact extended approximately 169 mm from the construct
when scanned using the Gradient Echo (GE). Testing was
conducted on a 3 T MRI system.
Radio-Frequency-(RF-)induced heating according to

ASTM F2182-11a
Non-clinical electromagnetic and thermal testing of worst
case scenario lead to peak temperature rise of 9.5 °C
with an average temperature rise of 6.6 °C (1.5 T) and a
peak temperature rise of 5.9 °C (3 T) under MRI Conditions
using RF Coils (whole body averaged specific absorption rate
[SAR] of 2 W/kg for 6 minutes [1.5 T] and for 15 minutes
[3 T]).
Precautions: The above mentioned test relies on non-clini-

cal testing. The actual temperature rise in the patient will
depend on a variety of factors beyond the SAR and time of
RF application. Thus, it is recommended to pay particular
attention to the following points:
–– It is recommended to thoroughly monitor patients under-
going MR scanning for perceived temperature and/or pain
sensations.
–– Patients with impaired thermoregulation or temperature
sensation should be excluded from MR scanning proce-
dures.
–– Generally, it is recommended to use a MR system with
low field strength in the presence of conductive implants.
The employed specific absorption rate (SAR) should be
reduced as far as possible.
–– Using the ventilation system may further contribute to
reduce temperature increase in the body.
© DePuy Synthes Trauma, a division of Synthes GmbH. 2016. All rights reserved. 036.000.235 DSEM/TRM/0614/0094(2) 09/16
Synthes GmbH
Eimattstrasse 3 Not all products are currently available in all markets.
4436 Oberdorf
Switzerland This publication is not intended for distribution in the USA.
Tel: +41 61 965 61 11
Fax: +41 61 965 66 00 All surgical techniques are available as PDF files at
www.depuysynthes.com www.depuysynthes.com/ifu 0123

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Less invasive stabilization system

(LISS) for LISS and LCP DF Plates.

This publication is not intended for

Instruments and implants

Image intensiﬁer control

Processing, Reprocessing, Care and Maintenance

Introduction L ess invasive stabilization system (LISS)  2

Indications and Contraindications 5

Surgical Technique Preoperative Planning 8

Instruments for Minimally Invasive Osteosynthesis 40

Product Information Implants41

Locking Screws B 5.0 mm 42

Anatomically precontoured low Angular stability LCP combi-holes

Wide variety of anatomically Wide variety of screws

Use of cortex screws

The threaded holes in the plate head

Note: Cortex screws are only recom-

In 1958, the AO formulated four basic principles, which have

4_Priciples_03.pdf 1 05.07.12 12:08

1 Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixation.

Stuttgart, New York: Thieme. 2007.

4 DePuy Synthes Expert Lateral Femoral Nail Surgical Technique

Preoperative Follow-up after 6 weeks

Follow-up after 3 months Follow-up after 5 months

Follow-up after 4 weeks

length of the plate and the position of the screws.

Preoperative planning of lag screws may be necessary.

All rights reserved Synthes is trademark of Synthes, Inc. or its affiliates

© 09/2010 Synthes, Inc. or its affiliates

weaken the plate and the plate-screw interface and can 0

compro­mise the targeting function of an aiming arm, if in

use. However, there may be cases in which plate bending is

clinically necessary. In such cases, the plate should only be

bending press (329.300), and never bend back-and-forth.

Insert at least one screw distal to the bend.

Synthes is trademark of Synthes, Inc. or its affiliates

All rights reserved

© 06/2010 Synthes, Inc. or its affiliates

1. Place the x-ray calibrator medially or laterally at the height

6. Determine the screw lengths for the screw holes A to G

Length of locking screws (mm)

The maximum condyle width on the radiograph (MCW)

The real condyle width (RCW) is therefore 83 mm.

The screw lengths are therefore:

Screw hole Screw length (mm)

Note: The proper placement of the plate on the condyle is

511.750 AO/ASIF Quick Coupling, for Compact Air

68.122.050 Modular Insert, for Modular Screw Rack,

68.122.051 Modular Insert, for Modular Screw Rack,

68.122.052 Modular Insert, for Modular Screw Rack,

68.122.054 Modular Screw Rack, with Drawer, Mea-

Note: The LISS instruments are compatible with both LISS

Position the patient supine on a radiolucent table. The leg

Avoid too strong a traction and a fully extended knee, as the

In very short distal fragments, it is recommended to flex the

321.170 Pin Wrench B 4.5 mm, length 120 mm 2

324.022 Drill Sleeve for LISS Insertion Guide,

324.044 Stabilization Bolt for LISS Insertion Guide,

324.043 Fixation Bolt for LISS Insertion Guide,

Note: In certain cases (e.g. distal fracture treated with a

Insert the fixation bolt in hole A of the insertion guide.

Place the insertion guide on the three-point locking

For a more stable fixation of the plate on the insertion guide

Introduction L ess invasive stabilization system (LISS) 2

Indications and Contraindications 5

Surgical Technique Preoperative Planning 8

Instruments for Minimally Invasive Osteosynthesis 40

Product Information Implants41

Locking Screws B 5.0 mm 42

1 Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixation.

compromise the targeting function of an aiming arm, if in

321.170 Pin Wrench B 4.5 mm, length 120 mm 2

324.022 Drill Sleeve for LISS Insertion Guide,

324.044 Stabilization Bolt for LISS Insertion Guide,

324.043 Fixation Bolt for LISS Insertion Guide,

324.022 Drill Sleeve for LISS Insertion Guide,

324.022 Drill Sleeve for LISS Insertion Guide,

324.022 Drill Sleeve for LISS Insertion Guide,