ABSTRACT

Purpose. To review the outcomes of 53 patients who underwent minimally invasive plate osteosynthesis (MIPO) for distal tibial fractures. Methods. Medical records of 31 men and 22 women aged 22 to 78 (mean, 51) years who underwent MIPO using a locking compression plate for distal tibial fractures of the left (n=28) and right (n=25) legs with or without intra-articular extension were reviewed. Results. Patients were followed up for a mean of 26 (range, 2438) months. The mean time from injury to surgery was 9 (range, 312) days. The mean operating time was 105 (range, 75180) minutes. The mean hospital stay was 16 (range, 825) days. Non-weight bearing walking with a crutch was started after a mean of 5.7 (range, 39) days. The mean time to callus formation was 12 (range, 815) weeks. The mean time to full weight bearing was 15 (range, 822) weeks. The mean time to bone union was 25 (range, 2030) weeks. All except 2 fractures united anatomically. At 10 months, the range of motion of the ankle joint in

Minimally invasive plate osteosynthesis for distal tibial fractures

Pramod Devkota,1 Javed A Khan,2 Suman K Shrestha,2 Balakrishnan M Acharya,2 Nabeesman S Pradhan,2 Laxmi P Mainali,2 Padam B Khadka,3 Hemanta K Manandhar31 Department of Orthopaedics and Trauma Surgery, Gandaki Medical College Teaching Hospital, Pokhara, Nepal2 Department of Orthopaedics and Trauma Surgery, Patan Hospital, Lalitpur, Nepal3 Department of Orthopaedics and Trauma Surgery, Kaski Sewa Hospital, Pokhara, Nepal

Address correspondence and reprint requests to: Dr Pramod Devkota, Department of Orthopaedics and Trauma Surgery, Gandaki Medical College Teaching Hospital, Pokhara, Nepal. Email: devkotap@gmail.com

Journal of Orthopaedic Surgery 2014;22(3):299-303

all patients was similar to the contralateral side. Two patients had malunion but this was not clinically significant. Five patients had superficial infection, and 2 patients had persistent pain. Conclusion. MIPO is effective for closed, unstable fractures of the distal tibia. It reduces surgical trauma and preserves fracture haematoma.

Key words: bone plates; fracture fixation, internal; tibial fractures

introduction

The optimal treatment for unstable distal tibial fractures remains controversial. Non-operative treatment can be technically demanding and is associated with joint stiffness (up to 40%) as well as shortening and rotational malunion (>30%).1,2 Open reduction and internal fixation (ORIF) requires extensive soft tissue dissection and may lead to periosteal injury. ORIF is associated with high rates of infection, delayed union, and non-union.36 External fixation is preferred when soft tissue injury

300 P Devkota et al. Journal of Orthopaedic Surgery

is severe, but it is associated with pin tract infection, malunion, and non-union.7 Furthermore, coping with the external fixator over a long period is a challenge for patients. Ilizarov frames, ankle-spanning, and hybrid constructs can be used in conjunction with limited internal fixation.8 Nail osteosynthesis is the preferred treatment for shaft fractures, but it is not always practical for the distal tibia, as fractures in this region are often spiral or extend to the tibial pilon.9 Minimally invasive plate osteosynthesis (MIPO) using an elastic bridging plate reduces iatrogenic soft tissue injury and preserves bone vascularity and haematoma.10 In accordance with the biomechanical principles of intramedullary nailing, MIPO is performed without stripping the periosteum or muscles from the bone. MIPO aims to achieve correct limb length and axial and rotational alignment of the main fragments, with minimal damage at the fracture site. Healing takes place by the formation of callus from the periosteum and soft tissues.9 Results of closed reduction and percutaneous plating for closed distal tibial fractures are encouraging.11,12 We reviewed the outcomes of 53 patients who underwent MIPO for distal tibial fractures.

MATERIALS AND METHODS

This study was approved by the ethics committees of our hospitals; informed consent was obtained from each patient. Medical records of 31 men and 22 women aged 22 to 78 (mean, 51) years who underwent MIPO using a locking compression plate for distal tibial fractures of the left (n=28) and right (n=25) legs with or without intra-articular extension between January 2007 and December 2009 were reviewed. Patients with a complex pilon fracture or open fracture more severe than type 113 according to the AO classification14 were excluded, as were those in whom MIPO was converted to ORIF owing to unsatisfactory reduction. Patients were initially treated with a plaster splint with elevation until definitive fixation. Surgery was delayed only if patients had soft tissue swelling or were unfit for anaesthesia. Patient was placed supine on a radiolucent table; a tourniquet was used. A small incision was made over the medial malleolus, sparing the saphenous vein and nerve. The anatomic pre-shaped narrow 4.5 mm locking plate (Sharma Surgical, Vadodara, India) was inserted extraperiostally under fluoroscopic guidance. The fracture was then reduced indirectly by manual traction and/or with the help of the distractor. The plate was fixed with at least 3 locking

screws in the proximal and distal ends (5.0-mm and 4.5-mm screws, respectively). In 6 patients with severe comminution of the tibia, the fibula was also fixed with plates for accurate reconstruction of leg length using ORIF (Fig.). A conventional screw was also used when necessary to reduce the malalignment of the fracture.12 Postoperatively, an above-knee plaster of Paris slab was applied for one week. Sutures were removed at week 2. Early active and passive knee and ankle range of motion exercises were encouraged. Partial weight bearing with crutches was allowed for the first 6 weeks and then gradually increased to full weight bearing. Patients were followed up at week 6 and months 3, 6, 9, 12, 18, and 24. Bone union was defined as presence of callus bridging on radiographs and the ability to full weight bearing without pain.15

results

Patients were followed up for a mean of 26 (range, 2438) months (Table). The mean time from injury to surgery was 9 (range, 312) days. The mean operating time was 105 (range, 75180) minutes. The mean hospital stay was 16 (range, 825) days. Non-weight bearing walking with a crutch was started after a mean of 5.7 (range, 39) days. The mean time to callus formation was 12 (range, 815) weeks. The mean time to full weight bearing was 15 (range, 822) weeks. The mean time to bone union was 25 (range, 2030) weeks. All except 2 fractures united anatomically (

Vol. 22 No. 3, December 2014 invasive plate osteosynthesis for distal tibial fractures 301

Sex/age (years)

Side Cause* AO fracture

type

Open fracture

type

Associated injuries Hospital stay

(days)

Operating time

(minutes)

Time to mobi-

lisation (days)

Time to radio-logical union

(weeks)

Full weight bearing (weeks)

Bone union

(weeks)

F/63 Left FFH 43.A2 No No 13 80 4 11 10 21M/28 Left RTA 42.B1 I No 10 90 6 9 9 20F/66 Left RTA 43.A2 No Right distal radial fracture 18 75 3 13 13 25M/70 Right FFH 42.C1 No Posterior malleolar fracture 19 110 5 15 16 24F/22 Right RTA 43.A3 I Right ulnar and radial

fractures22 100 9 10 18 30

M/68 Right RTA 42.B3 No No 17 80 3 12 12 20F/52 Left Direct hit 43.A2 No No 21 85 8 14 19 29M/45 Right RTA 42.B1 No No 20 120 5 13 17 28M/50 Right RTA 42.B3 I Right distal fibular fracture 23 105 7 11 13 22M/57 Left FFH 43.A3 No No 16 90 3 13 21 27F/58 Left RTA 42.A2 No Lateral malleolar fracture 21 125 5 12 16 20M/37 Right RTA 43.A2 I Right humeral fracture 8 110 7 11 22 26M/78 Right FFH 42.A1 No No 25 95 9 14 20 25F/45 Left FFH 43.A3 No Left distal fibular fracture 10 80 9 13 21 28F/22 Left RTA 43.A2 No No 11 100 6 10 20 29M/29 Right RTA 42.A1 No No 15 80 4 10 18 27M/46 Left RTA 42.B1 I Undisplaced pelvic fracture 9 75 3 12 19 28F/69 Left RTA 43.A2 No Right distal radial fracture 18 95 6 11 22 30F/46 Left RTA 42.A2 No No 24 100 8 8 10 20M/66 Right FFH 42.C1 No No 17 120 5 9 8 22F/49 Right RTA 43.A2 No No 14 125 9 12 13 26M/57 Left FFH 43.A1 No No 20 130 7 9 10 29F/35 Right RTA 43.A3 I No 23 140 6 14 18 28M/39 Left FFH 43.A3 No No 9 120 9 13 12 27M/61 Right Direct hit 43.C1 No No 25 130 6 15 15 23F/71 Right RTA 43.A3 No No 21 75 7 13 12 29M/75 Left Physical

assault43.A3 No Left middle and index fingers

fractures25 80 7 15 22 28

M/62 Left FFH 43.A2 No No 10 85 4 10 9 20F/44 Right RTA 43.A3 No No 12 90 8 12 11 23M/53 Left Direct hit 42.B3 I No 9 80 5 14 14 26M/32 Left FFH 43.C1 No No 12 150 3 14 13 24F/54 Right RTA 42.A1 No No 17 95 7 12 17 28M/29 Right Direct hit 43.A2 No No 13 100 8 13 12 20F/49 Left Physical

assault42.C1 No Undisplaced pelvic fracture 11 110 7 15 15 22

M/61 Right RTA 43.A3 I No 19 115 6 14 13 27F/71 Right FFH 42.A1 No No 16 120 3 15 21 22F/56 Left Direct hit 42.B1 No No 23 110 4 12 11 20M/48 Left Physical

assault42.A1 No No 9 100 6 13 13 28

F/65 Right FFH 42.B1 I No 25 90 7 10 12 22M/24 Right Physical

assault42.A2 No Left distal radial fracture 10 180 3 8 9 27

F/28 Left RTA 43.A3 No No 11 100 4 10 10 23M/53 Left FFH 43.C1 No No 14 95 3 11 16 22M/61 Right Direct hit 43.A3 No No 16 90 6 13 13 21F/66 Left FFH 43.A2 No No 22 160 3 12 11 27M/47 Right RTA 43.C1 No No 12 100 7 14 13 28M/64 Left Physical

assault43.A2 No Left ulnar fracture 10 150 5 13 13 22

M/49 Left Physical assault

43.A1 No No 17 105 7 9 12 20

M/25 Right FFH 42.A3 No No 11 115 6 10 12 21F/67 Left FFH 42.B1 No No 20 110 3 15 13 27M/37 Left Physical

assault42.B1 No No 12 95 8 12 14 25

M/45 Left RTA 43.A2 No No 13 80 3 14 20 22F/63 Right FFH 42.C1 No Right intercondylar of

humeral fracture19 115 7 15 15 20

M/23 Right RTA 43.A3 No No 10 120 4 13 15 21

Table Patient characteristics and outcomes

* RTA denotes road traffic accident and FFH fall from a height

302 P Devkota et al. Journal of Orthopaedic Surgery

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months, the range of motion of the ankle joint in all patients was similar to the contralateral side. Two patients had malunion, but this was not clinically significant (varus angulation of 10 and 8). Five patients had superficial infection, which was resolved with intravenous antibiotics and regular dressings. One patient had pain in the medial malleolar region after 18 months. One patient had non-specific pain around the ankle and foot suspected to be reflex sympathetic dystrophy, which was treated with aggressive physiotherapy; the pain decreased dramatically but persisted. In 10 patients, implants were removed after a mean of 21 (range, 1825) months for various social reasons.

discussion

Complications of ORIF with plates or closed intramedullary nailing for distal tibial fractures include nail or locking bolt failures, malunion, wound infection, and bone healing problems.16,17 MIPO was initially developed for subtrochanteric and distal femoral fractures,18 and then modified for fractures of the femoral shaft and proximal and distal tibia.11,19 Indirect fracture reduction and percutaneous plating techniques20 minimise the extent of soft tissue damage in long bone fractures.21,22 The distal metaphyseal tibia has a rich extra-osseous blood supply provided by branches of the anterior and

posterior tibial arteries; disruption of this extra-osseous blood supply is greater in open plating than MIPO.23 Thus, it is challenging to achieve mechanical stability without impairing the blood supply.9 In our study, the delay in surgery was due to swelling, medical problems, unavailability of the operating room, and financial reasons. Longer hospital stay was due to the long distance to the patients homes and transportation problems. The longer time needed to non-weight bearing walking was because elderly patients and those multiple contusions were reluctant to mobilise earlier (isometric muscle exercises were nonetheless encouraged). The longer time needed for callus formation was due to the poor nutritional status of the patients. Nonetheless, the times to full weight bearing and bone union were comparable to other studies24,25

conclusion

MIPO using the locking compression plate is effective for closed, unstable fractures of the distal tibia. It reduces surgical trauma and preserves fracture haematoma.

disclosure

No conflicts of interest were declared by the authors.

Vol. 22 No. 3, December 2014 invasive plate osteosynthesis for distal tibial fractures 303

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