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ABSTRACTThe diaphyseal tibia fracture is best treated withintramedullary nail but in some cases where the nail is notapplicable, plate fixation will be the next option of fixation.The extensile anterior approach is normally used forconventional compression plate fixation in tibia shaftfractures. The extensive surgical dissection may devitalizesthe bony fragments and interfere with the fracture union aswell as soft tissue healing. Minimally Invasive PlateOsteosynthesis (MIPO) provides good preservation of bloodsupply and fracture hematoma at the fracture site thuspromotes biological bone healing. The use of indirectreduction techniques and small skin incisions to introducethe plate is technically demanding and requires fluoroscopyexposures throughout the surgery, being some of itsdrawbacks. We recommend MIPO for conventionalcompression plate fixation in tibial shaft fractures in view ofthe reduced surgical trauma to the surrounding soft tissueand good functional outcome.

Key Words: Diaphyseal tibia fracture, conventional compression plate,minimally invasive plate osteosynthesis

INTRODUCTIONThe diaphyseal tibia fracture is best treated withintramedullary nailing. It promotes biological bone healingwith preservation of osteogenic fracture hematoma and ismechanically stable with load-sharing principles. However,in certain cases the selection of intramedullary nailing fortibial shaft fracture is inappropriate; for example tibialfracture in children, proximal diaphyseal tibia fracture withipsilateral avulsion fracture of Posterior Cruciate Ligament(PCL) and distal diaphyseal tibia fracture with ipsilateralankle injury that requires fixation. These cases may requireother methods of fixation, and plating is a good option.

The indications for using Locking Compression Plate (LCP)for tibial fractures are mainly in osteoporotic bone fracture,

diametaphyseal fracture and comminuted peri-articularfracture. LCP provides stable construct as internal externalfixator, and promotes biological bone healing, coupled withthe minimally invasive surgical approach, or MinimallyInvasive Plate Osteosynthesis (MIPO) 1. Generally, fixationof tibial shaft fracture in children and young patient is byusing conventional compression plates [or dynamiccompression plate (DCP)] that normally use extensileanterior surgical approach. The disadvantages of thisextensile approach are loss of fracture hematoma, extensivesoft tissue dissection and periosteal stripping that eventuallymay lead to fracture non-union, wound infection and skinbreakdown 2.

To minimize all the complications in the extensile approach,MIPO method is the best solution. We report two cases ofdiaphyseal tibia fractures fixed with conventionalcompression plates by MIPO techniques.

CASE REPORTS Case 1A 16-year old teenage boy had sustained injury to his rightknee and leg in motor-vehicle accident (MVA) in September2013. Clinical assessment revealed swollen right knee withtenderness at mid-right shin with no signs of compartmentsyndrome. The radiographs showed fracture mid-shaft ofright tibia with ipsilateral Posterior Cruciate Ligament (PCL)avulsion fracture. The diagnoses were closed fracture mid-shaft right tibia and closed avulsion fracture of right PCL. Heunderwent plating of right tibia (MIPO technique) and screwfixation of the PCL avulsion fracture.

Patient was positioned supine on the operating table. Afterthe usual preparations of the operation site, two small skinincisions were made, about 1 cm lateral to the anterior tibialcrest, proximal and distal to the fracture site. The twoincisions were aimed for the most proximal and most distalscrew hole of the conventional compression plate. Asubcutaneous tunnel was created onto the periosteum of thelateral tibial surface by using bone lever (Fig.2A). Then, the

Minimally Invasive Plate Osteosynthesis withConventional Compression Plate for

Diaphyseal Tibia Fracture

IM Anuar-Ramdhan, M Med Orth, IM Azahari, MD

Department of Orthopaedic Surgery, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia

Corresponding Author: Orthopaedic Surgeon, Hospital Sultanah Nur Zahirah, Jalan Sultan Mahmud, 20400 Kuala Terengganu,Terengganu Email: dr_anuarr@yahoo.com.my

Doi:http://dx.doi.org/10.5704/MOJ.1411.008

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conventional compression plate was introduced andadvanced directly onto the periosteum on the lateral surfaceof the tibia. The periosteum itself was not opened. After theplate was placed in the correct position, it was heldtemporarily in place with two Kirschner wires for the mostproximal and most distal hole of the plate, respectively(Fig.2B). With indirect reduction of the fracture, the platewas fixed to the bone with percutaneously directed screws,and the skin wounds closed after irrigation. (Fig.2C). Duringthe whole procedure fluoroscopic (image intensifier) controlwas essential.

At follow-up the operative wounds had healed well (Fig.2D)and the tibial fracture had united after five months withoutany complications (Fig. 2E)

Case 2A 13-year old boy who was involved in motor-vehicleaccident (MVA) in July 2013 had sustained injury to the leftleg. There was no other injury. The left leg was deformedand tender with laceration wound over the proximal part ofthe leg. Neurovascular status was intact. The radiographsshowed comminuted fracture proximal third of the left tibiaand oblique fracture proximal third of the left fibula(Fig.3A). With the diagnosis of open fracture of the proximalthird of the left tibia and fibula, wound debridement andexternal fixation of the left tibia was performed on Day 2post-injury, with antibiotic cover as per standard protocol foropen fractures. After 6 days post-debridement, definitivesurgery was performed: the external fixator was removed

Fig. 2: A. Subcutaneous tunnel created -using bone lever. B. Theplate being held temporarily in place with two Kirschnerwires. C. Final operative wound with MIPO technique. D.The operative wound healed well. E. The tibial fracturehad united well.

A

B

C

E

D

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and the left tibia was fixed with dynamic compression plate(DCP) using minimallly invasive plate osteosynthesis(MIPO) technique (as described above). He was dischargedwell on Day 2 post-plating. At review, the operative woundshad healed well (Fig. 3B) and -serial radiographs showedunited fracture after four months post-MIPO surgery withoutany complications. (Fig.3C).

DISCUSSIONMIPO technique is synonym to the locking compressionplate (LCP) fixation, and conventional compression plate isusual with extensile anterior approach of the tibia (for tibialshaft fracture). As MIPO is well known to have many

advantages, include preservation of osteogenic potential ofthe fracture hematoma, biologically friendly, and lesssurgical trauma to the surrounding soft tissues, it isrecommended that all fractures should be preferably befixed by this MIPO technique 1.

This less invasive surgery has been described widely forproximal and distal tibial fractures, especially fractures at thediametaphyseal region and peri-articular fractures 3-4. Theoutcomes of this techniques showed good wound healing aswell as fracture union. There were limited literaturesmentioning about MIPO technique for mid-diaphyseal ormiddle-third tibia shaft fractures, especially lateralplacement of the conventional compression plate on thetibia.

Our experience in using MIPO for conventional compressionplate in diaphyseal tibia fracture fixation has revealed lesssoft tissues dissection and periosteal stripping withpercutaneous screw placement through smaller surgicalwound and less intra-operative bleeding. The amount ofsutures for closure of the surgical wound was also minimalwhich is also cost saving. However, not all tibial shaftfractures are suitable for MIPO technique. Severelydisplaced comminuted shaft fractures with unstableipsilateral fibula fracture are among cases that are notsuitable to be fixed by MIPO approach. Good selection ofcases is important in order to achieve positive outcome offracture union.

MIPO for diaphyseal tibia fractures can be performed eitherin closed or open tibial fractures. In closed tibial shaftfractures, there was not much issues in MIPO approach asthe skin was nicely covered the fracture. We would be ableto plan the skin incision from the beginning unlike in opentibial shaft fractures. The traumatic laceration wound andpost-debridement wound in open fractures gives the surgeona challenge to plan the skin incision for MIPO. In case 2described above, the traumatic wound was at theanteromedial aspect of the leg. Therefore we needed to makea long curvilinear skin incision in order to achieve 5 cm skinbridge (to reduce the risk of skin necrosis) (Fig 3B).

A B

C

C

Fig. 3: A. Fracture proximal third of the left tibia and obliquefracture proximal third of the left fibula. B. Theoperative wound healed well. C. United fractures after 4month post-MIPO surgery.

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The placement of the plate requires additional skills, as theexposure was minimal. The use of Kirschner wires astemporary fixation was essential to hold the plate at thecorrect position before inserting the screws. Unlike the LCPthat has threaded sleeve to hold the plate close to the bone,the conventional plate needs manual pushing to ensure goodcontact between the plate and the bone before placing thescrews. The plate-bone contact was important for theconventional compression plate as it provides stability to theplate fixation.

This MIPO technique has some drawbacks as well. As itrequires indirect reduction of the fracture, there are risks ofmal-reduction and mal-alignment which subsequently maycause mal-union 4. Severe mal-union in tibial shaft fracturesmay deviate the mechanical axis of the lower limb causingimbalance in force distribution to the adjacent joints, with

adverse joint effects. Furthermore, with the small skinincisions the insertion of the plate is technically demandingand also requires strict fluoroscopic control throughout theprocedure leading to greater radiation exposure compared toopen extensile surgical approach 5.

In conclusion, tibial shaft fractures are best treated withintramedullary nailing but in some cases where this is notapplicable, the use of conventional plate with MIPOtechnique may give good results for bone union as well assoft tissue healing. The smaller surgical wounds also lessenthe pain around the operation site and thus accelerate post-operative rehabilitation and faster recovery. We recommenduse of MIPO technique for conventional compression platefixation in tibial shaft fractures.

REFERENCES

1. Wagner M, Frenk A, Frigg R. Locked plating: Biomechanics and biology and locked plating: Clinical indications. Techniques inOrthopaedics. 2007; 22(4): 209-18.

2. Vallier HA, Le TT, Bedi A. Radiographic and clinical comparisons of distal tibia shaft fractures (4 to 11 cm proximal to theplafond): plating versus intramedullary nailing. J Orthop Trauma. 2008; 22(5): 307-11.

3. Shrestha D, Acharya B, Shrestha P. Minimally invasive plate osteosynthesis with locking compression plate for distaldiametaphyseal tibia fracture. Kathmandu Univ Med J. 2011; 9(2): 62-8.

4. Gupta RK, Rohilla RK, Sangwan K, Singh V, Walia S. Locking plate fixation in distal metaphyseal tibial fractures: series of 79patients. Int orthop. 2010; 34(8): 1285-90.

5. Francois J, Vandeputte G, Verheyden F, Nelen G. Percutaneous plate fixation of fractures of the distal tibia. Acta orthop belg.2004; 70(2):148-54.

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