Address for Correspondence
Mr. Mohamed Sukeik
Specialty Registrar in Trauma & Orthopaedics
University Hospitals of North Tees and Hartlepool,
Hardwick Road, Stockton on Tees, TS19 8PE, United Kingdom.
Objectives: Treatment of distal tibial fractures using minimally invasive plate osteosynthesis (MIPO) technique may minimise damage to soft tissues and the vascular integrity of bony fragments. This is a multicentred study to assess the outcome of patients treated with MIPO technique for distal tibial fractures.
Methods: A retrospective study of 27 patients from two institutions treated for distal tibial fractures using a distal tibial locking plate through the MIPO technique.
Results: There were 18 males and 9 females of mean age 43 years. The mean follow-up period was 12 months (SD±4.7). According to the AO classification system, there were 22 patients with 43A type fractures, one 43B, two 43C and
There were 27 patients in the study including 18 males and 9 females of mean age 43 years. According to AO classification; there were 22 patients with 43A type fractures, one 43B, two 43C and two 42A type fractures. The commonest cause of injury was high-energy trauma. Twenty four patients had closed fractures and 25 patients had closed reduction. All patients were fully weight bearing at a period of 8 weeks (SD ±5.0) after surgery. The mean time to union was 4 months (SD ±1.9). There was one non-union in a 36-year-old heavy smoker who sustained a 43A type closed fracture and was treated with the standard MIPO technique after closed reduction of the fracture. The patient was managed with a non weight-bearing plaster two 42A type fractures. There were 3 open fractures as per Gustilo and Anderson classification. Mean time to union was 4 months (SD±1.9). All patients were fully weight bearing at 8 weeks (SD±5.0). There was one non-union in a chronic heavy smoker who underwent autologous bone grafting at 5 months, but still failed to unite at 9 months post operatively. In the open fracture group; there were two delayed unions again in heavy smokers who achieved union at 7 and 8 months postoperatively with no further complications. There were two superficial infections treated successfully using oral antibiotics and no failures of fixation. There were no cases of rotational malalignment.
Keywords: Distal tibial fractures; locking plates; MIPO
Management of distal tibial fractures remains challenging1. They are usually the result of high energy axial compression and rotational forces. Soft tissue compromise is often severe2. Several methods of treatment are implemented including non-operative treatment, external fixation, intramedullary nailing, and internal fixation with traditional implants (standard screws and plates). However, each of these treatment options is associated with certain challenges3. Non-operative treatment requires prolonged immobilisation and may be complicated by loss of reduction and subsequent malunion4. External fixation may lead to pin-track infections, septic arthritis, malalignment, and delayed union5. Intramedullary nailing problems include the technical difficulties with distal nail fixation, the risk of nail propagation into the ankle joint, and the discrepancy between the diaphyseal and metaphyseal diameter of the intramedullary canal. Open reduction and internal plate fixation results in extensive soft tissue dissection which may result in wound complications and infections3.
MIPO technique for distal tibial fractures offers several theoretical advantages such as mechanically stable fracture fixation and less disturbance of the fracture site haematoma and the surrounding soft tissues6.
The aims of this study were to assess the outcome of patients treated with MIPO technique for open or closed distal tibial fractures with specific reference to fracture union, implant failure or other surgical complications.
Patients and Methods:
We conducted a multicentred; retrospective study of 27 consecutive patients from two institutions treated with MIPO using the distal tibial locking plate for open or closed distal tibial fractures and followed them up a period of 12 months (SD±4.7). Case notes were analysed for patients’ demographic parameters, follow-up reviews and complications. Radiographs were assessed for classification of fractures and evidence of union. Fractures were classified according to the AO classification system. Open fractures were graded using the Gustilo and Anderson classification7.
The operations were performed by four different surgeons. However, all patients received cefuroxime 1.5g at induction followed by 750mg at 8 hours and 16 hours postoperatively. Deep vein thrombosis prophylaxis was administered as per the units’ protocols. Physical therapy was commenced first day postoperatively. Fracture union was defined as radiological evidence of bridging mature callus combined with clinical union as evidenced by pain free full weight bearing. Delayed union was defined as healing of the fracture between 5-9 months and non-union was considered when no evidence of healing was detected after 9 months from the operation8. Patients with a clinical rotation difference of >15° and a clear rotation difference between both legs as assessed on the radiographs by a senior orthopaedic trauma surgeon were considered to have rotational malalignment.
Results for 4 weeks then partial weight-bearing for 6 weeks followed by full weight bearing. At 5 months postoperatively, there was no evidence of clinical or radiological union and the patient underwent autologous bone grafting from the iliac crest. At 9 months postoperatively, there was still no evidence of radiological union and the patient had pain on weight-bearing. He had normal inflammatory markers and tissue biopsy from the fracture site was negative for infection. There was a delayed union at 7 months in another heavy smoker who was 46- year-old and sustained an open Gustilo I 43A type fracture. He was treated using MIPO after closed reduction and was allowed full weight-bearing at 11 weeks follow-up. Another patient aged 46 years and a heavy smoker showed delayed union at 8 months postoperatively. He had an open Gustilo I 43A type fracture treated by wound debridement and application of locking plate by MIPO technique. The third patient in the open fractures group was a 27 years old patient who presented with persistent pain around the distal end of the scar after sustaining a Gustilo I 43C type fracture which was treated with MIPO technique after closed reduction. He had an area of osteolysis around the distal screw which was subsequently removed with no further problems. There were two superficial wound infections which were treated with oral flucloxacillin and progressed to union. There were no failures of fixation or implants and no rotational malalignment on clinical and radiographic evaluation of the patients.
MIPO technique has become widely practised in the operative management of articular, metaphyseal and transitional zone fractures over the last few years9. It has the advantages of respecting soft tissue via small skin incisions, minimal surgical dissection, indirect fracture reduction and minimal hardware application. As a result, healing time is accelerated, and complication rates are low10. MIPO is easy to insert and gives better results with respect to alignment correction. However, there is a learning curve and practising the open technique initially is advisable10. Adequate preoperative planning is mandatory, as well as accurate surgical timing in secondary skin compromise11. Mechanism of action depends on principles of “biological internal fixation” where the aim is to produce the best biological conditions for healing rather than absolute stability of fixation which usually requires a fairly extensive surgical approach to the bone. This takes advantage of indirect reduction of the fracture and application of a bridging plate with minimal screw insertion through stab incisions to fix the plate. The plate functions purely as a splint rather than causing compression of the fracture. The resulting flexible stabilisation has been shown to give early solid union by callus formation12. Our study supports this finding with all patients able to fully weight bear at 8 weeks and achieving union at an average period of 4 months after surgery. This is consistent with results from other studies6 where union was achieved at 22.4 and 23 weeks follow-up respectively. Complications of nonunion and delayed union in our case series may be associated with heavy smoking; a well recognised factor that inhibits bone and soft tissue healing13,14. In this study, we had two cases of superficial wound infection, which were treated with oral antibiotics, and no cases of deep infection or revision fixation. These results are also similar to those previously reported in the literature15 by Stromsoe et al who reported stable osteo-fixation and no soft tissue complications affecting the final result in any of his patients.
Distal tibial fracture treated with MIPO technique preoperative and 6 months postoperative x-rays.
MIPO technique is an effective method of treatment for fractures of the distal tibia. The use of indirect reduction techniques and small incisions is technically demanding but decreases surgical trauma to soft tissues.
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