SLR - June 2015 - Anna Wojcik-Stepien

Minimally Invasive Plate Osteosynthesis for Distal Tibial Fractures

Reference: Devkota, P, Khan JA, Shrestha SK, Acharya BM, Pradhan NS, Mainali LP, Khadka PB, Manandhar HK.  Minimally invasive plate osteosynthesis for distal tibial fractures. J Orthop Surg (Hong Kong). 2014 Dec;22(3):299-303

Scientific Literature Review

Reviewed By: Anna Wojcik-Stepien, DPM
Residency Program: Morristown Memorial Hospital, Morristown, NJ

Podiatric Relevance: The treatment for unstable distal tibial fractures may become complicated with high complication rates or with multiple co-morbidities. Open reduction and internal fixation (ORIF) and external fixation are a couple of the main options of treatment, however, each associated with high risks of complications. This particular article evaluates the results of patients with distal tibial fractures treated with minimally invasive plate osteosynthesis (MIPO).

Methods: A retrospective cohort study was performed reviewing medical records between January 2007 and December 2009 of 22 women and 31 men that underwent MIPO using a locking compression plate for distal tibial fractures with or without intra-articular extension. Exclusion criteria included patients with open fractures more severe than type 1, complex pilon fractures, and those in whom MIPO was converted to an ORIF. The surgical procedure involved performing a small incision over the medial malleolus while preserving the neurovascular structures. Through the incision and under fluoroscopic guidance, an anatomic contoured 4.5mm locking plate (Sharma Surgical, Vadodara, India) was inserted superficial to the periosteum. After the fracture was reduced with manual traction or a distractor, the plate was held in place with at least 3 locking screws proximally and distally (5.0mm and 4.5mm screws, respectively). Postoperatively, the patients were placed in above-knee plaster casts for one week. Partial weight-bearing with crutches was permitted for the first six weeks and then progressively converted to full weight-bearing.

Results: The patients in the study were followed up for a mean of 26 months. The mean time for full-weight bearing was 15 weeks. The mean time for osseous union of the fractures was 25 weeks. At 10 months, the ankle range of motion at the affected side was similar to the contralateral side. Some of the complications encountered in the study included two malunions (not clinically significant), five patients with superficial infections, two patients with persistent pain and one possible case reflex sympathetic dystrophy. Also, 10 patients required removal of fixation after a mean of 21 months.

Conclusions: This article discusses minimally invasive plate osteosynthesis (MIPO), which uses minimal dissection and bridge plating inserted extraperiostally for the treatment of distal tibial fractures. According to the study, MIPO preserves the periosteum and soft tissues, which promotes healing of the fracture to take place. These results allow the practitioner to choose MIPO for treatment of distal tibial fractures in order to decrease the amount of surgical trauma and preserve the fracture hematoma for the formation of a callus. 

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