|Year : 2016 | Volume
| Issue : 3 | Page : 691-697
Evaluation of treatment of distal tibial fractures using the minimally invasive percutaneous plate osteosynthesis technique
Hassan A Neinaa, Yasser S Hannout, Ayman A Mohammed Abdel Wahab
Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||30-Aug-2015|
|Date of Acceptance||13-Sep-2017|
|Date of Web Publication||23-Jan-2017|
Ayman A Mohammed Abdel Wahab
Orthopedic Surgery resident, Mansoura New General Hospital, Dakahlia, 35511
Source of Support: None, Conflict of Interest: None
The goal of this study was to report and evaluate the treatment of distal tibial fractures using the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique.
MIPPO has been used for the management of fractures since a long period of time. Good fixation, mild blood loss, and early mobilization are always the main advantages of this technique. Other advantages include the following: it is simple, quick, and causes minimal surgical trauma.
Materials and methods
From August 2013 to January 2015, 20 (13 male and seven female) patients with a mean age of 49.5 years suffering from type A distal tibial fracture were treated in the Orthopedic Department, El-Menoufiya University Hospital, and Mansoura New General Hospital with medial distal locked plate using the MIPPO technique and early mobilization.
Fracture union was achieved within 16-23 weeks. In 16 cases union was achieved within 16-20 weeks and was delayed in three cases and achieved within 23 (mean: 19.2) weeks. There was only one case in which nonunion occurred.
The MIPPO technique is effective in achieving union and excellent functional outcome in metaphyseal distal tibial fractures.
Keywords: distal tibial fractures, minimally invasive plate osteosynthesis, percutaneous, type A
|How to cite this article:|
Neinaa HA, Hannout YS, Mohammed Abdel Wahab AA. Evaluation of treatment of distal tibial fractures using the minimally invasive percutaneous plate osteosynthesis technique. Menoufia Med J 2016;29:691-7
|How to cite this URL:|
Neinaa HA, Hannout YS, Mohammed Abdel Wahab AA. Evaluation of treatment of distal tibial fractures using the minimally invasive percutaneous plate osteosynthesis technique. Menoufia Med J [serial online] 2016 [cited 2020 Feb 16];29:691-7. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/691/198756
| Introduction|| |
Controversy and debate continue to surround the management of fractures of the distal tibia. Open reduction and internal fixation require extensive soft tissue dissection with consequent periosteal injury even in expert hands. High rates of complications including infection, delayed union, and nonunion have been reported. External fixation has an established place in the treatment of distal tibial fractures, particularly when associated with significant soft tissue injury. Ilizarov frames, ankle-spanning, and hybrid constructs have been proposed either as a sole treatment or more frequently in conjunction with limited internal fixation. In addition, external fixation can be used as a preliminary reduction and fixation tool. Complications of external fixation include the development of pin track infection, malunion, or nonunion ,,, .
Minimally invasive plate osteosynthesis (MIPPO) is a technique that aims to reduce iatrogenic soft tissue injury and damage to bone vascularity, as well as to preserve the osteogenic fracture hematoma. This philosophy is especially applicable in the management of distal tibial fractures, owing to the vulnerable extraosseous-metaphyseal blood supply in the distal region of the tibia. Encouraging results for closed reduction and percutaneous plating of closed extra-articular distal tibial fractures have been reported using contoured dynamic compression plates ,, .
There has been an increasing trend toward the use of the locking compression plate for fracture fixation. The device allows the screws to lock to the plate, therefore creating a stable, fixed-angle device. The development of these locked 'internal external fixators' has been based on the scientific insights into bone biology, especially with reference to preserving bone blood supply , .
In this prospective study, we report results and experiences with MIPPO for distal tibial fractures using distal locked tibial plate, with respect to fracture and soft tissue healing, infection rates, and other complications encountered.
| Materials and methods|| |
Twenty patients, 13 male and seven female, with type A distal tibial fractures were treated using the MIPPO technique using distal locked tibial plate between August 2013 and January 2015. Inclusion criteria were as follows: skeletally mature patients (above 18 years) or closed fracture, extra-articular type A, male or female, and ambulatory patient before fracture. Exclusion criteria were as follows: open fractures, nonunion or pathological fractures, and immunocompromised patients.
Consent from the patient was taken before inclusion in this study.
The youngest patient was 34 years old and the oldest patient was 65 years old; the mean age of the patients was 49.5. Ten patients had injury on the right side (50%) and 10 patients had injury on the left side (50%). Fall was the cause in six (30%) cases and road traffic accident was the cause in 14 (70%) cases.
According to the AO classification, all cases were classified as type A. Eight cases presented with associated injuries; seven of them had associated fracture of the fibula, and distal radius fracture was present in one case.
We performed all procedures using the medial approach to the tibia.
Step 1: under general or spinal anesthesia, the patient was placed supine on a radiolucent operating table supporting the knee with towels to be flexed in the appropriate position.
Step 2: medial vertical incision is made at the level of the medial malleolus with care so as to not to injure the great saphenous vein.
Step 3: subcutaneous plane is made with hemostat without striping periosteum and causing disturbance to fracture hematoma.
Step 4: fracture is reduced under C-arm control. When reduction is difficult despite repeated attempts, a small incision is made using a Kirschner wire (3 mm) as a joystick to aid in fracture reduction and a towel clip or reduction clamp to hold reduction.
Step 5: the plate is tunneled into the subcutaneous plane and its position is reconfirmed with C-arm. Before fixing the plates with screws, shagging of the distal fragment is prevented by placing a towel roll under the fracture site.
Step 6: K-wires were used preliminarily through the plate to assess its position before fixation.
Step 7: provisional nonlocking screw is applied to bring the plate on the bone. Compression osteosynthesis is achieved in simple fracture using a nonlocking screw proximal to the fracture site as a hybrid fixation.
Step 8: thereafter, 2 of the 5 distal locking screws were applied before applying the proximal locking screws. With separate stab incision, at least three locking screws are applied on the either side of fracture. All screws were tightened again securely before closing, after removing the preliminary K-wires.
Step 9: at the end of the procedure, closure was performed in layers with nonabsorbable sutures. Good dressing of the incision and below knee plaster slab was applied for 2 weeks.
Active toe movement after recovery from anesthesia was started. The patients were allowed intermittent ankle mobilization once the skin sutures and posterior splint were removed, usually in 14 days. Patients are progressed to full weight bearing depending on radiological fracture consolidation - usually after 8-10 weeks, but not before there is radiological evidence of callus formation. Routine follow-up visits were scheduled, with radiographs taken at 4-weekly intervals to assess healing and alignment.
Assessment of union
On each follow-up, patients were subjected to clinical and radiological assessment.
On each follow-up, patients were asked about subjective symptoms such as pain, limping, need for support when walking, the walking distance, and the return to prefracture activities. The patients were examined for range of active and passive movements as well as shortening and rotational deformities. Examination to assess union of the fractures was performed.
The fracture was considered united radiologically on the following criteria: disappearance of the fracture line, re-establishment of bone continuity, and good callus formation. The fracture was considered united clinically on the following criteria: no pain, no tenderness, and no abnormal mobility.
For evaluation of the functional outcome, the Ankle-Hindfoot Scale was used.
| Results|| |
Twenty cases of type A distal tibial fractures treated using the distal tibial locked plate MIPPO techniques were studied, and the minimum follow-up time was 18 weeks. The medial approach was used in all cases. Seven patients had associated ipsilateral fracture of the fibula, four of which were fixed with one-third tubular plate using the lateral approach to the fibula, and one patient had distal radius fracture, which was fixed with T-buttress plate.
The results were analyzed and revealed the following: fracture union was achieved within 16-23 weeks; six (30%) fractures healed within 16 weeks and 13 (65%) fractures healed within 23 (mean: 19.5 weeks) weeks. There was only one case in which nonunion occurred; the patient was followed up for 6 months and then lost to follow-up.
Patients were analyzed for the functional outcome using the Ankle-Hindfoot Scale (AOFAS): 14 patients were graded as excellent, five patients graded as good, and one patient graded as fair [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7] and [Table 1], [Table 2], [Table 3], [Table 4], [Table 5] and [Table 6].
|Figure 1: Preoperative radiograph. (a), Preoperative radiograph anteroposterior view, (b) preoperative radiograph lateral view.|
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|Figure 2: A photograph of the locked anatomical medial distal tibial plate used.|
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|Figure 3: (a and b) A photograph showing incision and great sephaneous vein secured.|
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|Figure 4: (a and b) A photograph showing preliminary fixation with K-wires.|
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|Figure 5: (a and b) C-arm photos to assess reduction and plate length during operation.|
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Plain radiographs of posteroanterior and lateral views were obtained for each case. Varusvalgus angulation less than 5° and anteroposterior angulation less than 10° and shortening of less than 15 mm are considered acceptable criteria for reduction.
As regards time from injury to surgery it ranged from 1 to 7 (mean: 2.40) days. Time of fracture to union ranged from 16 to 23 (mean: 19.5) weeks. Follow-up time ranged from 18 to 25 (mean: 21.50) weeks.
There were 18 patients who had no complication; one had nonunion of fracture and was lost to follow-up, and one patient who had diabetes had superficial skin infection. The cases healed after treatment with appropriate antibiotics and aseptic dressings, and the infection did not appear to have any long-term effect on fracture healing or the rehabilitation of the patient.
| Discussion|| |
Biological osteosynthesis is a new biological fixation principle that is comparable to the traditional AO principle. The MIPPO technique is a typical method based on biological fixation, which involves minimal soft tissue dissection with preservation of the vascular integrity of the fracture as well as preservation of osteogenic fracture hematoma  .
The incidence of distal tibial fractures, one of the most common periarticular fractures, is increasing regularly due to road traffic accident. At the same time, surgical treatment options are also being modified continuously. Hence, the treatment of distal tibial fractures has become a challenge for orthopedic surgeons as a difficult fracture to manage  .
To overcome these difficulties and for early restoration of the strength of the bone and the function of the ankle joint with minimal injury to soft tissues, the locking compression plate has been developed, which has been available for clinical use since 2001. This system combines two different principles of internal fixation, each of which has advantages in specific situations. Thus, a single implant gives the surgeon access to the entire range of options for internal fixation, from compression screw osteosynthesis with the principle of absolute stability to biological osteosynthesis with relative stability  .
With the development of the technique of MIPPO, which preserves extraosseous blood supply and respects osteogenic fracture hematoma, biologically friendly and stable fixation method is available for distal tibia fracture. Indirect reduction method and subcutaneous tunneling of the plate and application of screws with small skin incisions in the MIPPO technique prevent iatrogenic injury to the vascular supply of the bone  .
MIPPO for distal tibia fracture has been found to be an effective treatment option, which finally leads to decreased infection rate and better fracture healing. MIPPO offers several theoretical advantages compared with the conventional open plating technique. A mechanically stable fracture bridging osteosynthesis can be obtained without significant dissection and surgical trauma to the bone and surrounding soft tissues. As a consequence, the vascular integrity of the fracture and the osteogenic fracture hematoma are preserved , .
However, MIPPO does not allow direct visualization of the fracture and the surgeon is dependent on intraoperative fluoroscopy to confirm that an adequate reduction has been achieved. Additional radiation exposure during application of the plate to the bone and screw fixation is the disadvantage of this technique.
In this study, patients' ages ranged from 34 to 65 years, with a mean age of 49.5 years with the maximum incidence involving the age group 51-60 (55%) years. This age group differs from that reported in most series in which the fracture is high in the active age group, and this may be because of the economic impact. The series is a prospective study. According to the AO classification  all were classified as acute type A extra-articular fracture. The study included 20 patients with less than 10-day-old fractures that were fixed with distal locked tibial plate using the MIPPO technique through medial approach and followed up for a minimum of 18 weeks. There were 13 men and seven women.
The overall result in this study was evaluated according to the Ankle-Hindfoot scale  . The clinical results at the end of this study were satisfactory in 19 (95%) patients and unsatisfactory in one (5%) patient. The results were graded as excellent in 14 (70%) patients, good in five (25%) patients, and fair in one (5%) patient.
In this study, there were 12 (60%) patients who had no associated injures and eight (40%) patients who had associated injures; seven of them had associated fracture of the fibula and one patient had distal radius fracture that was fixed with T-buttress plate. Four of the seven fibular fractures needed fixation, which was performed using the one-third tubular plate through lateral approach to the fibula.
In this study, only 2 weeks of immobilization in below knee cast was used. In this study, there were no complications related to soft tissue stripping and instability during the follow-up period. Even with acute unstable fractures, this method is considered an effective alternative to open techniques. Closed indirect reduction under image intensifier was an excellent technique for reduction without soft tissue dissection.
In this study, all patients had excellent union, with duration ranging from 16 to 23 weeks and a mean duration of 19.5 weeks; six (30%) fractures healed within 16 weeks and 13 (65%) fractures healed within 23 weeks. One patient developed nonunion and had been followed up for 6 months and then lost to follow-up. All fractures united without the need for bone graft.
In this study, the range of ankle motion in this study in degrees was 15.5 for dorsiflexion (average) and 35.6 for plantar flexion (average), with excellent results in both dorsiflexion and planter flexion of up to 90%.
In this study, 18 (90%) patients had no complication, one (5%) had nonunion of fracture (lost to follow-up), and one (5%) patient who had diabetes had superficial skin infection. The cases healed after treatment with appropriate antibiotics and aseptic dressings, and the infection did not appear to have any long-term effect on fracture healing or the rehabilitation of the patient.
The results compare favorably with those using the same or other techniques. Paluvadi et al.  reported that all of the 50 patients had an AOFAS score  of 90 or greater out of a possible 100 points. The mean score was 95.06. Collinge and Protzman  reported a good-to-excellent result with a mean AOFAS score of 85. In the study undertaken by Redfern et al.  , all patients returned to their preinjury occupation or level of activity. The mean AOFAS score in the MIPPO group of the study by Guo et al.  was 83.9. Pai et al.  in their study on minimally invasive plate fixation of the distal tibia reported excellent results in 11 patients, good in nine, fair in two, and poor results in one patient.
Walia et al.  reported that locking plates provide excellent fixation in difficult situations such as comminuted fractures, osteoporotic fractures, and periarticular fractures. Lau et al.  noted a delayed union rate of 10%, deep infection in 8%, and hardware removal in 48% in a series of 48 patients treated with medial locked plating, although prolonged healing times were observed in simple fracture patterns.
Ahmad et al.  demonstrated an average time to union of 23.1 weeks in 16 of 18 patients treated with the MIPPO technique. Bahari et al.  reported one hardware failure, two superficial infections, one deep infection, and appropriate alignment in all 42 patients managed with medial locking plates. Collinge et al.  found a high infection rate of 19%, although these were all high-energy fractures; higher complication rates were expected. Cheng et al.  compared MIPPO with open plating and found no malunion or loosening in either group and concluded that there was no significant difference between the two methods of fixation. Studies by Bahari et al.  and Collinge et al.  showed that functional outcome scores for patients treated with MIPPO were comparable to that of the general population by 6 months postoperatively.
| Conclusion|| |
On the basis our observations, we conclude that the MIPPO technique using locked plate is effective in achieving union and excellent functional outcome in distal tibial fractures. The MIPPO technique is a reliable fixation approach to fractures of the distal third tibia, preserving most of the osseous vascularity and fracture hematoma and thus providing for a more biological repair. There was reduced incidence of infection due to limited exposure. Infection can also be prevented by careful handling of soft tissues and by minimizing the operating time.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]