minimally invasive percutaneous plate osteosynthesis

1. OUTCOME OF DISTAL END TIBIA FRACTURES MANAGED BY MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS TECHNIQUE Dr sagar tomar Llrm medical college , meerut ,up

2. INTRODUCTION Earlier, the treatment of distal tibia was done using intramedullary osteosynthesis but it does not provide a stable rigid fixation. open reduction and internal fixation was attempted with classical plates, but it requires a quite larger incision causing larger periosteal damage. This Traditional ORIF results in extensive soft tissue dissection and periosteal injury and are associated with high rates of infection, delayed union, and non‐union.

3. Because of these drawbacks, research and development leads to the invention of new plates called “BIOLOGICAL PLATE” and new surgical procedures ,one of which is “MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS”

4. MIPO technique In this technique, only the normal bone cortexes, both proximal and distal to the fracture site, are exposed for positioning the plate and inserting the screws, while the fracture site is not explored so that osteogenic tissues surrounding the fracture are well protected and their blood supply is also well preserved.

5. biomechanics Mipo relies on relative stability rather than absolute rigid fixation because of which micromotion is produced at the fracture site and a larger and rapid callus formation occurs leading to rapid bone healing. Relative stability does not require accurate apposition of fragments as the # gap are filled up by bridging callus .

6. Indication of mipo in distal tibial # intraarticular or periarticular fractures which are considered unsuitable for intramedullary nailing. They include Communited fractures low-grade open fractures of the distal tibia displaced pilon fractures with sufficient medial soft-tissue coverage to allow articular reconstruction and percutaneous plating unstable distal metaphyseal and diaphyseal fractures.

7. Contra-indication MIPO is contraindicated in situations where the medial soft tissue is compromised, such as in severe open fractures or badly contused skin. If the bone is osteoporotic or comminution is so excessive that surgery cannot restore or stabilize the joint, then other methods of treatment must be sought such as external fixator . In severely shattered pilon fractures when only choice is external fixator .

8. Advantage of mipo minimizes risk of soft tissue damage preserve vascular supply to bone and soft tissue decrease periosteum damage have better and faster callus formation have better healing and union rate decrease complication of infection and re-fracture decrease the use of supplementary bone grafting

9. IMPLANT CHOICE Choice of implant could be Metaphyseal plate (broad or narrow) Precountoured distal tibia locking plate Clowerleaf LCP

10. procedure POSITIONING OF PATIENT

11. INCISION anteromedial approach , a 2–3 cm incision is made starting at the level of the tibial plafond and extending proximally along the medial surface of the distal tibia. OR posteromedial incision along the posterior border of medial malleolus about 4–5 cm in length and slightly curved can be used

12. PRELIMINARY REDUCTION REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY PLATE INSERTION PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

13. PRELIMINARY PLATE STABILIZATION BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE PLATE FIXATION A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

14. REVIEW OF WORK THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS:

15. REVIEW OF WORK STUDY NO. OF FRACTURE FIXATION OUTCOME COMPLICATION Ronga M et al. 2010 19 MIPO Union: 18 (22.3 wks, range 12-24) Nonunion:1 No malunion ( ≥7° deformity or ≥1 cm LLD) Deep infection:3 Ahmad MA et al. 2010 18 MIPO Union: 15 (21.2 wks) Delayed union: 3 Superficial wound infarction: 1 Chronic wound infection: 1 Implant failure: 1 Ronga M, Longo UG, Maffulli N. Minimally invasive locked plating of distal tibia fractures is safe and effective. Clin Orthop Relat Res 2010, Ahmad MA, Sivaraman A, Zia A, Rai A, Patel AD. Percutaneous locking plates for fractures of the distal tibia: Our experience and a review of the literature. J Trauma 2010,

16. Hasenbohehler E et al. (2007) 32 (open fracture: 8) MIPO Union: 29 ( 27.7 wks, range 24–60) Nonunion: 2 No malunion (≥ 5° deformity or ≥ 1 cm LLD) Plate bending (18°): 1 Pseudoarthrosis : 2 Hazarika S et al. (2006) 20 (open fracture: 8) MIPO Union: 18 ( 28.5 wks, range, 9–68) Nonunion: 2 Delayed wound break down: 2 Wound infection: 1 Implant failure: 1 Secondary procedure: 2 Hasenboehler E, Rikli D, Babst R. Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective study of 32 patients. Injury 2007, Hazarika S, Chakravarthy J, Cooper J. Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients. Injury 2006,

17. Bahari S et al. (2007) 42 (open fracture: 8) MIPO Union: 42 (22.4 wks) No malunion Superficial wound infection: 2 Deep infection: 1 Implant failure: 1 Collinge C et al.(2010) 38 (open fracture: 8) MIPO Union: 38 (21 wks, range 9–48) Malunion ( ≥ 5° deformity) : 1 Secondary procedure: 3 Mushtaq A et al. (2009) 21 (open fracture: 4) MIPO Union: 21( 5.5 months, range 3–13) Delayed union: 1 Non union :1 Wound infection: 2 Secondary procedure: 2 Bahari S, Lenehan B, Khan H, Mcelwain JP. Minimally invasive percutaneous plate fixation of distal tibia fractures. Acta Orthop Belg 2007, Collinge C, Protzman R. Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures. J Orthop Trauma 2010, Mushtaq A, Shahid R, Asif M, Maqsood M. Distal tibial fracture fixation with locking compression plate (LCP) using the minimally invasive percutaneous osteosynthesis (MIPO) technique. Eur J Trauma Emerg Surg 2009,

18. Lau TW et al. (2008) 48 (open fracture: 9) MIPO Union: 47 ( 18.7 wks, range 12-44 wks) Delayed union: 5 Wound infection: 8 Secondary procedure:1 Gupta RK et al.(2010) 80 (open fracture:19) MIPO Union: 77 (19 wks, range 16-32) Delayed union :7 Non union: 3 Malunion (≥ 5° deformity or ≥ 1 cm LLD): 2 Wound infection:1 Wound breakdown: 2 Secondary procedure: 2 Lau TW, Leung F, Chan CF, Chow SP. Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures. Inter Orthop 2008, Gupta RK, Rohilla RK, Sangwan K, Singh V, Walia S. Locking plate fixation in distal metaphyseal tibial fractures: series of 79 patients. Inter Orthop 2010,

19. Shreshta et al (2011) 20 MIPO Union: 20 (18.5 wks, range 14-28) Delayed union :1 No malunion (≥ 5° deformity or ≥ 1 cm LLD) Superficial wound infection: 2 Deep infection: 1 Secondary procedure: 1 Oog Jin et al 10 MIPO Union:10(21 wks,range17-28) no non-union, no angular deformity > 5°, shortening > 10 mm no infection Shrestha D, Acharya BM, Shrestha PM. Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture. Kathmandu Univ Med J 2011;

20. hong et al Fractures of the Distal Tibia Treated with Polyaxial Locking Plating Hong Gao , MD,   Chang-Qing Zhang , MD, PhD,  Cong- Feng Luo , MD, PhD,  Zu -Bin Zhou , MD, and  Bing-Fang Zeng , MDClin Orthop Relat Res. 2009 March; 467(3): 831–837. Total pts: 32 The average healing time was 13 weeks (range, 10–18 weeks) for fractures using the MIPO technique and 15.6 weeks (range, 10–20 weeks; p = 0.0045) for fractures using the ORIF technique. The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group, which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

21. ADVANTAGE OF MIPPO OVER ORIF

22. mipo orif Smaller incision Fracture site is undisturbed Better callus formation Blood supply to fracture fragments maintained Larger incision Fracture site explored Callus formation is delayed Blood supply is hampered

23. mipo orif Low infection rate due to smaller incision and decrease soft tisue damage decreased need for bone grafting High infection rate due to poor soft tissue handling over large incised wound Bone grafting is required sometimes

24. conclusion Minimally invasive plate osteosynthesis (MIPO) of the distal tibia offers several theoretical advantages compared to classic open reduction and internal fixation. A mechanically stable fracture-bridging osteosynthesis can be obtained without significant dissection and surgical trauma to the bone and surrounding soft tissues MIPO has a high union rate and less complication rate.

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