OUTCOME OF DISTAL END

TIBIA FRACTURES MANAGED

BY MINIMALLY INVASIVE
PLATE OSTEOSYNTHESIS
TECHNIQUE

Dr sagar tomar
Llrm medical college ,meerut ,up
 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.
 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”
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.
 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 .
 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.
 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.
 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
IMPLANT
CHOICE

Choice of
implant could be
•Metaphyseal
plate (broad or
narrow)
•Precountoured
distal tibia
locking plate
•Clowerleaf LCP
 procedure

POSITIONING OF PATIENT
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
PRELIMINARY REDUCTION PLATE INSERTION

PLATE COULD BE INSERTED

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

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

 THE VARIOUS STUDY DONE TO CHECK THE

EFFECTIVENESS OF MIPO TECHNIQUE FOR
DISTAL END TIBIA FRACTURES ARE AS
FOLLOWS:
 REVIEW OF WORK
STUDY NO. OF FIXATION OUTCOME COMPLICATI
FRACTURE ON
Ronga M et al. 19 MIPO Union: 18 (22.3 Nonunion:1
2010 wks, range 12- No malunion (
Ronga M, Longo UG, 24) ≥7° deformity
Maffulli N. Minimally or ≥1 cm LLD)
invasive locked plating
of distal tibia fractures Deep
is safe and effective.
Clin Orthop Relat Res
infection:3
2010,

Ahmad MA et 18 MIPO Union: 15 (21.2 Delayed union:

al. 2010 wks) 3
Superficial
Ahmad MA,
Sivaraman A, Zia wound
A, Rai A, Patel
AD.
infarction: 1
Percutaneous Chronic wound
locking plates for
fractures of the infection: 1
distal tibia: Our
experience and a Implant failure:
review of the
literature. J
1
Trauma 2010,
Hasenbohehler 32 (open MIPO Union: 29 ( 27.7 Nonunion: 2
E et al. (2007) fracture: 8) wks, range 24– No malunion (≥
Hasenboehler E, Rikli 60) 5° deformity or
D, Babst R. Locking
compression plate ≥ 1 cm LLD)
with minimally
invasive plate Plate bending
osteosynthesis in
diaphyseal and distal
(18°): 1
tibial fracture: a
retrospective study of
Pseudoarthrosis
32 patients. Injury :2
2007,

Hazarika S et 20 (open MIPO Union: 18 ( 28.5 Nonunion: 2

al. (2006) fracture: 8) wks, range, 9– Delayed wound
Hazarika S,
68) break down: 2
Chakravarthy J, Wound
Cooper J.
Minimally infection: 1
invasive locking
plate
Implant failure:
osteosynthesis for 1
fractures of the
distal tibia- Secondary
results in 20 procedure: 2
patients. Injury
2006,
Bahari S et al. 42 (open MIPO Union: 42 (22.4 No malunion
(2007) fracture: 8) wks) Superficial
Bahari S, Lenehan wound
B, Khan H, infection: 2
Mcelwain JP.
Minimally invasive Deep infection:
percutaneous plate
fixation of distal
1
tibia fractures. Implant failure:
Acta Orthop Belg
2007, 1

Collinge C et 38 (open MIPO Union: 38 (21 Malunion ( ≥ 5°

al.(2010) fracture: 8) wks, range 9– deformity) : 1
Collinge C, Protzman R.
Outcomes of minimally
48) Secondary
invasive plate procedure: 3
osteosynthesis for
metaphyseal distal tibia
fractures. J Orthop
Trauma 2010,

Mushtaq A et 21 (open MIPO Union: 21( 5.5 Delayed union:

al. (2009) fracture: 4) months, range 1
Mushtaq A, Shahid R, Asif
3–13) Non union :1
M, Maqsood M. Distal tibial
fracture fixation with
Wound
locking compression plate infection: 2
(LCP) using the minimally
invasive percutaneous Secondary
osteosynthesis (MIPO)
technique. Eur J Trauma procedure: 2
Emerg Surg 2009,
Lau TW et al. 48 (open MIPO Union: 47 ( 18.7 Delayed union:
(2008) fracture: 9) wks, range 12- 5
Lau TW, Leung F, Chan 44 wks) Wound
CF, Chow SP. Wound
complication of infection: 8
minimally invasive plate
osteosynthesis in distal
Secondary
tibia fractures. Inter procedure:1
Orthop 2008,

Gupta RK et 80 (open MIPO Union: 77 (19 Delayed union

al.(2010) fracture:19) wks, range 16- :7
Gupta RK, Rohilla
RK, Sangwan K,
32) Non union: 3
Singh V, Walia S. Malunion (≥ 5°
Locking plate fixation
in distal metaphyseal deformity or ≥ 1
tibial fractures: series
of 79 patients. Inter
cm LLD): 2
Orthop 2010, Wound
infection:1
Wound
breakdown: 2
Secondary
procedure: 2
Shreshta et al 20 MIPO Union: 20 Delayed union :1
(2011) (18.5 wks, No malunion (≥
Shrestha D, Acharya BM,
Shrestha PM. Minimally range 14-28) 5° deformity or ≥
invasive plate
osteosynthesis with
1 cm LLD)
locking compression Superficial
plate for distal
diametaphyseal tibia wound infection:
fracture. Kathmandu
Univ Med J 2011;
2
Deep infection: 1
Secondary
procedure: 1

Oog Jin et al 10 MIPO Union:10(21 no non-union, no

wks,range17- angular
28) deformity > 5°,
shortening > 10
mm
no infection
 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
ADVANTAGE OF
MIPPO OVER
ORIF
 mipo orif

 Smaller incision  Larger incision

 Fracture site is  Fracture site explored
undisturbed
 Callus formation is
 Better callus formation delayed
 Blood supply to  Blood supply is
fracture fragments hampered
maintained
 mipo orif

 Low infection rate due  High infection rate due

to smaller incision and to poor soft tissue
decrease soft tisue handling over large
damage incised wound
 decreased need for  Bone grafting is
bone grafting required sometimes
 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.
Thank you