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Research Article

Management of distal tibial fractures with minimally invasive plate osteosynthesis (MIPPO)

technique. A retrospective series

Rosario Spagnolo1, Fabrizio Caroli2, Francesco Sala3

1Surgery Free Land, Romano di Lombardia Hospital, Bergamo, Italy.

2Department of Orthopaedic Surgery and Traumatology, Romano di Lombardia Hospital, Bergamo, Italy.

3Department of Orthopedic Surgery and Traumatology, Niguarda Hospital, Milan, Italy.

Corresponding author: Rosario Spagnolo; Email: rosariospagnolo@libero.it

 

Citation: Spagnolo R, Caroli F, Sala F. Management of distal tibial fractures with minimally invasive plate osteosynthesis (MIPPO) technique. A retrospective series. J Minim Invasive Orthop, 2014, 1(6): e6. doi:10.15383/jmio.6.

Competing interests: The authors have declared that no competing interests exist.

Conflict of interest: None

Copyright: http://journalofnasopharyngealcarcinoma.org/Resource/image/20140307/20140307234733_0340.png2014 By the Editorial Department of Journal of Minimally Invasive Orthopedics. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

 

Abstract: The fractures of the distal tibia represent 7-10% of all tibial fractures and they usually are the result of high energy injuries as such as traffic accidents or fall from a height; in these cases the axial compression causes complex articular fractures characterized by metaphysis break and bone loss. Better prognosis are given in case of low energy traumas. The study evaluates the results of the surgical treatment of distal tibia fractures, using minimally invasive plate osteosynthesis (MIPPO) technique. We treated in our unit 30 patients with distal tibia fractures with the MIPPO technique. The fractures, intra-articular or extra-articular, were classified according to the AO classification. The cases studied did not involve open fractures or cutaneous lesions and we excluded the C3 and B2, B3 fractures, for which traditional osteosynthesis is preferable. We had one case of superficial wound infection in a diabetic patient with the dehiscence of the surgical wound than solved with the correct consolidation of the fractures; a malunion with more than 5 degrees of varus, one case of asymptomatic breaking of the distal screws. On the whole the outcomes were positive, thanks to a correct clinical indication. In conclusion we think that two are the elements that direct the choice regarding the type of approach and the type of device for the synthesis. The first is the condition of the skin, as far as its integrity is concerned, and the second is the articular condition, as far as the comminution and the number of fragments are concerned. Therefore we need to choose a synthesis that can guarantee a good outcome and can avoid dreadful complications and MIPPO is a valid technique when used correctly and by experts.

Keywords: Minimally invasive osteosynthesis; Fixed angle plate; Distal tibial fractures

 

 

Introduction

The fractures of the distal tibia and of the tibial vertical pole represent about 7-10% of all tibial fractures and they are usually the result of high energy traumas such as traffic accidents or fall from a height. In these cases the axial compression causes complex articular fractures characterized by metaphysis break and bone loss. When these fractures are caused by rotational forces with a minimum axial load, low energy traumas can occur. Better prognosis are given in case of low energy traumas. The study evaluates the results of the surgical treatment of distal tibia and tibial vertical pole fractures, using minimally invasive plate osteosynthesis (MIPPO) technique. This type of technique can give import an advantages, especially from a biological point of view and the vascularity of the bone fragments. We have treated 30 patients with distal tibia fractures with the MIPPO technique. In our studies we had a case of superficial wound infection in a diabetic patient, which was solved, a case of a bad consolidation with more than 5 degrees of varus, a case of asymptomatic breaking of the distal screws. On the whole the outcomes were positive, thanks to a correct clinical indication. In conclusion we think that there are two elements that direct the choice regarding the type of approach and the type of device for the synthesis. The first is the condition of the skin, as far as its integrity is concerned, and the second is the articular condition, as far as the comminution and the number of fragments are concerned. Therefore we need to choose a synthesis that can guarantee a good outcome and can avoid complications. MIPPO is a valid technique if it is used in the correct way and by experts.

 

Materials and methods

Between November 2004 and June 2007, we treated 30 fractures of the distal tibia with this surgery technique. These fractures regarded 30 patients (22 M and 8 F) aged from 29 to 65 years (range, 42.3 years old), who were victims of highy energy traumas. The fractures were classified according to the system AO: 18 were type 43-A (Fig. 1), 7 of the 43 type-B and 5 of the type 43-C (Fig. 2). The cases studied did not involve open fractures or cutaneous lesions and we excluded the C3 and B2, B3 fractures, for which traditional osteosynthesis is preferable. No fracture treated was exposed or presented an important interest of the soft tissues; complex articular fractures or comminuted fractures type 43C3 and 43B3, where an open technique is the gold standard, were excluded. LCP 4.5 mm plaques were used. The surgery was always performed within 96 hours in the low energy fractures, while in the complects fractures we preferred to delay the intervention of 7-10 days, when the edema was regressed and there was the appearance of skin wrinkles (1). When we accept the patient we put a transcalcaneal traction, in case of exposed fractures.

SURGICAL TECNIQUE

The surgery was performed with the patient, who was on supine position, on a radiolucent table, with the tourniquet applied to the thigh, but never used to avoid a vascular suffering in an unstable district from a circulatory point of view, with a small pillow under your ipsilateral buttock region to improve the surgical comfort. Depending on the pattern of the fracture, various direct and indirect reduction techniques have been described in the literature (4,5,6,9). They include the manual traction or the use of AO distractors.

The technique still provides the reduction and the synthesis of the fibula with one-third tubular plates, before the stabilization of the tibia. No external fixer was applied to obtain a reduction during surgery in any of the cases studied and this thanks to the synthesis of the fibula, which allows a perfect reduction of the tibia and a correct length of the limb. A small distal incision of about 2,5 cm is performed to the medial malleolus, while a proximal one is performed to the fracture along the medial edge of the tibia . In the case of fracture with the joint extension, we must pay great attention to the anatomical reduction of the surface. In articular fractures the arthrotomy is required to obtain the perfect reduction. When this is obtained, the articular fragments can be stabilized with 3.5-mm cortical screws. We used LCP 4.5 mm plaques that were previously shaped to the medial profile of the tibia. The correct length and the correct position were evaluated through the fluoroscopy. It is not necessary to insert as many screws as the holes of the plaque in order not to create a too rigid system of fixation, in order to respect the fracture site and in order to restrict the "gates" of the infection. In any cases we immobilized the limb during the postoperative. In all cases, during the first 48 postoperative hours, the limb was positioned in antideclive attitude. An antibiotic and antithrombotic prophylaxis was administered; after the operation the antibiotic therapy was administered for 4 days while the antithrombotic therapy was administered for at least six weeks. Since the first postoperative day an active and passive physiokinesitherapy was encouraged. The patient was verticalised and assisted during the protected ambulation with the Canadian sticks unloading on the operated limb as soon as the general clinical conditions allowed this. In some cases it was possible to grant a partial load (10-15 kg) since the 15 postoperative day. In the articular fractures the load was permitted after three weeks. Clinical and radiographic controls were made at the 2, 5, 8 and 16 weeks from the surgery and consequently depending on the development of the fracture. The clinical evaluation was performed using the schema of Ovaria and Beals (13).

 

Fig

Fig. 1. 36-year-old patient with an isolated, 43-A3 fracture. Definitive fracture treatment 2 days after the accident with a LCP 4.5 mm plaque. 1a: Preoperative radiograph; 1b: postoperative radiograph. 1c: fracture healing 6 months postoperatively.

 

Presentazione standard1

Fig. 2. A 54-year-old female polytraumatized patient with a closed 43-C2 fracture. A plate, pre-contoured to the anatomy, is inserted through a minimally invasive incision into the epiperiosteal space by means of an aiming device after indirect, closed fracture reduction. The implant is stabilized by insertion of screws which lock into the plate holes and prevent tilting. It is not necessary for a large area to be exposed at the fracture site. 2a: Preoperative radiograph; 2b: postoperative radiograph. 2c: Anteroposterior and lateral view radiographs show the limb at 4years after fracture healing.

 

Results

In 25 patients the osteosynthesis of the fibula with the plaque and the screws was required before proceeding to the minimal invasive synthesis of the tibia. The average time of the hospitalization was 14 days (range 2 to 35 days). The average time of the radiological evidence for the appearance of the callus was 9 weeks (range between 7 and 12). The average time in which it was granted the full load on the operated limb was 18 weeks (range of between 7 and 16). There were no cases of lack of consolidation but we had 3 case of a bad union with more than 5 degrees of varus. We have to report a case of the superficial infection in a diabetic patient resulting in dehiscence of the surgical wound at the fibular level. However, we had the complete consolidation of the fracture both at the peroneal and tibial level and the resolution of the of the infection. In a type 43A fracture with the diaphyseal extension we had the rupture of the distal screws, but the patient was asymptomatic and it was not necessary a surgical treatment; the fracture healed in 4 months. We don’t have to report any cases of the failure of the osteosynthesis. In 7 patients we decided to remove the means of synthesis (after 24 and 29 months) because of the intolerance during the trekking. The use of the system of Ovaia and Beals (13) has allowed the evaluation of the clinical objective and subjective measures. As regards type A fractures we had excellent results in 13 cases and good results in 5 cases; as regards type B and C fractures we had excellent results in 4 cases, good results in 5 cases and bad result in 3 case. In 80% of cases the movement of the ankle was between 18° and 35°, the patients did not report any pain in the movement and they did not report any limits in walking.

 

Discussion

The indication to the minimal invasive plaque osteosynthesis (Mippo) given by Helfet (13) include distal fractures of exposed or closed tibia with or without the joint involvement. We decided to apply this surgical technique to the closed fractures with intact skin as we believe that other means of synthesis (such as external fixation ) find a better indication in other cases .We believe that there are two elements that lead to the choice of the type of approach and of the means of synthesis. First of all, the situation of the skin as far as its integrity is concerned and, after that, the joint involvement as far as the comminution and the number of fragments (14-16) are concerned. For this reason it is necessary to choose a synthesis that can guarantee the result and avoid dreadful complications. The MIPPO is a valid technique if it is used correctly and by experts. The favourable results of the MIPPO technique have been reported in several studies (15-17) and the utility is, above all, “biological” that is the reduction of the soft tissues, the saving of the centre of infection of the fracture and its vascularity. A Borelli’s study has pointed out that the metaphyseal distal tibia is rich in ancillary extraosseous vascularity which is generated by the ancillary branches of the anterior and posterior tibial artery. It has also showed that the application of a plaque in this place with the traditional technique determines a larger destruction than a minimal invasive technique. Namazi (7) has reported the skin complications in 23.5% of the cases with traditional surgical technique (ORIF). Ovadia and Beals (13) have performed a study on 145 fractures of the tibia and have noticed a high number of complications that are not connetted with the employed treatment. The complications of the injuries occurred in 10% of their patients and the osteomyelitis developed in 6%. It was necessary to domany additional surgical procedures for the treatment of soft tissues, the bone grafting and the osteotomy for the incorrect consolidation. Finally three patients underwent the amputation below the knee. Another point at issue is if it is always necessary to perform the osteosynthesis of fibula fracture when this is associated with the tibial fracture, either it is used the intramedullary nailing or the tibial plaque. When you make the intramedullary nailing, according to Mori and others who have done studies of biomechanical on cadavers, the stabilization of the fibula does not lead to a significant improvement of the rotational stability. Otherwise Conversely Egol et al. (19) have reported a major failure, especially in the intramedullary nailing when the osteosynthesis of the fibula is not performed. The intramedullary nailing in distal fractures leads to a worse position than the osteosynthesis with plaques .Redfern, Hazarika (20 ) have reported some results on 20 fractures of the distal tibia treated with MIPPO technique without having considered the osteosynthesis of the fibula to restore the proper length of the limb. Faschingbauer (21), Kumar et al. 22, argue that the osteosynthesis of the fibula facilitates the tibial fixation. As far as the malalignment is concerned it would seem that it is more common when you are using the intramedullary nailing. Vallier et al. (9) examined 113 extra-articular fractures in 67 cases treated with intramedullary nailing and in 37 cases with plaques: the response was of 38% of malalignment in the cases treated with synthetic intramedullary compared with 5.4% in the second group. The difficulty of proper alignment has also been reported with the less invasive technique (MIPPO). A bad alignment, that was more than 5%, was reported in 20%-35% ( 23-24) of the cases. TW Lau et al. (25) have reported the 7% of infections in 48 cases of the fractures treated with minimal invasive techniques, while in 52% of the cases the fixation devices were removed for intollerance. Faschingbauer and others (21) had two infection cases: the first case was after removing the external fixator and consequently the treatment with MIPPO technique while the second was in a large obese smoker. This case was solved by removing the plaque and the treatment with external fixator. Pallister (17), Hazarika et al. (14) propose the external fixation as the first surgical approach, even in closed fractures, to achieve the indirect reduction of the fracture and to protect the soft tissues. In closed fractures we prefer the skeletal traction which gets the same result, but it avoids a surgery and perhaps the risk of pollution of the fiches. In our experience the osteosynthesis of the fibula facilitates the operation of the stabilization of the tibia. The use of the tourniquet should be avoided or limited both in the MIPPO technique and in the traditional one to avoid vascular stress in an area which is at risk from a circulatory point of view. In our cases we have always positioned it but we have never used it. This has improved the postoperative period either in terms of motility and of the edema of the limb or as far as the spread of the antibiotics administered intraoperatively with consequent reduction of post-surgical infections is concerned. If we critically analyze our results in treatment of closed fractures of the tibia they are almost the same as those we find in literature. The less good results were obtained in those fractures characterized by a significant comminution of the joint region, where the traditional technique is the gold standard.

 

Conclusion

The fractures of the distal tibia, with or without involvement of the articular surface, are difficult to treat. In case of exposed fractures and in presence of soft tissue injuries such as abrasions, skin localized or extended contusions we do not recommend the use of the minimal invasive technique. In these cases the external fixation may be the treatment to be chosen and this can lead to satisfactory results. Some stable fractures with metaphyseal distal extension can be treated with the intramedullary nailing. In our opinion this is, when it is possible, the gold standard. The surgical technique MIPPO is widely used in the distal closed fractures of the tibia with or without joint involvement. The MIPPO is a "biological" help to the skin for the mini-access, to the soft tissues reducing the traumatism, to the hotbed of the fracture as it does not open it and to the vascularization of both the soft tissues and of the bone. In conclusion, we believe that, in the treatment of the distal fractures of the leg, the choice of the mean of synthesis is not unique, but it should take into consideration the possibility to get an anatomic reduction and it should not damage the soft tissue. In conclusion we think that there are two elements that direct the choice regarding the type of approach and the type of device for the synthesis. The first is the condition of the skin, as far as its integrity is concerned, and the second is the articular condition, as far as the comminution and the number of fragments are concerned. Therefore we need to choose a synthesis that can guarantee a good outcome and can avoid complications. MIPPO is a valid technique if it is used in the correct way and by experts.

 

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