Minimally Invasive Plate Osteosynthesis for Distal Tibia Fractures

Retrospective comparison of minimally invasive plate osteosynthesis and open reduction and plate stabilization of antebrachial fractures in 105 dogs (2017-2022)

OBJECTIVE

To investigate differences in outcome measures between radius and ulna fractures stabilized with minimally invasive plate osteosynthesis (MIPO) or open reduction and plate stabilization (ORPS) and to determine if certain preoperative factors such as the dog's age and weight, fracture morphology, or the attending surgeon influenced which application method was employed.

STUDY DESIGN

Retrospective clinical outcome study.

SAMPLE POPULATION

Dogs undergoing plate stabilization of antebrachial fractures.

METHODS

Medical records and radiographs of dogs that underwent MIPO or ORPS of unilateral antebrachial fractures were reviewed. Signalment, fracture characteristics, attending surgeon, implant type, postoperative radial alignment and length, time to clinical union, and explant, were compared between application groups.

RESULTS

One hundred and five dogs (73 ORPS; 32 MIPO) were included. The proximal extent of the fracture (p = .004) and the attending surgeon (p < .001) were identified as factors influencing the decision to perform MIPO or ORPS. Median surgical time was 85 (ORPS) and 130 (MIPO) min (p < .001). The discrepancy between contralateral and postoperative radial frontal plane alignment (p = .047), sagittal plane alignment (p = .771), and radial length (p = .183) did not differ between application groups. Three (4.1%) fractures in the ORPS group and eight (25%) in the MIPO group underwent explant (p = .003). There was also an association between open (p < .001) or comminuted (p = .007) fractures and explant of the plate and screws.

CONCLUSION

The results do not corroborate several of the purported advantages ascribed to MIPO.

CLINICAL RELEVANCE

The authors would advocate that additional, well-designed, prospective clinical studies comparing MIPO to ORPS are warranted.

A Dilemma in the Management of Distal Tibia Fractures Solved by Minimally Invasive Percutaneous Plate Osteosynthesis Technique: A Prospective Study

Introduction Managing distal tibia fractures is challenging for trauma surgeons because of their peculiar anatomy with less soft tissue coverage and poor blood supply. There are various treatment options for distal tibia fractures such as open reduction and plating, minimally invasive percutaneous plate osteosynthesis, and intramedullary interlocking nailing. Open reduction and internal fixation can lead to excessive soft tissue dissection and devascularization of fracture fragments. We conducted a study on the functional outcome of distal tibia fractures treated by biological fixation with minimally invasive percutaneous plate osteosynthesis. Methods A total of 23 patients with distal one-third tibia fractures, fulfilling the inclusion criteria, who were treated at St. John's Medical College Hospital with minimally invasive percutaneous plate osteosynthesis between November 2020 and November 2022 were studied using the American Orthopaedic Foot & Ankle Society (AOFAS) score at six weeks, three months, and six months postoperative follow-up. Results This study included 17 males and six females. The mean age of the study participants was 43.78 years, with most of the participants being in the age group between 51 and 60 years (29.2%, n = 7). All the study participants were employed. The mean operative time was two hours and 10 minutes. The mean duration for the radiological union was 22 weeks. The mean AOFAS score at six months was 92.43 + 5.696. There was only one case of superficial infection, which was treated with intravenous antibiotics. There were no cases of malunion/nonunion. Conclusion Minimally invasive percutaneous plate osteosynthesis is an effective treatment for distal tibia fractures avoiding most of the complications such as wound dehiscence and malunion/nonunion involved in conventional open reduction and internal fixation with plating. Therefore, we recommend this technique for all distal tibia fractures.

Use of Three-dimensional Printing for Tibial Pilon Fracture Diagnosis and Treatment

Objective  To evaluate whether three-dimensional (3D) printing increases agreement in the classification of tibial pilon fractures. Methods  Orthopedists and traumatologists reviewed radiographs, computed tomography scans with 3D reconstruction, and prototyping 3D printing, and classified the fractures based on the Rüedi-Allgöwer and Arbeitsgemeinschaft für Osteosynthesefragen (AO, Association for the Study of Internal Fixation) Foundation/Orthopedic Trauma Association (AO/OTA) classification systems. Next, data evaluation used Kappa agreement coefficients. Results  The use of the 3D model did not improve agreement for tibial pilon fractures regarding the treatment proposed by the groups. Regarding the classification systems, the agreement only improved concerning the AO/OTA classification when the 3D model was used in the assessment by the foot and ankle specialists. Conclusion  Although 3D printing is statistically relevant for surgeons specializing in foot and ankle, its values remain lower than optimal.

Plate-Assisted Intramedullary Nailing of Distal Tibia Fractures

The combination of plate and intramedullary nailing has been established as the treatment of proximal tibial fractures. Nevertheless, at the distal end of the tibia, the application of the plate-assisted intramedullary nailing is rarely applied as a therapeutic technique. This technical note demonstrates the use of the reduction plating technique for nail insertion as the management of distal tibia fractures.

AO distractor and manual traction reduction techniques repair in distal tibial fractures: a comparative study

BACKGROUND

Minimally invasive plate osteosynthesis (MIPO) via percutaneous plate placement on the distal medial tibia can be performed with minimizes soft tissue injury and produces good clinical results. However, the difficulty with MIPO lies in how to achieve satisfactory fracture reduction and maintain that reduction via indirect reduction techniques to facilitate internal fixation. The purpose of this study was to compare the effects of AO distractor and manual traction reduction techniques combined with MIPO in the treatment of distal tibia fractures.

METHODS

Between January 2013 and December 2019, 58 patients with a distal tibia fracture were treated using MIPO. Patients were divided into two groups according to the indirect reduction method that was used: 26 patients were reduced with manual traction(group M), and 32 were reduced with an AO distractor (group A).Time until union and clinical outcomes including AOFAS ankle-rating score and ankle range of ankle motion at final follow-up were compared. Mean operative time, incision length, blood loss and postoperative complications were recorded via chart review. Radiographic results at final follow-up were assessed for tibial angulation and shortening by a blinded reader.

RESULTS

Mean operative time, incision length, and blood loss in group A were significantly lower than in group M(p = 0.019, 0.018 and 0.016, respectively).Radiographic evidence of bony union was seen in all cases, and mean time until union was equivalent between the two groups (p = 0.384).Skin irritation was noted in one case(3.1%) in group A and three cases(11.5%)in group M, but the symptoms were not severe and the plate was removed after bony union. There was no statistically significant difference in postoperative complications between the two groups(p = 0.461). Mean AOFAS score and range of ankle motion were equivalent between the two groups, as were varus deformity, valgus deformity, anterior angulation and posterior angulation. No patients had gross angular deformity. Mean tibial shortening was not significantly different between the two groups, and no patients had tibial shortening > 10 mm.

CONCLUSION

Both an AO distractor and manual traction reduction techniques prior to MIPO in the treatment of distal tibial fractures permit a high fracture healing rate and satisfying functional outcomes with few wound healing complications. An AO distractor is an excellent indirect reduction method that may improve operative efficiency and reduce the risk of soft tissue injury.

A new surgical strategy for the treatment of tibial pilon fractures with MIPO facilitated by double reverse traction repositor

The present study aims to introduce a technique combining double reverse traction repositor (DRTR) with minimally invasive plate osteosynthesis (MIPO) in the surgical treatment of pilon fractures and to observe the efficiency of this approach during a short-term follow-up period. From January to December 2018, patients with pilon fractures who were treated by MIPO with DRTR were reviewed. The demographic and fracture characteristics, surgical data, and prognostic data of 24 patients were extracted. In all 24 patients, closed reduction was achieved with the MIPO technique, and excellent functional and radiological outcomes were observed. The average duration of surgery and intraoperative blood loss were 95.0 ± 14.2 min and 152.1 ± 52.1 ml, respectively. A mean of 16.0 ± 1.9 intraoperative fluoroscopies were conducted. At the 12-month follow-up evaluation, the average AOFAS score was 85.2 ± 5.1. Anatomic or good reduction was observed in 23 (95.8%) patients. The mean ranges of motion of dorsiflexion and plantarflexion were 11.0 ± 2.7 and 32.7 ± 11.1, respectively. Two patients with deep venous thrombosis and one patient with wound non-purulent exudate were noted. Additionally, the wounds healed after routine dressing change. No other complications, including skin necrosis or delayed, non-union or malunion, were observed. The new strategy combining DRTR with MIPO in the treatment of pilon fractures allowed excellent radiological and clinical outcomes and a low postoperative complication rate to be achieved in a short-term follow-up period. Further large sample and comparative studies should be conducted to validate our results.

Results and complications of minimally invasive medial plate osteosynthesis for distal metaphyseal tibial fractures: A prospective case series from Vietnam

Introduction and importance

The treatment of a fractures in tibial distal metaphyseal remained controversial. The purpose of this study was to assess the results and complications of minimally invasive medial plate osteosynthesis for distal metaphyseal tibial fractures.

Material and method

From April 2014 to December 2019, 70 patients were enrolled in the study who were underwent MIPPO for metaphyseal tibial fractures using a medial distal tibial locking plate in our hospital. Wound healing, alignment, full weight bearing time, function, and complications were recorded.

Results

All wounds primarily healed, just one fibular plating wound was deeply infected. All tibial fractures were solid union without secondary displacement. The average time back to walk without a crutch was 12,5 weeks. The mean AOFAS score was 89 at a mean of 15 months follow-up. There were seven cases of late infection, 14 patients of skin impingement by implants and nine cases of broken screws, who were older than 65 years old. No case was varus, valgus or rotation >5°.

Conclusion

Minimally invasive medial plate osteosynthesis for the distal metaphyseal tibial fracture is safe and effective. This technique decreases the incidence of complications and can help patients to resume their function early. The implant impingement, late wound infections and screw breakage were the quite common complications in old patients but these complications could be simply resolved and did not affect the overall rehabilitation and functions of the patient.

Risk factors for infection in fixation of distal tibia fractures

BACKGROUND

The aim of this study is to evaluate risk factors for infection as well as infection rates after open reduction and internal fixation for distal tibia fractures with a distal tibia locking plate and/or isolated screws.

METHODS

This is a retrospective and descriptive study based on 55 patients treated in our Major Trauma Centre from January 2009 to December 2016. All patients were classified by age, sex, open or closed fracture, injury mechanism, comorbidities, fixation and time from injury to surgery. 22 extraarticular fractures AO/OTA 43-A and 33 intraarticular (14 cases 43-B and 19 43-C) were recorded. High energy trauma was related in 27 patients, while open fractures were observed in 10 patients. Splint until surgery was applied routinely while temporary external fixation (EF) was performed in 21 patients (7 extraarticular and 14 intraarticular). Patients were treated by 5 different consultant surgeons performing isolated screws (SC) in 20% of the surgeries, antero-medial locking distal tibia plate (AM) and anterolateral (AL) were used in 47% and 33% of the patients respectively. After assessing normality and homogeneity of the subgroups, statistical contrast tests were performed.

RESULTS

Infection rate was 31.5%, mainly caused by S. aureus. We obtained a statistically significant correlation between greater age and infection rate. In the same way, a positive statistical trend between infection and AL plating was found. The use of EF followed by ORIF was not observed as a risk factor for infection compared with splint followed by internal fixation, however, the group of patients in which a splint was used, a positive relationship was found between the infection rate and shorter time until the definitive fixation. No statistically significant associations were found between extra/intraarticular fracture pattern, use of corticosteroids or open fractures and infection rate.

CONCLUSION

Greater age was a predisposing factor for infection. The use of external fixation before definitive ORIF seems to be a safe procedure regarding risk infection, and if an external fixation is not used, we recommend longer waiting time until definitive ORIF. Screw fixation or antero-medial plates, if allowed by fracture pattern, can be an option to avoid infection.

Staged treatment and internal fixation of floating ankle: A case report and literature review

RATIONALE

Floating ankle is a rare traumatic condition characterized by a combination of tibial and ipsilateral foot fractures, with the ankle remaining intact. It is usually caused by high-energy trauma and also presents with serious soft tissue damage. Its treatment is mainly restricted to external fixation, which results in poor outcomes. We present a patient with a floating ankle who underwent staged treatment and achieved full internal fixation, subsequently returning to normal activity.

PATIENT CONCERNS

A 26 year- old man had an accident with an reel machine and sustained an open fracture on his right lower extremity.

DIAGNOSES

Digital radiograph demonstrated a distal tibial fracture, fibular fracture, and multiple metatarsal fractures, which fulfilled the criteria for a floating ankle.

INTERVENTIONS

Initial ankle-spanning external fixation was performed. After 21 days, the patient underwent open reduction and internal fixation on his first and fifth metatarsals, and K-wire fixation on his fourth metatarsal. The external fixator was replaced by plaster fixation. Seven days later, the patient underwent internal fixation of his leg, open reduction and internal fixation with plating was applied of the fibular fracture, and minimally invasive plate osteosynthesis of the tibial fracture.

OUTCOMES

At 1-year follow-up, bone union was identified by digital radiograph; after 2 years, his ankle function had fully recovered, and he resumed his normal activities.

LESSONS

In the staged treatment protocol of the floating ankle, temporary external fixation provided traction and immobilization of the skeletal and soft tissues. Secondary internal fixation maintained the reduction and alignment and allowed early exercise, which is critical to the prognosis of a floating ankle.

Minimally invasive plate osteosynthesis (MIPO) for mid-shaft fracture of the tibia (AO/OTA classification 42): A retrospective study

BACKGROUND

There is abundance of literature regarding the treatment of tibial mid-shaft fracture, and intramedullary nailing (IMN) is described as the treatment of choice. However, problems such as malunion and knee pain are known disadvantages of this approach. Minimally invasive plate osteosynthesis (MIPO) technique is another treatment option for tibial mid-shaft fracture.The purpose of this study is to evaluate the clinical, radiological results, and complication rates of tibial mid-shaft fractures treated with MIPO technique.

MATERIALS AND METHOD

Thirty-seven skeletally mature patients who underwent MIPO for a mid-shaft fracture of tibia (AO/OTA classification 42) from June 2016 to May 2018 were retrospectively reviewed. A total of 37 patients (12 females, 25 males) with a mean age of 52.7 years (range 28-78 years) were included. The clinical and radiological outcomes, such as the Jeju Lower Extremity Trauma Scale (JLETS), time to callus formation, time to bony union, and complications such as delayed union, malunion, nonunion, and infection were assessed.

RESULTS

Bony union was achieved in all cases but one (36 cases). Average callus formation was observed in 10.7 (6.5-14.5) weeks. The average time to union was 19.8 (11.5-26.5) weeks. The average JLETS score was 46.9 (40-53) point. Malunion deformities were observed in 3 cases (8.1%). Two superficial infection cases all resolved spontaneously. There was no statistically significant difference in clinical and radiographic outcomes by different AO/OTA fracture types.

CONCLUSION

The MIPO technique with locking compression plate provides stable fixation and satisfactory clinical and radiological results for mid-shaft fractures of tibia irrespective of the fracture type. Future study should aim to compare MIPO and IMN cases directly to clarify the differences and similarities between the two treatment modalities.

[Digital OR]

BACKGROUND

Numerous processes are involved in the orthopedic and trauma surgery operating room (OR). Technical progress, particularly in the area of digitalization, is increasingly changing routine surgical procedures.

OBJECTIVE

This article highlights the possibilities and also limitations regarding this matter.

MATERIAL AND METHODS

Based on the current literature this article provides insights into innovations in the areas of digitalization of surgical devices, hybrid OR, machine-2-machine networking, management systems for perioperative efficiency improvement, 3D printing technology and robotics.

RESULTS

The technical possibilities for the use of digital applications in the surgical environment are rapidly increasing. Close cooperation with industrial partners is important in this context. Technologies from the automotive, gaming and mobile phone industries are being adopted.

CONCLUSION

Digital technology in the OR can improve treatment quality, patient and staff safety and cost efficiency; however, the networking of devices, implementation of innovations in existing structures and the sometimes high acquisition costs are still limiting factors.

Tibial shaft fractures treated with intramedullary nailing and reduction device assistance

PURPOSE

This study aimed to assess the outcomes of a newly invented reduction device on assisting reduction of intramedullary nailing (IMN) in the treatment of tibial shaft fractures.

METHODS

From January 2015 to December 2018, data of patients with tibial shaft fractures treated with IMN were reviewed. In total, 42 patients underwent treatment with the new reduction device (group A) and 56 underwent treatment using a traditional reduction technique (group B). Data related to the closed reduction rate, surgical time, blood loss, number of fluoroscopies, number of surgeons, and number of complications were also reviewed. Fracture healing was assessed using radiographs at each follow-up, and the functional outcome (AOFAS score) was evaluated at the final follow-up.

RESULTS

The two treatment groups were evenly matched with respect to age, sex, fracture grade, and time to surgery. The average surgical time, blood loss, number of fluoroscopies, and number of surgeons in group A were all lesser than those in group B (P < 0.05). The closed reduction rate in group A was higher than those in group B (P < 0.05). The fracture healing time, AOFAS score, and complication rate were not significantly different (P > 0.05) between the two groups.

CONCLUSION

The new reduction device could effectively achieve and maintain the reduction of tibia shaft fractures in a minimally invasive fashion.

Combined Olecranon Osteotomy and the Posterior Minimal Invasive Plate Osteosynthesis Approach for a Concomitant Injury of the Humeral Shaft and a Distal Intraarticular Humerus Fracture

A complex fracture involving the distal humerus is a difficult fracture to treat and more so when it is involved with the ipsilateral shaft of the humerus. Open reduction and internal fixation of the humeral shaft with articular reconstruction have been described for a successful outcome of these complex fractures. However, it has drawbacks, especially in terms of soft tissue dissection and subsequent scarring and non-union.

A 42-year-old female presented to the emergency department with a fracture of the intercondylar humerus with an ipsilateral shaft of the left humerus. Combined olecranon osteotomy with posterior minimal plate osteosynthesis was used to treat this fracture. At the one-year follow-up at the postoperative fracture clinic, there was no pain, the range of motion (ROM) of the elbow was 10 degrees to 140 degrees and the radiograph showed a healed fracture with the implant in situ.

We present and review a novel technique to treat complex humerus fractures. Articular fragments can be directly visualized and fixed simultaneously. This approach allows for the biological fixation of the fracture and forms a reliable option for treating such complex fractures.

Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) Combined with Onionskin-Like Autologous Bone Grafting: A New Technique for Treatment of Tibial Nonunion

BACKGROUND Established tibial nonunions rarely heal without secondary intervention; revision surgery is the most common intervention. Herein, we evaluated the clinical outcomes of patients with tibial nonunion treated with a new technique - minimally invasive percutaneous plate osteosynthesis (MIPPO) - combined with a new onionskin-like autologous bone grafting method. MATERIAL AND METHODS From 2010 to 2013, 18 patients with tibial nonunions (average bone defect: 9.5 mm) were treated with MIPPO technology combined with onionskin-like autologous bone grafting. Indices for clinical evaluation included operative time, fluoroscopy time, blood loss, hospital stay, healing time, postoperative complaints, radiographic performances, the Short Musculoskeletal Function Assessment (SMFA) questionnaire, and the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. RESULTS The average operation and fluoroscopy times for tibial nonunion were 65 min and 15.5 s, respectively, with a total blood loss of 107.7 mL. The mean duration of hospital stay was 12.8 days. The mean follow-up time was 11.9 months, and all patients achieved radiologically confirmed bony healing in an average time of 13.1 weeks. No lower-leg deformity, fixation failure, infection, and vascular, or nerve injuries were recorded in any patient, and only 4 patients complained of slight limb pain upon total weight-bearing at the end of follow-up. The SMFA and AOFAS ankle-hindfoot scores of patients were graded excellent in 14 (77.8%) and good in 4 (22.2%), indicating high functional recovery. CONCLUSIONS MIPPO technology combined with onionskin bone grafting is an efficient method to treat patients with tibial nonunion, especially for patients with poor soft tissue condition.

Minimally invasive plate osteosynthesis for the treatment of sternal fracture in the lower chest: a case report

Sternal fracture is a common complication of chest trauma but has a low incidence. Various treatments have been developed to reconstruct sternal fractures. Among these approaches, analgesia, corset fixation, and open reduction with plate internal fixation have been suggested. The use of newly developed minimally invasive plate osteosynthesis is a feasible method. In this study, we report a case involving a 54-year-old man with a sternal fracture accompanied by bilateral pleural effusion and a small amount of right-sided pneumothorax. The patient was treated with minimally invasive plate osteosynthesis. The operation was successful and the postoperative recovery was good. No pneumothorax or complications such as chest pain, paresthesia, or wound infection were observed at the 1-year follow-up visit. Additionally, the bilateral pleural effusion had been completely absorbed. The incision in the lower chest was aesthetic and minimally traumatic. This case describes a novel method for internal fixation of sternal fractures.