Fractures of the distal tibia: minimally invasive plate osteosynthesis D.J. Redfern*, S.U. Syed, S.J.M. Davies
Department of Orthopaedics, Frimley Park Hospital NHS Trust, Surrey, UK Accepted 9 September 2003
Minimally invasive plate osteosynthesis; Plate ﬁxation; Fracture; Tibia; Metaphysis
Summary Unstable fractures of the distal tibia that are not suitable for intramedullary nailing are commonly treated by open reduction and internal ﬁxation and/or external ﬁxation, or treated non-operatively. Treatment of these injuries using minimally invasive plate osteosynthesis (MIPO) techniques may minimise soft tissue injury and damage to the vascular integrity of the fracture fragments. We report the results of 20 patients treated by MIPO for closed fractures of the distal tibia. Their mean age was 38.3 years (range: 17—71 years). Fractures were classiﬁed according to the AO system, and intra-articular extensions according to Ruedi and ¨ Allgower. ¨ The mean time to full weight-bearing was 12 weeks (range: 8—20 weeks) and to union was 23 weeks (range: 18—29 weeks), without need for further surgery. There was one malunion, no deep infections and no failures of ﬁxation. MIPO is an effective treatment for closed, unstable fractures of the distal tibia, avoiding the complications associated with more traditional methods of internal ﬁxation and/or external ﬁxation. ß 2003 Elsevier Ltd. All rights reserved.
Unstable fractures of the distal tibia with or without intra-articular fracture extension can present a management dilemma. Traditionally, there have been a variety of methods of management described and high rates of associated complications reported. Non-operative treatment can be technically demanding and may be associated with joint stiffness in up to 40% of cases as well as shortening and rotational malunion in over 30% of cases.14,20 Traditional operative treatment of such injuries is also *Corresponding author. Present address: 16 Byﬁeld Road, Isleworth, Middlesex TW7 7AF, UK. Tel.: þ44-(0)20-8847-1370; fax: þ44-(0)20-8847-1370. E-mail address: email@example.com (D.J. Redfern).
associated with a high incidence of complications. Intramedullary nailing remains the gold standard for treatment of most diaphyseal fractures of the tibia. However, although some authors have described good results with intramedullary nailing in the treatment of distal peri-articular tibial fractures, it is generally considered unsuitable for such injuries, due to technical difﬁculty and design limitations.17,20 Traditional open reduction and internal ﬁxation of such injuries results in extensive soft tissue dissection and periosteal injury and may be associated with high rates of infection, delayed union, and non-union.5,11,13,18,19,22 Similarly, external ﬁxation of distal tibial fractures may also be associated with a high incidence of complications, with pin infection and loosening in up to 50% of cases and malunion rates of up to 45%.20 Minimally invasive plate osteosynthesis (MIPO) may offer biological
0020–1383/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.09.005
D.J. Redfern et al.
advantages. MIPO involves minimal soft tissue dissection with preservation of the vascular integrity of the fracture as well as preserving osteogenic fracture haematoma.3 MIPO techniques have been used successfully in the treatment of distal femoral fractures.9,10,23 Experience of the application of these techniques to fractures of the distal tibia is less extensive and opinion regarding optimal technique differs. Some authors advocate temporary external ﬁxation prior to deﬁnitive MIPO and routine ﬁxation of associated ﬁbula fractures.7 Others advocate a more selective approach to the role of external ﬁxation and ﬁbular ﬁxation.2
We report our experience with minimally invasive plate...