Fractures of the Distal Tibia: Minimally Invasive Plate Osteosynthesis

Injury, Int. J. Care Injured (2004) 35, 615—620

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

KEYWORDS
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.

Introduction
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

References: 1. Borrelli J, Prickett W, Song E, Becker D, Ricci W. Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study. J Orthop Trauma 2002;16:691—5. 2. Collinge C, Sanders R, DiPasquale T. Treatment of complex tibial periarticular fractures using percutaneous techniques. Clin Orthop 2000;375:69—77. 3. Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H. Minimally invasive plate osteosynthesis and vascularity: preliminary results of a cadaver injection study. Injury 1997;28:S-A7—S-A12. 4. Field RJ, Tornkvist H, Hearn TC, et al. The influence of ¨ screw omission on construct stiffness and bone surface strain in the application of bone plates to cadaveric bone. Injury 1999;30:591—8. 5. Fisher WD, Hambledon DL. Problems and pitfalls of compression fixation of long bone fractures: a review of results and complications. Injury 1978;10:99—107. 6. Frigg R. Locking compression plate (LCP). An osteosynthesis plate based on the dynamic compression plate and point contact fixator (PC-Fix). Injury 2001;32:S-B63—6. 7. Helfet DL, Shonnard PY, Levine D, Borrelli J. Minimally invasive plate osteosynthesis of distal fractures of the tibia. Injury 1997;28:S-A42—8. 620 D.J. Redfern et al. 8. Koury A, Liebergall M, London E, Mosheiff R. Percutaneus plating of distal tibial fractures. Foot Ankle Int 2002;23: 818—24. 9. Krettek C, Schandelmaier P, Miclau T, Tscherne H. Minimally invasive percutaneous plate osteosynthesis (MIPPO) using the DCS in proximal and distal femoral fractures. Injury 1997;28:S-A20—30. 10. Krettek C, Schandelmaier P, Miclau T, Bertram R, Holmes W, Tscherne H. Transarticular joint reconstruction and indirect plate osteosynthesis for complex distal supracondylar femoral fractures. Injury 1997;28:S-A31—41. 11. McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J Orthop Trauma 1992;6:273—85. 12. Muller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Berlin: Springer-Verlag; 1990. 13. Olerud S, Karlstrom G. Tibial fractures treated by AO compression osteosynthesis. Acta Orthop Scand Suppl 1972; 1:1—104. 14. Oni OO, Stafford H, Gergg PJ. A study of diaphyseal fracture repair using tissue isolation techniques. Injury 1992;23: 467—70. 15. Perren SM. Editorial. Injury 2002;33:S-A-VI—S-A-VII. 16. Rhinelander F. The normal microcirculation of diaphyseal cortex and its response to fracture. J Bone Joint Surg Am 1968;50A:784—800. 17. Robinson CM, McLaughlan GJ, Mclean IP, Court-Brown CM. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br 1995;77B:781—7. 18. Ruedi T, Allgower M. Fractures of the lower end of the tibia ¨ ¨ into the ankle joint. Injury 1969;1:92. 19. Ruedi T, Allgower M. The operative treatment of intra¨ ¨ articular fractures of the lower end of the tibia. Clin Orthop 1979;138:105—10. 20. Russell TA. Fractures of the tibia and fibula. In: Rockwood CA, Green DP, Buckolz RW, Heckman JD, editors. Fractures in adults. 4th ed. Philadelphia: Lippincott; 1996. p. 2139— 57. 21. Sanders R, Haidukewych GJ, Milne T, et al. Minimal versus maximal plate fixation techniques of the ulna: the biomechanical effect of number of screws and plate length. J Orthop Trauma 2002;16:166—71. 22. Tornetta III P, Weiner L, Bergman M, et al. Pilon fractures: treatment with combined internal and external fixation. J Orthop Trauma 1993;7:489—96. 23. Wenda K, Runkel M, Degreif J, Rudig L. Minimally invasive plate fixation in femoral shaft fractures. Injury 1997;28:SA13—9. 24. Whiteside L, Lesker PA. The effects of periosteal and subperiosteal dissection. J Bone Joint Surg Am 1978;60A: 26—30.