Minimally Invasive Percutaneous Plate Osteosynthesis (Mippo) in Distal Tibial Fractures – A Prospective Study from Developing Nation

Fractures of the distal tibial metaphysis with or without intraarticular extension can present a management challenge because of their inherent instability, scarcity of soft tissues, subcutaneous nature and poor vascularity of bone. Treatment modality is dictated by the fracture displacement, comminution, intra-articular extension and injury to the soft-tissue envelope [1]. The surgical treatment of fractures has evolved a great deal since the development of the original “open reduction and internal fixation” technique by the AO group, even though high rates of complications have been reported in literature with conventional methods [2-6]. Although intramedullary nailing minimizes surgical trauma to already traumatize soft tissues envelop, but is generally not considered suitable for distaltibial fractures because of lack of biomechanical stability of fixation and subsequent risk of malunion. Conventional plating results in extensive soft tissue dissection and periosteal injury, further compromising the blood supply to already traumatize soft tissues. External fixators are effective in managing compound fractures and fractures associated with extensive soft-tissue injury, but are also not free of complications, and are associated with a high incidence of pin tract infection, loosening and malunion [7]. A mechanically stable fracture-bridging osteosynthesis can be obtained without significant dissection and surgical trauma to the bone and surrounding soft tissues by minimally invasive percutaneous plate osteosynthesis (MIPPO) [8]. This technique utilizes indirect reduction and internal fixation with locking compression plates. The plate is tunneled subcutaneously, but extra periosteally, through limited skin incisions placed at the proximal and distal ends of the plate, bypassing the fracture site and then making a stable construct by judicious use of compression and locking screws. This technique aims to preserve bone biology and minimizes surgical trauma to already traumatized soft tissues. MIPPO with LCP offers biological advantages over conventional plating techniques in terms of low surgical trauma, preservation of the Abstract