Minimally Invasive Plate Osteosynthesis: A Review

Present-day concepts of osteosynthesis emphasize upon biological healing of fractures. This has led to advent of minimally invasive plate osteosynthesis. This technique if used when indicated leads to numerous advantages such as higher rates of union with decreased surgical time, blood loss, post-operative pain, infection rates and certain other postoperative complications. This technique is being applied commonly in fractures such as shaft of humerus, proximal and distal femur, proximal and distal tibia with several benefits over its conventional counterparts. In this review, the authors highlight upon historical aspect of development of this technique, its implementation in different fractures, various factors determining its stable application and its pearls and pitfalls. Access this article online Quick Response Code: Website: www.innovativepublication.com DOI: 10.5958/2395-1362.2016.00029.3 Introduction History of plating dates back to 1886 when the first reported use of a plate for internal fixation of fracture was accomplished by Hansman. The science of plating flourished for several years till the early twenties following an era of disfavor. Plating returned to vogue following the introduction of revolutionary concepts by Muller. He and his colleagues, under the banner of Arbeitsgemeinschaft für Osteosythese (AO) foundation laid down the concepts of operative fixation of fractures. Complete restoration of the bony anatomy under direct vision during fracture fixation was the rule. This resulted in direct fracture healing with absolute stability. But, this came at a price. The price was the risk of bone or soft tissue necrosis and delayed healing as there was widespread soft tissue dissection and interruption of periosteal blood flow. This led to advent to more biology friendly techniques. These biological techniques lay stress upon maximal preservation of blood supply around the fractured bone by minimal direct handling of the fracture environment. They offer advantages which include preservation of the fracture hematoma, less surgical trauma to the surrounding soft tissues, reduced operative time therefore decreased risk of infection and ultimately leading to indirect bone healing with abundant callus. Minimally invasive plate osteosynthesis (MIPO) is a novel technique for application of principles of biological fracture healing with a philosophy of dealing with soft tissues with utmost respect. Brunner and Weber are credited for popularizing this method in the early eighties. Further later, following advancements in implant technology and development of techniques of indirect fracture reduction this technique gained more popularity. The evolution of MIPO began with the use of bridge plating. In initial days a conventional plate was applied for comminuted femoral fractures using long incisions but with preservation of the vastus lateralis muscle resulting in healing with abundant callus. Subsequently, the size of incisions got decreased, rather two small incisions were given at proximal and distal ends and plates were bridged sub muscularly over the fracture fragments. This technique causes minimal distress to soft tissues and bone, provides access to the bone through soft tissue windows, with minimal or no contact with the fracture by indirect reduction tools and leaving behind minimal foot prints. The study focuses over various aspects of application of MIPO technique used in commonly indicated fractures, along with factors influencing its mechanical stability, recent advances and its downside. What are the indications of MIPO? Although minimally invasive approach for plating bears numerous advantages, due to its limitations it is not universally applicable. A careful preoperative planning is required prior to its implementation with bearing in mind the anatomical aspect of the fracture, condition of soft tissue, etiology of the fracture, type of construct required and date since injury. Indications for MIPO have been summarized by Babst and Khong:  epi-/metaphyseal fractures;  poor soft tissue condition obviating an open procedure;  conditions where intramedullary nailing is not feasible: unsuitable fracture pattern (intra-articular extension), narrow, deformed or obstructed intra-