Journal of Orthopaedic Surgery 2014;22(3):299-303

Minimally invasive plate osteosynthesis for

distal tibial fractures
Pramod Devkota,1 Javed A Khan,2 Suman K Shrestha,2 Balakrishnan M Acharya,2 Nabeesman S Pradhan,2 Laxmi P
Mainali,2 Padam B Khadka,3 Hemanta K Manandhar3
Department of Orthopaedics and Trauma Surgery, Gandaki Medical College Teaching Hospital, Pokhara, Nepal
Department of Orthopaedics and Trauma Surgery, Patan Hospital, Lalitpur, Nepal
3
Department of Orthopaedics and Trauma Surgery, Kaski Sewa Hospital, Pokhara, Nepal
1
2

ABSTRACT
Purpose. To review the outcomes of 53 patients who
underwent minimally invasive plate osteosynthesis
(MIPO) for distal tibial fractures.
Methods. Medical records of 31 men and 22 women
aged 22 to 78 (mean, 51) years who underwent MIPO
using a locking compression plate for distal tibial
fractures of the left (n=28) and right (n=25) legs with
or without intra-articular extension were reviewed.
Results. Patients were followed up for a mean of 26
(range, 2438) months. The mean time from injury to
surgery was 9 (range, 312) days. The mean operating
time was 105 (range, 75180) minutes. The mean
hospital stay was 16 (range, 825) days. Non-weight
bearing walking with a crutch was started after a
mean of 5.7 (range, 39) days. The mean time to callus
formation was 12 (range, 815) weeks. The mean time
to full weight bearing was 15 (range, 822) weeks.
The mean time to bone union was 25 (range, 2030)
weeks. All except 2 fractures united anatomically. At
10 months, the range of motion of the ankle joint in

all patients was similar to the contralateral side. Two

patients had malunion but this was not clinically
significant. Five patients had superficial infection,
and 2 patients had persistent pain.
Conclusion. MIPO is effective for closed, unstable
fractures of the distal tibia. It reduces surgical trauma
and preserves fracture haematoma.
Key words: bone plates; fracture fixation, internal;
tibial fractures

INTRODUCTION
The optimal treatment for unstable distal tibial
fractures remains controversial. Non-operative
treatment can be technically demanding and is
associated with joint stiffness (up to 40%) as well
as shortening and rotational malunion (>30%).1,2
Open reduction and internal fixation (ORIF) requires
extensive soft tissue dissection and may lead to
periosteal injury. ORIF is associated with high
rates of infection, delayed union, and non-union.36
External fixation is preferred when soft tissue injury

Address correspondence and reprint requests to: Dr Pramod Devkota, Department of Orthopaedics and Trauma Surgery, Gandaki
Medical College Teaching Hospital, Pokhara, Nepal. Email: devkotap@gmail.com

Journal of Orthopaedic Surgery

300 P Devkota et al.

is severe, but it is associated with pin tract infection,

malunion, and non-union.7 Furthermore, coping with
the external fixator over a long period is a challenge
for patients. Ilizarov frames, ankle-spanning, and
hybrid constructs can be used in conjunction with
limited internal fixation.8 Nail osteosynthesis is the
preferred treatment for shaft fractures, but it is not
always practical for the distal tibia, as fractures in this
region are often spiral or extend to the tibial pilon.9
Minimally invasive plate osteosynthesis (MIPO)
using an elastic bridging plate reduces iatrogenic
soft tissue injury and preserves bone vascularity and
haematoma.10 In accordance with the biomechanical
principles of intramedullary nailing, MIPO is
performed without stripping the periosteum or
muscles from the bone. MIPO aims to achieve correct
limb length and axial and rotational alignment of
the main fragments, with minimal damage at the
fracture site. Healing takes place by the formation of
callus from the periosteum and soft tissues.9 Results
of closed reduction and percutaneous plating for
closed distal tibial fractures are encouraging.11,12 We
reviewed the outcomes of 53 patients who underwent
MIPO for distal tibial fractures.
MATERIALS AND METHODS
This study was approved by the ethics committees
of our hospitals; informed consent was obtained
from each patient. Medical records of 31 men and
22 women aged 22 to 78 (mean, 51) years who
underwent MIPO using a locking compression plate
for distal tibial fractures of the left (n=28) and right
(n=25) legs with or without intra-articular extension
between January 2007 and December 2009 were
reviewed. Patients with a complex pilon fracture or
open fracture more severe than type 113 according to
the AO classification14 were excluded, as were those
in whom MIPO was converted to ORIF owing to
unsatisfactory reduction.
Patients were initially treated with a plaster splint
with elevation until definitive fixation. Surgery was
delayed only if patients had soft tissue swelling or
were unfit for anaesthesia.
Patient was placed supine on a radiolucent table;
a tourniquet was used. A small incision was made
over the medial malleolus, sparing the saphenous
vein and nerve. The anatomic pre-shaped narrow 4.5
mm locking plate (Sharma Surgical, Vadodara, India)
was inserted extraperiostally under fluoroscopic
guidance. The fracture was then reduced indirectly
by manual traction and/or with the help of the
distractor. The plate was fixed with at least 3 locking

screws in the proximal and distal ends (5.0-mm and

4.5-mm screws, respectively). In 6 patients with
severe comminution of the tibia, the fibula was also
fixed with plates for accurate reconstruction of leg
length using ORIF (Fig.). A conventional screw was
also used when necessary to reduce the malalignment
of the fracture.12
Postoperatively, an above-knee plaster of Paris
slab was applied for one week. Sutures were removed
at week 2. Early active and passive knee and ankle
range of motion exercises were encouraged. Partial
weight bearing with crutches was allowed for the
first 6 weeks and then gradually increased to full
weight bearing. Patients were followed up at week
6 and months 3, 6, 9, 12, 18, and 24. Bone union was
defined as presence of callus bridging on radiographs
and the ability to full weight bearing without pain.15
RESULTS
Patients were followed up for a mean of 26 (range,
2438) months (Table). The mean time from injury to
surgery was 9 (range, 312) days. The mean operating
time was 105 (range, 75180) minutes. The mean
hospital stay was 16 (range, 825) days. Non-weight
bearing walking with a crutch was started after a
mean of 5.7 (range, 39) days. The mean time to callus
formation was 12 (range, 815) weeks. The mean time
to full weight bearing was 15 (range, 822) weeks.
The mean time to bone union was 25 (range, 2030)
weeks. All except 2 fractures united anatomically
(<5 of rotation, <1 cm of shortening, and <5 varus/
valgus deviation). No patient had plate bending,
neurovascular injury, or tourniquet palsy. At 10
(a)

(b)

Figure Radiographs (a) before and (b) 6 months after

minimally invasive plate osteosynthesis for distal tibial
fracture.

Vol. 22 No. 3, December 2014

invasive plate osteosynthesis for distal tibial fractures 301

Table
Patient characteristics and outcomes

Sex/
Side
age
(years)

Cause*

AO
Open
fracture fracture
type
type

F/63
M/28
F/66
M/70
F/22

Left
Left
Left
Right
Right

FFH
RTA
RTA
FFH
RTA

43.A2
42.B1
43.A2
42.C1
43.A3

No
I
No
No
I

M/68
F/52
M/45
M/50
M/57
F/58
M/37
M/78
F/45
F/22
M/29
M/46
F/69
F/46
M/66
F/49
M/57
F/35
M/39
M/61
F/71
M/75

Right
Left
Right
Right
Left
Left
Right
Right
Left
Left
Right
Left
Left
Left
Right
Right
Left
Right
Left
Right
Right
Left

42.B3
43.A2
42.B1
42.B3
43.A3
42.A2
43.A2
42.A1
43.A3
43.A2
42.A1
42.B1
43.A2
42.A2
42.C1
43.A2
43.A1
43.A3
43.A3
43.C1
43.A3
43.A3

No
No
No
I
No
No
I
No
No
No
No
I
No
No
No
No
No
I
No
No
No
No

M/62
F/44
M/53
M/32
F/54
M/29
F/49

Left
Right
Left
Left
Right
Right
Left

43.A2
43.A3
42.B3
43.C1
42.A1
43.A2
42.C1

M/61
F/71
F/56
M/48

Right
Right
Left
Left

F/65
M/24

Right
Right

F/28
M/53
M/61
F/66
M/47
M/64

Left
Left
Right
Left
Right
Left

M/49

Left

M/25
F/67
M/37

Right
Left
Left

M/45
F/63

Left
Right

RTA
Direct hit
RTA
RTA
FFH
RTA
RTA
FFH
FFH
RTA
RTA
RTA
RTA
RTA
FFH
RTA
FFH
RTA
FFH
Direct hit
RTA
Physical
assault
FFH
RTA
Direct hit
FFH
RTA
Direct hit
Physical
assault
RTA
FFH
Direct hit
Physical
assault
FFH
Physical
assault
RTA
FFH
Direct hit
FFH
RTA
Physical
assault
Physical
assault
FFH
FFH
Physical
assault
RTA
FFH

M/23

Right

RTA

Associated injuries

No
No
I
No
No
No
No

No
No
Right distal radial fracture
Posterior malleolar fracture
Right ulnar and radial
fractures
No
No
No
Right distal fibular fracture
No
Lateral malleolar fracture
Right humeral fracture
No
Left distal fibular fracture
No
No
Undisplaced pelvic fracture
Right distal radial fracture
No
No
No
No
No
No
No
No
Left middle and index fingers
fractures
No
No
No
No
No
No
Undisplaced pelvic fracture

43.A3
42.A1
42.B1
42.A1

I
No
No
No

42.B1
42.A2

Hospital Operating Time to

stay
time
mobi(days) (minutes) lisation
(days)

Time to
Full
Bone
radio- weight union
logical bearing (weeks)
union (weeks)
(weeks)

13
10
18
19
22

80
90
75
110
100

4
6
3
5
9

11
9
13
15
10

10
9
13
16
18

21
20
25
24
30

17
21
20
23
16
21
8
25
10
11
15
9
18
24
17
14
20
23
9
25
21
25

80
85
120
105
90
125
110
95
80
100
80
75
95
100
120
125
130
140
120
130
75
80

3
8
5
7
3
5
7
9
9
6
4
3
6
8
5
9
7
6
9
6
7
7

12
14
13
11
13
12
11
14
13
10
10
12
11
8
9
12
9
14
13
15
13
15

12
19
17
13
21
16
22
20
21
20
18
19
22
10
8
13
10
18
12
15
12
22

20
29
28
22
27
20
26
25
28
29
27
28
30
20
22
26
29
28
27
23
29
28

10
12
9
12
17
13
11

85
90
80
150
95
100
110

4
8
5
3
7
8
7

10
12
14
14
12
13
15

9
11
14
13
17
12
15

20
23
26
24
28
20
22

No
No
No
No

19
16
23
9

115
120
110
100

6
3
4
6

14
15
12
13

13
21
11
13

27
22
20
28

I
No

No
Left distal radial fracture

25
10

90
180

7
3

10
8

12
9

22
27

43.A3
43.C1
43.A3
43.A2
43.C1
43.A2

No
No
No
No
No
No

No
No
No
No
No
Left ulnar fracture

11
14
16
22
12
10

100
95
90
160
100
150

4
3
6
3
7
5

10
11
13
12
14
13

10
16
13
11
13
13

23
22
21
27
28
22

43.A1

No

No

17

105

12

20

42.A3
42.B1
42.B1

No
No
No

No
No
No

11
20
12

115
110
95

6
3
8

10
15
12

12
13
14

21
27
25

43.A2
42.C1

No
No

13
19

80
115

3
7

14
15

20
15

22
20

43.A3

No

No
Right intercondylar of
humeral fracture
No

10

120

13

15

21

* RTA denotes road traffic accident and FFH fall from a height

Journal of Orthopaedic Surgery

302 P Devkota et al.

months, the range of motion of the ankle joint in all

patients was similar to the contralateral side.
Two patients had malunion, but this was not
clinically significant (varus angulation of 10 and
8). Five patients had superficial infection, which
was resolved with intravenous antibiotics and
regular dressings. One patient had pain in the
medial malleolar region after 18 months. One patient
had non-specific pain around the ankle and foot
suspected to be reflex sympathetic dystrophy, which
was treated with aggressive physiotherapy; the pain
decreased dramatically but persisted. In 10 patients,
implants were removed after a mean of 21 (range,
1825) months for various social reasons.
DISCUSSION
Complications of ORIF with plates or closed
intramedullary nailing for distal tibial fractures
include nail or locking bolt failures, malunion,
wound infection, and bone healing problems.16,17
MIPO was initially developed for subtrochanteric
and distal femoral fractures,18 and then modified for
fractures of the femoral shaft and proximal and distal
tibia.11,19 Indirect fracture reduction and percutaneous
plating techniques20 minimise the extent of soft
tissue damage in long bone fractures.21,22 The distal
metaphyseal tibia has a rich extra-osseous blood
supply provided by branches of the anterior and

posterior tibial arteries; disruption of this extraosseous blood supply is greater in open plating than
MIPO.23 Thus, it is challenging to achieve mechanical
stability without impairing the blood supply.9
In our study, the delay in surgery was due to
swelling, medical problems, unavailability of the
operating room, and financial reasons. Longer hospital
stay was due to the long distance to the patients
homes and transportation problems. The longer time
needed to non-weight bearing walking was because
elderly patients and those multiple contusions
were reluctant to mobilise earlier (isometric muscle
exercises were nonetheless encouraged). The longer
time needed for callus formation was due to the poor
nutritional status of the patients. Nonetheless, the
times to full weight bearing and bone union were
comparable to other studies24,25
CONCLUSION
MIPO using the locking compression plate is effective
for closed, unstable fractures of the distal tibia. It
reduces surgical trauma and preserves fracture
haematoma.
DISCLOSURE
No conflicts of interest were declared by the authors.

REFERENCES
1. Oni OO, Stafford H, Gregg PJ. A study of diaphyseal fracture repair using tissue isolation techniques. Injury 1992;23:467
70.
2. 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; 1996:213957.
3. Fisher WD, Hamblen DL. Problems and pitfalls of compression fixation of long bone fractures: a review of results and
complications. Injury 1978;10:99107.
4. McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J Orthop
Trauma 1992;6:195200.
5. Redi T. Fractures of the lower end of the tibia into the ankle joint: results 9 years after open reduction and internal fixation.
Injury 1973;5:1304.
6. Ruedi TP, Allgower M. The operative treatment of intra-articular fractures of the lower end of the tibia. Clin Orthop Relat
Res 1979;138:10510.
7. Rammelt S, Endres T, Grass R, Zwipp H. The role of external fixation in acute ankle trauma. Foot Ankle Clin 2004;9:45574.
8. Blauth M, Bastian L, Krettek C, Knop C, Evans S. Surgical options for the treatment of severe tibial pilon fractures: a study
of three techniques. J Orthop Trauma 2001;15:15360.
9. Krackhardt T, Dilger J, Flesch I, Hntzsch D, Eingartner C, Weise K. Fractures of the distal tibia treated with closed reduction
and minimally invasive plating. Arch Orthop Trauma Surg 2005;125:8794.
10. 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(Suppl 1):A712.
11. Helfet DL, Shonnard PY, Levine D, Borrelli J Jr. Minimally invasive plate osteosynthesis of distal fractures of the tibia. Injury
1997;28(Suppl 1):A428.
12. Gautier E, Sommer C. Guidelines for the clinical application of the LCP. Injury 2003;34(Suppl 2):B6376.

Vol. 22 No. 3, December 2014

invasive plate osteosynthesis for distal tibial fractures 303

13. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long
bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:4538.
14. Mller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Berlin: SpringerVerlag; 1990.
15. Hasenboehler E, Rikli D, Babst R. Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal
and distal tibial fracture: a retrospective study of 32 patients. Injury 2007;38:36570.
16. Siebenrock KA, Schillig B, Jakob RP. Treatment of complex tibial shaft fractures. Arguments for early secondary intramedullary
nailing. Clin Orthop Relat Res 1993;290:26974.
17. Skoog A, Soderqvist A, Tornkvist H, Ponzer S. One-year outcome after tibial shaft fractures: results of a prospective fracture
registry. J Orthop Trauma 2001;15:2105.
18. 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(Suppl 1):A2030.
19. Oh CW, Kyung HS, Park IH, Kim PT, Ihn JC. Distal tibia metaphyseal fractures treated by percutaneous plate osteosynthesis.
Clin Orthop Relat Res 2003:408:28691.
20. Collinge CA, Sanders RW. Percutaneous plating in the lower extremity. J Am Acad Orthop Surg 2000;8:2116.
21. Rhinelander FW. The normal microcirculation of diaphyseal cortex and its response to fracture. J Bone Joint Surg Am
1968;50:784800.
22. Whiteside LA, Lesker PA. The effects of extraperiosteal and subperiosteal dissection. II. On fracture healing. J Bone Joint
Surg Am 1978;60:2630.
23. Borrelli J Jr, 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;16:6915.
24. Redferin DJ, Syed SU, Davies SJ. Fractures of the distal tibia: minimally invasive plate osteosynthesis. Injury 2004;35:615
20.
25. Hazarika S, Chakravarthy J, Cooper J. Minimally invasive locking plate osteosynthesis for fractures of the distal tibia
results in 20 patients. Injury 2006;37:87787.