Extra-articular Distal Tibia Fractures Research Articles

Functional Outcome of Extra-Articular Distal Tibia Fracture Treated with Tibia Interlocking Nail: A Case Series

Background: Intramedullary interlocking nailing has emerged as one of the suitable management options for distal tibia fractures as it allows mechanical compression on weight-bearing, which stimulates bone healing. We studied 40 cases of extra-articular distal tibia fracture treated by intramedullary nailing. Methods: We retrospectively studied 40 patients of both sexes above the age of 18 years with closed fractures and grade 1, 2, and 3A compound fractures treated at SVP Hospital, Ahmedabad, India. Clinically, the fracture was considered to be united when the patient was completely pain-free. Patients were followed up at monthly intervals till union. At each follow-up, patients were assessed both clinically and radiographically, and details were recorded based on proforma. Results: The evaluation of the result was done using American Orthopedic Foot and Ankle Society (AOFAS) criteria. Thirty-three patients had excellent functional results, five had good functional results, and Two had fair functional results. In this study, 38 (95%) patients had radiological union within 24 weeks. Two patients had union after 28 weeks. Conclusion: Intramedullary nailing is a minimally invasive procedure that preserves the soft tissue and the fracture hematoma. It maintains the length, alignment, and rotation and allows micromotion at the fracture site on weight-bearing, which stimulates callus formation. It has a good functional outcome with gratifying results when used in extra-articular distal tibia fractures.

Effect of tibial rotation on knee and ankle function in patients with extra-articular distal tibial fractures after minimally invasive plate osteosynthesis treatment

To investigate the effect of tibial rotation on knee and ankle function in the patients with extra-articular distal tibial fractures after minimally invasive plate osteosynthesis (MIPO) treatment. A retrospective analysis was conducted on 45 patients with extra-articular distal tibial fractures who underwent MIPO between January 2021 and December 2022. There were 20 males and 25 females, aged from 19 to 68 years (mean, 43.6 years). The causes of fractures included falling from heights in 11 cases, traffic accidents in 15 cases, bruising by a heavy object in 7 cases, and falling in 12 cases. The time from injury to hospitalization was 1-6 hours (mean, 3.7 hours). There were 28 cases of simple tibial fractures and 17 cases of tibial fractures combined with ipsilateral fibular fractures; 9 cases of open fractures and 36 cases of closed fractures. According to AO/Orthopaedic Trauma Association (AO/OTA) classification, the distal tibial fractures were classified as type 43A1 in 12 cases, type 43A2 in 17 cases, and type 43A3 in 16 cases. During follow-up, the Lower Limb Function Score (LEFS), American Orthopaedic Foot and Ankle Society (AOFAS) score, and Knee Injury and Osteoarthritis Score (KOOS) were used to evaluate the lower limb, ankle, and knee joint functions, respectively. The range of motion (ROM) of the knee and ankle joints was measured. The Short Form Health Survey (SF-36) was used to assess the quality of life of the patients. The fracture healing was observed by anteroposterior and lateral X-ray films of the ankle joint. The bilateral tibial rotation angles were measured on CT and the differences between the affected and healthy sides were caculated. The difference ≥10° was judged as tibial malrotation. According to whether there was tibial malrotation, the patients were allocated into a normal group and a malrotation group for efficacy comparison. The incisions of all patients healed by first intention without any early complications. All patients were followed up 12-26 months (mean, 18.6 months). Imaging re-examination showed that all fractures healed, with a healing time of 9-14 weeks (mean, 11.2 weeks). At last follow-up, the LEFS score was 60-68 (mean, 62.3); the AOFAS score was 89-97 (mean, 92.6); the KOOS score was 158-164 (mean, 161.3). The ROM of ankle was 40.0°-45.0° (mean, 42.8°) in flexion and 10.5°-22.0° (mean, 17.7°) in extension; the ROM of knee was 130.0°-135.0° (mean, 132.6°) in flexion and -8.8°- -5.0° (mean, -7.1°) in extension. The SF-36 score was 89-93 (mean, 90.7). The absolute value of difference of tibial rotation angle was 2.6°-17.3° (mean, 8.9°) in 45 patients, and the malrotation was observed in 15 patients (33.3%), including 10 cases of internal rotation and 5 cases of external rotation. There was no significant difference ( P>0.05) in the proportion of patients with fibular fractures before operation between the malrotation group and the normal group, as well as in the AOFAS score, KOOS score, LEFS score, SF-36 score, and ROMs of knee and ankle joints at last follow-up. The incidence of tibial malrotation after MIPO treatment for extra-articular distal tibial fractures is relatively high, but it has no significant effect on knee and ankle functions. However, careful manipulation and precise evaluation should be performed during operation to avoid the occurrence of malrotation.

Comparison of retrograde and antegrade tibial intramedullary nail in the treatment of extra-articular distal tibial fractures.

The aim of this study was to compare the effectiveness of retrograde and antegrade intramedullary tibial nails (RTN and ATN) in managing extra-articular distal tibial fractures, addressing current controversies in surgical approaches. A retrospective analysis included 56 patients treated between December 2019 and August 2022 with either RTN (n = 23) or ATN (n = 33). Data on baseline characteristics, operative specifics, fluoroscopy usage, hospitalization duration, fracture healing times, time to full weight-bearing, distal tibial alignment, American Orthopedic Foot and Ankle Society (AOFAS) scores at final follow-up, and complications were evaluated and compared. Baseline characteristics were generally comparable and no significant differences except for fracture line lengths (RTN: 6.1 ± 1.9cm vs. ATN: 7.8 ± 1.6cm) were observed. Follow-up ranged from 12 to 20 months. No significant differences were observed in operative duration, hospital stays, coronal angulation of the distal tibial joint surface, or AOFAS scores at final follow-up. Intraoperative fluoroscopy was more frequent in the ATN group (9.5 ± 1.5) compared to RTN (8.3 ± 1.1) (P = 0.001). RTN showed shorter healing times (9.6 ± 1.2 weeks) and quicker return to full weight-bearing (12.9 ± 1.3 weeks) than ATN (10.6 ± 1.2 weeks and 13.9 ± 1.7 weeks, respectively). RTN complications included one delayed union, one superficial infection, and two ankle pain, while ATN complications comprised one delayed union, one superficial infection, seven anterior knee pain, and one malalignment. Despite higher complication rates with ATN, the differences were not statistically significant. For the treatment of extra-articular distal tibial fractures, both RTN and ATN are effective approaches. RTN may offer benefits such as reduced fluoroscopy use, accelerated healing, and earlier return to full weight-bearing compared to ATN.

Open Reduction and Internal Fixation versus Minimally Invasive Plate Osteosynthesis in Management of Distal Tibia Extra-Articular Fracture (Mini Thesis)

Abstract Background Extra-articular distal tibia fracture is one of the difficult fractures to treat and the optimal treatment remains controversial, however plates seem to be the obvious choice for treating this type of fractures. The mechanism on how to achieve the balance between anatomic reduction and indirect reduction as well as direct and indirect healing remains unclear. Thus, the key point is whether to use ORIF or MIPO in treating fractures. Aim of the Work to provide a complete overview of the optimal plating technique for distal tibia fractures by evaluating and comparing the clinical and functional outcomes of minimally invasive plate osteosynthesis (MIPO) vs Open reduction and internal fixation (ORIF) for treating extra- articular distal tibial fractures. Outcomes of interest include operation time, time to union, non-union, mal-union, infection, secondary operations, and functional outcomes (AOFAS score). Patients and Methods From August 2020 to August 2021, a prospective randomized study was conducted at the department of orthopedic surgery of Ain-shams University Hospital including 36 patients to compare MIPO vs. ORIF in fixation of extra-articular distal tibial fractures. The patients were allotted to the MIPO or ORIF group with the flip of a coin. Results Regarding complications rate, no cases developed infection in MIPO technique. On the other hand, the ORIF technique had an infection incidence of 16.6% overall, with two cases (11.11 %) developing superficial infection and one case (5.56 %) developing deep infection. There was no significant difference in the incidence of mal-union between both techniques with no cases of non-union in both groups. The MIPO group had only one case of sagittal plane malunion (5.56%), compared with no cases in the ORIF group. There was no significant difference between both groups in secondary operations rate, with one case in each group. Conclusion Both MIPO and ORIF have similar therapeutic efficacy regarding the functional outcome and can be used safely in distal tibial extra-articular fractures. Although MIPO is advantageous over ORIF with earlier weight-bearing, earlier union, and clinical lower incidence of infection, it has delayed operation time.

The Lateral Para-Patellar Approach for Intramedullary Tibia Nailing in Distal Tibia Extra-articular Fractures: A Prospective Cohort Study.

The treatment of extra-articular distal tibiafractures is still a subject of debate and frequently necessitates surgical treatment, and intramedullary nailing (IMN) offers a minimally invasive approach with excellent results. Important factors in these procedures are positioning, operative duration, and radiation exposure. This study details the semi-extended lateral para-patellar approach for IMN of distal tibia extra-articular fractures and documents our findings regarding operative time, intra-operative radiation exposure, residual anterior knee pain, knee functional and radiological outcomes at six months follow-up. We reviewed the cases of 60 patients who underwent IMNfor distal tibia extra-articular fractures from May 2022 to March 2024, employing an extra-articular lateral para-patellar approach in the semi-extended position. Patients were evaluated clinically and radio-graphically for a minimum follow-up period of six months. Data collected included duration of surgery, intraoperative radiation exposure, and knee functional scorefor all patients. Assessment of fracture healing, residual deformities, residual anterior knee pain, and range of motion of the treated knee compared to the contralateral knee was done at a six-monthfollow-up. The average surgery duration was 54 ± 5 minutes, with intraoperative imaging averaging 48 exposures. The average time to union was 16 ± 3 weeks. Six months post-surgery, the mean Knee Society Score was 86.4 ± 3.5 (out of 100). At the six months follow-up, all patients exhibited clinical and radiographic healing, with only two cases showing mal-alignment (angular deformity <10 degrees).All patients regained a comparable range of motion in their knees. The semi-extended lateral para-patellar approachfor nailing of distal tibiaextra-articular fracturesenhances reduction, simplifies nail insertion,reduces both fluoroscopy and operative time, minimizes anterior knee pain and improves knee functional outcomes at six months follow-up.

Evaluation of the Stability of Internal Fixation Constructs in a Low Distal Tibia Extra-articular Cadaveric Fracture Model: A Comparative Biomechanical Study.

Introduction Despite the recent advances in implant design, the choice of an internal fixation modality for extra-articular distal tibia fractures remains controversial, and there is sparse literature comparing the stability of intramedullary nails and locked plates for such fractures. Hence, we conducted a biomechanical study on an AO type 43A3 tibia fracturecadaveric model stabilized by four different constructs, viz., intramedullary (IM) interlocking nail, anteromedial plate, anterolateral plate, and posterior plate.An AO type 43A3 fracture is defined as an extra-articular fracture of the distal tibia with metaphyseal comminution. Methods A biomechanical comparative study on formalin-preserved human cadaveric tibiae was undertaken; a total of four groups were tested, with eight bones in each group. Out of the 32 cadaveric tibiae, 19 bones belonged to male cadavers, and 13 bones belonged to female cadavers. All bones were dissected from age-appropriate cadavers and fixed with an implant, followed by the creation of a 1 cm osteotomy to simulate an AO type 43A3 fracture. All fixation constructs were subjected to three-point bending tests in the anteroposterior (AP) and mediolateral (ML) planes. Three parameters, viz., bending stiffness, peak fracture gap angle, and neutral zone, were evaluated on the load-displacement curves. Afixation construct was deemed biomechanically stable if it had a highbending stiffness, a low neutral zone (inherent toggle in the construct by its weight), and a low peak fracture gap angle. Results Out of the four implants tested, locked IM nails exhibited the maximum biomechanical stability in terms of higher bending stiffness, smaller peak fracture gap angle, and smaller neutral zones. The IM nail exhibited the highest bending stiffness in the AP plane, and the anterolateral plate had the lowest bending stiffness, and the difference was statistically significant (p= 0.032).In the AP plane, the anterolateral plate exhibited a bending stiffness of 1.51 ± 0.69 Nm/degree, whereas the intramedullary nail exhibited a bending stiffness of 2.34 ± 0.81 Nm/degree, and the posterior locked plate had a bending stiffness of 1.57 ± 0.44 Nm/degree. In the ML plane, the anterolateral plate exhibited the highest neutral zone as compared to the intramedullary nail, which had the lowest neutral zone, and the difference was statistically significant (p = 0.019). The intramedullary nail exhibited the lowest neutral zone of 0.46 ± 0.31 degrees, whereas the posterior locked plate exhibited a neutral zone of 0.78 ± 0.43 degrees in the ML plane. The anterolateral plate exhibited a neutral zone of 1.43 ± 1.00 (expressed as mean ± SD) degrees in the mediolateral plane. Conclusion Our biomechanical study supports the recommendations of using a locked intramedullary nail for AO type 43A3 fractures. We concluded that the anterolateral plate construct exhibited the least biomechanical stability, in terms of lower AP bending stiffness and higher neutral zone. If the surgeon must choose a locked plating technique for any reason, the anterolateral locking plate should be avoided. If plating is at all required, we can recommend both anteromedial and posterior locked plating as biomechanically sound options.

Intramedullary nail fixation of fibular fractures in combination with extra-articular distal tibial fractures (AO/OTA 43A): a single-center retrospective study.

Treatment of fibular fractures associated with extra-articular distal tibia fractures is technically challenging and the purpose of this study was to evaluate the use of intramedullary nail fixation of fibular fractures when associated with this fracture. Between January 2018 and December 2021, 33 patients presenting extra-articular distal tibia fractures and fibular fractures (AO/OTA 43A) were treated. Clinical and radiological data were collected during routine postoperative follow-ups. Thirty-one patients were monitored for a period of time ranging from 12 to 23 months, with an average follow-up of 17.5 ± 3.3 months. Fibular bone union took an average of 3.6 ± 0.9 months. At the last follow-up, the average fibular alignment and postoperative ankle talocrural angles were 1.8° and 9.1°, respectively. No detectable radiographic rotational malalignment and serious complications related to the fibular incision was observed. The average AOFAS and OMAS scores at the most recent follow-up were 88.3 ± 6.2 and 87.4 ± 6.0, respectively. Intramedullary nail fixation worked well to keep the fibula in place in fibular fractures connected to extra-articular distal tibia fractures.

Comparing Minimally Invasive Percutaneous Plate Osteosynthesis With Interlocking Intramedullary Nail Fixation for the Management of Adult Extra-Articular Distal Tibial Fractures: A Comprehensive Systematic Review and Meta-Analysis.

Intramedullary nailing (IMN) and minimally invasive percutaneous plate osteosynthesis (MIPPO) fixation are both viable approaches for managing distal tibia fractures. IM nailing offers advantages in terms of shorter operation time, faster union, and reduced infection rates, yet it may lead to alignment issues and residual knee pain. Conversely, MIPPO fixation provides better alignment and minimizes knee discomfort but comes with a higher risk of soft-tissue complications and hardware irritation. Notably, this review reveals that MIPPO is associated with a greater risk of both superficial (15% vs. 7% for IMN) and deep infections (14% vs. 6.3% for IMN). This study aims to comprehensively assess the optimal surgical approaches for distal tibia fractures by comparing clinical and functional outcomes between MIPPOand interlocking IMNtechniques in treating extra-articular distal tibial fractures. Key outcome parameters include operation duration, union time, non-union occurrence, malunion cases, infection rates, secondary surgical interventions, and functional results, as indicated by quality of life and ankle scores. Regarding union complications, it is notable that IMN demonstrates a higher incidence of malunion, affecting 14.7% of patients compared to 8.8% in the MIPPO fixation group. Interestingly, both treatment methods exhibit a similar incidence of non-union, occurring in 3.5% of patients in both groups. Furthermore, when assessing the union time, IMN fixation notably achieves significantly shorter union times, especially evident in AO 43A fracture types and closed fractures. The mean time for union is 18 weeks with IMN compared to 20 weeks with MIPPO fixation. In our analysis of nine studies involving 813 patients, the reported operation times revealed an overall weighted mean operation time of 74.1 minutes (ranging from 56.4 to 124 minutes) for IMN and 85.4 minutes (ranging from 51.4 to 124 minutes) for MIPPO fixation. Notably, the operation time for IMN was significantly shorter compared to MIPPO, showing a weighted mean difference (WMD) of -11.24 minutes, with a 95% confidence interval (CI) ranging from -15.44 to -7.05 (P<0.05). This difference exhibited significant moderate heterogeneity (I2 = 68%). In light of this comprehensive study, both MIPPO and IMN emerge as equally effective therapeutic options for addressing functional outcomes in distal tibial extra-articular fractures. While IMN offers several advantages, including lower infection rates, reduced implant irritation, shorter operation time, and earlier weight-bearing and union, it is associated with a heightened risk of malunion and anterior knee pain. Consequently, the choice of implant should be tailored on a case-by-case basis. Patients at elevated infection risk, stemming from factors, such as advanced age, comorbidities, smoking, or severe soft tissue injuries, are better suited for nail treatment. Conversely, MIPPO fixation may present a more advantageous choice for young, active, and healthy patients, given its ability to mitigate the risk of knee pain and malunion.

Functional Outcome of Distal Tibial Fractures Fixed with Distal Tibial Locking Plate using MIPPO Technique

Introduction: Because of the extensive list of potential consequences, treating extra-articular distal tibia fractures is a daunting task for an orthopedic surgeon. This study was designed to evaluate the clinical and functional outcomes of minimally invasive plating for the treatment of distal tibial fractures. Materials and Methods: This prospective study was conducted at the Department of Orthopedic Surgery, Popular Medical College and Hospital, Dhaka during June 2021 to May 2022. A total of 20 patients with distal tibial fracture were selected for surgery and treated with minimally invasive plating. Afterwards, the patients' clinical and radiological outcomes were recorded. The ankle-hindfoot score developed by the American Orthopedic Foot and Ankle Society (AOFAS) was used to assess the functional outcomes. Results: In 15 of the 20 cases, radiological union took place between 18 and 22 weeks (mean 20.5 weeks); however, in 5 cases, union was delayed and required almost 26 weeks to establish. Four of the 20 cases experienced a superficial infection, while the remaining patients showed no further complications. According to the AOFAS score, our research showed that, out of 20 patients, 9 had excellent outcomes, 8 had good results, and 3 had acceptable results. Conclusion: Treatment of distal tibia fractures with locking plates by MIPPO technique is an effective method of therapy to achieve union and excellent functional results since it aids in the early restoration of ankle movement while reducing ankle stiffness. Medicine Today 2023 Vol.35(2): 114-117

The Biomechanical Effects of Intramedullary Fixation to the Level of the Physeal Scar on Distal Tibia Fracture Stability.

The purpose of this study was to evaluate whether intramedullary nail contact with physeal scar improves construct mechanics when treating distal tibial shaft fractures. Axially unstable extra-articular distal tibia fractures were created in 30 fresh frozen cadaveric specimens (15 pairs, mean age 79 years). Specimens underwent intramedullary nailing to the level of the physeal scar locked with one or two interlocks or short of the physeal scar locked with two interlocks (reference group). Specimens were subjected to 800N of axial load for 25,000 cycles. Primary outcomes were stiffness before and after cyclic loading. Secondary outcomes were load to failure, load at 3 mm displacement, plastic deformation, and total deformation. The physeal scar with one interlock cohort demonstrated 3.8% greater stiffness before cycling ( P = 0.75) and 1.7% greater stiffness after cycling ( P = 0.86) compared with the reference group. The physeal scar with two interlocks group exhibited 0.3% greater stiffness before cycling ( P = 0.98) and 8.4% greater stiffness after cycling ( P = 0.41) in relation to the reference group. No differences were identified regarding load to failure or load at 3 mm displacement. In specimens with two interlocks, those in contact with the physeal scar demonstrated significantly less plastic ( P = 0.02) and total ( P = 0.04) deformation. Constructs ending at the physeal scar demonstrated stiffness and load to failure similar to those without physeal scar contact. Less plastic and total deformation was noted in two-interlock constructs with physeal scar contact, suggesting a possible protective effect provided by the physeal scar. These data argue that physeal scar contact may offer a small mechanical benefit in nailing distal tibia fractures, but clinical relevance remains unknown.

Retrograde tibial intramedullary nail versus minimally invasive locking plate for extra-articular distal tibial fractures: A comparative and retrospective study

BackgroundThe fractures of distal tibia represent common lower limb injuries, frequently accompanied by significant soft tissue damage. The optimal surgical approach for these fractures remains a considerable debate. This study was to perform a comparative analysis of retrograde intramedullary tibial nails (RTN) and minimally invasive plate osteosynthesis (MIPO) for extra-articular distal tibial fractures. Patients and methodsBetween December 2019 and December 2021, a retrospective review was conducted on 48 patients who sustained extra-articular distal tibial fractures. Patients underwent either RTN or MIPO procedures. Operative duration, intraoperative fluoroscopy exposure, time to union, duration until full weight-bearing, American Orthopedic Foot and Ankle Society (AOFAS) scores, and related complications were recorded and compared between the two groups. ResultsNo statistically differences were observed in operative duration, time to union, angulation of the distal tibial coronal plane, or AOFAS scores between RTN and MIPO groups. However, the RTN group had a higher average number of intraoperative fluoroscopy images (8.2 ± 2.3) compared to the MIPO group (4.1 ± 2.0). The RTN group demonstrated shorter average hospital stays (7.1 ± 1.4 days) and a quicker return to full weight-bearing (9.9 ± 1.3 weeks), which were significantly superior to the MIPO group (9.0 ± 2.0 days and 11.5 ± 1.5 weeks, respectively). In terms of complications, the RTN group had one case of superficial infection, whereas the MIPO group exhibited two cases of delayed union and nonunion, one instance of implant failure, two occurrences of deep infection, and an additional three cases of superficial infection. The complications rate was remarkably higher in the MIPO group. ConclusionBoth RTN and MIPO are effective treatment options for extra-articular distal tibial fractures. However, RTN may offer superior outcomes in terms of reduced hospital stay duration, faster return to full weight-bearing capacity, and a lower rate of complications.

Comparative Study of Minimally Invasive Plate Osteosynthesis (MIPO) and Intramedullary Nailing (IMN) for Treating Extraarticular Distal Tibial Fractures: Clinical and Radiological Outcomes.

BACKGROUND Treatment of extra-articular distal tibial fractures is problematic owing to limited soft tissue cover, poor vascularity of the location, and adjacency to the ankle, and thus continues to be controversial. This study aimed to compare clinical and radiological outcomes in 69 patients with extra-articular distal tibia fractures treated with minimally invasive plate osteosynthesis (MIPO) and an interlocking intramedullary nail (IMN). MATERIAL AND METHODS Sixty-nine patients, with mean of age 39.8±18.3 years, were retrospectively evaluated. Thirty-five patients were treated with IMN, and 34 patients were treated with MIPO. Clinical and radiological outcomes were evaluated. RESULTS The average follow-up was 13.3±6 months and union time was 16.2±5.4 weeks. Nonunion was observed in only 4.3% of patients treated with MIPO (P=0.114). Non-acceptable malalignment of extremity was observed in 4.3% of patients with IMN and 7.2% of patients with MIPO. There were no significant differences in union time, nonunion, surgical timing, operating time, malalignment, and complications between groups (P>0.05). The mean American Orthopaedic Foot and Ankle Society (AOFAS) surgery score was 95.8±5 in IMN and 91.9±14.3 in MIPO. AOFAS, Tenny-Wiss radiological, and Ovadia-Beals clinical scores were better in IMN than MIPO (P=0.019, P=0.03, P=0.02, respectively). Mean time of full weight-bearing and of return to daily life with IMN was significantly shorter than with MIPO (P.

Minimally Invasive Percutaneous Plate Osteosynthesis versus Interlocking Intramedullary Nail Fixation in Treating Extra-Articular Distal Tibial Fractures in Adults. A Systematic Review

Background IM nailing and MIPPO fixation remain viable options for management of distal tibia fractures. IM nailing provides superior operation time, union time, and time to full weight-bearing as well as a lower incidence of superficial and deep infection, but may provide inferior alignment and is associated with residual knee pain. MIPPO fixation provides superior alignment and avoids knee pain, but it has a higher rate of soft-tissue complications and hardware irritation. This review revealed that MIPPO has a higher risk of both superficial and deep infection among patients treated with MIPPO compared to IMN. In the MIPPO technique, 15% developed a superficial infection, compared to 7% after IMN, and 14% developed a deep infection, compared to 6.3% after IMN. Aim of the Work to provide a complete overview of the optimal surgical treatment of distal tibia fractures by evaluating and comparing the clinical and functional outcomes of minimally invasive percutaneous plate osteosynthesis (MIPPO) vs Interlocking intramedullary nail (IMN) for treating extra-articular distal tibial fractures. Outcomes of interest include operation time, time to union, non-union, mal-union, infection, secondary operations, and functional outcomes (quality of life scores and ankle scores). Patients and Methods In terms of union complication, IMN has a higher incidence of malunion which occurred in 14.7% of the patients after IMN compared to 8.8% after MIPPO fixation. The incidence of non-union was similar in both treatment methods, it occurred in 3.5% of patients. In addition to union rate, the union time was significantly shorter after IMN fixation compared to the MIPPO technique especially in AO 43A fracture type and the closed fractures. The mean time for union was 18 weeks in IMN compared to 20 weeks in MIPPO. Results Nine studies including 813 patients reported on operation time with an overall weighted mean operation time of 74.1 minutes (range 56.4 – 124 minutes) in IMN and 85.4 minutes (range 51.4 – 124 minutes) in MIPPO. The operation time in the IMN was significantly shorter compared to MIPPO (WMD -11.24 minutes, 95% CI -15.44 to -7.05, P &amp;lt; 0.05) with significant moderate heterogeneity (I2 = 68%). Conclusion Based on this study, both MIPPO and IMN have similar therapeutic efficacy regarding the functional outcome and can be used safely in distal tibial extra-articular fractures. Although IMN is advantageous over MIPPO with a lower incidence of infection and implant irritation symptoms, shorter operation time, earlier weight-bearing, and earlier union, it leads to a higher rate of mal-union and anterior knee pain. Overall, choosing an implant based on the findings of this meta-analysis is difficult and should be done on a caseby-case basis. Patients who have a high risk for infection (due to high age, comorbidities, smoking, or severe soft tissue injury) should preferably be treated with a nail. MIPPO fixation may be more beneficial to young, active, and healthy patients who are less prone to infection because it reduces the risk of knee pain and mal-union.

Outcome Assessment of Ankle Spanning External Fixator with Limited Internal Fixation for Distal Tibial Extra Articular Fractures

Background: Road traffic accident claims the lives of almost 1.35 million individuals every year. Because of its subcutaneous arrangement, long bones, particularly the tibia, are usually fractured in these accidents. Since the late 1980s, external fixation with moderate interior fixation has increased. Extra-articular distal tibia fractures generally result from complex, high-energy trauma, which frequently includes accompanying fibular fractures and soft tissue injuries. Method: This is a Hospital-based Prospective Interventional type of study, which include 54 patients, all patients were included in the study of the Orthopaedic department of S.M.S. (Sawai Man Singh) Medical College and attached hospitals in Jaipur Rajasthan, India. The most common trauma mode was road traffic accidents between October-2018 to march-2021. Results: External fixation was used on all fifty-four patients, with or without limited internal fixation. Thirty-eight (70%) of the fifty-four fractures were open, while sixteen (third) were closed. After the operation, the fractures healed in an average of 15.5 weeks. Although none of the patients received bone grafting during the initial treatment of the fracture, twelve patients had bone grafting six weeks after the initial treatment. Mazur’s scoring, modified by Teeny and Wiss, was used to score ankle functions. Angulation of more than 5 degrees is a sign of malunion. Conclusion: External fixation with or without limited internal fixation is an additional option for treating extra-articular distal tibial fractures. Open reduction and plate osteosynthesis have similar union rates.

Extra-articular Distal Tibial Fracture: A Comparative Study of the Outcome Between Closed IMLN and MIPO

Background: The treatment of distal tibial fractures (DTF) is still up for debate. For DTF, minimally invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMLN) are potentially effective techniques; however, they have been linked to complications. Thus, this study was aimed to evaluate and compare clinical and functional results in individuals with DTF that were managed with MIPO or IMLN.Patients and Methods: Between August 2020 and February 2022, 31 patients with closed extra-articular distal tibia fractures were enrolled in a comparative study of locking plate by MIPO versus closed IMLN at the Sulaimani Teaching Hospital and Shar Teaching Hospital. The Foot and Ankle Ability Measure (FAAM) and Johner and Wruh's criteria were used to evaluate the results.Results: IMLN was used on 16 individuals, while MIPO was used on 15 patients that underwent surgery. In terms of time, there was no significant difference (p&gt;0.05) in fracture union, malunion, or functional results. However, there was a significant difference in total weight-bearing following surgery, blood loss, and complications in terms of the operation time.Conclusions: Both techniques were effective in treating a distal tibial extra-articular fracture. IMLN had a faster complete weight-bearing time and a shorter operation time. At the same time, MIPO had less blood loss and equal time in complete union. Thus, we recommend using FAAM as a valuable tool in evaluating functional outcomes after distal tibia fracture.

A Critical Analysis of Lateral Versus Central Endpoint in Distal Tibia Nailing: Does It Affect Alignment?

To evaluate the effect of a traditional "center-center" end point for distal tibia nailing in comparison with a lateral-of-center end point on fracture malalignment in a cadaver model. Nine matched pairs of human cadaveric lower-extremity specimens were used to model the effect of nail end point on fracture alignment in extra-articular distal tibia fractures. After simulation of the fracture through a standardized osteotomy, 1 member of each pair was fixed with an intramedullary nail using a "center-center" end point, whereas a lateral-of-center end point was used for the other member of the pair. Specimens were stripped of soft tissue, and digital calipers were used to measure fracture translation and gap medially, laterally, anteriorly, and posteriorly. Coronal plane angulation at each fracture was measured on the final mortise image. The average coronal angulation was 7.0 degrees of valgus (with a SD of 4.1) in central-end point specimens versus 0.2 degrees of valgus (SD = 1.5) in lateral-end point specimens ( P < 0.001). Lateral-end point specimens also demonstrated significantly less fracture gap medially (mean 0.2 vs. 3.1 mm for central-end point specimens, P < 0.001), anteriorly (mean 0.1 vs. 1.3 mm, P = 0.003), and posteriorly (mean 0.3 vs. 2.2 mm, P = 0.003). Lateral-end point specimens also showed less lateral translation (mean 0.6 vs. 1.6 mm, P = 0.006). Lateral-of-center nail end points may help surgeons restore native alignment in extra-articular distal tibia fractures and avoid valgus malalignment.

Comparison of Intramedullary Interlocking Nailing (IMLNG) and Minimally Invasive Plate Osteosynthesis (MIPO) in Treating Extra Articular Distal Tibial Fractures

Background: Due to limited blood flow and sparse soft tissue coverage, treating distal tibia fractures presents a considerable challenge for orthopaedic surgeons. Objective: Our study's objectives were to compare the outcomes of the two treatment modalities of minimally invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) for extraarticular distal tibia fractures. Study Design: Randomized Controlled Trial Place and Duration of the Study: This study was conducted at Department of Orthopedic and Spine Surgery Sughra Shafi Medical Complex, Narowal from March 2021 to March 2022. Material Methods: During A total of 59 patients ( 30 in IMLN group and 29 in MIPO group), both male and female, with AO Type A, b and C distal tibial fractures lasting less than three days and ages ranging from 20 to 60, were enrolled for this research. At the most recent follow-up, clinical and radiological data were assessed. Results: The average duration to union was 21.9 weeks in the IMN group and 19.9 weeks in the MIPO group, and all of the examined patients eventually recovered. In the IMN group, the time to union was substantially greater (p= 0.001). Conclusion: Low operating, union, and hospitalisation times make MIPO advantageous. In order to lessen the morbidity of these patients, we advise using the minimally invasive plate osteosynthesis (MIPO) procedure as the first line of treatment for distal tibia fractures.. Keywords: Distal tibia fracture, minimally invasive plate osteosynthesis, intramedullary nailing,

Extreme nailing and immediate weight bearing constructs in fractures of the distal tibia.

Extraarticular fractures of the distal tibia can present as difficult but manageable lower extremity injuries. Historically, these injuries have been fixed in a myriad of ways. Early management with intramedullary nailing had higher complication rates due to the unique anatomical and biomechanical features of the distal tibia. Modern improvements in intramedullary nailing surgical techniques and implant design have significantly decreased complication rates and led to improvement in patient outcomes. Many surgeons protect weight bearing postoperatively, but recent literature suggests that patients may safely weight bear immediately following intramedullary fixation. This article reviews technique and implant design changes that have facilitated immediate safe weight bearing following intramedullary nailing of extraarticular distal tibia fractures.

MIPO vs. intra-medullary nailing for extra-articular distal tibia fractures and the efficacy of intra-operative alignment control: a retrospective cohort of 135 patients.

Definitive treatment of distal extra-articular fractures of the tibia is challenging and both minimal invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are considered to be feasible surgical modalities with their own implant-specific merits and demerits. This retrospective study was designed to compare MIPO versus IMN in terms of fracture healing, complications, functional and radiological outcomes and to assess the efficacy of intra-operative alignment control to reduce the rate of malalignment after definitive fixation of distal extra-articular fractures of the tibia. All consecutive adult patients with extra-articular distal meta- or diaphyseal tibia fractures that were treated between January 2012 and September 2019 either with MIPO or IMN were included. Outcome measures included fracture healing, complications (infection, malalignment, subsequent surgeries), functional and radiological outcomes. Intra-operative alignment control encompassed bilateral draping of the lower extremities. A total of 135 patients were included out of which 72 patients (53%) were treated with MIPO and 63 patients (47%) underwent IMN. There was a significantly higher incidence of non-union for fractures treated with IMN (13 (22%) vs. 4 (6%), p = 0.04). There was no significant difference between both groups in terms of rotational malalignment (3% vs. 10%) and angular malalignment (4% vs. 5%). A significantly higher rate of infection was found after MIPO after correction of significant differences in baseline characteristics. No differences were found in subsequent surgeries or functional outcomes. Both MIPO and IMN are reliable surgical techniques. IMN is associated with higher rates of non-union, whereas MIPO results in a higher risk for infection. The incidence of malalignment was surprisingly low endorsing the utility of the intra-operative alignment control.

The outcome of minimally invasive distal tibia plating in a case of an extra articular distal tibia fracture

Background: Aim was to delineate the functional and radiological outcome of minimally invasive distal tibia plating in a case of extra-articular distal tibia fracture using contoured 4.5 DCP plate and long periosteal elevators. Methods: The study was conducted on patients who were diagnosed with extra-articular distal tibia fractures and underwent minimally invasive distal tibia plating in the Department of Orthopaedics, KEM hospital Parel Mumbai from March 2020 till June 2021. Participants were evaluated for functional outcome using the AOFAS score at minimum of 6 months postop, time to full radiological union and time to partial and full unaided weight-bearing was calculated based on follow up OPD visits at 6 weeks, 3 months, and 6 months. Results: Of the 30 participants involved in the study the average period of follow up was 8.47 months, the mean AOFAS score was 89.67, mean time to partial weight bearing was 6.13 weeks. And the mean time to full unaided weight bearing was 10.17 weeks, and the average time to complete radiological union was 17.03 weeks. One patient developed superficial wound complication which was managed with antibiotics and dressing. No patient developed deep infection osteomyelitis and non-union. Conclusions: minimal invasive plate osteosynthesis with contoured 4.5 dynamic compression plate can be successfully used for fixation of extra articular distal tibia fractures with minimal soft tissue compromise and wound complications and excellent results.