Invasive Plate Osteosynthesis Research Articles

A comparative study of locking plate combined with minimally invasive plate osteosynthesis and intramedullary nail fixation in the treatment of Neer classification of two-part and three-part fractures of the proximal humerus.

To compare the clinical efficacy of the minimally invasive locking plate technique (Philos plate) and interlocking intramedullary nailing technique (TRIGEN intramedullary nail) in the treatment of Neer two-part and three-part proximal humeral fractures. The clinical data of 60 patients with Neer two-part and three-part proximal humerus fractures admitted to the hospital from April 2017 to April 2021 were retrospectively analyzed. Thirty-two patients were treated with the minimally invasive locking plate technique (minimally invasive plate group), and 28 patients were treated with the interlocking intramedullary nailing technique (intramedullary nail group). The operation time, intraoperative blood loss, incision length, fracture healing time, and postoperative complications were compared between the two groups. The ASES score and Constant-Murley score were used to evaluate the shoulder joint function of the two groups one year after surgery. All 60 patients were followed up for 12 to 24months, with an average of 16months. There was no significant difference in operation time, intraoperative blood loss, incision length, or fracture healing time between the two groups (P > 0.05). The incidence of postoperative complications in the intramedullary nail group was significantly lower than that in the minimally invasive steel plate group, and the difference between the groups was statistically significant (P < 0.05). There was no significant difference in the ASES score or Constant-Murley score between the two groups one year after surgery (P > 0.05). The use of the minimally invasive locking plate technique and interlocking intramedullary nailing technique in the treatment of Neer two-part and three-part proximal humerus fractures has the advantages of a small incision, less blood loss, and a high fracture healing rate, and both can achieve satisfactory clinical effects. The internal nail technique is more convenient than the minimally invasive locking plate technique in controlling postoperative complications.

Minimally Invasive Plate Osteosynthesis (MIPO) of Comminuted Radial Fractures Using a Locking Plate Contoured on a 3D-Printed Model of the Feline Antebrachium: A Cadaveric Study.

(1) Background: Due to the unique structural and functional characteristics of the forelimb in cats, fractures of the radius and ulna are best repaired using internal fixation and stabilization in accordance with AO principles. This study presents the results of reduction of 42 cadaveric comminuted feline radial fractures reduced by minimally invasive plate osteosynthesis (MIPO). (2) Methods: Radius fractures were created on 21 pairs of forelimbs with intact bones. MIPO was then performed using two locking bone plates pre-contoured on 3D-printed bone models of the antebrachium of a male and a female cat. Pre- and postoperative radiographs were taken, and radius length and anatomical lateral distal radial angle (aLDRA) were measured. (3) Results: All fractures were classified as complex diaphyseal fractures of the radius. The radial bone length did not change significantly after surgery (F1,18 = 0.01, p = 0.933). However, the aLDRA was modified after surgery (F1,18 = 7.51, p = 0.013), but this change was only observed in females, in whom the aLDRA was significantly reduced (p = 0.035) compared to the value determined by the shape of the plate. In males, the pre- and postoperative aLDRA values were similar (p = 0.824). In 40 cases, alignment, adjacency of bone fragments, and apparatus were judged to be satisfactory. In two cases, the plate was fixed to the proximal radius and distal ulna due to misidentification of the distal radius. In both cases, revision surgery and correct fixation of the radius gave proper alignment, adjacency, and apparatus. (4) Conclusion: A pre-contoured plate on a 3D-printed model of the male and female domestic cat antebrachium was suitable for the reduction and stabilization of comminuted radial fractures in a cohort of domestic cat cadavers without the need to print individual antebrachial bone models for each patient.

Open reduction and internal fixation versus minimally invasive plate osteosynthesis of unstable proximal humerus fractures treated with locking plate and intramedullary allograft: A retrospective study

Background This retrospective clinical study aims to compare the functional and radiological outcomes after open reduction and internal fixation versus minimally invasive plate osteosynthesis of unstable proximal humerus fractures treated with both locking plate and intramedullary graft. Methods Forty-seven patients with proximal humerus fractures were treated with either open reduction and internal fixation (25 cases) or minimally invasive plate osteosynthesis (22 cases) and evaluated retrospectively with a minimum follow-up of 12 months. Thirty-one fresh-frozen fibulae and 16 lyophilized tibia allografts were used for augmentation. Change of both neck-shaft angle and humeral head height were evaluated radiologically. Functional outcomes were assessed using Disabilities of the Arm, Shoulder and Hand Score (DASH), Absolute Constant–Murley Score (CSabs), Relative Constant–Murley Score (CSrel), and Individual Relative Constant–Murley Score (CSindiv). Results Follow-up period and age for open reduction and internal fixation/minimally invasive plate osteosynthesis were 27.4 ± 16.2/29.6 ± 17.6 months and 60.5 ± 13.7/66.3 ± 11.7 years. CSabs, CSrel, and CSindiv were 57.3 ± 21.2/52.4 ± 18.9, 73 ± 24.1/73.9 ± 23.4, and 69.6 ± 24.8/64 ± 25.5 for open reduction and internal fixation/minimally invasive plate osteosynthesis, p ≥ 0.409. DASH was 14.8 ± 12.5/18.7 ± 14.5 for open reduction and internal fixation/minimally invasive plate osteosynthesis, p = 0.324. Decrease of neck-shaft angle and humeral head height was 7.8 ± 9.4/8.2 ± 15.6° and 0.6 ± 5.5/1.4 ± 2.6 mm for open reduction and internal fixation/minimally invasive plate osteosynthesis, p ≥ 0.380. Surgical time was 165.8 ± 77.6/84.7 ± 38.1 min for open reduction and internal fixation/minimally invasive plate osteosynthesis, p &lt; 0.001. Conclusions Locked plating with intramedullary graft augmentation of unstable proximal humerus fractures demonstrates similar functional and radiological outcomes when comparing open reduction and internal fixation with minimally invasive plate osteosynthesis. However, minimally invasive plate osteosynthesis is related to significantly shorter surgical time versus open reduction and internal fixation.

Evaluation of a 3D-Printed Reduction Guide for Minimally Invasive Plate Osteosynthesis of Short Oblique Radial Diaphyseal Fracture in Dogs: A Cadaveric Study.

This study aims to evaluate the clinical application of three-dimensional (3D)-printed custom reduction guides (3DRG) for minimally invasive plate osteosynthesis (MIPO) of short oblique radial diaphyseal fractures. Canine forelimb specimens (n = 24) were prepared and a diaphyseal short oblique fracture was simulated in the distal radius and ulna. Bone fragments were stabilized with the MIPO technique using a 3DRG (Group A), open reduction (Group B), or closed reduction with circular external skeletal fixation (ESF) (Group C). The diaphyseal short oblique fractures were created in each radius at one-third of the radial length from the distal radial articular surface. Surgical stabilization of the fractures was performed in each group. Pre and postoperative radiographic images were obtained to measure frontal angulation (FA), sagittal angulation (SA), frontal joint reference line angulation (fJRLA), sagittal joint reference line angulation (sJRLA), translational malalignment and fracture gap width. Surgical time was also measured. In the homogeneity test, differences in SA, sJRLA, craniocaudal translation and fracture gap before and after surgery had no significant difference among the three groups. On the other hand, differences in FA, fJRLA, mediolateral translation and surgical time before and after surgery had significant differences among the three groups. In the post hoc test, only surgical time showed a significant difference between the three groups, and group A showed the shortest surgical time. The use of 3DRG for MIPO of short oblique radial diaphyseal fractures in dogs is reliable for the alignment and apposition of fractures and reduces surgical time.

Influence of Surgeon's Expertise on the Duration of Approach and Closure during Osteosynthesis of Distal Radius Fractures

Abstract Background The aim of this study was to determine whether the duration of the approach (PII) and closure (PV) phases for minimally invasive plate osteosynthesis (MIPO) of distal radius fractures varied according to the surgeon's level of expertise. The main hypothesis was that the PII or PV duration was inversely proportional to the level of expertise. Methods The method measured the duration of PII and PV for 50 videos of MIPO operated by one surgeon with level 3E expertise, three with level 4E, and one with level 5E. The videos were viewed to identify any technical errors. Results The average PII duration was 3 minutes 8 seconds for level 5E, 4 minutes 7 seconds for 4E, and 6 minutes 19 seconds for 3E. Average PV duration was 2 minutes 12 seconds for level 5E, 2 minutes 36 seconds for 4E, and 2 minutes 41 seconds for 3E. The average duration of PII + PV was 5 minutes 20 seconds for level 5E, 6 minutes 37 seconds for 4E, and 9 minutes for 3E. These findings indicate that both PII and PV duration was the longest in the level 3E surgeons' practice. Six technical errors were identified for levels 3E and 4E during PII (hemostasis control, multiple incisions, instrument handling, improper use of the fluoroscope, time-outs) and PV (intradermal reattachment). Clinical Relevance The main hypothesis was verified since the duration of PII or PV was inversely proportional to the surgeon's level of expertise. This study identified technical errors in hand surgery practices of new surgeons. By early identification and correcting these minor errors, it would be possible to speed up the learning curve. We recommend surgical videos to be systematically recorded and analyzed to improve hand surgery practices. Type of Study/Level of Evidence Therapeutic/Level IIIa.

Wound infection and healing in minimally invasive plate osteosynthesis compared with intramedullary nail for distal tibial fractures: A meta-analysis.

To systematically explore the effects of minimally invasive plate osteosynthesis (MIPO) versus intramedullary nail (IMN) on wound infection and wound healing in patients with distal tibia fractures. A computerised search of PubMed, Web of Science, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database (CBM) and China National Knowledge Infrastructure databases was performed, from their inception to October 2023, to identify relevant studies on the application of MIPO and IMN in patients with distal tibial fractures. The quality of the included literature was evaluated by two researchers based on inclusion and exclusion criteria, and basic information of the literature was collected, with wound infection, postoperative complications and wound healing time as the main indicators for analysis. Stata 17.0 software was applied for analysis. Overall, 23 papers and 2099 patients were included, including 1026 patients in the MIPO group and 1073 patients in the IMN group. The results revealed, when compared with IMN treatment, patients with distal tibia fractures who underwent MIPO treatment had a lower incidence of postoperative complications (OR = 0.33, 95% CI: 0.25-0.42, p < 0.001) and a shorter wound healing time (SMD = -1.00, 95% CI: -1.51 to -0.49, p < 0.001), but the incidence of postoperative wound infection was higher (OR = 2.01, 95% CI: 1.35-3.01, p = 0.001). Both MIPO and IMN are excellent treatments for distal tibia fractures. MIPO is effective in reducing the incidence of complications as well as shortening the time of wound healing time but increases the risk of wound infection. In clinical practice, surgeons can make individual choices based on the patient's wishes and proficiency in both techniques.

Minimally Invasive Plate Osteosynthesis and Clinical Outcomes in Distal Radius Fracture

Minimally Invasive Plate Osteosynthesis and Clinical Outcomes in Distal Radius Fracture

3D printing assisted MIPO for treatment of complex middle-proximal humeral shaft fractures

BackgroundThis study was designed to explore the clinical efficacy of 3-dimensional (3D) printing assisted minimally invasive percutaneous plate osteosynthesis (MIPO) technique by comparing the clinical outcomes with traditional open reduction and internal plating fixation (ORIF) for treating complex middle-proximal humerus fractures (AO 12C fracture type).Materials and methodsThe data of 42 participants who received a complicated middle-proximal humerus fracture from the beginning of 2018 to the end of 2022 were retrospectively analyzed. All patients were assigned to two groups: MIPO with detailed preoperative planning assisted by 3D printing technique (MIPO group), and traditional ORIF (ORIF group).ResultsThis study included 21 patients in the ORIF group and 21 patients in the MIPO group. All patients were followed-up for at least one year (mean: 16.12 ± 4.13 months), and no difference was observed in the range of shoulder joint motion (ROM), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores and Constant scores between the two groups. However, the occurrence of complications (surgical incision site infection, implant loosening, bone nonunion and radial nerve palsy) in ORIF group was remarkably higher compared to the MIPO group. All the cases achieved bone union within the MIPO group. Significant differences were found in surgical time, intraoperative blood loss and fracture healing time between the two groups.ConclusionPreoperative 3D printing assisted MIPO technique exhibits obvious advantages in high operational efficiency and low occurrence of complications, which is worthy of clinical application for treating complex middle-proximal humeral shaft fractures.

Comparative Study Between Intramedullary Nail and Minimally Invasive Plate Osteosynthesis in Tibial Shaft Fracture

Background: Casting, open plate fixation, minimally invasive plate osteosynthesis, intramedullary nailing, and external fixation are some treatment options for tibial fractures. The aim of treatment is anatomical alignment with sufficient stability to permit early motion. The least invasive and most popular techniques are intramedullary nailing, external fixation, and minimally invasive plate osteosynthesis. Aim of Study: To compare the clinical and functional outcome between Intramedullary nailing and external fixation and minimally invasive plate osteosynthesis in treating tibial shaft fracture. Patients and Methods: A randomized clinical trial study was conducted at Al-Yarmouk Teaching Hospital and other private hospitals in Baghdad, Iraq, during a period of 17 months from September 2020 to January 2022, including a period of one year for follow-up. Patients were selected according to certain inclusion criteria and divided into two groups, each with 20 patients. IMN was treated by intramedullary nailing, and the MIPO group was treated by minimally invasive plate osteosynthesis. Patients were followed up radiologically and clinically using the JETTS Lower Extremity Trauma Scale score. Result: The difference was significant (P&lt; 0.05) regarding partial and full weight bearing, union time, and return to work. Ankle stiffness, implant irritation, and knee pain revealed significant differences. Conclusion: Intramedullary nailing and external fixation and minimally invasive plate osteosynthesis are effective methods for the treatment of extra-articular tibial shaft fracture. They provided rigid fixation, preventing major complications and good functional and anatomical outcomes.

Remodeling of Rotational Malunion of Femoral Shaft in Children.

The degree of expected rotational remodeling in femoral shaft fractures is poorly understood, partly because of the difficulty in accurately measuring rotational alignment radiographically before and after treatment. This study aimed to assess the degree of rotational remodeling in the short-term following post-traumatic fracture shaft of the femur with > 10° rotational malunion in children under 15years. We carried out an observational study with a prospective follow-up on 18 children aged < 15years with isolated, unilateral, oblique, or spiral, closed femur shaft fracture treated with closed reduction and immobilization with hip spica or internal fixation with elastic stable intramedullary nails or minimal invasive plate osteosynthesis. Only those with an initial axial malalignment measured on postoperative reduction radiographs of more than 10° by Ozel et al. technique were included. We evaluated the residual rotational malunion outcome using the ultrasound technique of Terjesen et al. by assessing the difference in femoral torsion as a guide to rotational malunion. The difference between the initial malreduction and the torsional difference between the hips at follow-up was deemed the extent of rotational change or remodeling. The mean axial malalignment was 21.6° (10°-32°). The mean rotational remodeling was 13.6° (range 7°-21°), with an SD of 3.9. This study shows that a significant amount of rotational remodeling occurs in children up to 14years of age within 2years of injury. It is higher in younger patients (r = 0.786; p < 0.001), and the extent of remodeling is proportional to the magnitude of the initial deformity (r = 0.81, p < 0.001).

Comparative study of mechanical performance of various fixation constructs in multifragmentary distal humeral shaft fracture: a finite element analysis.

There has been no scientific mechanical assessment demonstrating the optimal fixation technique in multifragmentary fractures of the distal humeral shaft. The purpose of the present study was to compare the biomechanical performance of 5 fixation constructs as used in minimally invasive plating osteosynthesis (MIPO) for distal humeral shaft fractures. Three-dimensional (3D) humerus model with 20mm distal humeral shaft fracture gap simulating multifragmentary fracture was created from computed tomography data and virtually fixed by 5 fixation techniques as MIPO, i.e., anterior narrow dynamic compression plate (DCP), anterior narrow locking compression plate (LCP), anterior reversed proximal humeral internal locking system (R-PHILOS), extra-articular distal humerus locking compression plate (LCP-EADH), and anteromedial LCP. All constructs were biomechanically tested under 6 loading conditions by means of finite element analysis, i.e., 250-N axial compression, 7.5-Nm internal rotation, 7.5-Nm external rotation, 10-Nm posterior bending, 10-Nm valgus rotation, and 10-Nm varus rotation. In addition, A 3D model of each construct was fabricated as 3D printed models. Fixations were applied to the 3D printing model which were later mechanically tested to validate the FE results. EQV stress exhibited on anterior narrow LCP and anterior R-PHILOS were comparable which were lower than other constructs under axial compression and valgus-varus bending. Anterior R-PHILOS produced lower EQV stress than other constructs under internal-external rotation and posterior bending. On the whole, R-PHILOS demonstrated a comparable fracture displacement to those LCP with anterior or anteromedial approaches, that achieved the lowest displacement values. In addition, the experimental mechanical test values shared a correlation with the FE model results. Overall, the anterior R-PHILOS was considered as a potential candidate for multifragmentary distal humeral shaft fractures. It demonstrated efficacious biomechanical performance in terms of implant stress and distal fragment displacement.

A novel technology integrating robotics and 3D printing for closed reduction of tibia shaft fracture with MIPPO:A proof-of-concept study

Less invasive fixation techniques, such as intramedullary nailing (IMN) and minimally invasive percutaneous plate osteosynthesis (MIPPO), are now the preferred choices for treating tibia shaft fractures (TSFs). However, malreduction and radiation exposure are the main deficiencies associated with less invasive fixation techniques, especially when assessing rotation around the shaft axis intra-operatively. The purpose of this study was to investigate the feasibility and reduction accuracy of an innovative technology that integrates robotics and 3D printing for achieving anatomical reduction of TSFs with MIPPO. The surgical workflow from a standardized CT protocol, via 3D reconstruction, 3D printing tibia model, pre-contouring plate, 3D scanning plate, 3D planning of the trajectories of the robot, and use of a commercial surgical robot, robot-assisted screw hole drilling, to automatic fracture reduction through precise installation of the plate was described. The reduction accuracy was evaluated by an optical tracking system. The mean variations of 1.95 ± 1.36mm in length, 1.63 ± 0.92 mm in apposition, 2.78 ± 1.69° in alignment, and 1.99 ± 1.81° in rotation. The interoperator reliabilities were almost perfect, with values of 0.91, 0.93, 0.92, and 0.90, respectively. The proposed technology achieved anatomic reduction on phantom bones.

Modified medial minimally invasive double-plating osteosynthesis techniques for the treatment of distal third diaphyseal fracture of humerus

The optimal surgical approach and placement of plates for the treatment of distal third diaphyseal fracture of the humerus are the subjects of debate. The aim of this retrospective study was to evaluate the clinical and radiographic outcomes of modified medial minimally invasive plate osteosynthesis (MIPO) techniques using a double technique for the treatment of distal third diaphyseal fracture of the humerus. A total of 30 patients with a distal third diaphyseal fracture of the humerus were selected from our hospital. Patients were seen between January 2017 and October 2022. They were treated with a modified medial approach combined with MIPO using a double plate technique. Patient demographics, operation time, bleeding volume, union time, complications, the mean fracture length (FL) and distal cortical length (DCL), and the number of screws in the distal fragment were analyzed. The function of the shoulder and elbow was evaluated using Neer’s assessment of the shoulder and Mayo’s assessment of the elbow. The FL was 56.1 ± 7.2 mm and the DCL was 38.3 ± 5.3 mm. The mean operative time was 84.8 ± 13.4 min (range 60–110 min). The mean blood loss during surgical treatment was 46.5 ± 10.2 ml (range 30–60 ml). Bone healing was observed in all patients from 10 to 16 weeks (average 12.1 ± 1.7) postoperatively, and one case with poor surgical wound healing was recorded. All the patients had good function of both the shoulder and elbow. The maximum flexibility of the elbow ranged from 130° to 145° (average 138.1 ± 4.8°), with a maximum flexibility straightness ranging from 0° to 5° (average 2.2 ± 1.3°). The Mayo elbow joint function score was 80–100 (average 91.4 ± 5.0). The Neer shoulder joint function score ranged from 85 to 100 (average 92.5 ± 3.9). The modified medial approach was beneficial it did not cause any iatrogenic radial nerve or ulnar nerve injuries. The anterior and the medial side plates are fixed perpendicular to the distal humerus and provide excellent stability at the same time producing better shoulder and elbow joint function.

Percutaneous plate fixation of displaced proximal humerus fractures: Do minimally invasive techniques improve outcomes and reduce complications?

ObjectiveThe aim of this study was to analyze the outcomes and complications of minimally invasive plate osteosynthesis (MIPO) for displaced proximal humerus fractures and elucidate if the percutaneous technique reduces the rate of avascular necrosis (AVN) without jeopardizing fracture reduction. Material and methods118 patients with a displaced proximal humerus fracture were treated with a polyaxial locking-plate through a standardized percutaneous approach. 73 % were women and mean age was 63 years (18–89) with an average follow-up of 51 months (12–256). There were 32 two-part fractures (27 %), 57 three-part fractures (48 %) and 24 four-part fractures (25 %). Shoulder function at the last follow-up, including ROM and ability to perform daily living activities, was objectively evaluated with an adjusted Constant Score (CS). Subjective patient satisfaction was rated with an Visual Analogic Scale from 0 to 10 and the degree of residual pain with a Verbal Rating Scale (VRS). Radiographic analysis at the most recent follow-up evaluated the presence of AVN, degree of residual medial calcar displacement, and the cervicodiaphiseal angle. ResultsForty patients (34 %) had a complication, 25 of them (21 %) requiring further surgery. ROM at the last follow-up was 131° of elevation (40°-180°), 38° of external rotation (SD: 17.7) and internal rotation to L3. Average adjusted Constant Score was 68 (SD: 17.76). Twenty-one patients (18 %) complained of shoulder pain (14 moderate and 7 severe) and seven were not satisfied. Radiographically, 29 patients (25 %) had varus malunion and 17 patients (14 %) showed some degree of AVN. Patients with varus malunion (CS 64.3 versus 69.8, p = 0.16) and AVN (CS 56.9 versus 70.4, p = 0.005) had lower CS. The presence of a varus malunion was directly related to the degree of initial medial calcar displacement (p = 0.001) and deficient calcar reduction at surgery (p = 0.004). AVN was statistically more prevalent when the medial calcar was inadequately reduced (p = 0.01). ConclusionsMIPO surgery for proximal humerus fractures through an anterolateral approach does not reduce the rate of mechanical complications or AVN compared with standard ORIF techniques. Moreover, percutaneous plating may preclude adequate medial calcar reduction, leading to humeral head malunion and a worse clinical outcome.

Minimal invasive plate osteosynthesis for the dislocated humeral head fracture associated with ipsilateral humeral shaft fracture: A case report.

The condition combining a dislocated humeral head fracture and an ipsilateral humeral shaft fracture is seen to be rare in literature, which is limited to case report or case series. Furthermore, effective management of these coexistent injuries is still a subject of debate. The essential purpose of this article is to report another treatment method for this condition. We present a case of a 79-year-old female patient who suffered a three-part humeral head fracture-dislocation associated with the ipsilateral humeral shaft fracture. The combined injuries were managed by minimal invasive plate osteosynthesis (MIPO) through the deltopectoral approach with the eventual result of bone healing and good function after thirty-three months of follow-up. In conclusion, MIPO should be considered a safe and effective option, however, the risk of traumatic osteonecrosis of the humeral head is taken into account before operation decision-making.

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.

Comparative Study of Intramedullary Interlocking Nailing and Minimally Invasive Percutaneous Plate Osteosynthesis for Distal Tibia Extra-Articular Fractures

Management of distal tibial extra-articular fractures presents a significant challenge in orthopedic practice due to their complex anatomical features and variable fracture patterns. Surgical intervention plays a crucial role in achieving stable fixation and optimal functional outcomes. This study aimed to compare the effectiveness between minimally invasive percutaneous plate osteosynthesis and intramedullary nailing for the management of distal tibial extra-articular fractures. This was a prospective observational study that was conducted in the Department of Orthopedics, Bangabandhu Sheikh Mujib Medical College, Hospital (BSMMCH), Faridpur, Bangladesh from January 2021 to December 2022. Total 24 patients having a fracture of the distal third of the tibia were enrolled in this study as the study subjects. Total patients were divided into two groups. In group A, 12 patients underwent minimally invasive percutaneous plate osteosynthesis (MIPPO) and in group B, 12 patients underwent intramedullary nailing (IMN). A random selection method was used in sample selection. According to Olerud Molander’s score, Excellent, Good and Fair results were found in 50%, 50%, and 0% of the group A patients respectively. On the other hand, those results were found in 42%, 50% and 8% of group B patients respectively. Although both minimally invasive percutaneous plate osteosynthesis and intramedullary nailing procedures are effective in managing distal tibial extra-articular fractures, considering excellent union rate, low blood loss and remarkable Olerud Molander’s score, MIPPO may be considered as the better option. Bangabandhu Sheikh Mujib Med. Coll. J. 2023;2(2):92-96.

Fracture gap and working length are important actionable factors affecting bone union after minimally invasive plate osteosynthesis for the treatment of simple diaphyseal or distal metaphyseal tibia fractures

IntroductionIndirect reduction of minimally invasive plate osteosynthesis (MIPO) can often result in delayed union in tibia fractures. This study evaluated several factors in MIPO in relation to bone union. HypothesisWe hypothesized that the fracture gap, plate – tibia distance, or working length would have a substantial effect on the tibia union rate. Materials and methodsForty-one patients with simple diaphyseal or distal metaphyseal tibia fractures who underwent internal fixation surgery using the MIPO technique were divided into two groups: patients with delayed union and patients without delayed union. Non-actionable factors involving AO/OTA classification, fibula fracture and actionable factors including postoperative fracture gap, plate – tibia distance, working length in relation to parameters of bone union were compared between the two groups. Also cumulative rates of bone union and risk factors of delayed union according to variables of interest were investigated. ResultsAO/OTA classification, site of fibula fracture, postoperative fracture gap, working length, and bone union rate of the two groups significantly differed (p<0.05). The cumulative rate of bone union during 1-year follow-up according to 43A tibia fracture, distal fibula fracture, fracture gap, and working length significantly differed between the two groups (p<0.05). By univariate Cox proportional hazards model, 43A tibia fracture, distal fibula fracture, facture gap, and short working length were risk factors for delayed union (p<0.05). DiscussionNon-actionable factors involving AO/OTA classification, distal fibula fracture and actionable factors including postoperative fracture gap, working length were significant factors affecting bone union after MIPO. The present study indicated that small fracture gap and long working length during MIPO might facilitate bone healing in tibia fracture. Level of evidenceIV; single-center retrospective cohort study.

Minimally invasive lateral plating for diaphyseal fractures with extension into the proximal humerus and its implications for the deltoid muscle and its distal insertion: functional analysis and MR-imaging

BackgroundIn minimally invasive lateral plate osteosynthesis of the humerus (MILPOH) the plate is introduced through a deltoid split proximally and advanced through the central portion of the deltoid insertion and between bone and brachial muscle to the distal aspect of the humerus. The fracture is then indirectly reduced and bridged by the plate. Whereas it has been shown that the strong anterior and posterior parts of the distal deltoid insertion remain intact with this maneuver, its impact on deltoid muscle strength and muscular morphology remains unclear. It was the aim of this study to evaluate deltoid muscle function and MR-morphology of the deltoid muscle and its distal insertion after MILPOH.MethodsSix patients (median age 63 years, range 52–69 years, f/m 5/1) who had undergone MILPOH for diaphyseal humeral fractures extending into the proximal metaphysis and head (AO 12B/C(i)) between 08/2017 and 08/2020 were included. Functional testing was performed for the injured and uninjured extremity including strength measurements for 30/60/90° shoulder abduction and flexion at least one year postoperatively. Constant-Murley-Score (CMS) including an age-and gender-adjusted version, were obtained and compared to the uninjured side. Oxford Shoulder Score (OSS) and the Disability of the Arm, Shoulder and Hand (DASH) questionnaire were acquired for the affected extremity. Quality of life was measured using the EQ visual analogue scale (EQ-5D-5 L VAS). MR imaging was performed for both shoulders accordingly at the time of follow-up to assess the integrity of the distal insertion, muscle mass and fatty degeneration of the deltoid muscle. Muscle mass was determined by measuring the area of the deltoid muscle on the axial MR image at the height of the center of the humeral head.ResultsMedian follow-up was 29 months (range 12–48 months). Median difference of abduction strength after MILPOH was + 13% for 30°, 0% for 60° and − 22% for 90°. For flexion, the difference to the uninjured side was measured 5% for 30°, -7% for 60° and − 12% for 90°. Median CMS was 75 (66–82) for the operated extremity compared to 82 (77–90) for the uninjured side. Age- and gender-adapted CMS was calculated 88 (79–99) vs. 96 (89–107). Median OSS was 47 (40–48). DASH was 26 (15–36). EQ-5D-5 L VAS ranged from 81 to 95 with a median of 90. The median difference of the deltoid muscle area on MRI was 2% (-21% to + 53%) compared to the uninjured side. No fatty degeneration of the deltoid muscle was observed. The weaker central part of the distal deltoid insertion was exclusively perforated by the plate, leaving the strong anterior and posterior parts of the insertion intact in all patients.ConclusionsMILPOH was associated with good functional and subjective outcome. Minor impairment of abduction strength was observed with increasing abduction angles. The reason for this impairment is unclear since MILPOH did not affect the structural quality of the deltoid muscle and the integrity of the strong anterior and posterior parts of its insertion remained intact.Trial registration26/05/2023: ISRCTN51786146.

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.