Minimally Invasive Percutaneous Osteosynthesis Research Articles

Unstable Distal Tibia Fracture Management By Anatomically Contoured Plate With Mipo Technique

Background: Fracture at distal tibia is a notorious fracture and difficult to manage. This fracture can be managed conservatively or operatively. Minimally invasive percutaneous osteosynthesis (MIPO) technique can be applied in distal tibia fracture and it usually provides better outcome. This technique ensures minimal soft tissue damage, preserves periosteum and hematoma of the fracture. As the fracture site is not opened, indirect fracture reduction technique is applied. This study tries to evaluate the outcome of MIPO technique application in distal tibia fracture management. Methods: The study was cross sectional study and was carried out on 20 patients during the period of January 2019 to July 2021 in orthopaedic department of Combined Military Hospital (CMH), Dhaka. During this tenure all patients who fulfilled the inclusion and exclusion criteria was included in the study. All had close fracture. Follow up interval was at 2 weeks then 06 weeks, thereafter at 3 months, 6 month and 12 months' time from the date of operation. Data were collected and evaluated in terms of bony union and postoperative complications. Results: 12 patients i.e. 60% were male and same percentage of patient had fracture at right lower limb. Mode of trauma was mostly road traffic accidents (RTA) and fall from height. 40 years was mean age of the patients. It was 07 weeks mean partial weight bearing time and 14 weeks mean full weight bearing time. Mean radiological union time was seen at 18 weeks. Non union or delayed union did not happen in any case. But ankle stiffness (3/20) was most commonly found postoperative complications. Conclusion: For distal tibia fracture MIPO technique is a better treatment option as it gives good outcome and fewer complications. Bangladesh Armed Forces Med J Vol 56 No (1) June 2023, pp 1-6

Lower Limb Malrotation following Minimally Invasive Plating in Distal Tibia Fractures.

Minimally invasive percutaneousosteosynthesis (MIPO) plating techniques havedemonstrated good outcomes in the treatment of distal tibia fractures. Early arthritis and functional impairment mayoccur if length and rotation are not restored. This study aims to determine the incidence and severity of tibia malrotation following MIPO plating of isolated unilateral distal tibia fractures, defined as torsional difference of greater than 10° as compared to the contralateral limb and whether the degree of malrotation affects functional outcomes scores. This was a level 2 prospective cohort study. All patients with fractures of the distal tibia who underwent surgical fixation with the exclusion ofpatients with polytrauma, neurovascular injuries or pre-existing disabilities were recruited. Patients underwent MIPO plating followed by a post-operative ComputedTomography (CT) scan of bilateral lower limbs. AOFAS ankle-hindfoot score was recorded at six months and one year follow-up. A total of 24 patients (28 to 83 years old) were recruited. Nineteen patients obtained CT scans. Nine of the 19 patients (47.3%) had tibia malrotation. The mean tibia malrotation angle was 10.3° (0° - 45°). The average AOFAS scores was 82.4 and 84.3 at 6 months and 1 year follow-up. Degree of CT malrotation was not significantly associated with AOFAS scores at 6 month (spearman rho -0.386) and 1 year (spearman rho -0.343). Tibia malrotation following MIPO plating of distal tibia fractures is common, with an incidence of 47.3% and an average malrotation angle of 10.3°. The degree of malrotation does not appear to have significant mid-term functional impact on the patient.

Comparison between outcome of various modalities of management of distal tibia fractures

Introduction: Fractures of distal tibia are usually due to high velocity injuries with extensive damage to the soft tissue. The best modality of method of management for distal tibial fracture is one that achieves a good reduction and stability and minimizes soft tissue compromise as well as devascularization of the bony fragments. The aim of our study is to compare, analyse and individualize the best modality of treatment for management of distal tibial fractures. Materials and Methods: This study of 30 patients of distal tibial fractures, was conducted at Dr. D.Y. Patil Medical College and Research Center, Pimpri, Pune, from September 2018 - August 2020. Required consents from all the patients and ethical committee clearance was taken before conducting the study. Necessary data was collected from all the patients during their hospital stay and regular follow-up was recorded. Results: Patients treated with Intra-Medullary Nail had mean AOFAS (American Orthopaedic Foot and Ankle Society) score of 75.2, while patients treated with External Fixator and MIPO (Minimally Invasive Percutaneous Osteosynthesis) had mean AOFAS(American Orthopaedic Foot and Ankle Society) score 71.5 and 87.1 respectively. Conclusion: In our study, we have analysed overall results including functional recovery, radiological assessment in terms of malalignment and complications related to different modalities of treatment of distal tibial fractures. Keywords: Distal tibia, MIPO, AOFAS, Trauma.

Outcome of various modalities of management of distal tibia fracture

Background: Distal tibial fractures represent less than 7% of all tibial fractures. The present study was conducted to compare outcome of various modalities of management of distal tibia fractures. Materials & Methods: 45 distal tibia fracture patients of both genders were divided equally into 3 groups of 15 each. Group I patients were treated with intra-medullary nail, group II patients treated with external fixator and group III patients with MIPO (Minimally Invasive Percutaneous Osteosynthesis). The American Orthopaedic Foot and Ankle Society score was recorded. Gustilo Anderson (GA) type of fractures and complications were recorded. Results: GA type 1 was seen in 10, 2 in 8, 3A in 7 and no GA type in 20 patients. AO classification A1 was present in 5, A2 in 6, A3 in 15, B1 in 8, C1 in 5, C2 in 5 and C3 in 3 patients. The mean AOFAS score was 74.2 in group I, 70.5 in group II and 89.2 in group III. Complications were non- union seen in 1, 2 and 3, ankle stiffness in 2, 2 and 1, wound discharge in 0, 1 and 1, vagus deformity in 3, 2 and 0 and valgus deformity in 1, 3 and 2 in group I, II and III respectively. The difference was significant (P

Functional outcome following fixation of distal tibial fracture (Extra articular) with locking compression plate (LCP) using the minimally invasive percutaneous osteosynthesis (MIPO) technique

Background: Distal tibia is more superficial, with minimal soft tissue coverage and poor blood supply, hence operative treatment can lead to complications, making it a challenging surgery. The aim is to see the results of the distal tibial fracture fixation with LCP using MIPO technique.Methodology: Twenty consecutive patients with type AO 43A distal tibia fractures were prospectively included into the study during the period of march 2018 to march 2019 with a follow-up of minimum one year. Fourteen male and six female patients with a mean age of 47 years were reviewed. Patients of Bidar institute of medical sciences with closed extra articular distal tibial fractures who fulfill the inclusion & exclusion criteria were taken in to study after obtaining informed written consent. History, Clinical examination and details of investigations were recorded in the study Performa. Minimally Invasive Percutaneous Plate Osteosynthesis was carried out depending on requirement for specific fracture pattern. These cases were reviewed periodically at 6, 12, 24 weeks and regularly both clinically and radiologically for bony union. Clinical outcome and Radiological criteria (RUST SCORE) regarding fracture union and complications was evaluated and documented. Functional outcome was measured by lower extremity functional score (LEFS).Results: Mean time to union was 6.5 months (range 4–16 months). Sixteen fractures healed with good functional outcome. Two patient had delayed union. One patient had nonunion which was treated with iliac crest bone grafting that ultimately healed with good functional outcome. One patient developed superficial infection that was treated with appropriate antibiotics and the fracture united eventually.Discussion: The MIPO technique for pilon A type fractures is proven ti be more effective over the conventional methods. Early mobilization with no risk of secondary displacement helps to prevent stiffness of the ankle joint and good wound healing.

EVALUATION THE SIGN OF UNION, DURATION OF SURGERY AND POST-OPERATIVE SKIN COMPLICATION IN MID SHAFT CLAVICLE FRACTURE.

INTRODUCTION: It is impossible to support and immobilize a fracture of middle 3rd of clavicle in an adult by external means with figure-of-eight bandages. Clavicle fractures accounts for approximately 2.6% of all fractures in adults2 10% to 15% in children and comprise about 30 -40% of all shoulder girdle injuries and 5% fractures occurs in medial end. The goal of clavicle fracture treatment is to achieve bony union while minimizing dysfunction, morbidity, and cosmetic deformity. Definitive indications for acute surgical intervention include skin tenting, open fractures, the presence of neurovascular compromise, multiple trauma, or floating shoulder. Outside of these indications, the management of displaced fractures of the mid shaft (Edinburgh type 2B) remains somewhat controversial. Recent literature is challenging the traditional belief that mid- shaft clavicle fractures uniformly heal without functional deficit. 
 MATERIAL AND METHODS: Patients included were cases of mid shaft clavicle fractures. 30 patients with mid shaft clavicle fractures were included in the study.All patients above 18 years of age were included in the study falling into Robinson’s type 2 B1 (Mid shaft simple displaced and single butterfly fragment fracture), type 2 B2 (Mid shaft segmental fracture) classification. The patients were selected randomly and were divided in the following two groups of 15 patients each: Group A: 15 patients treated by anatomical locking compression plate (LCP) by open technique. Group B: 15 patients treated by minimal invasive percutaneous osteosynthesis (MIPO) technique. All patients were operated as early as possible once the patient was declared fit for the surgery by the physician. Open reduction and internal fixation with LCP was done.
 RESULTS: A total of 30 patients were included in the study. In group A 15 patients treated by anatomical locking compression plate (LCP) by open technique and in group B 15 patients treated by minimal invasive percutaneous osteosynthesis (MIPO) technique. In Group A, 7 (46.7%) patients had operative time of 80-100 minutes whereas 6 (40%) and 2 (13.3%) patients had operative time of 100-120 and 120-140 minutes respectively. The mean operative time was 104.9 ± 13.52mins. In Group B, 6 (40%) patients had operative time of 80-100 minutes whereas 8 (53.4%) and 1 (6.6%) patients had operative time of 100-120 and 120-140 minutes respectively. The mean operative time was 106.5 ± 11.72mins. The mean duration for radiological union in Group A was 12.7 ± 4.61 weeks. Majority of the patients (60%) achieved radiological union in <12 weeks while 6 (40%) patients achieved union in 12-24 weeks. In Group B, majority of the patients (66.7%) achieved radiological union in <12 weeks while 5 (33.3%) patients achieved union in 12-24 weeks. The mean duration for radiological union in Group B was 12.1 ± 6.68 weeks.
 CONCLUSION: MIPOs can used to preserve the biology at the fracture site, to maximise the healing potential of the bone, and to facilitate early and pain free recovery and MIPPO technique with the application of LCP offered an ideal combination in terms of bone fixation and soft-tissue sparing.

FUNCTIONAL OUTCOME FOLLOWING ANATOMICAL LOCKING COMPRESSION PLATE BY OPEN TECHNIQUE AND MINIMAL INVASIVE PERCUTANEOUS OSTEOSYNTHESIS (MIPO) TECHNIQUE IN MID SHAFT CLAVICLE FRACTURE

INTRODUCTION: Clavicle fractures are common injuries in adults, accounting for 5% of all fractures and 44% of all shoulder fractures. Furthermore, there is an increasing incidence of complex fracture patterns after high-energy trauma. Incidence in males is usually highest in second and third decade which decreases thereafter as per age. Clavicles mid shaft fractures have classically been treated non-operatively. However, factors including severity of displacement, degree of comminution, and greater than 2 cm of shortening have been reported in the literature to predispose patients to unsatisfactory outcomes with non-operative treatment. Minimally invasive surgery is increasingly being used for the treatment of mid shaft clavicle fracture. The two most commonly used implant are titanium elastic nail (TEN) and locking compression plate (LCP). Minimally invasive percutaneous plate osteosynthesis (MIPPO) is widely used for long bone fracture.
 MATERIAL AND METHODS: The patients were selected randomly and were divided in the following two groups of 15 patients each: Group A: 15 patients treated by anatomical locking compression plate (LCP) by open technique. Group B: 15 patients treated by minimal invasive percutaneous osteosynthesis (MIPO) technique. Follow up period were 1 months, 2months and 6months. Functional outcome was evaluated using the constant shoulder score, which is scored from 0 to 100, with a lower score representing a higher level of functional disability.
 RESULTS: Majority of the patients (40%) in Group A were in the age group of 31-40 years followed by 26.7% in the age group of 21-30 years, 20% in the age group 41-50 years and 13.3% in the age group of 51-60 years. The mean age of the patients was 36.2 ± 9.09 years. Majority of the patients in both groups were male. There were 80% and 73.3% male patients in Group A and Group B respectively whereas female patients constituted 20% and 26.7% of the study group respectively. In Group A, 7 (46.7%) patients had operative time of 80-100 minutes whereas 6 (40%) and 2 (13.3%) patients had operative time of 100-120 and 120-140 minutes respectively. The mean operative time was 104.9 ± 13.52mins. In Group B, 6 (40%) patients had operative time of 80-100 minutes whereas 8 (53.4%) and 1 (6.6%) patients had operative time of 100-120 and 120-140 minutes respectively. The mean operative time was 106.5 ± 11.72mins. There was no significant association between the groups as per Student t-test (p>0.05).
 CONCLUSION: Operative treatment with a LCP for clavicle shaft fractures can be used to obtain stable fixation. Particularly, MIPPO of displaced mid shaft clavicular fractures resulted in a better cosmetic than conventional open reduction, although the functional outcomes were no different between the two groups.

Minimally invasive percutaneous medial plate-rod osteosynthesis for treatment of humeral shaft fractures in dog and cats: Surgical technique and prospective evaluation.

To describe and prospectively report outcomes associated with a novel minimally invasive percutaneous osteosynthesis (MIPO) technique for the treatment of humeral fractures in dogs and cats. Prospective clinical case series. Eleven dogs and 4 cats with traumatic nonarticular humeral fractures. Dogs and cats that presented with traumatic humeral fractures were enrolled in the study. After closed reduction, the fracture was stabilized by using a plate-rod combination applied via remote medial incisions. Postoperative alignment in the frontal and sagittal planes was statistically compared with the contralateral limbs. Time to clinical union and complications were also recorded. Eleven dogs and 4 cats were included in this study. Body weight ranged from 4.5 to 33.6 kg in dogs and from 2.2 to 3.6 kg in cats. A veterinary cuttable plate (6/11 dogs and 3/4 cats) or locking compression plate was used in a plate-rod configuration (11/11 dogs and 2/4 cats) or alone (2/4 cats). Rod-to-medullary-cavity ratio was 30%. Plate-span ratio was 5.8 (range, 2-13.5). No significant differences were found in frontal or sagittal plane alignment. Healing time in cases that completed on-time follow-up (12/15) was 36 ± 14 days (range, 20-69). No major complications were recorded. The reported technique was associated with good outcomes in a large variety of fracture configurations and animal sizes, with no complications. This report provides evidence that MIPO is a compelling alternative to open reduction and internal fixation in the treatment of various humeral fractures.

Outcome of minimally invasive plate osteosynthesis in distal tibial fractures

Introduction: Distal tibial fractures present as a major challenge for the orthopedic trauma surgeons. Most non-operative treatments result in non-union or malunion and needs prolonged immobilization of the knee and ankle joints, with resulting stiffness. Open reduction and internal fixation as well as external fixation has high rate of infection and non-union. Minimally Invasive Plate Osteosynthesis has been shown to have a better outcome and has been the procedure of choice in most distal tibial fractures since the introduction of the locking compression plate. The objective of the study is to review the outcome of Minimally Invasive Percutaneous Osteosynthesis (MIPO) in unstable distal tibial fractures.Methods: Charts of patients who underwent MIPO from the year 2008 to 2013 for unstable distal tibial fractures over five years at Patan Hospital and Om Hospital were reviewed. All displaced closed fractures and Gustillo Anderson Type I and II fractures were included in the study. Plates consisted of the anatomically contoured 4.5 mm LCP and 3.5 mm LCP-Pilon form plate. A simple uniplanar external fixator was used to retain the reduction till the plate was inserted and secured with locking screws. The outcome of MIPO in distal tibial fractures were followed up and evaluated. Clinical and radiological assessments were performed at 6 weeks, and at 3, 6, 9, 12 and 24 months.Results: Of the 75 patients (45 male, 30 female) age ranging from 19 to 70 years (mean 47 years), 5 patients were lost to follow-up. 28 patients at 3 months, 32 at 6 months, and 8 at 9 months met the criteria for a healed fracture. Two patients required autologous bone grafting at 9 months for non-union ultimately resulting in the fracture union at 16 months. There was one malunion attributable to the loss of reduction during plate fixation. There were no deep infections, no soft tissue complications and no failures of fixation. The cause of fracture were RTA (n=35), fall from height (n=9), twisting of ankle as a result of fall from standing height (n=22), and others (n=11). The mean time for surgery from the time of injury was 5 (range, 2 to 14) days; the mean hospital stay was 10 (range, 7 to 21) days.Conclusion: MIPO is an effective treatment for closed, unstable fractures of the distal tibia, avoiding the complications associated with more traditional methods of internal fixation and/or external fixation.Journal of Society of Surgeons of NepalVol. 17, No. 2, 2014, Page: 7-11

Minimally invasive percutaneous osteosynthesis versus ORIF for Sanders type II and III calcaneal fractures: a prospective, randomized intervention trial

BackgroundThis randomized controlled trial compared the clinical outcomes and complications of a novel minimally invasive percutaneous osteosynthesis (MIPO) with those of conventional treatment via an extended L-shaped lateral approach for calcaneal fractures.MethodsSixty-four patients with displaced intraarticular calcaneal fractures were enrolled. The patients were randomly allocated to receive either MIPO (29 patients) or open reduction and internal fixation via an extended L-shaped lateral approach (35 patients). The same calcaneal plate (AO Synthes, Oberdorf, Switzerland) was used in both groups. The primary clinical outcomes included operative time, VAS postoperatively, and wound healing complications. Secondary clinical outcomes included time to operation, length of incision, postoperative drainage, length of hospital stay, medical expense, AOFAS score, and SF-36 score. Preoperative and postoperative calcaneal height, width, and length, Bohler’s angle, and Gissane’s angle were compared.ResultsThe operative time in the MIPO group was 52.5 ± 11.1 min, which was significantly shorter than 82.8 ± 16.2 min in the conventional treatment group (P < 0.001). One week postoperatively, the VAS value was 3.2 ± 1.4 in the MIPO group, which was lower than that in the conventional treatment group, 3.9 ± 1.3 (P = 0.038). In the conventional treatment group, 13 of 35 fractures (37.1%) had wound healing problems, whereas this issue occurred in only 2 of 29 fractures (6.7%) in the MIPO group (P = 0.004). In the MIPO group, deep and superficial infections occurred in none of the cases and 1 of 29 (3.4%) patients, respectively. Length of incision in the MIPO group was shorter than that in the conventional treatment group (4.2 ± 0.6 vs. 10.9 ± 1.5 cm; P < 0.001). Hospital stay was 9.7 ± 2.8 days in the MIPO group and 11.7 ± 2.6 days in the conventional treatment group (P = 0.004). At the last follow-up, the SF-36 scores and AOFAS scores in the two groups were comparable (P > 0.05). The postoperative radiographic data, the Bohler’s angle, Gissane’s angle, and calcaneal height, width, and length in the two groups were comparable (P > 0.05).ConclusionsCompared with conventional ORIF, the advantages of MIPO are a considerably shortened operating time and hospital stay, decreased postoperative pain, and reduced risk of wound healing complications.

Are clinical and functional results of MIPPO and IMN for treatment of extraarticular distal tibia fractures similar?

Aim: Controversy still exists on whether intramedullary nailing (IMN) or minimal invasive percutaneous osteosynthesis (MIPPO) is better for treatment of extra-articular distal tibia fractures. In this study, our aim was to retrospectively compare the clinical and functional results of patients with distal tibia fractures that were treated f by plate or nail. Materials and Methods: This study included 46 patients with a mean age of 40,3 (range, 18-63 years). All had closed extra-articular distal tibia fractures within 4 to 10 cm away from the tibial plafond and two senior trauma surgeons operated them with either MIPPO (n=27) or IMN (n=19) technique. Patients were followed up until full bony union occurred and also hospitalization time, union time, malunion criteria; complication rates and AOFAs were evaluated. Results: Mean follow up was 12.5 (range, 10-16 months) months and no major vessel injury or deep infection was observed in either group. Full bony union time was similar in two groups (15±12.7 weeks in MIPPO and 16±11.3 weeks in IMN group; p=0.062). Also, there was not statistically significant difference in MIPPO and IMN groups for nonunion rates [3 (11%) vs. 1 (5.3%)] and malunion rates 3 (11.1%) vs. 2 (10.5%)] (p>0.05). However, secondary surgical intervention was performed in two patients (7.4%) of MIPPO group for severe wound dehiscence (p=0.04). Conclusion: The two surgical techniques are equivocal for nonunion or malunion rates. However, wound problems may be seen after MIPPO technique and surgeon must be cautious for applying plate when patient has apparent wound problem.

Minimally Invasive Plate Osteosynthesis in Open Pediatric Tibial Fractures

The aim of this study is to investigate the effectiveness and reliability of limited-contact locking plates in minimally invasive percutaneous osteosynthesis (MIPO) of the lateral tibia. A retrospective study. The retrospective study included 14 patients who were operatively treated with an MIPO technique due to open tibial fractures between 2006 and 2012. The patients were 11 males and 3 females with a mean age of 13.2 (range, 9 to 16) years. The patients were followed up for a mean period of 2.4 (range, 1 to 5) years. The mechanism of the injuries included a motor vehicle accident (n=11), a shotgun injury (n=2), and a fall from height (n=1). According to the Gustilo-Anderson classification, 10 patients had type I (72%), 2 had type II (14%), and 2 had type III (14%) open fractures. The mean time to radiologic union was 18 (range, 11 to 32) weeks. No infection was detected that would require implant removal. No complications such as early epiphyseal closure, angulation, or limb-length inequality were observed. Limited-contact locking plates in MIPO of the lateral tibia is an effective alternative method in the treatment of open pediatric tibial fractures. Level IV-therapeutic.

Treatment of Vertebral Body Metastases in Palliative Patients: Radiofrequency Ablation, a New and Secure Treatment Option

IntroductionAbout a quarter of all people dying in germany succumb to cancer. In 40% metastases of the spine are present. Potentially vertebro- or kyphoplasty in combination with a tumorablation may be a treatmentoption in painful metastases or metastases with fractures. Cementing alone leads to dislocation of metastases and scattering of tumoral mass in the patient. (Principle of Archimedes) Therefore local reduction of tumoral mass should be performed whenever possible.The use of ablation systems in the vicinity of nervous and vascular structures is potentially dangerous. The presented observational study is to assess the security and effectivity of a new spinal intravertebral radiofrequency-ablation sonde. Materials and MethodsDuring the period from 11/2013 until 6/2015 we treated 24 patients (14f, 10m) with 58 vertebral bodies with the radiofrequency-ablation system followed by radiofrequency-kyphoplasty. The mean follow-up was 7,04 months (total 169 mon.). Mean age 67 years (Range 51–84 years). All vertebral bodies were treated unipedicular. Cancers treated were breast cancer (8), multiple myeloma (7), lung cancer (3), chondrosarcoma (1), prostate (1), urothel (1), cancer of unknown primary (1), gastric cancer (1) and fibrous dysplasia (1). In two patients this technique was combined with minimal-invasive percutaneous osteosynthesis. The ablationsystem contains a navigable, bipolar electrode with two temperature detection sondes, which allow for real-time temperaturemonitoring at the proximal end of the ablation zone. The ablation zones were planned preoperatively via computertomography and mri. Patients were examined for neurological or other deficits postopertively and during follow-up outpatient clinic visits. ResultsThe ablation of the preoperatively determined areas were intraoperatively radiologically and via monitoring of temperature securely performed. The maneuverability of the ablation device allowed via unipedicular access the exact positioning of the device in the planned ablation zone. No patient presented neurological deficits or vascular lesions due to radiofrequency-ablation. One cementextravasation, while performing kyphoplasty at a site where the lateral wall of the vertebral body had already been preoperatively destroyed by the tumor, lead to affection of a peripheral nerve with intercostal neuralgia (<7 days). ConclusionsThe treatment of 24 tumorpatients in the advanced stadium of the cancer disease with percutaneous, minimally-invasive radiofrequency-ablation followed by cementaugmentation could be verified as secure treatmentoption for vertebral body metastases. The combination of a unipedicular access for radiofrequency-ablation and –kyphoplasty facilitates the careful and safe treatment of palliative cancer patients.

The service impact of failed locking plate fixation of distal tibial fractures: a service and financial evaluation at a major trauma centre

The surgical treatment of distal tibial fractures is challenging and controversial. Recently, locking plate fixation has become popular, but the outcomes of this treatment are mixed with complication rates as high as 50 % in the published literature. There are no reports specifically relating to the financial and resource costs of failed treatment in the literature. Retrospective service analysis of patients who had undergone locking plate fixation of a distal third tibial fracture between 2008 and 2011 with at least 12 months follow-up. Rates of readmission, reoperation, bony union and infection were ascertained. The financial and resource (hospital stay and number of outpatient appointments) implications of failed treatment were calculated. Forty-two patients were identified. There were 31 type A fractures, one type B fracture and 10 type C fractures. Three injuries were open. Twenty patients were treated with minimally invasive percutaneous osteosynthesis (MIPO). The readmission and reoperation rates were 26 % (n = 11) and 19 % (n = 8), respectively. A total of 89 % of readmissions were due to infection. All patients had received appropriate antibiotic regimens. The average costs of successful and failed treatment were £ 5538 and £ 18,335, respectively. The average time to union was 24.5 weeks. The rate of non-union was 21 % (n = 9). The rate of infection was 28 % (n = 12), with all patients with open fracture incurring an infection. Tourniquet time had no effect on the incidence of complications. Smokers were more likely to incur a complication (p < 0.05), and non-union was lower in the MIPO group (p < 0.05). The length and total cost of inpatient care were significantly lower in the MIPO group (p < 0.05). MIPO patients were five times less likely to incur readmission or reoperation. Failed treatment was three times more expensive and four times longer than successful treatment. The study identified a large burden to the service following failure of locking plate treatment of these fractures, but the outcomes were similar to series published in the literature. Readmission rates were high following these injuries, and failed treatment was costly and had a significant impact on hospital resources. The implementation of major trauma networks and centralised subspecialised units should improve quality and value for money.

Minimal Invasive Percutaneous Osteosynthesis for Elderly Valgus Impacted Proximal Humeral Fractures with the PHILOS.

There is a growing concern about elderly valgus impacted proximal humeral fractures. The aim of this study was to evaluate the treatment and clinical outcomes following minimal invasive percutaneous plate osteosynthesis (MIPPO) with the proximal humeral internal locking system (PHILOS) for the treatment of elderly valgus impacted proximal humeral fracture. Between May 2008 and May 2012, 27 patients (average age 67.3, range 61–74) with valgus impacted proximal humeral fractures were enrolled in the study. The patients were treated with MIPPO using PHILOS-plate through the anterolateral delta-splitting approach. Rehabilitation exercises were done gradually. The NEER score and Constant-Murley score were used to evaluate shoulder function. All the patients were followed up by routine radiological imaging and clinical examination. There were 15 cases of II-part greater tuberosity fractures, 10 cases of III-part greater tuberosity fractures, and 2 cases of IV-part fractures according to the NEER classification. The surgery was successful in all patients with an average follow-up of 20.8 (range: 11–34) months. The fractures united in an average of 7.2 (6–14) weeks without implant loosening. According to NEER score, there were 17 excellent, 7 satisfactory, 2 unsatisfactory, and 1 poor. The mean Constant-Murley score was 89.4 ± 4.35. No complication including axillary nerve damage, postoperative nerve or vessel damage, infections, DVT, or death was observed. In conclusion, the MIPPO technique with the PHILOS through the anterolateral delta-splitting approach seems to be a safe and easy treatment for elderly valgus impacted proximal humeral fractures. A case-control study and longer follow-up time are needed.

Stereotactic Radiosurgery and Fracture Fixation in 6 Dogs With Appendicular Osteosarcoma

To evaluate clinical outcome of dogs with appendicular osteosarcoma (OSA) treated with stereotactic radiosurgery (SRS) and subsequent internal fixation of a pathologic fracture. Retrospective case series. Dogs with spontaneous-occurring appendicular OSA (n = 6). Medical records (May 2002-January 2008) of dogs that had SRS for appendicular OSA were reviewed. Dogs were included if they had a pathologic fracture either before or after SRS and were treated with internal fixation. Signalment, history, physical examination findings, clinicopathologic data, diagnostic imaging findings, biopsy results, surgical complications, number of surgeries, adjuvant therapy, development of metastatic disease and cause of death were recorded. Six dogs met the inclusion criteria. Two dogs had a pathologic fracture at admission and 4 dogs developed a fracture after SRS with a mean ± SD time to fracture development of 6.25 ± 1.65 months. The first 3 fractures were repaired using an open approach and the latter three using minimally invasive percutaneous osteosynthesis (MIPO). Infection occurred in 5 dogs and implant failure in 3. Limb function was subjectively assessed as good in all dogs when the implants were stable and infections were subclinical. Survival times ranged from 364-897 days; 1 dog was lost to follow-up. Fracture repair using internal fixation should be considered a viable limb-sparing alternative for pathologic fractures that have been treated with SRS.

상완골 간부 단순 골절에서 최소 침습적 금속판 골유합술을 이용한 치료

Purpose: The purpose of this study is to evaluate the clinical and radiological outcomes of treatment of humerus shaft simple fracture by minimally invasive percutaneous osteosynthesis (MIPO) technique using locking compression plate (LCP). Materials and Methods: Six patients who were operated for humerus shaft simple fracture from August 2010 to May 2011 were enrolled for this study. We checked the cause of injury and the accompanying injuries and evaluated the operation time, the clinical and radiological period of union, postoperative range of motion of the shoulder and elbow joint, pain, activities in daily living, radiologic alignment, and other complications. Results: The clinical period of bone union was 7.2 weeks on average, and the radiologic period of bone union was 8 weeks on average. Follow-up period was more than 12 months in all cases. The angulation through postoperative alignment was 2.8 degrees in AP view and 2 degrees in lateral view. The postoperative range of motion was 167 degrees in forward flexion, 50 degrees in external rotation, and thoracic vertebra 12 level in internal rotation. The average value of visual analogue scale (VAS) was 1.2 and that of KSS was 91.3. The American Shoulder and Elbow Surgeons’ score (ASES) was 26.5 and the UCLA score was 31.5. Conclusion: MIPO technique for the humerus shaft simple fracture showed good functional and radiological outcomes and may be considered as one of the treatment options for humerus shaft simple fracture.

Currents of plate osteosynthesis in osteoporotic bone

Osteoporotic fractures are becoming more prevalent with ageing of populations worldwide. Inadequate fixation or prolonged immobilization after non-surgical care leads to serious life-threatening events, poor functional results and lifelong disability. Thus, a stable internal fixation and rapid initiation of rehabilitation are required for faster return of function. Conventional internal fixation attempts to achieve the exact anatomy, often with extended soft-tissue stripping and compression of the periosteum, causing disturbance of the metaphyseal and comminuted fracture's bone blood supply. This technique relies on frictional forces between bone and plate. Osteoporotic bone might not be able to generate enough torque with the screw to securely fix the plate to bone. Thus, this surgical management have resulted in increased incidence of poor results in elderly, osteoporotic patients. The newly developed locked internal fixators, locking compression plates and less invasive stabilization system, consist of plate and screw systems where the screws are locked in the plate, minimizing the compressive forces exerted between plate and bone. Thus, the plate does not need to compress the bone nor requires precise anatomical contouring of a plate disturbing the periosteal blood supply. These fixators allowed the development of the minimal invasive percutaneous osteosynthesis. Nowadays, locking plates are the fixation method of choice for osteoporotic, diaphyseal or metaphyseal, severely comminuted fractures.

Tibial plateau fractures: Internal fixation with locking plates and the MIPO technique

Proximal tibial fractures are difficult lesions to treat because of the involvement of the articular surface, the often occurring comminution, and the precarious condition of the soft tissues, especially following high-energy trauma. Aim of the treatment is to restore the congruence of the articular surface supporting the tibial plateau cartilage which is usually depressed; to fix the fracture with a stable device; to allow early rehabilitation. We present our treatment strategy, utilising closed or open reduction and internal fixation, angle-stable polyaxial plates, immediate osteointegration, when necessary, with autologous bone graft or other osteoconductive material augmented with autologous platelet gel. Surgery is soft-tissue dependent in terms of timing, and it is usually performed directly or under supervision of an experienced surgeon utilising, whenever possible, a tissue sparing technique. A cohort of 58 proximal tibial fractures, surgically treated, from January 2004 to June 2007, was retrospectively reviewed. Fractures were classified according the OTA/AO classification. The assessment of the functional outcome with the use of the Rasmussen score identified good to excellent results in 78% of the cohort 12 months post-surgery. Internal fixation with locking plates, following the principles of MIPO (Minimally Invasive Percutaneous Osteosynthesis), provides satisfactory fracture reduction with good results regarding the mid-term clinical outcome.

Lower limb malrotation following MIPO technique of distal femoral and proximal tibial fractures

Objective To determine the incidence of rotational malalignment in distal femoral and proximal tibial fractures using computed tomography (CT) scanograms following indirect reduction and internal fixation with the minimally invasive percutaneous osteosynthesis (MIPO) technique. Design Prospective Cohort. Setting Level I Trauma Centre. Patients/Participants A total of 27 consecutive subjects, and 14 proximal tibia and distal femur fractures. Intervention All patients underwent indirect reduction and internal fixation with a MIPO plating system. A CT scanogram to measure rotational malalignment between the injured and non-injured extremity was then undertaken. Main outcome measure(s) Femoral anteversion angles and tibial rotation angles between the injured and non-injured extremities were compared. Malrotation was defined as a side-to-side difference of >10°. Results A total of 14 postoperative tibias and 13 femurs underwent CT scanograms. Three females and 11 males with an average age of 38.1 years sustained proximal tibia fractures and six females and seven males with an average age of 55.8 years sustained distal femur fractures. The difference between tibial rotation in the injured and the non-injured limbs ranged from 2.7 to 40.0° with a mean difference of 16.2° ( p = 0.656, paired T-test). Fifty percent of the tibias fixed with MIPO plates were malrotated >10° from the uninjured limbs. The difference between femoral anteversion in the injured and non-injured limbs ranged from 2.0 to 31.3° with a mean difference of 11.5° ( p = 0.005, paired T-test). A total of 38.5% of the distal femurs fixed with MIPO plates were malrotated >10° from the uninjured limb. Conclusions Following fixation of distal femoral and proximal tibial fractures, the incidence of malrotation was 38.5% and 50%, respectively. The difference of the mean measures was significant for femoral malrotation; however, statistical significance could not be demonstrated for tibial malrotation. The incidence of malrotation following MIPO plating in this study is much higher than that quoted in previous studies.