Minimally invasive percutaneous plates versus conventional fixation techniques for distal tibial fractures: A meta-analysis

Effects of intramedullary nailing and internal fixation plates on postoperative wound infection and pain in patients with distal tibia fractures: A meta-analysis

A meta-analysis was performed to assess the effects of intramedullary nailing (IMN) and internal fixation plates (IFP) on postoperative wound infection and pain in patients with distal tibia fractures, to provide evidence for the selection of surgical options for this group of patients. Computerised searches were performed on PubMed, Cochrane Library, EMBASE, MEDLINE, CNKI and Wanfang databases from the inception of each library to August 2023. All published randomised controlled trials (RCTs) comparing IMN with IFP for the treatment of patients with distal tibial fractures were selected. Literature screening, data extraction and literature evaluation were independently completed by two researchers. Data analysis was performed using the Review Manager 5.4 software. Overall, 25 RCTs with a total of 2011 patients were finally included, comprised by 1009 patients in the IMN group and 1002 patients in the IFP group. The rate of wound infection was significantly lower in the IMN group than that in the IFP group (5.05% vs. 9.58%, odds ratio [OR]: 0.52, 95% confidence intervals [CIs]: 0.37-0.73, p < 0.001). Meanwhile, the IMN group had a significantly higher rate of joint pain than that of the IFP group (14.57% vs. 2.90%, OR: 4.93, 95% CIs: 3.02-8.03, p < 0.00001), whereas the difference between the two surgical procedures in terms of operative time was not statistically significant (standardised mean differences: 0.08 95% CIs: -0.58-0.74, p = 0.82). Current clinical evidence suggests that both IMN and IFP are excellent treatments for distal tibial fractures. Although IMN is better in reducing postoperative wound infection, the risk of postoperative pain is higher. Thus, an appropriate surgical procedure should be selected in clinical practice in accordance with the actual situation of the patient, and IFP is used to reduce the incidence of postoperative joint pain when the anterior tibial soft tissue of the distal tibial fracture is in good condition, and vice versa. IMN is used to reduce the risk of infection.

Treatment of Distal Metaphyseal Tibial Fractures with Anterolateral Plates or with Anterolateral-Medial Plates: A Retrospective Series

Distal metaphyseal tibial fractures (3-5 cm from the joint with zones of comminution or <3 cm from the joint) are challenging to fix and are associated with many complications. The study objective was to evaluate the functional outcomes and complications after treating distal metaphyseal tibial fractures using anatomical anterolateral tibia locking plates or anterolateral-medial plates. This retrospective study included 57 patients with distal metaphyseal tibial fractures. Thirty patients were treated by open reduction internal fixation with anterolateral plates; 27 patients were treated with anterolateral-medial plates. Patients were followed at regular intervals. The time to fracture union and complications were recorded. We evaluated the stage of fracture healing using the Radiographic Union Score for Tibial fractures. The patients treated with anterolateral plates had significantly higher rates of loss of reduction and malunion than those treated with anterolateral-medial plates (p = .02 and p = .002, respectively). There were no significant differences in the radiographic union scores (p = .22), non-union (p = .17), incision necrosis (p = .91), or infection (p = .94) between the 2 groups. The functional outcomes were assessed using the American Orthopedic Foot and Ankle Society hindfoot-ankle score at the 12-month follow-up. The mean hindfoot-ankle scores were 90.9 ± 5.0 (range 79 to 100, median 90) and 92.3 ± 5.1 (range 82 to 100, median 92) for the anterolateral plates and anterolateral-medial plates, respectively (p = .29). For distal metaphyseal tibial fractures, anterolateral-medial plates may be worthwhile for reducing loss of reduction and malunion.

Posterolateral Plating of Distal Tibia Fractures: Extending the Use of a Familiar Approach

BACKGROUND

Distal tibia fractures present challenges in surgical management and when nailing is not an option, plate osteosynthesis is performed. This is usually done with a minimally invasive approach to reduce the risk of wound complications in an already fragile soft-tissue envelope. We propose that a posterolateral open approach can lead to stable fixation construct and comes with advantages of approaching fibula fractures via same approach and has a thicker soft tissue envelope over the fixation. We report a series of distal tibia fractures with posterolateral plate fixation and present the outcomes.

METHODS

This is a retrospective review conducted at a single institution, where 13 patients underwent posterolateral approach for distal tibia fracture fixation. Where required, medial plating and fibular fixation was additionally performed. Patients were followed-up with primary endpoint of successful clinical and radiological union or complications required re-intervention. Operative and long-term clinical outcomes were recorded.

RESULTS

Long term follow-up was available for 12 patients. There was 1 non-union requiring revision (8.3%). For the other patients, clinical union occurred by 14.5 weeks and radiological union by 20 weeks on average. There was no malunion and 2 patients (16.6%) underwent removal of implants for symptoms of hardware irritation.

CONCLUSION

We found that outcomes in our cohort demonstrate posterolateral plating is safe as a primary or adjunctive method of fixation, and does not compromise other outcomes when compared with traditional fixation methods.

Clinical comparison of single-incision and dual-incision approaches for the treatment of distal tibial and fibular fractures: A randomized controlled trial

PURPOSE

The purpose of this study was to clinically compare the single-incision and dual-incision approaches for the treatment of distal tibial and fibular fractures.

METHODS

In total, 93 patients were enrolled, and the mean follow-up was 15 months (range 12-19 months). The patients treated for open reduction and internal fixation were randomly classified into two groups based on the approach used: 45 patients were treated using the single-incision approach (group 1) and 48 patients were treated using the dual-incision approach (group 2). In these two groups, operation time, discharge time, postoperative complications, and ankle function evaluations (Olerud-Molander Ankle Score) were compared between the two groups.

RESULTS

There were no significant differences in the mean operation time (98.2 ± 18.5 vs. 103.6 ± 19.3), discharge time (11.1 ± 3.9 vs. 12.5 ± 5.7), overall surgical complication rates (9/45 vs. 15/48), or ankle function between the two groups (p > 0.05). However, the rate of soft tissue-related complications, such as skin slough, infection, nonunion, and delayed union, was significantly lower in group 1 (5/45) than in group 2 (14/48) (p < 0.05).

CONCLUSION

The two incision approaches were found to have similar clinical outcomes. However, with regard to soft tissue conservation, the single-incision approach was superior to the dual-incision and maybe a reliable alternative.

Minimally invasive plate osteosynthesis: An update of practise

Since its conception in 1989, minimally invasive plate osteosynthesis (MIPO) has gained widespread popularity. It has been studied in over forty countries with most of the publications originating from Asia, Europe and North America. This review aims to describe the scientific path of MIPO from the very beginning to where it stands in current day times; study the pattern and contributing factors influencing its global spread. Finally, the up to date evidence is discussed with regard to several anatomical regions in which MIPO is mostly used. In the meantime, MIPO treads steadily towards accomplishing the same or better outcomes for more and more indications with the goal to leave a smaller surgical footprint to allow for undisturbed bone healing.

Minimally invasive plate osteosynthesis or conventional intramedullary nailing for distal tibial fractures: A cohort study protocol

BACKGROUND

Currently, both minimally invasive plate osteosynthesis (MIPO) and intramedullary nailing are the two most commonly used methods of treatment in distal tibial fractures, but controversy still exists regarding the clinical effects of 2 techniques. Our purposes were to compare MIPO and intramedullary nailing for distal tibia shaft fractures by assessing functional outcomes and complications.

METHODS

Data were collected retrospectively from the charts of patients treated for distal tibial extra-articular fractures between May 2012 and July 2018. All cases were performed by a single surgeon. Institutional review board approval in the Second Affiliated Hospital of Army Medical University was obtained prior to conducting chart review and analysis. The criteria for inclusion in the study were being aged at least 18 years at the time of diagnosis and having a closed or type I open fracture of the distal third of the tibial diaphysis. The primary outcome compared between the 2 groups was the American Orthopedic Foot and Ankle surgery score. The secondary outcome measures in this trial included Olerud and Molander Ankle Score, radiographic outcomes, and complications. Statistical analysis was performed using SPSS version. P values < .05 were considered statistically significant.

RESULTS

We hypothesized that MIPO would be associated with better functional outcomes and fewer complications.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5808).

Comparison of 3 Treatment Methods for Distal Tibial Fractures: A Network Meta-Analysis

Background

The choice of optimal internal fixation device for distal tibial fractures remains controversial. The purpose of our study was to evaluate the effectiveness and safety of open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and intramedullary nailing of distal tibial fractures in adults using network meta-analysis of data from clinical trials.

Material/Methods

The studies were abstracted from MEDLINE, EMBASE, CNKI, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials meeting inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 13.0 (Stata Corporation, College Station, Texas, USA).

Results

Eleven randomized controlled trials were included. The total number of participants was 710 and the studies were published between 2005 and 2017. There were no significant differences in rates of delayed union, nonunion, or malunion among the various treatments (all p>0.05). The intramedullary nailing group had a lower incidence of wound complications than did the open reduction and internal fixation group and minimally invasive percutaneous osteosynthesis technique group. The SUCRA probabilities were 28.6% for ORIF, 98.4% for IMN, and 22.9% for MIPPO.

Conclusions

Given the superior results for intramedullary nailing in terms of wound complications, we recommend this procedure for treatment of distal tibial fractures. More RCTs focused on distal tibial fractures are needed to support the current evidence.

Perceptions of minimally invasive osteosynthesis: A 2018 survey of orthopedic surgeons

OBJECTIVE

To report perspectives of minimally invasive osteosynthesis (MIO) techniques in veterinary surgical practice in 2018.

STUDY DESIGN

Electronic questionnaires.

SAMPLE POPULATION

Diplomates and residents of the American College of Veterinary Surgery and European College of Veterinary Surgery and members of the Veterinary Orthopedic Society.

METHODS

Survey questions pertaining to MIO and minimally invasive plate osteosynthesis (MIPO) were sent electronically to the sample population. Questions assessed training, current caseload, benefits, and limitations of MIO and MIPO.

RESULTS

Two hundred fifty-six veterinary surgeons completed questions pertaining to MIO, and 238 veterinary surgeons completed questions pertaining to MIPO. With regard to MIO, only 16% of respondents reported that they performed MIO regularly or exclusively, and 62% wanted to perform more MIO than they were currently undertaking. Tibial fractures were most commonly selected for MIO/MIPO stabilization techniques in both cats and dogs. Challenges in achieving adequate fracture reduction were identified as the greatest limitations of MIO/MIPO techniques. Forty-three percent of respondents felt there were not enough MIPO training opportunities.

CONCLUSION

Currently, MIO/MIPO techniques are performed infrequently, with a large proportion of respondents revealing that they would like to perform more in the future. There is also evidence that additional training opportunities would be welcomed for MIPO.

CLINICAL SIGNIFICANCE

The results of our survey provide evidence that, despite the benefits of MIO and MIPO compared with more traditional fracture stabilization approaches, significant barriers must be overcome before the techniques are likely to be more widely adopted.

Minimally invasive plate osteosynthesis versus conventional open insertion techniques for osteosynthesis

Osteosynthesis has evolved theoretically and practically throughout its evolution. Similar to trends in other surgical fields, surgical techniques in fracture fixation, such as minimally invasive plate osteosynthesis (MIPO), have moved from large dissections to more tissue sparing methods. These plating techniques have been developed for a variety of bones, but more universal clinical adoption will rely upon improved clinical outcomes. The current review will describe minimally invasive techniques, evaluate their rationale, and summarize evidence for their efficacy.

Soft tissue complications in distal tibial fractures managed with medial locking plates: A myth or reality?

BACKGROUND

Distal tibial fractures are common injuries that are prone to complications and require careful management. The use of medial periarticular locking plates is an established modality in the treatment if these fractures. These plates are inserted using the minimally invasive plate osteosynthesis (MIPO) or open technique. Our study looks at the soft tissue complications associated with the use of medial locking plates in the management of these fractures.

METHODS

This was a retrospective study carried out at a tertiary care university hospital in an urban setting. Forty four patients with distal tibia fractures treated with periarticular locking plates during a three year period were included in the study. Both closed and open fractures were included while those with an established non-union were excluded. Patient data related to inpatient stay, outpatient visits as well as readmissions was extracted from hospital records and analysed. Spanning external fixation was done if necessary and definitive fixation was done using medial locking plates with either MIPO technique or open reduction and internal fixation (ORIF) with biological technique. The sub cohort of patients with soft tissue complications was compared to the parent group.

RESULTS

The study group included 44 patients (28M:16F) with 45 fractures with a median age of 42.6 years (range 18-65 years) followed up for a mean of 9.2 months (range 5-20 months). Domestic falls were the cause of injury in 61.4% (n = 27) of the fractures. The average time to union was 26.2 weeks (range 12-66 weeks). Out of these 45 fractures, soft tissue complications were seen in 22.2% of cases (n = 10) with road side accidents seen in 60% (n = 6) of cases. In four patients, there was difficulty in achieving primary wound closure and in five other cases wound dehiscence with exposure of implant was seen within 12 to 30 days of surgery. One patient required secondary suturing after readjustment for malreduction. No statistically significant difference was found in the parent cohort and the sub cohort with soft tissue complications with respect to the use of spanning external fixator, MIPO/ORIF technique or fibular fixation.

CONCLUSION

The incidence of soft tissue complications with the use of medial locking plates in distal tibial fractures may be more than what is currently reported in literature and further studies are required to shed more light on this subject.