Minimally invasive plate osteosynthesis using the oblong hole of a locking plate for comminuted distal fibular fractures

Advancing fracture management: the role of minimally invasive osteosynthesis in orthopedic trauma care

PURPOSE

Minimally Invasive Osteosynthesis (MIO) developed to be a key technique in orthopedic trauma surgery, offering a less invasive alternative for managing fractures in various anatomical regions. However, standardized guidelines for its application are lacking. This study aims to establish comprehensive principles for MIO to guide surgeons in treating different types of fractures and its locations.

METHODS

A retrospective analysis including 57 fractures in 53 patients was conducted. All patients were treated with MIO. Study range - March 2017 to January 2022 at a Level-I trauma university hospital. The analysis covered various fracture types, focusing on surgical approaches, reduction techniques, plate insertion methods, and its outcomes. The efficacy and safety of MIO was evaluated by analyzing complications, fracture healing time, and necessary revision surgeries.

RESULTS

MIO is a versatile and effective fracture treatment that minimized soft tissue damage and ensured stable osteosynthetic results. Articular fractures typically used a "one way up" plate insertion technique, while non-articular fractures applied an "inside-up-and-down" approach. Low complication rates confirmed the safety and efficiency of MIO.

CONCLUSION

This research established generalized principles for MIO, offering a systematic approach that can be applied for various fracture types and its locations, by overall enhancing the surgical efficiency as well as patient recovery, without compromising outcomes.

LEVEL OF EVIDENCE

This study is classified as Level III evidence according to "The Oxford 2011 Levels of Evidence".

A retrospective comparison of double-hooked locking plates versus non-locking plates in minimally invasive percutaneous plate osteosynthesis for the treatment of comminuted distal fibular fractures accompanied by tibial Pilon fractures

BACKGROUND

Surgical approach and fixation material are crucial in the treatment of comminuted distal fibular fractures accompanied by tibial Pilon fractures. This study compared the efficacy of double-hooked locking plates and anatomic plates in minimally invasive percutaneous plate osteosynthesis (MIPPO) for the treatment of comminuted distal fibular fractures accompanied by tibial Pilon fractures.

METHODS

Clinical data were collected from 96 patients diagnosed with comminuted distal fibular fractures accompanied by tibial Pilon fractures who had undergone MIPPO. Patients in the study group (n = 48) received double-hooked locking plate fixations and the control group (n = 48) received anatomical plate fixations. The operating time, intraoperative bleeding, length of hospital stays, full weight-bearing time, fracture healing time and complication rates in the two groups were compared. The quality of fracture reduction was evaluated using the Burwell-Chamley imaging scoring system; the ankle function was assessed based on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score.

RESULTS

Patients in the study group had shorter operating time, less bleeding, significantly shorter hospital stays, and shorter time to full weight-bearing as well as fracture healing compared to the control group (P < 0.05). Additionally, the post-operative complication rates were significantly lower in the study group (6.16% vs. 22.92%) (P < 0.05), but there was no significant difference in the fracture reduction rate between the two groups (P > 0.05). Patients in the study group experienced better ankle recovery than those in the control group (93.75% vs. 75.00%) (P < 0.05).

CONCLUSION

Double-hooked locking plates have advantages in the treatment of comminuted distal fibular fractures accompanied by tibial Pilon fractures during MIPPO due to their shorter operating time and less intraoperative bleeding, as well as shorter hospital stays, full weight-bearing time and fracture healing time, fewer complications and better ankle recovery. Therefore, double-hooked locking plates are worthy of clinical application.

Treatment of Symptomatic Subfibular Ossicle by Excision and Modified Broström Procedure for Skeletally Immature Patients

BACKGROUND

Ossicle resection combined with ligament repair using the modified Broström procedure (MBP) is generally associated with favorable results in adults with symptomatic subfibular ossicles; however, the surgical results of this approach in skeletally immature patients remain unclear. The purpose of this study was to investigate the midterm clinical outcomes and radiographic outcomes including leg length and physeal growth of skeletally immature patients after this procedure.

METHODS

Twenty-six consecutive skeletally immature patients who underwent ossicle resection combined with the MBP were retrospectively evaluated. Clinical scores were evaluated using the visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Karlsson-Peterson score, and Tegner score. The talocrural angle, fibular length on radiographs, and tape-measured leg length between the 2 ankles were also measured at the final follow-up. Time of return to sports and postoperative complications were also evaluated.

RESULTS

Fourteen girls (53.8%) and 12 boys (46.2%) had surgery at a mean age of 12.7±2.4 years. Mean postoperative follow-up time was 40.0±10.8 months. Mean VAS pain score improved from 4.1 preoperatively to 0.5 at final follow-up (P < .05). Mean AOFAS score, Karlsson score, and Tegner score all improved from 62.0, 54.0, and 2.8 preoperatively to 95.5, 94.0, and 5.4 (P < .05), respectively, at final follow-up. Median time of return to sports was 17.0 weeks. Mean talocrural angle, fibular length, and tape-measured leg length of the injured ankle were not significantly different from those of the contra-side at the final follow-up. All patients were satisfied with the results; repeat ligamentous injury occurred in 2 patients (7.7%). We had no cases of wound infection, nerve injury, compartment syndrome, or any other complications.

CONCLUSION

Ossicle resection combined with the MBP performed in skeletally immature patients with symptomatic subfibular ossicles resulted in improved clinical outcomes without disruption of fibular physeal growth by an average of 3.3-year follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

Determining the Tightrope Tightening Force for Effective Fixation of the Tibiofibular Syndesmosis during Osteomeatal Synthesis of Fibula Injuries

The issue of choosing the method for optimal surgical treatment of a broken fibula has been debatable for many years. At the same time, concomitant repair of tibiofibular syndesmosis injuries does not have a unified approach. It has been determined that osteosynthesis of broken shin bones with syndesmosis injury should combine stable fixation of the broken bone and should not limit the elastic properties of the syndesmosis. In case of a broken fibula, it is recommended to use a stable extracortical fixator and an elastic connection of the syndesmosis injury using a tightrope. An analytical model of the broken fibula, which is blocked with an extracortical fixator metal plate and elastically fixed with a tightrope, has been developed. The research object is the stress–strain state of the “broken fibula–extracortical titanium plate” composition under the action of tightrope tightening fixation. The main research result is an analytical dependence, which makes it possible to determine the permissible value of the tightrope tightening force for elastic fixation of the tibiofibular syndesmosis. The research results have been tested numerically, and the influence of the parameters of plate, bone and damage localization on the permissible value of the tightrope tightening force has been analyzed. By using the rational tightrope tightening force with stable–elastic fixation of the broken shin, it is possible to reduce the time before the start of loading on the injured extremity and accelerate the functional recovery of the patient.