Suprapatellar intramedullary nail combined with screw fixation has comparable surgical outcomes to minimally invasive locking plate fixation in ipsilateral tibial plateau and shaft fractures.

PURPOSE: To compare union rate, union time, alignment, and complication rate in ipsilateral tibia plateau and shaft fractures treated via suprapatellar intramedullary nailing with screw fixation and minimally invasive locking plate fixation. MATERIALS AND METHODS: A retrospective study was conducted on 48 patients who underwent minimally invasive plate fixation (n = 35) or suprapatellar intramedullary nailing with screw fixation (n = 13), for the treatment of ipsilateral tibial plateau and shaft fractures with at least 1-year follow-up. Union rate, union time, radiologic alignment, and complication rate such as malalignment, nonunion, and fracture-related infection (FRI) were investigated. RESULTS: Demographic data were not different between the two groups. Coronal plane alignment was 0.17 ± 4.23 in the plate group and -0.48 ± 4.17 in the intramedullary nail group (p = 0.637). Sagittal plane alignment was -0.13 ± 5.20 in the plate group and -1.50 ± 4.01 in the suprapatellar intramedullary nail group (p = 0.313). Coronal and sagittal malalignment recorded equal results: (p > 0.99), FRI (p = 0.602), nonunion and union times recorded (p = 0.656) and (p = 0.683, 0.829), respectively, and showed no significant difference between the two groups. CONCLUSION: Suprapatellar intramedullary nailing with screw fixation had similar surgical outcomes with minimally invasive locking plate fixation in ipsilateral tibial plateau and shaft fractures in terms of union rate, union time, alignment, and complication rate. Thus, frequent use of intramedullary nailing combined with screw fixation is anticipated in patients with ipsilateral tibial plateau and shaft fractures when the soft tissue condition is not desirable. LEVEL OF EVIDENCE: Level III.

Precontoured dynamic compression plate using patient-specific 3D-printed models in minimally invasive surgical technique for midshaft clavicle fractures.

INTRODUCTION: This study introduced a novel approach for the treatment of midshaft clavicle fractures, utilizing patient-specific 3D-printed models for accurate preoperative contouring of dynamic compression plates (DCPs) and an alternative minimally invasive plate osteosynthesis (MIPO) technique with precontoured DCPs through small vertical separated incisions. PATIENT AND METHODS: Mirror image 3D clavicular models were reproduced from 40 patients with acute displaced midshaft clavicle fractures who underwent MIPO using precontoured DCPs inserted through small, vertical separated incisions. Exclusion criteria included patients with open fractures, pathological fractures, ipsilateral limb injury, skeletal immature patients, and those who had previous clavicle fractures or surgery. Postoperative evaluation was conducted using clinical and radiographic review. The Constant-Murley and American Shoulder and Elbow Surgeons Shoulder Scores were used for clinical evaluations, and the Patient and Observer Scar Assessment Scale was used to assess surgical scars. RESULTS: The average time to union of all fractures was 12.88 weeks (range, 8-15) without loss of reduction. The patient-specific precontoured DCPs fitted well in all cases, with fracture consolidation and minimal three cortical sides connecting the fracture fragment. No hardware prominence and skin complications occurred, and clinical evaluation showed no existing difference compared with the contralateral sides. The average Constant-Murley and American Shoulder and Elbow Surgeons Shoulder Scores were 96.33 ± 3.66 and 93.26 ± 5.15, respectively. Two patients requested their implant removal, and scar qualities were satisfactory. CONCLUSIONS: Our study demonstrated that the use of a patient-specific precontoured DCP, in combination with 3D printing technology, provides accurate preoperative planning, effective fracture reduction, and improved postoperative outcomes in displaced midshaft clavicle fractures. The MIPO with a patient-specific precontoured DCP through separated vertical incisions along the Langer's lines appears to be a promising option, regarding appearance, avoiding associated complications, and obviating the need for reoperation. These results suggest that this technique has merit and can be a viable option for the treatment of midshaft clavicle fractures.

Lateral minimally invasive plate osteosynthesis (MIPO) with long PHILOS for proximal metaphyseal-diaphyseal humeral fracture: surgical techniques and a clinical series.

The minimally invasive plate osteosynthesis (MIPO) for proximal metaphyseal-diaphyseal humeral fracture is an effective alternative treatment with satisfactory outcomes. In this study, we described the surgical techniques and clinical results using MIPO via a lateral approach and long PHILOS plate fixation in 23 patients. All fractures were successfully united within a mean union time of 13.5 weeks (range 9-18). There was no iatrogenic radial nerve palsy. The deltoid power was grade 5 in all patients, except for 2 patients who had associated brachial plexus injury and gunshot injury at the deltoid muscle. The mean Constant-Murley score was 85.6 (range 16-98) and DASH score was 12.1 (range 1.7-85). Based on these findings, the lateral MIPO with long PHILOS plate fixation could be an alternative for the proximal metaphyseal-diaphyseal fractures of the humeral shaft.

Minimally invasive plate osteosynthesis (MIPO) for distal humeral fractures: a cadaveric study and first clinical application.

BACKGROUND: The indication for minimally invasive plate osteosynthesis (MIPO) may include articular fractures depending on the fracture pattern. The goal of this study was to evaluate the feasibility of the MIPO technique for extra- and intra-articular distal humeral fractures. METHODS: The feasibility of the MIPO technique was assessed on 8 cadaveric elbows and 2 clinical cases. The four surgical approaches tested included a 20-mm ulnar incision, a 20-mm dorsoradial incision, and two incisions for olecranon osteotomy (A and B). Surgical incision A was 40 mm on the osteotomy level of the olecranon, and surgical incision B was an extension of the radial incision toward the osteotomy of the olecranon (80 mm). The four approaches were tested on 4 extra-articular (AO 13 A3) fractures and 4 intra-articular (AO 13 C3) fractures. RESULTS: Reduction and plate fixation of all distal humeral fractures (8 cadaveric) with and without osteotomy was feasible. However, when using approach B, the soft tissue tension is reduced due to the wider incision. Nevertheless, both approaches A and B showed the same adequate intra-articular fracture control and reduction. CONCLUSION: The MIPO technique for reduction and plate fixation in distal humeral fractures is feasible. LEVEL OF EVIDENCE: As a feasibility study, this study cannot be clearly classified into a level of evidence. It corresponds most closely to level IV.

Minimally invasive plate osteosynthesis for displaced midshaft clavicle fractures: An indirect reduction using joystick technique.

BACKGROUND: A minimally invasive plate osteosynthesis (MIPO) technique has become increasingly popular in long bone fracture fixation as it could eliminate postoperative complications. However, the most challenging aspect of employing the MIPO for midshaft clavicle fractures among general orthopedic surgeons is the technically demanding that indirect reduction is typically a closed maneuver. METHODS: We present a consecutive series of patients with displaced midshaft clavicle fractures undergoing clavicular fixation using the MIPO technique between January 2017 and October 2019. The joystick technique was used to obtain anatomical reduction. Clinical outcomes were assessed using the Constant-Murley and the American shoulder and elbow surgeons shoulder scores. RESULTS: Thirty patients with a mean age of 42.44 years were included. The functional shoulder scores showed no disabilities compared with those of a healthy population. No major complications requiring re-operation were noted, and all fractures were completely healed with an average time of 12.53 weeks. CONCLUSION: This study demonstrated that facilitating the MIPO for midshaft clavicle fractures using simple operative devices and techniques was possible. The joystick technique with the use of an external fixator for temporary stabilization is a safe and effective method that can be added to achieve anatomical alignment with the fracture site unexposed. This technique could be performed either in a fresh fracture or a delayed case with failed conservative treatment.

Methods of assessment of the level of surgeons for minimally invasive fixation of distal radius fractures: "expertise" versus "performance".

INTRODUCTION: The results of surgical techniques vary depending on the level of the surgeon's experience. The level of expertise can be evaluated quantitatively or qualitatively. In this study, we evaluated the duration of the procedure and the size of the incision of minimally invasive fixation of distal radius fractures as a means of grading expertise and surgical performance. The null hypothesis of our study was that the level of expertise did not match the level of performance. MATERIAL AND METHODS: The study included 52 surgeons split in five levels of expertise who had performed 467 minimally invasive fixations of distal radius fractures. The performance of the surgeons in terms of duration of the procedure and size of the incision were scored according to the five levels of surgical experience using four different methodologies: clinical (setting limits compared to data found in literature), statistical (setting statistical limits of comparison in percentiles (20th, 40th, 60th, 80th) for each of the two parameters measured), arithmetical (setting limits compared to equal intervals for each of the 2 variables), and success rate (setting a threshold for each of the 2 variables). RESULTS: Our results showed a great disparity between levels of experience depending on the method used. The scores for levels 1 and 2 were 72% for expertise, 13% for performance according to the clinical method, 75% for the statistical method, 0% for the arithmetical method, and 57% according the success rate. The rate of level 3 was 23% for expertise, 41% for performance by the clinical method, 17% by the statistical method, 17% by the arithmetical method, and 15% by the success rate. The rates of levels 4 and 5 were 5% for expertise, 46% for performance clinical method, 8% by the statistical method, 83% by the arithmetical method, and 28% by the success rate. DISCUSSION: The null hypothesis of our study was confirmed by the results which show that there was no correlation between levels of expertise and performance. The clinical method of assessment appears to reflect best the true level of performance of the surgeon. CONCLUSION: Publications reporting the results of a surgical technique for a given pathology should always mention the level of performance as measured on a clinical scale.

Biomechanical analysis of helical versus straight plating of proximal third humeral shaft fractures.

BACKGROUND: Proximal humeral shaft fractures are surgically challenging and plate osteosynthesis with a long straight plate is one operative treatment option in these patients although endangering the radial nerve distally. Helical plates potentially avoid the radial nerve by twisting around the humeral shaft. Aim of the study was to investigate in a human cadaveric model the biomechanical competence of helical plates versus straight lateral plates used for fixation of proximal third comminuted humeral shaft fractures. METHODS: Eight pairs of humeral cadaveric humeri were instrumented using either a long 90°-helical plate (Group1) or a straight long PHILOS plate (Group2). An unstable proximal humeral shaft fracture was simulated by means of a 5 cm osteotomy gap. All specimens were tested under quasi-static loading in axial compression, internal and external rotation, and bending in four directions. Subsequently, progressively increasing cyclic loading in internal rotation until failure was applied and interfragmentary movements were monitored by motion tracking. RESULTS: During static testing flexion/extension deformation in Group1 was significantly higher, however, varus/valgus deformation as well as shear and torsional displacement under torsional load remained statistically indifferent between both groups. During cyclic testing shear and torsional displacements were both significantly higher in Group1 compared to Group 2. However, cycles to catastrophic failure remained statistically indifferent between the groups. CONCLUSIONS: From a biomechanical perspective, although 90°-helical plating is associated with higher initial stability against varus/valgus collapse and comparable endurance under dynamic loading, it demonstrates lower resistance to flexion/extension and internal rotation with bigger shear interfragmentary displacements versus straight lateral plating and, therefore, cannot be considered as its real alternative. Alternative helical plate designs should be investigated in the future.

Comparison of suprapatellar intramedullary nailing versus minimal invasive locked plating for proximal tibia fractures.

PURPOSE: To compare the radiological alignment, union time, union rate, and complication rate between suprapatellar intramedullary nails and minimally invasive locking plate fixation in the treatment of proximal tibial fractures. MATERIALS AND METHODS: We retrospectively analyzed 103 patients who underwent plate fixation (n = 50) or suprapatellar intramedullary nailing (n = 53) for proximal tibial fractures involving the meta-diaphyseal junction between November 2015 and October 2020 at our institution. The union rate, union time, radiologic alignments, and complications, such as malalignment, nonunion, and deep infection, were investigated. RESULTS: The demographic data did not differ between the plate and suprapatellar intramedullary nail groups. The alignment of the coronal plane was 0.24 ± 3.19 in the plate group and - 0.49 ± 2.22 in the intramedullary nail group (p = 0.196). Sagittal plane alignment was - 0.29 ± 4.97 in the plate group and 0.24 ± 4.12 in the intramedullary nail group (p = 0.571), and coronal malalignment (p = 0.196), sagittal malalignment (p = 0.57), deep infection (p = 0.264), nonunion (p = 0.695), union time (p = 0.329), and final union rate (p = 0.699) were not significantly different between groups. CONCLUSION: Compared with the minimally invasive locking compression plate group, the suprapatellar intramedullary nail group yielded comparable results in terms of radiological alignment and complications. Considering that proximal tibial fractures are associated with high-energy trauma and severe soft tissue damage, we believe that a suprapatellar intramedullary nail may be a good alternative. LEVEL OF EVIDENCE: Level III.

Treatment of Soft Tissue Defects after Minimally Invasive Plate Osteosynthesis in Fractures of the Distal Tibia: Clinical Results after Reverse Sural Artery Flap.

Introduction: Distal tibial fractures make up approximately 3% to 10% of all tibial fractures or about 1% of lower extremity fractures. MIPO is an appropriate procedure and method to achieve stable metal plate fixation and osseointegration by minimizing soft tissue damage and vascular integrity at the fracture site. MIPO to the medial tibia during distal tibial fractures induces skin irritation due to the thickness of the metal plate, which causes discomfort and pain on the medial side of the distal leg, and if severe, complications such as infection and skin defect may occur. The reverse sural flap is a well-researched approach for covering defects in the lower third of the leg, ankle, and foot. Materials and Methods: Among 151 patients with distal tibia fractures who underwent minimally invasive metal plate fixation, soft tissue was injured due to postoperative complications. We treated 13 cases with necrosis and exposed metal plates by retrograde nasogastric artery flap surgery. For these patients, we collected obligatory patient records, radiological data, and wound photographs of the treatment results and complications of reconstructive surgery. Results: In all the cases, flap survival was confirmed at the final outpatient follow-up. The exposed area of the metal plate was well coated, and there was no plate failure due to complete necrosis. Three out of four women complained of aesthetic dissatisfaction because the volume of the tunnel through which the skin mirror passed and the skin plate itself were thick. In two cases, defatting was performed to reduce the thickness of the plate while removing the metal plate. Conclusions: Metal plate exposure after distal tibial fractures have been treated with minimally invasive metal plate fusion and can be successfully treated with retrograde nasogastric artery flaps, and several surgical techniques are used during flap surgery.

Helical Plating Compared with Straight Plating and Nailing for Treatment of Proximal Third Humeral Shaft Fractures-A Biomechanical Study.

Background and Objectives: The surgical treatment of proximal humeral shaft fractures usually considers application of either long straight plates or intramedullary nails. By being able to spare the rotator cuff and avoid the radial nerve distally, the implementation of helical plates might overcome the downsides of common fixation methods. The aims of the current study were (1) to explore the biomechanical competence of different plate designs and (2) to compare their performance versus the alternative treatment option of using intramedullary nails. Materials and Methods: Twenty-four artificial humeri were assigned to the following four groups for simulation of an unstable proximal humeral shaft fracture and instrumentation: Group 1 (Straight-PHILOS), Group 2 (MULTILOC-Nail), Group 3 (45°-Helical-PHILOS), and Group 4 (90°-Helical-PHILOS). All specimens underwent non-destructive, quasi-static biomechanical testing under loading in axial compression, torsion in internal/external rotation, and pure bending in four directions, accompanied by motion tracking. Results: Axial stiffness/displacement in Group 2 was significantly higher/smaller than in all other groups (p ≤ 0.010). Torsional displacement in Group 2 was significantly bigger than in all other groups (p ≤ 0.017). Significantly smaller coronal plane displacement was identified in Group 2 versus all other groups (p < 0.001) and in Group 4 versus Group 1 (p = 0.022). Significantly bigger sagittal plane displacement was detected in Group 4 versus all other groups (p ≤ 0.024) and in Group 1 versus Group 2 (p < 0.001). Conclusions: Intramedullary nails demonstrated higher axial stiffness and smaller axial interfragmentary movements compared with all investigated plate designs. However, they were associated with bigger torsional movements at the fracture site. Although 90°-helical plates revealed bigger interfragmentary movements in the sagittal plane, they demonstrated improved resistance against displacements in the coronal plane when compared with straight lateral plates. In addition, 45°-helical plates manifested similar biomechanical competence to straight plates and may be considered a valid alternative to the latter from a biomechanical standpoint.

Outcomes following minimally invasive plate osteosynthesis (MIPO) application in tibial pilon fractures - A systematic review.

BACKGROUND: This systematic review evaluates postoperative complications and functional outcomes of minimally invasive plate osteosynthesis (MIPO) for distal tibial pilon fractures. This paper aims to fill a key literature gap, as no previous reviews have specifically addressed MIPO for tibial pilon fractures or fractures other than those involving the humeral shaft. METHODS: This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic literature search was done using PubMed, Embase, Web of Science, and Scopus databases from 2000 to 2022. Inclusion criteria were MIPO treatment in skeletally mature patients, while exclusion criteria were non-English papers, conference abstracts, papers with multiple treatment modalities that didn't analyze MIPO outcomes separately, skeletally immature patients, case reports, and cohorts smaller than five patients. Unpublished papers were also searched using Clinical Trials. Data extraction included general study information, injury specification, outcome measures, and complications. Finally, a risk of bias assessment (RoB) was performed. RESULTS: A total of 1732 studies were identified, of which 23 were included in this review, with 673 patients and 678 fractures analyzed. The mean follow-up ranged from 6 to 62.53 months, with most studies representing intermediate to long-term follow-up. Primary outcome measures showed that 87.33% achieved 'excellent to good' results, 8.67% achieved 'fair' results, and 4% achieved 'poor' results. Stratified by fracture type, 76.47%, 80.05%, and 76.92% of AO/OTA type A, B, and C fractures, respectively, achieved 'excellent to good' results. 35.06% of cases reported complications (236 in total). These included one case of deep infection (0.148%), 28 superficial wound infections (4.16%), 4 nonunion cases (0.59%), and 22 malunion instances (3.27%). RoB assessment showed that 52.17% had a moderate overall risk of bias, 39.13% had a serious overall risk of bias, and 8.7% had a critical overall risk of bias. CONCLUSION: MIPO technique for pilon fractures showed good functional outcomes and reliability, with low complication rates and should be considered in cases where proper indirect reduction is possible. However, while the evidence is promising, further high-quality studies with larger sample sizes, longer-term follow-up, and comparison to other techniques are needed to evaluate the efficacy and safety of this technique. LEVEL OF EVIDENCE: IV.

Minimally invasive plate osteosynthesis via posterior approach for type B and C fractures of distal humeral shaft: surgical tactics and a clinical series.

The optimal technique and implant for fixation of multifragmentary fractures of the distal humeral shaft remain inconclusive. We describe the use of minimally invasive plate osteosynthesis (MIPO) via posterior approach and extra-articular distal humerus locking compression plate (LCP-EADH) fixation for 18 such fractures. All fractures were united with a mean union time of 17.6 weeks (range 12-20). Transient radial nerve palsy was demonstrated in 2 patients. Six patients had 5° varus angulation and 1 had 5° valgus angulation. Triceps power was Grade 5 in all patients. The mean arc of elbow motion was 127.5 degrees (range 115-140). Six patients had an excellent MEP score and 12 had a good MEP score. As the results, posterior MIPO and LCP-EADH fixation could be an alternative for multifragmentary fractures of the distal humeral shaft, particularly for fractures with a very short distal fragment.

Time until union in absolute vs. relative stability MIPO plating in simple humeral shaft fractures.

PURPOSE: The objective of this study is to evaluate the effect of absolute stability (AS) versus relative stability (RS) performed through a minimally invasive plate osteosynthesis (MIPO) in AO/OTA 12A1 and 12A2 fractures on healing and the time to radiographic union. METHODS: This was a retrospective cohort study of all patients treated with plate fixation for AO/OTA type 12A1-A2 fractures at a single institution. Patients were grouped according to the type of stability used in their surgery. Time until radiographic union was estimated using the Kaplan-Meier method, which was compared by long-rank test between both types of surgical techniques. RESULTS: A total of 70 patients were included in this study with 35 patients in each group. The median follow-up was 9 (IQR 6-14) months. The median time to radiographic union was significantly lower in the AS group than in the RS group: 12 (interquartile range (IQR) 10-14) weeks versus 18 (IQR 16-19) weeks, respectively (p < 0.001). Non-union was seen in two cases (7%) in the relative stability group. Three patients in the RS group developed a post-operative radial nerve palsy. CONCLUSION: The main finding of this study is that the median time to radiographic union was significantly shorter in the patients treated with AS compared to those with a RS technique. These findings support the recommendations of the AO foundation in that simple metaphyseal fractures (type A) that require surgical treatment should be treated with an AS construct. RS techniques should be reserved to multifragmentary fractures where fragment preservation of blood supply is paramount.

The utility of reverse distal femur locking compression plate in minimally invasive osteosynthesis for type C subtrochanteric fractures of the femur: technical description and a clinical series of 50 cases.

BACKGROUND: Establishing fracture consolidation and avoiding postoperative complications of comminuted subtrochanteric fractures of the femur are technically challenging. The authors delineated a technical description of minimally invasive plate osteosynthesis (MIPO) by using a reverse distal femur locking compression plate (LCP-DF) and retrospectively reviewed the outcomes of these particular fractures. METHODS: Fifty patients with 51 type C subtrochanteric fractures of the femur were operated on by MIPO and reverse LCP-DF fixation. The collected data included postoperative complications, union times, and clinical outcomes. RESULTS: All fractures were united with a mean union time of 19.4 weeks (range 16-22). Regarding postoperative complications, asymptomatic valgus angulation occurred in five patients and trochanteric pain in six. According to Harris hip score, nine patients were determined to be excellent, 36 to be good and five to be fair. CONCLUSION: MIPO by reverse LCP-DF is reliable and effective for type C subtrochanteric fractures of the femur particularly in situations where intramedullary nailing is not feasible.

Treatment of humeral shaft fractures: a new minimally-invasive plate osteosynthesis versus open reduction and internal fixation: a case control study.

BACKGROUND: To evaluate the feasibility and safety of a new minimally-invasive surgical approach-anteromedial minimally-invasive plate osteosynthesis (MIPO)-in the treatment of middle and distal humeral shaft fractures. METHODS: Fourteen patients with humeral shaft fracture treated with anteromedial MIPO from November 2016 to March 2020 (MIPO Group) were selected as the study subjects. Open reduction and internal fixation (ORIF) were used to treat 14 patients with humeral shaft fractures as the control group (ORIF group). The two groups were fixed with a locking compression plate (LCP) or LCP + multi-directional locking screw system (MDLS). The incision length, intraoperative blood loss, intraoperative fluoroscopy time, operation time, length of hospital stay, fracture healing time, QuickDASH score and Constant score were observed and compared between the two groups. RESULTS: Fourteen patients were enrolled in each group. The incision length (7.79 ± 2.39 cm), intraoperative blood loss (96.07 ± 14.96 mL), operative time (110.57 ± 21.90 min), hospital stay (6.29 ± 1.49 days) and fracture healing time (14.94 ± 0.99 weeks) in the MIPO group were all lower than those in the ORIF group, and the difference was statistically significant for each parameter (P < 0.05). The intraoperative fluoroscopy time (20.07 ± 3.22) in the MIPO group was significantly higher than that in the ORIF group (P < 0.05). There were no significant differences in age (P = 0.078), QuickDASH score (P = 0.074) or Constant score (P = 0.293) between the two groups and no postoperative complications occurred in any of the patients. CONCLUSION: The anteromedial approach MIPO technique has the advantages of less trauma, less bleeding, low risk of nerve injury and high rate of fracture healing. It is one of the most effective methods for the treatment of middle and middle-distal humeral shaft fractures.

Intramedullary nailing via suprapatellar approach versus locked plating of proximal extra-articular tibial fractures: a randomized control trial.

OBJECTIVE: Currently, nailing through the suprapatellar approach and minimally invasive plating have been generally accepted in the management of displaced proximal tibial fractures. This investigation was aimed at comparing these two treatment methods in terms of their effectiveness and safety. METHODS: We randomized 328 patients into one of two groups: one underwent intramedullary nailing via the suprapatellar approach (IMN group), while the other underwent locking compressive plate (LCP group) placement. The primary outcome was the Iowa Knee Score at 12 months. The clinical history, amount of intra-operative blood loss, rate of fracture healing, and post-operative complications were assessed as secondary outcomes. Participants were assessed at one, two, three, six and 12 months after surgery. RESULTS: Follow-up data for a year were available for 152 and 154 patients in the IMN group and LCP group, respectively. No intergroup difference was detected with regard to the Iowa Knee Scores (91 ± 8.2 in the IMN group and 90 ± 7.3 in the LCP group, respectively (p = 0.26)), at 12 months. Duration of operation (83.5 ± 35.3 min), amount of blood loss (55 ± 43 mL), duration of fluoroscopy (53.7 ± 3.9 s), and cases with difficult reduction (n = 46) in the IMN group did not differ significantly from those in the LCP group (80.1 ± 43.6 min; 65 ± 56 mL; 48 ± 12 s; 32) (p < 0.05). The two groups had similar post-operative complications and rate of fracture union, with the pre-injury activity level being restored in most patients. Removal of the implants was performed in 31.6% and 63.0% of the cases in the IMN and LCP groups, respectively, indicating a significant intergroup difference. CONCLUSION: Both IMN through the suprapatellar approach and minimally invasive LCP were found to yield no significant intergroup difference of clinical outcomes in the treatment of proximal, extra-articular tibial fractures. However, the requirement of implant removal was more relevant to LCP.

Outcome of minimally invasive plate osteosynthesis using locking compression plate in long bone fractures.

OBJECTIVE: To evaluate radiological and clinical outcome of minimally invasive plate osteosynthesis (MIPO) using locking compression plate in long bone fractures. METHODS: This was a prospective study for the long bones fracture managed by MIPO using locking compression plate in thirty patients from January to December 2017. All the skeletally mature patients and the patients with osteoporotic bones were included. Patients with open injuries, paediatric patients and plating done in non-traumatic conditions were excluded. Patients were followed as outpatient after one week, six weeks, after three months and then after 6 months. RESULTS: Among 30 patients, 12(40%) were males and 18 (60%) females with male to female ratio 1:1.5. Average age of 30 patients was 59.5 ± 16.72 years (Range =21 to 91 years). Mean duration of surgery was 98.0±27.1 (Range=50 to 150) minutes. Majority 14(46.7%) had operative time 90-110 minutes. There were two complications, one (3.3%) had screw pull out and other had deep infection. CONCLUSIONS: LCP system is a reliable and safe tool that extends the options for fixation by plating and has advantages over the other systems in term of stability that can be achieved with it especially in osteopenic bones.

Minimally invasive treatment of AO B ankle fractures: Surgical technique and long-term outcomes.

BACKGROUND: Ankle fractures are the most common traumatic bone injuries of the lower limb. Over 50% of ankle fractures occur at the syndesmosis level (type AO B). The goal of treatment is to achieve an anatomical reduction and appropriate stabilization. The present study aimed to evaluate the clinical-functional and radiological results, and complications of minimally invasive reduction and fixation technique for ankle fractures type AO B. The surgical technique also is detailed. MATERIAL AND METHODS: A prospective analysis of 451 patients undergoing surgery for type AO B displaced ankle fracture was performed. All patients were treated with minimally invasive surgery. The following times were recorded: time between trauma and osteosynthesis, hospitalization length, surgical time, and exposure time to fluoroscopy. Age and gender, mechanism of injury, and characteristics of fractures were recorded. For functional outcome, AOFAS score, VAS, and Weber score were used. Radiographic analysis was performed. The average follow-up was 112 months. RESULTS: Mean age was 48.2 years old. Average length of stay in hospital was 5.72 h. Mean duration of the surgery was 32.8 min. Average fluoroscopic exposure time during surgery was 9.25 s. Mean bone union time was 38.2 days. Weber's score was on average 1.5/24 points and the long-term follow-up AOFAS score was on average 97.5/100. Postoperative complications incidence was 2.7%. CONCLUSIONS: Distal fibula fixation with the MIPO technique presented good functional outcomes and could be helpful in the avoidance of the complications associated with conventional open reduction and internal fixation. However, it needs more exposition to intraoperative fluoroscopy. LEVEL OF EVIDENCE: II.

Novel anterior curved incision combined with MIPO for Pilon fracture treatment.

BACKGROUNDS: Poor prognosis was reported for complex Pilon fractures involving severe soft tissue damage. It is therefore useful to explore the evolution of different treatment strategies in an effort to reconstruct the axial alignment and articular surface, while minimizing additional damage to the surrounding soft tissues. METHODS: Seventeen patients with Pilon fractures were enrolled in this retrospective study from December 2009 to October 2014. The injuries were graded according to AO Classification and the Gustilo-Anderson system. Patients were treated with minimally invasive plate osteosynthesis (MIPO) combined with curved incision on the anterior area of ankle. The ankle function and radiological outcome were assessed by the modified Mazur ankle score and Burwell-Charnley criteria, respectively. Visual analogue score (VAS) score was used to assess the degree of patient's ankle pain, and related complications were also recorded. RESULTS: The mean time for fracture healing was 3.6 months (range: 3-6 months). According to Mazur's criteria, surgical treatment achieved good or excellent outcome in 15 (88.2%) cases, and the average VAS score was 1.19 ± 0.52. On the basis of Burwell-Charnley score, 12 (70.5%) patients achieved anatomic recovery, 4 (23.5%) obtained good reduction, and only 1 (5.9%) patient was diagnosed with valgus deformity. Additionally, 1 (5.9%) patient developed a superficial infection around incision, and 2 (11.8%) experienced superficial peroneal nerve damage. In addition, 2 (11.8%) patients showed radiographic evidence of existing ankle osteoarthritis at the final follow-up. CONCLUSIONS: This retrospective study is the first to assess the application of a curved incision on the anterior area of ankle with MIPO for the treatment of Pilon fractures, which achieves high functional recovery with a low complication rate. However, large randomized controlled trials comparing different approaches and fixation methods are still needed to conclusively identify the optimal treatment protocol.

Anterior minimally invasive plating osteosynthesis using reversed proximal humeral internal locking system plate for distal humeral shaft fractures.

OBJECTIVE: To describe the surgical application of anterior minimally invasive plating osteosynthesis (MIPO) using reversed proximal humerus internal locking system (PHILOS) plate for multifragmentary distal humeral shaft fractures. METHODS: Twelve patients with distal humeral shaft fractures (type 12B, n = 6 and type 12C, n = 6) were operated on by anterior MIPO and reversed PHILOS plate fixation. The amount of intact bone in the distal fragment was measured by fracture-to-coronoid distance (FCD). Data of the postoperative alignment, complications, union time, and clinical outcomes were collected. RESULTS: The mean time for fractures to unite in all patients was 14.8 weeks (range 12-22). There was no perioperative complication. The mean FCD was 4.8 cm (range 2.1-8.1). The mean coronal angulation was 3.4° (range 0-9), and the mean sagittal angulation was 1° (range 0-5). All patients had excellent UCLA shoulder score and MEP score results, and the mean range of elbow motion was 140° (range 130-145). CONCLUSION: Anterior MIPO using reversed PHILOS plate is safe and effective for multifragmentary fractures of the distal humeral shaft even in a fracture with a length of intact bone above the coronoid fossa of only 2 cm.