Distal tibial fractures are a very common presentation in orthopedic practice; they present several challenges due to their close location to the ankle joint and the presence of relatively thin soft tissue coverage as compared to the rest of the tibial bone. The common etiological factors for distal tibial fractures are high-energy trauma such as Road Traffic Accidents and other causes including falls from height and accidental slipping. They comprise 1% of the lower limb fractures and 5-10% of tibial fractures [1-3]. These fractures are frequently comminuted and unstable in nature. They may be present with or without intraarticular extension. If injury to the articular surface of the distal tibia occurs, it is in varying degrees with fragments of the articular surface being driven proximally into the metaphysis of the tibia by the impact [4] These types of fractures are generally considered to be difficult to treat due to soft tissue involvement [5]. Because of the complexity and nature of injury, there is no consensus regarding the optimal treatment for these kinds of fractures. The range of treatment for these fractures varies from conservative management to surgical management. Non-operative (conservative) management is technically demanding and sometimes associated with joint stiffness in 40% of cases as well as shortening and rotational malunion in more than 30% of treated cases [6, 7]. In recent years Minimally Invasive Plate Osteosynthesis [MIPO] has become the preferred technique when operative treatment of distal tibial fractures is required. Some authors have claimed that the results of Minimally Invasive Plate Osteosynthesis [MIPO] are comparable or superior to the results of open anatomic reduction and internal fixation [8]. The AO distal tibia locking plate applied percutaneously by adhering to a minimally invasive percutaneous plate osteosynthesis technique was developed by the AO group to address the soft tissue problems associated with open reduction and internal fixation. The minimally invasive plate osteosynthesis [MIPO] involves small skin incisions, minimal surgical dissection, and gentle soft tissue retractions followed by indirect fracture reduction and minimal hardware application like screw insertion with stab incision and avoidance of excess screw placements. This technique is reported to have minimal periosteal disturbances, faster callus, and the best possible option as it permits adequate fixation in a biological manner [5]. MIPO aims to achieve correct limb length and axial and rotational alignment of the main fragments with minimal damage at the fracture site [9]. However, the disadvantage is the surgeons have to rely on C-arm intensifiers during the reduction and maintenance because the fractures are not visible to the naked eye during minimally invasive plate osteosynthesis causing an increased risk of radiation exposure [10]. The distal tibia receives circulation from extra-osseous anastomosis of branches of anterior and posterior tibial arteries which enter the tibia through its medial surface. Open plating usually causes greater disruption of the blood supply of the metaphyseal region than the percutaneously applied plates [11, 12]. MIPO, therefore, has higher rates of union and lower postoperative complications as compared to the traditional approach [13, 14] with this background we in the present study tried to evaluate the outcomes of treatment of distal tibial fractures with MIPO in both male and female patients reporting to RIMS hospital, Adilabad.

This prospective clinical study was conducted at the Department of Orthopaedics, Rajiv Gandhi Institute of Medical Sciences (RIMS), Adilabad. Institutional Ethical approval was obtained for the study from the institutional Ethical committee. Written consent was obtained from all the participants of the study and possible outcomes after explaining the nature of the study in vernacular language. Only those patients who were willing to participate in the study voluntarily were included in the study. 

Inclusion Criteria

1. Patients aged 18 years and above.
2. Closed or Gustilo-Anderson Grade I open fractures of the distal third of the tibia.
3. Fresh fractures (<2 weeks old).
4. Patients are willing to participate and comply with follow-up.

Exclusion Criteria

1. Gustilo-Anderson Grade II and Grade open fractures
2. Pathological fractures.
3. Polytrauma patients.
4. Associated neurovascular injuries.
5. Patients are medically unfit for surgery or lost to follow-up.

Surgical Procedure: All surgeries were performed under regional or general anesthesia. The MIPO technique was carried out using a pre-contoured locking compression plate (LCP) applied through small incisions made proximal and distal to the fracture site, avoiding direct exposure to the fracture. Fracture reduction was achieved using indirect methods under fluoroscopic guidance. Care was taken to preserve soft tissue and periosteal blood supply.

Postoperative Management: Postoperative antibiotics and analgesics were administered as per protocol. Passive and active range of motion exercises were initiated early, depending on pain tolerance. Weight-bearing was gradually started based on radiological signs of healing, typically after 6–8 weeks.

Follow-up and Outcome Assessment: Patients were followed up at regular intervals (2, 6, 12, and 24 weeks) and assessed clinically and radiologically. Functional outcome was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score. The radiological union was determined by the presence of bridging callus on at least three cortices.

Statistical Analysis: Data were compiled and analyzed using SPSS software (version 22). Continuous variables were expressed as mean ± SD and percentage. The categorical data was calculated using appropriate statistical tests (Chi-square test), with a p-value < 0.05 considered statistically significant.

A total of 20 patients were studied during the study period. Table 1 describes the demographic profile of 20 patients treated with the MIPO technique. The majority (35%) were aged 31–45 years, followed by 30% in the 18–30 age group. Males accounted for 70% of the study population, while females made up 30%. The right side was more commonly involved (60%) compared to the left (40%). This distribution indicates that middle-aged males with right-sided fractures were more frequently treated using the MIPO technique in this study.

Table 2 shows the mode and type of injury among the 20 patients. Road traffic accidents were the most common cause, accounting for 60% of cases, followed by falls from height at 30%, and sports injuries at 10%. This indicates that high-energy trauma, particularly from road traffic accidents, was the predominant cause of distal tibial fractures in patients managed with the MIPO technique.

Table 3 shows the intraoperative and postoperative parameters. The mean operative time was 78.6 ± 12.4 minutes, with a range of 60 to 105 minutes. The average incision length was 4.5 ± 1.2 cm. Patients achieved full weight-bearing at a mean of 8.1 ± 1.4 weeks, ranging from 6 to 10 weeks. The average duration of hospital stay was 6.2 ± 1.1 days, with a range of 4 to 8 days. These findings suggest favorable surgical efficiency and recovery timelines with the MIPO technique.

Table 4 presents the complications observed in patients treated with the MIPO technique. Out of n=20 patients, n=2 (10%) developed superficial infections, which resolved with appropriate antibiotic therapy. One patient (5%) experienced delayed union, requiring extended follow-up. Implant irritation was reported in one case (5%), but it did not necessitate implant removal. Importantly, there were no instances of non-union or malalignment greater than 5° angulation. Overall, 80% of patients had an uneventful recovery with no complications, indicating that MIPO is a relatively safe and well-tolerated procedure.

Table 5 shows the functional outcomes assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score at 6 months postoperatively. A majority of patients (60%) achieved excellent outcomes with scores between 90 and 100, while 30% had good outcomes (80–89). Only 2 patients (10%) had fair outcomes (70–79), and none had poor results (<70). The mean AOFAS score was 91.4 ± 5.2, reflecting overall high patient satisfaction, good functional recovery, and effectiveness of the MIPO technique in managing distal tibial fractures.

Recently Minimally Invasive Plate Osteosynthesis (MIPO) has emerged as one of the most effective methods of management of distal tibial fractures. It offers the advantage of preserving soft tissue integrity as well as maintaining periosteal blood supply and reducing infection risk. In the current study, we found 20 cases of distal tibial fractures treated in our hospital. The demographic pattern of the cohort showed male preponderance in 70% with the most effective age group in 31-45 (35%).  The results of our study are in accordance with the findings of other studies where they showed that middle-aged males were the predominant group affected, largely due to their higher involvement in road traffic accidents and occupational injuries [15, 16] In this study we found that Road traffic accidents were the most common cause of injury in this study (60%), followed by falls from height (30%) and sports-related injuries (10%). Our findings were consistent with other studies when they pointed out that the pattern of high-energy trauma typically involved distal tibial fractures [17].    The laterality of involvement showed that the right limb was more frequently involved (60%), reflecting no significant side predilection but possibly influenced by dominance and protective reflex mechanisms. The operative parameters of this study showed the feasibility of MIPO in routine clinical settings. The mean operative time in our cohort was 78.6 ± 12.4 minutes. This is comparable to other similar studies where operative durations ranged between 75–90 minutes [18, 19]. The mean incision length was small (4.5 ± 1.2 cm) highlighting the minimally invasive character of the intervention. The period to full weight-bearing was 8.1 ± 1.4 weeks which was due to early mobilization and good bone healing. The length of stay in the hospital was short (mean 6.2 ± 1.1 days), which evidences the effectiveness of the MIPO approach. The evaluation of complications revealed that the complication rate in this study was low. Our experience revealed that the superficial infection occurrence was present in two patients (10%) and was treated conservatively.

Delayed union and implant irritation occurred in one case each, while no instances of non-union or mal-alignment were recorded. These results are favorable compared to traditional open reduction and internal fixation (ORIF) methods, which are associated with higher risks of soft tissue complications and wound dehiscence (20, 21). The results indicated that our approach was standard and postoperative protocol was followed adequately in all cases. Functional outcomes, as measured by the American Orthopaedic Foot and Ankle Society (AOFAS) score were done at six months. They were excellent scores in 60% and good scores in 30% of patients, with no poor outcomes. The mean AOFAS score of 91.4 ± 5.2 is indicative of high functional restoration. Similar observations have been reported in previous studies, such as those by Redfern et al. [22] and Hasenboehler et al., [23] where MIPO yielded high patient satisfaction and reduced complications.  The main strength of our study was in its focused evaluation of clinical outcomes using a standardized scoring system and careful documentation of intraoperative parameters and complications. However, limitations include the small sample size and the short follow-up period of six months. Longer-term follow-up and larger multicentric studies would provide a more comprehensive understanding of implant longevity, late complications, and functional outcomes.

In conclusion, minimally invasive plate osteosynthesis [MIPO] is a safe and effective technique for managing distal tibial fractures. It has advantages like early rehabilitation, mobilization, and reduced postoperative pain. It provides good stability with pre-contoured plates and improves the outcomes, particularly in elderly patients. It has overall lower incidences of complications and excellent clinical outcomes. It offers excellent functional results, minimal complications, and early mobilization, making it a preferred choice in appropriate fracture patterns.

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