Fractures of the distal tibia, particularly tibial pilon fractures, represent a significant challenge for orthopedic surgeons due to their complex anatomy and the precarious nature of the surrounding soft tissues. These fractures often occur in areas where the bone is subcutaneous, blood supply is limited, and soft tissue coverage is minimal, which increases the risk of complications1. The involvement of the ankle joint adds further complexity, as it requires precise restoration of the articular surface to preserve function. Additionally, the high-energy mechanism often responsible for these fractures frequently leads to severe comminution and soft tissue injury, making management even more demanding.2 Over the years, multiple classification systems have been proposed to categorize distal tibial fractures, but the AO-OTA alphanumeric system remains the most widely accepted due to its comprehensiveness and clinical applicability. Early work by Rüedi and Allgöwer emphasized the role of open reduction and internal fixation (ORIF) in restoring alignment and joint congruity, achieving notable functional outcomes. However, subsequent studies revealed a high incidence of major complications, including wound breakdown, infection, and delayed union, largely attributable to the extensive soft tissue dissection required for traditional ORIF2,3. This recognition has shifted the treatment philosophy toward approaches that prioritize soft tissue preservation. Currently, two primary strategies have gained prominence in the management of distal tibial fractures: external fixation using wire or hybrid fixators and the minimally invasive plating osteosynthesis (MIPO) technique. External fixation is particularly advantageous in cases of severe comminution and significant soft tissue compromise, providing stable alignment while minimizing further trauma to the soft tissue envelope4. On the other hand, MIPO is increasingly preferred for fractures with minimal articular comminution and relatively intact soft tissues.5 The MIPO technique adheres to the principles of biological fixation, which focus on preserving the vascularity of the fracture fragments and minimizing operative trauma. In this approach, plates are introduced percutaneously and positioned epiperiosteally, with fixation achieved at sites proximal and distal to the fracture through small incisions, thereby avoiding direct exposure of the fracture fragments6.The principles of biological fixation underpinning MIPO include indirect reduction techniques, where realignment is achieved at a distance without disturbing the fracture site or compromising soft tissues7. Comminuted fragments are typically left outside the mechanical construct, allowing them to retain their native blood supply and contribute to natural healing. Additionally, the use of low elastic modulus, biocompatible implants helps distribute stress evenly and reduces the risk of hardware-related complications. Finally, the limited operative exposure associated with MIPO not only reduces soft tissue trauma but also lowers the risk of infection and promotes faster recovery.8 Together, these principles offer a balanced approach to managing distal tibial fractures, optimizing both functional outcomes and soft tissue preservation. AIM To evaluate the functional outcome of distal tibial fractures treated with pre-contoured medial locking compression plates using the minimally invasive plating osteosynthesis (MIPO) technique, focusing on fracture healing, restoration of limb alignment, joint function, and complication rates.

This prospective observational study was carried out in the Department of Orthopaedics at a JLN medical college, Ajmer over a period of 1 yr years from period 1 july 2024 to 30 june 2025. The study included adult patients presenting to the outpatient department and emergency services with distal tibial fractures who were treated using pre-contoured medial locking compression plates by the minimally invasive plating osteosynthesis (MIPO) technique. A detailed clinical evaluation was performed for each patient, including history taking, physical examination, and radiological assessment with anteroposterior and lateral radiographs of the leg including the ankle joint. Fractures were classified according to the AO-OTA classification system. Patients aged 18 years and above with closed distal tibial fractures, including extra-articular and simple intra-articular fractures suitable for MIPO fixation, were included in the study. Only those patients who were medically fit for surgery and willing to comply with the postoperative rehabilitation protocol and follow-up schedule were enrolled. Patients with open fractures, pathological fractures, associated neurovascular injuries, polytrauma requiring damage control orthopedics, or severe comminution with extensive articular destruction were excluded from the study. Patients who were unfit for surgery or did not complete the required follow-up were also excluded.

Table 1: Age Distribution of Study Population (n = 36) Age group (years) Number of patients Percentage (%) 18-30 8 22.2 31–40 10 27.8 41–50 11 30.6 >50 7 19.4 The age-wise distribution showed that the highest number of patients belonged to the 41–50 years age group (30.6%), followed by those aged 31–40 years (27.8%). Younger patients aged 18–30 years constituted 22.2% of the study population, while patients above 50 years accounted for 19.4%. Table 2: Mode of Injury Mode of injury Number of patients Percentage (%) Road traffic accident 23 63.9 Fall from height 9 25 Others 4 11.1 Road traffic accidents were the most common mode of injury, accounting for 63.9% of cases, followed by falls from height in 25% of patients. Other causes of injury were observed in 11.1% of the study population. Table 3: Associated Injuries Associated injuries Number of patients Percentage (%) Present 6 16.7 Absent 30 83.3 Associated injuries were present in 16.7% of patients, while the majority of cases (83.3%) had no associated injuries. This indicates that most patients sustained isolated injuries without additional trauma. Table 4: Type of Fracture According to AO-OTA Classification (n = 36) AO-OTA type Number of patients Percentage (%) 43 A1 10 27.8 43 A2 9 25 43 A3 7 19.4 43 B2 5 13.9 43 C1 2 5.6 43 C2 2 5.6 43 C3 1 2.8 According to the AO-OTA classification, 43 A1 fractures were the most common (27.8%), followed by 43 A2 (25%) and 43 A3 (19.4%). Less frequent patterns included 43 B2 (13.9%) and complex fractures such as 43 C1, 43 C2, and 43 C3, together accounting for a small proportion of cases. Table 5: Time to Partial and Full Weight Bearing (n = 36) Weight-bearing status Number of patients Percentage (%) Partial weight bearing 6–8 weeks 14 38.9 9–12 weeks 22 61.1 Full weight bearing 12–16 weeks 26 72.2 >16 weeks 10 27.8 Partial weight bearing was initiated between 6–8 weeks in 38.9% of patients and between 9–12 weeks in 61.1% of cases. Full weight bearing was achieved by 12–16 weeks in 72.2% of patients, while 27.8% required more than 16 weeks. Table 6: Radiological Outcome (n = 36) Radiological outcome Number of patients Percentage (%) Union within 16 weeks 27 75 Delayed union 6 16.7 Malunion 2 5.6 Non-union 1 2.7 Radiological assessment showed union within 16 weeks in the majority of patients (75%). Delayed union was observed in 16.7% of cases, while malunion and non-union were uncommon, occurring in 5.6% and 2.7% of patients, respectively. Table 7: Functional Outcome Based on AOFAS Score (n = 36) Functional outcome AOFAS score Number of patients Percentage (%) Excellent 90-100 18 50 Good 80-89 11 30.6 Fair 70-79 5 13.9 Poor <70 2 5.5 Based on the AOFAS score, 50% of patients achieved an excellent functional outcome, while 30.6% had good results. Fair and poor outcomes were observed in 13.9% and 5.5% of patients, respectively. Table 8: Complications Observed (n = 36) Complication Number of patients Percentage (%) Superficial infection 4 11.1 Deep infection 1 2.8 Delayed union 6 16.6 Implant irritation 3 8.3 Ankle stiffness 5 13.9 Non union 1 2.8 No complications 20 55.6 Complications were observed in a subset of patients, with delayed union (16.6%) and ankle stiffness (13.9%) being the most common, followed by superficial infection (11.1%) and implant irritation (8.3%). More than half of the patients (55.6%) had no complications, while deep infection and non-union were rare (2.8% each). Table 9: Ankle Range of Motion at Final Follow-up (n = 36) Range of motion Number of patients Percentage (%) Near normal (>75% of normal) 21 58.3 Moderate restriction (50–75%) 11 30.6 Severe restriction (<50%) 4 11.1 Range of motion was near normal in the majority of patients (58.3%), while 30.6% showed moderate restriction. Severe restriction of movement was observed in 11.1% of cases.

The study included patients across different age groups, with the youngest group (18–30 years) comprising 8 patients, accounting for 22.2% of the total population. Patients aged 31–40 years formed the next largest group with 10 individuals, representing 27.8%. The majority of participants, 11 patients (30.6%), were in the 41–50-year age group. Older patients above 50 years accounted for 7 cases, making up 19.4% of the study population. This distribution indicates a higher prevalence of the condition in middle-aged adults. The majority of patients sustained injuries due to road traffic accidents, accounting for 63.9% of cases. Falls from height were the second most common mode of injury, seen in 25% of patients. A smaller proportion of injuries, 11.1%, were caused by other factors. Road traffic accidents remain the leading cause, highlighting the high-risk nature of vehicular trauma. Falls indicate significant occupational or accidental hazards. The remaining injuries under “others” suggest varied and less common causes contributing to the overall injury profile.S.L. Binesh et al9 The age group of patientsranged from 28‐52 years of age with the maximumpatients 16(42.1%) in the age group of 31‐40 years. The mean age group of the patients was 37.5±7.5 years. Themechanism of injury was Road Traffic Accident (RTA) in35 (92.1%) patients while 3(7.9%) had history of fall. Associated injuries were present in a small proportion of patients, accounting for 16.7% of the study population. The majority of patients (83.3%) did not have any associated injuries. This indicates that most cases involved isolated primary injuries. The low incidence of associated injuries suggests a relatively localized pattern of trauma. The AO-OTA classification showed that type 43 A1 fractures were the most common, accounting for 27.8% of cases. This was followed by type 43 A2 fractures in 25% of patients and type 43 A3 fractures in 19.4%.Among partial articular injuries, type 43 B2 fractures constituted 13.9% of cases. Complete articular fractures were less frequent, with type 43 C1 seen in 5.6% of patients. Type 43 C2 fractures also accounted for 5.6% of the study population. The least common pattern was type 43 C3 fracture, observed in 2.8% of cases. Partial weight bearing was initiated between 6–8 weeks in 38.9% of patients, while the majority (61.1%) began partial weight bearing between 9–12 weeks. This indicates a tendency toward delayed partial loading in most cases. Full weight bearing was achieved between 12–16 weeks in 72.2% of patients. A smaller proportion of patients (27.8%) required more than 16 weeks to attain full weight bearing, reflecting variability in fracture healing and recovery. Radiological assessment showed that the majority of patients achieved fracture union within 16 weeks, accounting for 75% of cases. Delayed union was observed in 16.7% of patients, indicating a prolonged healing period. Malunion occurred in a small proportion of cases (5.6%).Non-union was rare and noted in only 2.7% of patients.Kundu et al10 Radiologic union and full weight bearing was achieved in 13-16 weeks in 75% of cases while in 25% it was seen in 17-20 weeks Functional outcome assessed using the AOFAS score showed excellent results (90–100) in half of the patients (50%).Good outcomes (80–89) were observed in 30.6% of cases, indicating satisfactory functional recovery in most patients.Fair results (70–79) were seen in 13.9% of patients, reflecting residual functional limitations. Poor outcomes with scores below 70 were noted in only 5.5% of cases. Behal, T et al11 A majority of patients demonstrated excellent recovery, with 7 patients (70%) classified as having excellent outcomes and 2 patients (20%) achieving good results. Only 1 patient (10%) fell into the fair category, while none had poor results. This distribution emphasizes the effectiveness of MIPO in achieving favorable functional outcomes, with most patients regaining near-normal limb function and early return to daily activities. More than half of the patients (55.6%) did not develop any complications during the follow-up period. Delayed union was the most common complication, observed in 16.6% of cases. Ankle stiffness was seen in 13.9% of patients, indicating postoperative functional limitation in a subset. Superficial infection occurred in 11.1% of cases, while deep infection was rare (2.8%).Implant irritation was noted in 8.3% of patients. On-union was uncommon and occurred in only 2.8% of cases. Lakhotia D et al12 Minor complications were identified in 9 cases which comprised 4 cases of marginal necrosis of the surgical wound, 1 case of superficial infection, 1 case of sensory disturbance over the anterolateral foot, 1 case of muscle hernia and 2 cases of delayed union. Assessment of ankle range of motion showed that the majority of patients achieved near-normal mobility, with more than 75% of normal movement in 58.3% of cases. A moderate restriction of motion, ranging between 50–75% of normal, was observed in 30.6% of patients. Severe restriction of ankle movement, with less than 50% of normal range, was noted in a smaller proportion (11.1%).Only a limited number experienced significant stiffness affecting joint movement.

The study demonstrates that middle-aged adults, particularly those aged 31–50 years, were most commonly affected. Road traffic accidents were the predominant mode of injury, followed by falls, with most patients sustaining isolated fractures without associated injuries. AO-OTA type 43 A fractures were the most frequent, and most patients achieved radiological union within 16 weeks. Functional outcomes were favorable, with the majority showing excellent or good recovery according to the AOFAS score. Complications were relatively uncommon, the most frequent being delayed union and ankle stiffness. Overall, minimally invasive plate osteosynthesis (MIPO) provided effective fracture management with satisfactory functional recovery and early return to daily activities.

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