Tibial fracture look very simple to treat, but it posses a bigger exigent problem when it comes to choose a suitable implants and method to fix the Simple , Segmental or Comminuted tibial shaft fracture.
In the past a large incision was used in exposing the bone to achive reduction and plate fixation. Soft tissue like skin, muscle and vascularityof the will be damaged and jeopardized because of the large incision and extensive dissection.
The insertion of Implant through a small incision will reduce the damage to the muscle, surrounding soft tissue and will preserve the blood supply to the bone.
As tibia is eccentrically placed in the circumference of the leg ,and due to its triangular shape, which is beautifully flat to accommodate a flat plate on it surface without any hitch. I therefore decide to put plate subcutaneously through a small hole in a uncomplicated tiia fracture.
The peculiarity of the study, we used 4.5.narrow / broad DCP for fixation of fracture with MIPO. technique and under the image intensifier guidance.
There are difficult in reduction of tibia fracture when it is spiral and long spiral fracture. In the transvse fracture a simple technique is applied with a small periostal elevated a small hole lift the posterior displaced fragment while levearging on the anteriorly displaced fracture fragment. Long spiral fracture posses difficultly in reduction because of soft tissue and periostal interposition. In this situation Interfragmentary screw screw through the plate or direct IF screw is used to achivenear complete reduction. Technique of MIPO with DCP in the initial was difficult and more time consuming and radiation exposure time nearly 2-4 minutes.
We did not use this in impending compartment syndrome or very much swollen limb. In the swollen limb waiting period of 2-3 days with limb elevation till the swelling subside.
In all cases we achieved 99% accurate bone contact and alignment in non comminuted fracture. Very acceptable accuracy in severely comminuted fracture. Average union time 10 weeks – 14 weeks. Longer in severely comminuted fractures. Delayed union in 16 cases but no surgery required for achievement of union and 8 were non union. Where bone grafting and change of implant was required. No skin or soft tissue break down observed. Superficial soft tissue infection in 5 cases and deep bone infection in 2 cases. Infected Non union tibia case and refixed locking plate used as locking plate. Non union is seen and implant fracture plate removed and fixed with locking plate and Bone gravity.
Percutaneouse plating is minimally invasive and uses indirect reduction technique to achieve a biological stable fixation. In addition to better fixation it gives a better cosmetic value, functional rehabilitation and lees soft tissue complication are encouraging and so it prompt the usage of this technique more commonly. The graph of time started coming time with increase numbers of Patient. It is difficult to put a screw in DCP hole as there is no way to hold the plate in position with reduction is maintained. Spiral fracture easier to plate but complete reductions are not achieved all the time because of soft tissue interposition. Comminuted facture with large fragment is difficult to plate than the small fragment communatio
To conclude it was technically difficult in the initial stage but gradually the graph of time consumption of surgery started falling with increasing number.
Comparison with Locking plate time consumption with this technology, it is 60% - 70%. less
Advantage is less exposure to x-ray radiation and very good results with low cost and the same logistic. The union rate with the plate and screw through MIPO is highly commendable.
MIPO featuring small incision, limited periostal strippering and indirect reduction technique has biological advantage compare to standard plating method. Although technically challenging, acceptable reduction and stable fixation was achieved in all the patients.
Dr.Sanjib Kumar Behera
Consultant Orthopaedic Surgeon
Yashoda Hospital, Secunderabad
Ph - 9440180980