International Journal of Orthopaedics Sciences 2017; 3(4): 830-835

ISSN: 2395-1958
IJOS 2017; 3(4): 830-835
© 2017 IJOS Surgical management of distal tibia fracture by mippo
www.orthopaper.com
Received: 22-08-2017 using locking compression plate
Accepted: 23-09-2017

Dr. Vijay Chandar Dr. Vijay Chandar, Dr. Harish K, Dr. Chethan Kumar R and Dr. Vilas BN
Department of Orthopaedics,
Adichunchanagiri Institute of
Medical Sciences, B G Nagar, DOI: https://doi.org/10.22271/ortho.2017.v3.i4l.112
Mandya, Karnataka, India
Abstract
Dr. Harish K Introduction: The following study was conducted to examine the short term clinical and radiological
Assistant Professor results particularly early complications and healing rate of distal tibia fracture treated by MIPPO using
Department of Orthopaedics, LCP.
Adichunchanagiri Institute of Methodology: The study was conducted in patients treated for distal tibia fracture (type A, B & C – AO
Medical Sciences, B G Nagara, classification) at Adichunchanagiri Institute of Medical Science, BG Nagar from the month of Nov 2013
Karnataka, India
to Nov 2015. Twenty distal tibia fracture patients were taken into the study, all were fixed with LCP by
mippo, some with Bone grafting where the distal tibia fractures were associated with bone loss and
Dr. Chethan Kumar R
Department of Orthopaedics, communition. Patients’ age ranged from 27 to 68 years with a mean of 50.
Adichunchanagiri Institute of Results: The sample consisted of twenty patients with 11 males and 09 were female. The patients’ ages
Medical Sciences, B G Nagar, ranged from 27-68 years with a mean age of 50 years. The causes of fractures were motorvehicle
Mandya, Karnataka, India accident in 13 patients and fall in 07 patients. There were no sports or industrial accidents. 12 fractures
involved the right side and 08 involved the left. The average length of hospitalisation was 15 days with a
Dr. Vilas BN range of 10 to 20 days. The average number of days from injury to surgery was 5 days with a range of 2
Department of Orthopaedics, to 10 days. The operative time ranged from 45 minutes to 120 minutes. Patients were followed up from
Adichunchanagiri Institute of 01 to 24 months. Functional outcome was rated as per The modified ankle score of Olerud and Molander,
Medical Sciences, B G Nagar, we got excellent results in 10 cases, good in 07, fair in 02 and poor in one patient.
Mandya, Karnataka, India Conclusion: The LCP is a good implant to use for fractures of the distal tibia by mippo method.
However, accurate positioning and fixation are required to produce satisfactory results. We recommend
use of this implant in Type A, B and C, osteoporotic fractures. Our early results were encouraging but
long term studies are needed to prove definitively acceptable outcomes so that the technique can become
part of the armamentarium of the orthopaedic trauma surgeon.

Keywords: Distal tibia fracture, MIPPO, Distal tibia LCP, Pilon fracture

1. Introduction
Increased incidence of road traffic accidents, natural disasters, industrial accidents claim most
of human mortality and morbidity. Of these fractures distal tibia have historically been
difficult to treat.
Distal tibial fractures often presents a challenge to orthopaedic surgeon. Destot first used the
term in 1911, likening the pilon to a pestle. The tibial pilon comprises anatomically the distal
end of the tibia including the articular surface. Its proximal limit is found approximately 8-
10cm from the ankle articular surface, where the triangular section of the tibial diaphysis, with
its anterior crest, changes direction forming the metaphysis. The three-dimensional
configuration of this region appears to be designed to increase the area of the articular surface,
reducing the stress on the ankle joint.
Tibial pilon fracture represents 5-7% of all the tibial fractures [1]. These are usually the result
of high energy axial compression and rotation forces. They are usually associated with severe
soft tissue compromise. The limited soft tissue coverage, subcutaneous location, poor bone
Correspondence quality, osteoporosis renders the tibial fracture very challenging. The treatment of unstable
Dr. Harish K distal tibia or pilon fracture remains controversial. To achieve union many procedures are
Assistant professor recommended such as closed reduction and cast, open reduction and internal fixation,
Department of Orthopaedics,
Adichunchanagiri Institute of
intramedullary nailing, hybrid or ring external fixation.
Medical Sciences, B G Nagara,
Karnataka, India
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The difficulties that arises in the treatment of fracture distal in fracture reduction and towel clip or reduction clamp to hold
tibia are reduction. Varus -valgus angulation < 5° and anterior-
1. Tendency to re-displacement of fracture fragment posterior angulation < 10° and shortening of < 15 mm were
following subsidence of swelling specially in oblique, considered acceptable criteria for reduction. Precontoured low
spiral and comminuted fractures when treated by cast metaphyseal LCP was tunneled into subcutaneous plane and
2. Delayed union due to the precarious vascularity in distal its position was reconfirmed with C arm. Before fixing the
tibia plates with screws, shagging of distal fragment was prevented
3. Functional and cosmetic deformation if rotational or by putting towel roll under the fracture site. Provisional
alignment position of the fragment is not achieved, as it is nonlocking screw was applied to bring the plate on the bone.
important because knee and ankle joints are in same If necessary, interfragmentary compression was achieved by a
parallel axis screw through the plate or outside the plate. Compression
4. Bone loss osteosynthesis was achieved in simple fracture by using
nonlocking screw on proximal to fracture site as a hybrid
Non surgical treatment option is possible for fracture with fixation [51, 52]. With separate stab incision, at least three
minimal shortening, but requires prolonged immobilisation. It locking screws were applied on the either side of fracture
has also been associated with malunion, deformity, shortening under c arm guidance Primary bone graft was done whenever
of affected limb, limitation of range of motion and early necessary to promote union. Skin was closed with
osteoarthritis. Also prolonged recumbency resulted in high nonabsorbable sutures
incidence of thromboembolic disease and pneumonia.
Non-surgical approach with calcaneal traction remained the 3. Results
treatment of choice prior to case series reported by Reudi and The sample consisted of twenty patients with 11 males and 09
Allgower in 1969 with 84 fractures treated with standard open were female. The patients’ ages ranged from 27-68 years with
protocol with 74% of patients reported good to excellent a mean age of 50 years. The causes of fractures were
function. motorvehicle accident in 13 patients and fall in 07 patients.
External fixation can be a useful option in open fractures with There were no sports or industrial accidents. 12 fractures
soft tissue injury, but can lead to pin-track infections, septic involved the right side and 08 involved the left. The average
arthritis, mal-alignment and delayed union. Soft-tissue length of hospitalisation was 15 days with a range of 10 to 20
management has been seen to play a vital role in the days. The average number of days from injury to surgery was
management alongside the bony reconstruction. 5 days with a range of 2 to 10 days. The operative time ranged
Conventional plating techniques if applied to from 45 minutes to 120 minutes. Patients were followed up
multifragmentary fractures, requires anatomic reduction, wide from 01 to 24 months. 6 were closed and 14 were open
surgical exposure and the fractured fragments are stripped off fractures Successful fracture union was defined as complete
the soft tissue attachments resulting in a variety of bridging callus in three cortices, together with painless full
complications like delayed union or non-union, infections, weight bearing Functional outcome was rated as per The
implant failure skin necrosis and wound dehiscence. modified ankle score of Olerud and Molander, we got
Biological plate fixation technique are based upon the excellent results in 10 cases, good in 07, fair in 02 and poor in
principles of limited soft tissue stripping, maintenance of one patient.
osteogenic fracture hematoma and preservation of vascular
supply to the individual fracture fragment while restoring 3.1 Observation and results
axial and rotational alighnment and providing sufficient
stability to allow progression of motion, uncomplicated Table 1: Distribution of sample by age
fracture healing and eventual return to function. As such, the Age (Years) Frequency Percentage (%)
evolution of biological plating technique has led to 18-30 1 5
development of low profile, precontoured implants 31-40 3 15
specifically intended for application in the distal tibia 41-50 7 35
51-60 4 20
2. Materials and methods 61-70 5 25
The study was conducted in patients treated for distal tibia TOTAL 20 100
fracture (type A, B & C – AO classification) at
Adichunchanagiri Institute of Medical Science, BG Nagar Table 2: Distribution of sample by sex
from the month of Nov 2013 to June 2016. twenty distal tibia
Sex Frequency Percentage
fracture patients were taken into the study, all were fixed with Male 11 55
LCP by MIPPO Patients’ age ranged from 27 to 68 years with Female 9 45
a mean of 50 with the duration of follow up ranged from 6
months to 24 months Surgical Technique: Patient in supine Table 3: Distribution of sample by side
position. Initial fibula fixation was routinely done with one
third tubular plate. It restores limb length and helps in the Side Frequency Percentage (%)
reduction of the tibial plafond in the correct position [50] A Right 12 60
Left 08 40
vertical or curvilinear incision was made at the level of medial
malleolus with the utmost care not to injure great sephanous Table 4: Distribution of sample by mechanism of injury
vein and sephanous nerve. Sub cutaneous plane was made
with hemostat without striping periosteum and disturbance to Mechanism of Injury No. of Case Percentage (%)
fracture haematoma. Fracture was reduced under C arm Road traffic accident 13 65
control. where reduction was difficult, we made a small Fall from height 07 35
incision and used a Kirschner wire (3mm) as a joystick to aid Total 20 100

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Table 5: Relationship between sex and the cause of fracture

Road traffic accident Fall
Sex No. Percent No. Percent
Male 09 45 02 10
Female 04 20 05 25
Total 13 65 07 35

Table 6: Distribution of sample by type of fracture

Type No. of Fracture Percentage
Open 06 30
Closed 14 70

Table 7: Distribution of sample by type of fracture (classification)

Type No. of cases Percentage
A1 05 25
A A2 -
A3 06 30
B1 - - Pre op xray: AP view Pre op Xray: Lateral view
B B2 02 10
B3 - -
C1 03 15
C C2 02 10
C3 02 10

Table 8: Distribution of sample by operative time

Operative Time No. of Fracture Percentage
0-45 MIN 02 10 Parts prepared and draped Placement of locking
45-60 MIN 06 30 compression plate
60-90 MIN 09 45
90-120MIN 03 15

Table 9: Distribution of sample by time taken for fracture union

Union (Weeks) No. of Cases Percentage
< 16 07 35
18 04 20
20 04 20
22 02 10 Placement of drill sleeve Wound closure
>24 03 15

Table 10: Distribution of sample by full weight bearing

Achieved Times (Weeks) No. of Cases Percentage
< 16 06 30
16-20 06 30
20-24 06 30
24-28 02 10
1 year follow up Xray: AP and Lateral view 1 year follow up
Table 11: Distribution of sample by complications
Complication No. of Cases Percentage 4. Discussion
Stiffness 03 15 Pilon fractures or distal tibial fractures are one of the complex
Delayed union 02 10 injuries associated with significant soft tissue damage because
Infection 02 10 of subcutaneous natures of bone and high velocities trauma
Skin necrosis 0 0 associated with these fractures. Main aim of management is to
Varus angulation 0 0 provide stable fixation of fracture, prevention of further soft
tissue damage, infection, nonunion and wound dehiscence [53].
Table 12: Functional rating as per olerud and molander score When soft tissue damage is significant, bridging external
fixator is considered as superior option as it decreases the
Rating (In Points) No. of Cases Percentage excessive soft tissue stripping and provides a temporary stable
Excellent (90-100) 10 50 fixation to skeletal component. Definitive fixation can be
Good (70-89) 05 25
planned after resolution of edema and wrinkling of skin is
Fair (50-69) 04 20
evident. In cases of open fractures primary care is to provide
Poor (less than 50) 01 05
proper wound debridement, tetanus immunization and broad
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spectrum antibiotic cover as prevention of infection is the external fixation. Other complication we found was delayed
main aim. If there is significant soft tissue loss after union which of due to primary bone grafting was not done
debridement, adequate soft tissue cover is difficult in this area and due to infection. Primary bone grafting was done in 3
hence skin graft and free flap are viable treatment options [54]. patient where there was communition of fracture fragments
Reports in the literature on ORIF of distal tibia or pilon and bone loss. All patients were returned to work in 6 months.
fractures are plagued by wound infection [55-58]. During high 80 % patients felt pre injury status in 6 months.
velocity trauma the initial injury causes massive soft tissue
damage which devitalizes the tissue around the fracture site, 5. Conclusion
in distal tibia the anterio medial aspect is most risk for wound Locking compression plate by mippo technique is an optimal
infection and wound dehiscense [59]. tool for distal end tibia fracture. It provides rigid fixation in
Open reduction and internal fixation has shown increased the region of distal tibia, where a widening canal, thin cortices
rates of deep infection and wound dehiscence are the major and frequently poor bone stock make fixation difficult.
soft tissue complications. Wound debridement, antibiotics, Surgical exposure for plate placement requires significantly
skin grafting, myocutaneous flap and even arthrodesis have a less periosteal stripping and soft tissue exposure than that of
role to play in management [54]. Studies using external fixation normal plates. Orthopaedic surgeons experience with locking
techniques reported significant reduction in infection rates [53, compression plating technique will find it a useful technique.
60, 61]
. The rate of infection is drastically decreased with the However careful understanding of its basic principles,
use of minimmaly invasive percutaneous plate osteosynthesis identification of appropriate fracture patterns for use of LCP
(MIPPO) in comparison with external fixator and ORIF [53, 62]. is essential to avoid complications like generation of non-
This is reflected in our results, with only two cases of union. To conclude, LOCKING COMPRESSION PLATE BY
superficial wound infection, which completely resolved with MIPPO is an important armamentarium in treatment of
appropriate antibiotics. Reports suggest that intramedullary fractures of distal tibia, especially when fracture is severely
nailing has the lowest infection rates compared with other comminuted and in situations of osteoporosis.
techniques [63] but the technique is associated with other
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