Dr. Chakravarthy.R, Dr. Pratheesh Mohanraj, Dr. Ramprashanth.K
Abstract: A STUDY OF FUNCTIONAL OUTCOME OF DISTAL TIBIAL FRACTURES TREATED BY MINNMALLY INVASIVE PERCUTANEOUS PLATE OSTEOSYNTHESIS AUTHORS -1.DR. CHAKRAVARTHY.R 2. DR. PRATHEESH MOHANRAJ 3.DR.RAMPRASHANTH.K INTRODUCTION The distal part of tibia is more superficial in nature. The soft tissue coverage and the blood supply to the bone in this area is comparatively less. Injuries to the distal end of tibia produce more morbidity due to the compromised blood supply, variable involvement of the articular surface and soft tissue damage. Fracture pattern, soft tissue injury, and bone quality critically influence the selection of fixation technique. Various methods of treatment like external fixation, intramedullary nailing, and locking plates have been considered. Among these, intramedullary nailing is not feasible in this region due to the distal nature of the injury because of which the distal screws cannot be placed and to the possibility of rotational misalignment during the course of fracture healing. Classic open reduction and internal plate fixation require extensive soft tissue dissection and periosteal stripping even in expert hands, with high rates of complications, including infection, delayed union, and nonunion. Minimally invasive techniques offer fixation in the biological manner with preservation of the bones vascularity, soft tissue envelope and containment of the fracture hematoma. AIMS AND OBJECTIVES To evaluate the technique of surgical management distal tibial fractures treated by internal fixation with locking compression plates and screws through MIPPO. To analyze the functional outcome in terms of -Time taken to unite, Range of ankle motion at the end of union, Rate of wound infection, Percentage of skin necrosis, Amount of angulation at union and, Associated complications, To comment on the efficacy of treatment of distal tibia fractures with Locking compression plates through MIPPO. MATERIALS AND METHODS We prospectively followed up twenty one patients who presented to the casualty during the period from December 2015 to September 2017. Out of the twenty one study subjects 12 were males and 9 were females showing a male preponderance. All study subjects were adults within the age group of 18 to 65 years with a mean age 45 years. Mechanisms of injuries varied from road traffic accidents to falls and crushing injuries with twelve road traffic accidents forming the major cause, eight self falls and one crushing injury. There were two compound fractures. All fractures were classified under AO/ OTA 43 classification. This included both intra articular (tibial plafond) fractures and extra articular where interlocking intramedullary nailing was not feasible or would produce rotational instability. RESULTS 85 % of the fractures united within 16 weeks with an average of 15.7 weeks. Two delayed unions were observed in patients with compound and intra-articular fracture. 18 (86 %) patients had satisfactory ankle movements leading to normal walking or a minimal limp. The minimal limp was due to some amount of ankle stiffness in the elderly and diabetics. This improved with physiotherapy. 3 (14 %) patients had ankle stiffness which produced limping at 22 weeks. This reduced to 2 at 32 weeks, one due to prolonged immobilisation and one due to intra-articular nature of the fracture.18 (86 %) patients with normal bone union were allowed full weight bearing at or before 18 weeks. The other 3 patients (14 %) were allowed full weight bearing at or before 39 weeks. Final outcome 19 (90 %) patients had good and excellent results with fracture union at 23 weeks. Fair results were observed in two patients. One was due to the crushing injury producing associated injuries in the foot, and another due to old age and prolonged immobilisation. CONCLUSION Minimally invasive locking plate osteosynthesis aims to reduce surgical tissue trauma and help preserve the periosteal vascular integrity and osteogenic fracture haematoma. We have strived to use this as a biomechanically sound method of biological plating for treating closed and open, Peri-articular fractures of the distal tibia. Based on our study, good and excellent results were obtained in 90 % of the cases. 2 fair results were attributed to the crushing nature of the injury in one patient and old age with delayed union in another. Subjects in whom the fibula was fixed did not have any angulation at union. Ankle stiffness was attributed to old age, diabetes, associated injuries and intra-articular fractures which will improve with early mobilization and physiotherapy. We thus conclude that the use of locking compression plate for intra and extra articular fractures of the distal tibia through minimally invasive technique along with fibular fixation is safe and effective.
Keywords: MIPPO- Minimally invasive percuteneous plate osteosynthesis