A minimally invasive medial approach for proximal tibial fractures

Numerous techniques have been described for MIPPO (minimally invasive percu taneous plate osteosynthesis) for metaphyseal or combined metaphyseal-artic ular fractures of the proximal tibia. Surgical management is often complica ted by the initial soft tissue damage, malalignment, remaining instability, or infection. In this prospective cohort study, we describe the diagnostic procedures vital for preoperative planning. These include plain radiograph s and CT scans in case of articular fracture components. The techniques for temporary stabilization and definitive fracture care using 4.5 mm DCP, LC- DCP, and LISS (Less Invasive Stabilization System) by limited medial incisi ons are described in a stepwise protocol. From 1996 to 1998, six fractures in six patients were studied. According to the AO classification, there were four type 41 fractures and two type 42 f ractures. One patient died of ARDS. All patients had an intact medial soft tissue coverage allowing a medial approach. One patient developed a compart ment syndrome, which was addressed by lateral dermato-fasciotomy prior to o steosynthesis. A LISS was used in three patients. The only complication rel ated to surgery was in a patient with a four-part fracture with lateral com minution and a dislocated postero-medial fragment, which was reduced and bu ttressed with a short posteromedial 3.5 mm small fragment plate. This patie nt developed a deep, intraarticular infection, which was successfully treat ed with revision surgery; the implants were left in situ. At her latest fol low-up at 18 months, she had a range of motion of 0/10/110, was back at wor k, and able to participate in recreational sports. The average time to heal ing was between 12 and 20 weeks postoperatively. There was no delayed heali ng, pseudarthrosis, recurrent fracture or late infection. None of the cases needed bone grafting. At the most recent follow-up, all patients were bear ing full weight without walking aids. All cases achieved a neutral alignmen t and satisfactory range of movement. Though further data are needed we hav e sound reason to propagate a single medial approach and minimally invasive osteosynthesis as a sufficient and subtle technique for stabilization of t hese complicated fractures.