Comparative study between intramedullary interlocking nailing and minimally invasive percutaneous plate osteosynthesis for distal tibia extra-articular fractures

Anil Kumar, Johney Juneja, Raghvendra Choubisa, Nitin Jeenjwadia, A. K. Mehra, Ramesh Sen


Background: Treatment of distal tibia fractures poses significant challenge to orthopedic surgeon because of poor blood supply and paucity of soft tissue coverage. There is considerable controversy regarding the superior option of treatment for distal tibia fracture between the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique and intramedullary interlocking (IMIL) nailing for extra-articular distal tibia fractures. The aim of our study is to compare the functional outcome between the two treatment methods.

Methods: This was the prospective comparative study of 50 patients with distal third tibia fractures divided into two groups. First group of patients were treated with MIPPO technique while second group of patients were managed by IMIL nailing. Patients were followed up in outpatient department to assess the functional outcomes, malunion, delayed union, non-union, superficial and deep infection between the two groups.

Results: Average time taken by patients for full weight bearing in group A was 17.6 weeks as compared to 16.7 weeks in group B. All patients were able to bear weight prior to complete union of fracture. By the process of weight bearing, we believed that it would promote secondary bone healing. On taking X-rays during follow up of included patients starting of radiological union was observed carefully by looking for bridging callus, haziness of fracture line. Appearance of callus was taken average time of 12.5 weeks in group A and 12.1 weeks in group B.

Conclusions: Both procedures have shown the reliable method of fixation for distal extra-articular tibia fractures preserving the soft tissue, bony vascularity and fracture hematoma that provide a favourable biological environment for fracture healing. Considering the results of the study, we have slightly more preference for the MIPPO technique.


Tibial fractures, Malunion, Bone plates, Intramedullary interlocking nailing

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Tornetta P, Court-Brown C, Heckman JD, McKee M, McQueen MM, Ricci W et al. Rockwood, Green, and Wilkins fractures in adults and children: Eighth edition. 2014;4026.

Court-Brown CM, Birnie MCJ. The epidemiology of tibia fractures, Jbone Joint Surg. 1995;77B:417-21.

Vallier HA, Le TT, Bedi A. Radiographic and clinicalcomparisons of distal tibia shaft fractures: Platingversus intramedullary nailing. J Orthop Trauma. 2008;22:15-22.

Zelle BA, Bhandari M, Espiritu M. Treatment of distaltibia fractures without articular involvement: a systematic reviewof 1125 fractures. J Orthop Trauma 2006;20(1):96-9.

Bedi A, Le TT, Karunakar MA. Surgical treatment of nonarticulardistal tibia fractures. J Am Acad Orthop Surg. 2006;14(7):256-9.

Anglen JO. Early outcome of hybrid external fixation for fracture of the distal tibia. J orthop Trauma. 1999;13:92-97.

Watson JT, Moed BR, Karges DE, Cramer KE. Pilon fractures. Treatment protocol based on severity of soft tissueinjury. Clin orthop Relat Res. 2000;375:78-90.

Gueorguiev B, Ockert B, Schwieger K, Wahnert D, Lawson-Smith M, Windolf M, et al. Angular stability potentiallypermits fewer locking screws compared with conventional lockingin intramedullary nailed distal tibia fractures: a biomechanicalstudy. J Orthop Trauma. 2011;25(6):29-35.

Mosseiff R, Safran O, Segal D. The unreamedtibial nail in the treatment of distal metaphyseal fractures. Injury. 1999;30:21-25.

Jenssen KW, Biert J, Van Kampen A. Treatment ofdistal tibia fractures: Plate versus nail: A retrospectiveoutcome analysis of matched pairs of patients. Int Orthop. 2007;31:33-9.

Tyllianakis M, Megas P, Giannikas D. interlockingintramedullary nailing in distal tibia fractures. Orthopedics. 2000;23:85-90.

Mosseiff R, Safran O, Segal D. The undreamed tibial nail in the treatment of distal metaphyseal fractures. Injury. 1999;30:115-20.

Chen AL, Tejwani NC, Joseph TN, Kummer FJ, Koval KJ. The effect of distal screw orientation on the intrinsic stability of a tibial intramedullary nail. Bull Hosp Jt Dis. 2001;117-21.

Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res. 1995;315:96-110.

Robinson CM, McLauchlan GJ, McLean IP, Court-Brown CM. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br. 1995;77:85-8.

Tanna DD. Interlocking nailing. 2nded. New Delhi: Jaypee Publishers. 2004;105-25.

Krettek C, Miclau T, Schandelmaier P. The mechanical effectof blocking screws (“Poller screws”) in stabilizing tibia fractures withshort proximal or distal fragments after insertion of small diameterintramedullary nails. J Orthop Trauma. 1999;5:56-8.

MIPPO. An update current orthopaedics.2008;22(3):202-7.

Milner SA. A more accurate method of measurement of angulation after fractures of the tibia. J Bone Joint Surg Br. 1997;79:53-9.

Puno RM, Vaughan JJ, Stetten ML. Long-term effects of tibial angular malunion on the knee and ankle joints. J Orthop Trauma. 1991;3:5-8.

Ian P, Awen I. Indirect reduction using a simple quadrilateral frame in the in the application of distal tibial LCP-technical tips. Injury. 2005;36(9):1138-42.

Newman SD, Mauffrey CP, Krikler S. Distal metadiaphyseal tibial fractures. Injury. 2010;41(7):15-20.

Ronga M, Shanmugam C, Longo UG. Minimally invasive osteosynthesis of distal tibial fractures using lockingplates. Orthop Clin North Am. 2009;40(4):230-5.

Dogra AS, Ruiz AL, Thompson NS. Dia-metaphysealdistal tibial fractures: treatment with a shortened intramedullarynail: a review of 15 cases. Injury. 2000;31:159-65.

Gorczyca JT, McKale J, Pugh K. Modified tibial nails for treating distal tibia fractures. J Orthop Trauma. 2002;16:18-22.

Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. Arch Orthop Trauma Surg. 1984;103:52-60.

Gustilo RB, Anderson JT. The prevention of infection intreatment of 1000 and 25 open fractures of long bones—retrospectiveand prospective analysis. J Bone Joint Surg Am. 1976;58(4):205-10.

Kuhn S, Hansen M, Rommers PM. Extending the indicationof intra medullary nailing of tibial fractures. Eur J Trauma Emerg Surg. 2008;75(2):126-31.

Ibrahimi AE, Shimi M, Daoudi A. Intramedullarynailing in the management of distal tibial fractures. Current Orthopaedic Practice. 2009;20(3):209-20.

Court-Brown CM, Christie J, McQueen MM. Closed intramedullary tibial nailing. Its use in closed and type I open fractures. J Bone Joint Surg Br. 1990;72(4):78-89.

Bucholz RW, Heckman JD. Rockwood and Green'sfractures in adults, Sixth ed. Lippincott Williams and Wilkins. 2007;185-95.

Court-Brown CM, MC Birnie J. The epidemiology of tibia fractures. J Bone Joint Surg. 1995;77B.

Borg T, Larsson S, Lindsjo U. Percutaneous plating of distal tibia fractures: Preliminary results in 21 patients. Injury. 2004;35:200-5.

Muller ME, Nazarian S, Koch P. The comprehensive classification of fractures of long bones. Berlin:Springer – Verlag. 1990;75-8.

Francois J, Vandeputte G, Veheyden F. Percutaneousplate fixation of fractures of the distal tibia. ActaOrthop Belg. 2004;70:105-8.

Helfet DL, Shonnard PY, Levine D. Minimallyinvasive plate osteosynthesis of distal fractures of the tibia. Injury. 1997;28:A42-7.

Bombaci H, Guneri B, Gorgec M, Kafadar A. A comparison between locked intramedullary nailing andplate and screw fixation in the treatment of tibial diaphysealfractures. Acta Orthop Traumatol Turc. 2004;38:51-3.

Borrelli J, Jr, Prickett W, Song E, Becker D, Ricci W. Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study. J Orthop Trauma. 2002;16(10):3-5.

Hazarika S, Chakravarthy J, Cooper J. Minimally invasive locking plate osteosynthesis for fractures of the distal tibia—results in 20 patients. Injury. 2006;37(9):156-66.

Oh CW, Kyung HS, Park IH, Kim PT, Ihn JC. Distal tibial metaphyseal fractures treated by percutaneous plate osteosynthesis. Clin Orthop Relat Res. 2003;18:15-22.

Redfern DJ, Syed SU, Davies SJ. Fractures of the distal tibia: minimally invasive plate osteosynthesis. Injury. 2004;35(6):185-91.

Borg T, Larsson, Lindsjo U. Percutaneous plating of distal tibial fractures. Preliminary results in 21 patients. Injury. 2004;35:56-9.

Collinge C, Sanders R, DiPasquale T. Treatment of complex tibial periarticular fractures using percutaneous techniques. Clin Orthop. 2000;375:89-96.

Rao H, Patil SR, Sharma LR. Clinical study of fractures in lower third tibia. Indian Journal of Orthopedics. 1999;33(4):145-9.

Pradyumna PP, Raiturker AA, Salunkhe. Minimally invasive plate osteoynthesis (mipo) in the treatment of multifragmentary fractures of the tibia. 2012;3(4):14-9.

Sarmiento A, Latta LL. 450 closed fractures of the distal third of the tibia treated with a functional brace. Clin Orthop Relat Res. 2004;428:261-71.

Tscherne H, Gotzen L. Fractures with soft tissue injuries Berlin: Springer-Verlag. 1984;2(1):12-4.

Court-Brown CM, Gustilo T, Shaw AD. Knee pain after intramedullarytibial nailing: its incidence, etiology, and outcome. J Ortho Trauma. 1997;11:25-33.

Robinson CM, McLauchlan GJ, McLean IP. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br. 1995;77:189-200.

Kumar A, Charlebois SJ, Cain EL Effect of fibular plate fixation on rotational stability of simulated distal tibia fractures treated with intramedullary nailing. J Bone Joint Surg Am. 2003;85:203-8.