Limb Fractures Treated With the Novel Plate Osteosynthesis Application Technique: Second to Minimally Invasive Plates osteosynthesis

Abstract

Background:

The main aim of this article was to propose a new concept of minimally invasive surgery for treating limb fractures, named as second to minimally invasive plates osteosynthesis (STMIPO).

Methods:

We have described the STMIPO technique in a step-wise and standardized manner based on our findings from a study involving six patients treated at our institution. All patients with fracture achieved satisfactory outcomes.

Results:

Ours clinical trials have shown that the STMIPO technique can be successfully applied in various limb fractures, including fibula fractures, tibial fractures, femur fractures, humerus fractures, ulna fractures, and radius fractures. All fracture patients achieved satisfactory outcomes.

Conclusion:

As a new minimally invasive technology, the STMIPO technique can serve as an alternative solution for fractures that are difficult to reduce with minimally invasive plates osteosynthesis (MIPO).

IntroductionIn 1886,¹ Hansmann first reported on the use of plate fixation in the treatment of fractures. The technique of internal fixation with steel plates did not become widely adopted and disseminated until antiseptic and aseptic operation room conditions were established.² In 1977, AO/ASIF group introduced the principles of fracture treatment, namely anatomical reduction and rigid internal fixation.³ With the widespread application of the fracture treatment principles of AO/ASIF in clinical practice, previous data have shown that achieving rigid internal fixation and anatomical reduction often requires iatrogenic damage to the vascular supply of the fracture site, which can result in delayed or nonunion of the fracture .^4,5 Therefore, the concept of biological internal fixation was proposed.⁶ In 1995, based on the theory of biological internal fixation, the Wenda team first applied the minimally invasive plates osteosynthesis (MIPO) technique in the treatment of femoral fractures. This technique reduces vascular damage to the fracture site through closed reduction, promoting fracture healing.^7,8

MIPO technique, developed in the past 30 years, is considered because it most closely aligns with the concept of biologic internal fixation for fracture treatment, and it has found widespread application in treating fractures in various sites throughout the body, including the tibia, fibula, ulna, radius, humerus, clavicle, and scapula, among others.^9,17 The advantages of this technique include reducing iatrogenic damage to the soft tissues surrounding the fracture site and minimizing postoperative scar formation, thereby meeting patients' aesthetic requirements.^18,19 However, there are also some drawbacks associated with the MIPO technique in practical clinical operations.²⁰ First, the biggest challenge in implementing the MIPO technique is the difficulty of achieving closed reduction of the fracture, often necessitating the use of fluoroscopy images to prevent harm to both the patient and the surgeon. Nevertheless, some fractures are still difficult to achieve proper alignment and reduction through closed reduction alone and ultimately require open reduction. Second, in some cases, closed reduction may not effectively clear soft tissues that are interposed between the fracture ends, which can potentially result in delayed healing or nonunion of the fracture. Finally, frequent closed reduction procedures can also potentially worsen the soft-tissue damage around the fracture site, and repeated closed reduction may increase the duration of the surgery.²⁰

Based on the advantages and disadvantages of the MIPO technique, our team has developed a groundbreaking fracture treatment theory known as the second to minimally invasive plates osteosynthesis (STMIPO) technique. This approach offers an alternative solution for cases where implementing the MIPO technique poses difficulties.

Methods

Concept

The MIPO technique is mainly applicable to fractures that have acceptable alignment or can be easily closed reduced. In this technique, the fracture is first reduced by closed reduction and temporarily fixed. Then, a plate of appropriate length selected is inserted through a small incision remote of the fracture site. The plate is inserted through the incision subcutaneously into the appropriate position and sequentially screws are inserted with the blind technique.

STMIPO technique has the advantages of MIPO technique, such as small incisions, minimally invasive, and aesthetic outcomes. STMIPO technique differs from MIPO technique in the following certain aspects: Its incision of similar width to the plate is made at the fracture site according to the direction of the fracture line. Then, the periosteum (the outer layer of the bone) can be partially dissected, and the fracture was reduced under direct visualization through a small incision. Next, a clean-up is performed to remove the soft tissue embedded in the fracture site, and a temporary fixation is performed using the Kirschner needle. Finally, the plates were inserted percutaneous onto the bone surface and fixed by screws one by one.

Second to Minimally Invasive Plates Osteosynthesis Operating Steps

1. Identify bony anatomical landmarks of the fracture site, such as the tip of the lateral malleolus on the fibular, the tip of the medial malleolus on the tibia, the tip of the radius styloid process, and the capitulum ulnae.

2. Preoperatively measure relevant data based on the clinic imaging, including the distance from the bony landmarks to the fracture line and the length of the plate.

3. Determine the incision location: Based on the preoperative data, determine the location and direction of the incision. The incision direction generally follows the direction of the fracture line, and the size of the incision is similar to the width of the plate. Partially dissect the periosteum to expose the fracture ends.

4. Reduce the fracture: Explore for any soft tissues embedded in the fracture ends and remove them if present. Two Kirschner wires were used as handles in the proximal and distal fracture fragments to reduce the fracture. Temporarily stabilize the reduction using Kirschner wires and confirm proper alignment of the fractured reduction through fluoroscopy. Suture the periosteum dissected.

5. Implant the plate for internal fixation: Use the plate to separate the periosteum from the subcutaneous tissue through the incision. The selected appropriate plate is inserted between the subcutaneous tissue and the periosteum. Adjust the plate to the appropriate position on the surface of fracture bone.

6. Secure the plate in place using screws: Perform percutaneous screw fixation one by one. After stabilizing the plate, remove the Kirschner wires and confirm the alignment of the fracture reduction and the position of the plate under fluoroscopy. Close the incision.

Second to Minimally Invasive Plates Osteosynthesis Clinical Cases

All clinical cases included in this study were from patients treated at our medical institution and gave informed consent before surgery. This study was also approved by the Ethics Committee of our medical institution.

Case One: Distal Fibula Fracture

An 18-year-old adolescent girl accidently twisted her left ankle while going downstairs at school, resulting in a fracture of the distal end of the left fibula and a fracture of the posterior malleolus of the left tibia. The surgical approaches used were the STMIPO technique for the left fibula fracture and the open reduction and internal fixation (ORIF) technique for the posterior malleolus fracture (Figure 1).

Figure 1.

Radiographs and images depicting a fibula fracture. (A) Preoperative anterior-posterior and lateral radiographs, (B) preoperative 3D CT scan, (C) preoperative measurement of relevant data, (D) surgical incision of the STMIPO technique, (E) postoperative anterior-posterior and lateral radiographs, and (F) postoperative 1-month anterior-posterior and lateral radiographs. STMIPO = second to minimally invasive plates osteosynthesis

Case Two: Tibial Shaft Fracture

A 51-year-old female accidently fell down the stairs, resulting in a fracture of the shaft of the right tibia. She initially sought medical treatment at another hospital but later requested to be transferred to our hospital for further management. The surgical approach used was the STMIPO technique for the fracture of the shaft of the right tibia (Figure 2).

Figure 2.

Radiographs and images depicting a tibial shaft fracture. (A) Preoperative anterior-posterior radiograph, (B) preoperative 3D CT scan, (C) preoperative measurement of relevant data, (D) surgical incision of the STMIPO technique, (E) postoperative anterior-posterior and lateral radiographs, (F) postoperative 1-month anterior-posterior and lateral radiographs, and (G) postoperative 3-month anterior-posterior and lateral radiographs. STMIPO = second to minimally invasive plates osteosynthesis

Case Three: Femoral Shaft Fracture

A 7-year-old girl met with a traffic accident, resulting in the left femoral shaft fractures. The surgical approach used was the STMIPO technique for the left femoral shaft fracture (Figure 3).

Figure 3.

Radiographs and images depicting a femoral shaft fracture. (A) Preoperative anterior-posterior radiograph, (B) preoperative 3D CT scan, (C) preoperative measurement of relevant data, (D) surgical incision of the STMIPO technique, (E) postoperative anterior-posterior and lateral radiographs, (F) postoperative 1-month anterior-posterior and lateral radiographs, (G) postoperative 2-month anterior-posterior and lateral radiographs, and (H) postoperative 3-month anterior-posterior and lateral radiographs. STMIPO = second to minimally invasive plates osteosynthesis

Case Four: Humeral Shaft Fracture

A 67-year-old female met with a traffic accident, resulting in the left humeral shaft fractures. The surgical approach used was the STMIPO technique for the left humeral shaft fracture (Figure 4).

Figure 4.

Radiographs and images depicting a humerus shaft fracture. (A) Preoperative anterior-posterior radiograph, (B) preoperative 3D CT scan, (C) preoperative measurement of relevant data, (D) surgical incision of the STMIPO technique, (E) postoperative anterior-posterior and lateral radiographs, (F) postoperative 1-month anterior-posterior and lateral radiographs, (G) postoperative 3-month anterior-posterior and lateral radiographs, and (H) postoperative 5-month anterior-posterior and lateral radiographs. STMIPO = second to minimally invasive plates osteosynthesis

Case Five: Ulna Shaft Fracture

A 58-year-old man sustained a fracture of the shaft of the right ulna as a result of an assault. The surgical approach used was the STMIPO technique for the left ulna shaft fracture (Figure 5).

Figure 5.

Radiographs and images depicting an ulna shaft fracture. (A) Preoperative anterior-posterior and lateral radiographs, (B) preoperative 3D CT scan, (C) preoperative measurement of relevant data, (D) surgical incision of the STMIPO technique, (E) postoperative anterior-posterior and lateral radiographs, (F) postoperative 5-month anterior-posterior and lateral radiographs, and (G) postoperative 12-month anterior-posterior and lateral radiographs. STMIPO = second to minimally invasive plates osteosynthesis

Case Six: Radius Shaft Fracture

A 35-year-old female accidently fell down the stairs, resulting in a fracture of the shaft of the right radius. The surgical approach used was the STMIPO technique for the right radius shaft fracture (Figure 6).

Figure 6.

Radiographs and images depicting a radius shaft fracture. (A) Preoperative anterior-posterior and lateral radiographs, (B) preoperative 3D CT scan, (C) preoperative measurement of relevant data, (D) surgical incision of the STMIPO technique, (E) postoperative anterior-posterior and lateral radiographs, (F) postoperative 1-month anterior-posterior and lateral radiographs, (G) postoperative 3-month anterior-posterior and lateral radiographs, and (H) postoperative 11-month anterior-posterior and lateral radiographs. STMIPO = second to minimally invasive plates osteosynthesis

Based on Theory, Second to Minimally Invasive Plates Osteosynthesis Techniques Differs From Minimally Invasive Plates Osteosynthesis Techniques and Open Reduction and Internal Fixation Techniques

1. Incision positions: In the STMIPO technique, the incision is made at the fracture site. In the MIPO technique, the incision is made away from the fracture site, usually on the far side of the fracture. In the ORIF technique, the incision is centered around the fracture site, and the length of the incision is determined relative to the selected plate length (Figure 7).

2. Fracture reduction methods： In the STMIPO technique, the periosteum at the fracture site is partially disrupted, and fracture reduction is achieved through a semidirect visualization approach. In the MIPO technique, the periosteum at the fracture end remains intact, and closed reduction is performed. In the ORIF technique, reduction is done through complete direct visualization under direct visualization (Figure 8).

3. Extent of soft-tissue involvement： The STMIPO technique has a greater range of soft-tissue damage around the fracture site compared with the MIPO technique and ORIF technique (Figure 9).

Figure 7.

Images showing the incision positions. (A) Incision of the MIPO technique, (B) incision of the STMIPO technique, and (C) incision of the ORIF technique. STMIPO = second to minimally invasive plates osteosynthesis, MIPO = minimally invasive plates osteosynthesis, ORIF = open reduction and internal fixation

Figure 8.

Images showing the fracture reduction methods. (A) Closed reduction, (B) semidirect visualization reduction, and (C) visualization reduction. STMIPO = second to minimally invasive plates osteosynthesis

Figure 9.

Images showing the extent of soft-tissue involvement. (A) MIPO technique, (B) STMIPO technique, and (C) ORIF technique. STMIPO = second to minimally invasive plates osteosynthesis, ORIF = open reduction and internal fixation

Surgical Challenges of Second to Minimally Invasive Plates Osteosynthesis Technique

1. Difficulty in achieving satisfactory plate positioning: The subcutaneous blind insertion technique in STMIPO makes it challenging to accurately position the plate in the desired location. The narrow subperiosteal and subcutaneous tunnel also makes it difficult to adjust the plate position once implanted.

2. Difficulty in locating the screw holes: Particularly with compression locking screws, it can be challenging to accurately position the screw holes in the plate. There is a risk of inadvertently placing the locking screws into the compression holes, which may compromise the intended locking mechanism.

Results

Our clinical study shows that the STMIPO technique can be successfully applied in various limb fractures. All patients with fracture achieved satisfactory outcomes.

Discussion

Compared with open surgical methods, the MIPO technique achieves fracture reduction and fixation through small incisions and indirect techniques, reducing direct damage to soft tissues. This approach can minimize surgical trauma, alleviate postoperative pain, expedite the recovery process, and provide better cosmetic outcomes.^12,21,22Indeed, research has shown that closed reduction is the greatest challenge in the MIPO technique. In addition, radiation exposure during the procedure is another factor that young orthopaedic physicians consider when opting for open reduction and internal fixation (ORIF) instead.²³

Our team has proposed the STMIPO technique, which has been successfully applied in fractures of the fibula, tibia, femur, ulna, radius, and humerus. In theory, the STMIPO technique allows for direct visualization during fracture reduction, resulting in shorter surgical times and reduced soft-tissue damage and radiation exposure. Compared with the MIPO technique, the STMIPO technique primarily involves additional disruption of the periosteum at the fracture ends.

It is true that there is limited research on the STMIPO technique, and our team's understanding of it is currently at the theoretical stage. Although initial data suggest that the clinical outcomes of the STMIPO technique are not inferior to those of the MIPO technique, the sample size is still small, and additional validation is necessary.

Conclusions

Our clinical data have shown that the STMIPO technique can be applied to fractures of the fibula, tibia, femur, ulna, radius, and humerus. The STMIPO technique can serve as an alternative solution for fractures that are difficult to reduce.