Conventional Open Reduction and Internal
Fixation (ORIF) Compared to Minimally
Invasive Plate Osteosynthesis (MIPO) for
Treatment of Extra-Articular Distal Tibia
Fractures - A Prospective Randomized Trial
Ahmed A Khalifa1*, Tarek A Abdel-Daym1, Hamdy Tammam1, ElSayed Said1 and Hesham Refae2
1Qena faculty of medicine and its university hospital, South Valley University, Egypt
2Aswan faculty of medicine, Aswan University, Egypt
Submission: January 20, 2019;Published: February 12, 2019
*Corresponding author: Ahmed A KhalifaFRCS (Tr. & Ortho), Assistant Lecturer, Orthopaedic and Traumatology Department, Qena faculty of medicine and its University hospital, South Valley University, Qena, Egypt
How to cite this article: Ahmed A K, Tarek A A D, Hamdy T, ElSayed S, Hesham R. Conventional Open Reduction and Internal Fixation (ORIF) Compared to Minimally Invasive Plate Osteosynthesis (MIPO) for Treatment of Extra-Articular Distal Tibia Fractures - A Prospective Randomized Trial. Ortho & Rheum Open Access J 2019; 13(4): 555867.DOI: 10.19080/OROAJ.2019.13.555867
Introduction/Objective: Extra-articular distal tibia fracture considered one of the most common fracture faced by a trauma surgeon with a diversity of treating techniques with no consensus regarding the best option for management, the objective of this study was to prospectively compare our results of 2 groups of extra-articular distal tibia fracture treated by ORIF or MIPO technique.
Patient and Methods: 40 patients included in the study, 20 patients randomly allocated to each group, including closed or open GI fractures in patients older than 18 years, both pre, post-operative and last follow up AP and Lat. radiographs was assessed, incidence of wound complications, fracture union, blood loss, operative time and fluoroscopy time were reported.
Results: There were no significant differences between the two groups in terms of age, sex, type of fracture, distribution of infection, operative time, bone union time, and Teeny & Wiss score (p>0.05). Nevertheless, skin infection was more in the ORIF group 5 cases against 1 in MIPO group. fluoroscopy time was significantly longer in the MIPO group than in the ORIF group: 87.25±24.52 seconds for, and 41.25±10.37 seconds respectively (p<0.05). Amount of blood loss in the ORIF group was significantly larger than the MIPO group: 46.75±12.16 cc, and 79.1±21.48 cc respectively (p<0.05).
Conclusion: From our results we believe that both ORIF and MIPO techniques are valid in treating extra-articular distal tibia fracture, although MIPO may have a longer operating and fluoroscopy time, but it has the advantage of less bleeding and minimal wound complications.
The (AO-43A) extra-articular distal tibia facture considered to be one of the most common fracture types, which mainly can result from simple falls, traffic accidents, or sports-related injuries as a result of axial compression and/or rotational forces [1-3]. The decision to treat these fractures conservatively or operatively depends mainly on the fracture pattern and soft tissue status, usually conservative treatment leads to unacceptable results . intramedullary nailing, plate osteosynthesis and external fixation considered the main lines of operative intervention [5,6]. However, there is no consensus for the optimal surgical technique . With the advancement of internal fixation techniques, minimally invasive
plate osteosynthesis (MIPO) designed as a new approach for a biological friendly osteosynthesis, which rapidly gained superiority over conventional open reduction and internal fixation (ORIF) especially in treating distal tibia extra-articular fractures (AO-43A) [8-12]. The objective of this study was to prospectively compare the results of 2 groups of extraarticular distal tibia fracture treated by ORIF or MIPO at Qena university Hospital (a new tertiary referral centre in upper Egypt).
This is a prospective randomized study of (40) patients diagnosed with extra-articular distal tibia fracture(AO-43A) according to AO classification system, presented to trauma unit
at Qena University hospital (a new tertiary referral hospital in
upper Egypt) in the period between July 2017 to April 2018.
Patients aged 18 years and older diagnosed with closed or open
GI (according to Gastillo classification) extra-articular distal
tibial fracture with or without fibular fracture were included in
the study. patients with pathological fracture, open Gǁ or above,
fracture of the proximal two thirds of the tibia and intra-articular
fracture extension were excluded. patients were randomized
into two groups 20 patients in each group.
Following ATLS protocol for initial assessment and after
following careful history taking including (occupation, special
habits of medical importance, pre-fracture walking ability, history
of trauma and duration of fracture), local clinical examination
was performed for all patients mainly for assessment of skin
condition, evaluation of distal neurovascular structures and to
detect any signs suggesting compartment syndrome.
Apart from radiographs needed for the ATLS protocol, Plain
radiographs (pre- and immediate post-operative) including
an anteroposterior (AP) and lateral views (Figure 1) of tibia
including knee and ankle joints and an ankle mortise view
whenever needed. Verbal and written informed consent was
taken prior to surgery, all patients were consulted about type of
surgery and possible complications.
All cases were operated upon or supervised by a senior
trauma surgeon and under spinal anesthesia for all cases with
a tourniquet used and inflated to 150 above systolic blood
pressure, the patient was positioned supine on a radiolucent
operative table to ease intraoperative fluoroscopy usage, draping
was done in the usual manner to above the knee level, if the
fibula fracture was comminuted or involving the syndesmosis it
was managed first by ORIF using plate and screws followed by
fixation of the tibia fracture.
In ORIF group, the standard anteromedial approach was
performed. The distal tibia Fracture was fixed using anatomical
distal tibia plate (The choice to use a locked versus non-locked
plate in both groups was determined according to the patient
bone quality and the surgeon preference, where locked plate
was preferred in osteoporotic patients) with at least 3 screws
(6 cortices) for each main fragment. In MIPO group, an indirect
reduction technique was carried out manually and alignment
checked under fluoroscopy.
A distal longitudinal incision was performed at the medial side
of the distal tibia approximately 2 cm in length cantered over the
medial malleolus to allow insertion of the plate. The saphenous
vein and nerve were identified and protected. After choosing
an appropriate plate length (according to the configuration and
extension of the fracture, taking in consideration that at least 3
screws can be inserted in the proximal fragment), A proximal
incision was made under fluoroscope for delivery of the plate. A
subcutaneous extra-periosteal tunnel was created by a dissection
forceps and followed by the insertion of a plate from the distal
to proximal incision. The plate position was checked under
fluoroscopy until proper positioning was achieved. screws were
inserted with at least 3 screws in each main fragment, wound
closure done in layers with no suction drain used in either group.
Immediate postoperative plain radiograph (AP and lateral)
to assess the reduction and plate position, all patients were
encouraged to move the ankle joint starting from day 1 postoperative,
and ambulation with crutches at day 2 with Strict
non- weight bearing on the operated side, leg was elevated to
reduce swelling using elastic bandage, with close monitoring for
any signs suggesting development of compartment syndrome.
Patients follow up protocol was as follows: after 2 weeks for
stitch removal, then at 6 weeks, 3 months and after 6 months
for assessment of skin condition and for clinical and radiological
At 6 months follow up Visit: The functional outcome
was evaluated with the clinical rating for the ankle by Teeny
and Wiss criteria  and radiographs (AP and lateral views) were obtained to assess fracture union according to Apley and
Solomon’s criteria  complete bone union according to these
criteria defined as the time at which there is no pain upon local
palpation, no swelling in the limb, an ability to walk without
support and pain free, and an evidence of a radiographic bridging
callus or trabecula between fragments (Figure 2).
Statistical analysis was performed using SPSS statistical
software (version 22.0). Independent samples t-test or Mann-
Whitney U test were used to compare the quantitative variables.
The qualitative variables were compared using the chi-square
test. P < 0.05 was considered statistically significant.
All patients were available for the last follow up, the groups
were compared with respect to gender, age, fracture type, operating
time, type of plate used, amount of blood loss, fluoroscopy
time, bone healing time, incidence of skin infection (in the first 2
weeks), gait and functional ankle outcome.
Table 1 presents the demographic data and all outcomes
for the two groups that were cross-matched. As is shown, there
were no significant differences between the two groups in terms
of age, sex, and type of fracture. The time of surgery was shorter
in the ORIF group; however, the difference was not statistically
significant (p>0.05). There were no significant differences in the
distribution of infection, bone union time, gait or Teeny & Wiss
score (p>0.05). Nevertheless, the difference in skin infection is
considered clinically relevant (Figure 3), being more in the ORIF
group, of the 5 cases that had superficial wound infection in the
ORIF group, 4 were diagnosed as open GI fracture. Our results
indicated that the fluoroscopy time was significantly longer in
the MIPO group than in the ORIF group: 87.25±24.52 seconds for
the MIPO, and 41.25±10.37 seconds for the ORIF group (p<0.05);
but the amount of blood loss in the ORIF group was significantly
larger than in the MIPO group: 46.75±12.16 cc, and 79.1±21.48
cc respectively (p<0.05). 30 patients (75%) had associated fibula
fracture, 23 patients needed ORIF. At the last follow up, we didn’t
encounter any cases with skin problems especially sloughing or
1Independent t-test; 2Mann-Whitney U test; 3Chi-square test; *p<0.05.
MIPO: Minimally Invasive Plate Osteosynthesis; ORIF: Open Reduction And Internal Fixation; SD: standard Deviation.
Extra-articular distal tibia fracture (AO- 43A) represents
a challenging situation for the trauma surgeon, insufficient
blood supply, proximity to the ankle joint and often poor bone
quality of the distal fragment contributes to this situation [2,3].
The main goals in treating distal tibia fractures are: anatomical
reduction, restoration of axial alignment, maintenance of joint
stability, achievement of fracture union, pain free weight baring,
and minimal wound complications , Although these goals can
be achieved by different lines of management, but each carries
its own deficiency, non-operative treatment may be complicated
by loss of reduction and subsequent malunion; external fixation
may result in insufficient reduction, malunion, and pin tract
infection; there is some concern about the use of IMN with a
short distal segment and lastly ORIF necessities extensive soft
tissue dissection which may increase the incidence of wound
complications and infections .
To minimize disruption of the particularly delicate softtissue
envelope and periosteal blood supply, minimally invasive
plate osteosynthesis (MIPO) was developed  to maintain a
more biologically favourable environment for fracture healing
. In this study we focused mainly on comparing ORIF to
MIPO prospectively in randomised matched 2 groups of patients
presented at our trauma unit, which is considered as a new
tertiary referral centre in upper Egypt.
According to clinical rating for the ankle by Teeny and
Wiss, 90 % of patients in our series had excellent and good
results while 10 % had a fair or poor results, with no significant
difference between both treatment groups, our results were
comparable to Mahajan who reported 91 % excellent and good
clinical results with MIPO technique in 20 patients with distal
tibia fractures while 9% had a fair results . Webb et al.
reported a functional outcome following MIPO in distal tibia
fractures which did not significantly differ from that of the
general population . Wound problems considered to be one
of the most annoying complication to the trauma surgeon while
treating this type of fracture, mainly infection and skin necrosis
[3,21-23]. Extensive soft tissue dissection accompanied with
ORIF increases the risk of wound complications [21,24,25].
Overall wound complications (mainly infection) in our series
in both groups were 15 %, distributed as five cases in the ORIF
group against one only in the MIPO group, although there was no
statistically significant difference in the incidence between both
groups, but we consider this a clinical significant finding, apart
from soft tissue dissection needed for exposure and fixation in
ORIF group, four of the five cases had an open fracture, both
factors may contribute to increase incidence of infection in ORIF
Our results in the ORIF which was 12.5 % of overall infection
incidence were comparable to what was reported by Yih-Shiunn
Lee et al. who had a superficial infection rate of 8% in distal
tibia fracture treated by ORIF technique  also Jensen et al.
 reported 9% superficial infections in a case series of one
hundred and five patients treated with ORIF. Guo et al.  and
Yong chuan Li et al.  reported a rate of wound complications
of 14.6% and 19% respectively using MIPO technique, which
considered higher than the reported incidence in our MIPO
group which was only 2.5%.
At the last follow up, fracture union was observed in all study
cases in both groups, although at 3 months follow up, three
patients didn’t show signs of union, but they did show bone
healing at the last follow up after advising the patients to strictly
stop smoking, up to 12% non-union incidence among patients
treated for distal tibia fracture had been reported in some series
[28-30]. while MIPO with the idea of biological osteosynthesis
was popularized with the advantage of minimizing the trauma
to the already injured zone and preserve the circulation around
the fracture site which preserves the biological environment for
optimum fracture healing , Hasenboehler et al.  reported
that prolonged healing times were observed in simple fracture
patterns treated with MPIO, also other studies reported a rate of
delayed union or non-union to be 5 to17% .
Although, operative time was not statistically different
between both groups, but it was relatively longer in the MIPO
group which can be attributed to the longer time of fluoroscopy
usage (which was significantly longer than the ORIF group), but
we did find a comparable operative time in MIPO group to what
had been reported by Guo et al. , Wang Cheng et al.  and
Jun Shen et al.  where they reported a mean operative time
with MIPO technique to be 97.9 min, 113.33 min and 56.0 min
respectively. Even with the use of tourniquet in both groups,
we did find a significant difference in blood loss between both
groups, being more in the ORIF group, while the mean blood
loss in MIPO group was comparable to the results by Jun Shen
et al.  where they had a mean blood loss of 20 ml with MIPO
technique for distal tibia fracture. Surprisingly, blood loss with a
MIPO technique can even reach to a mean of 350 ml as had been
reported by Wang Cheng et al. .
23 patients underwent ORIF out of total 30 patients
with a concomitant fracture fibula in our series, according to Bonnevialle et al. , the decision to fix the fibula was made
when instability of the inferior tibio-fibular syndesmosis is
diagnosed or if the fracture was comminuted and this offers
restoration of the lateral column which may help in indirect
reduction of a comminuted distal tibia fracture, also it prevents
fracture collapse .
From our results we believe that both ORIF and MIPO
techniques are valid in treating extra-articular distal tibia
fracture, although MIPO may have a longer operating and
fluoroscopy time, but it has the advantage of less bleeding and
minimal wound complications.
I would like to acknowledge the great effort done for the
statistical analysis of the data by Dr. Ahmed Ahmed, an intern
in orthopaedic and traumatology department, Qena university
hospital. All authors declare no conflict of interest and no